Cardiovascular disease and atherosclerosis

Question 1

Cardiovascular Disease

Answer 1

Defined by the presence of stenosis which impairs blood flow.
Flow limiting lesion.

Question 2

Major Risk Factors for Cardiovascular Disease (non modifiable)

Answer 2

Gender (Male>Female)
Age
Male >40
Female >50 (post menopause)
Race (African American or Asian)
Family History

Question 3

Major Risk Factors for Cardiovascular Disease (modifiable)

Answer 3

Hypertension
Tobacco use
Elevated blood glucose (IFG/diabetes)
Physical inactivity
overweight or obese
hyperlipidemia

Question 4

Atherosclerosis

Answer 4

Commonly known as “hardening of the arteries.”

pathogenesis involves lipids, thrombosis, elements of the vascular wall, and immune cells.

Question 5

Structure of Arterial Wall

Answer 5

intima: has endothelial cells
media: smooth muscle cells
adventia

Question 6

Three Main Pathological Stages

Answer 6

Fatty Streak
Plaque Progression
Plaque Disruption

Question 7

Fatty Streak

Answer 7

Endothelial dysfunction
Lipoprotein entry and modification
Leukocyte recruitment
Foam cell formation

Question 8

Plaque Progression

Answer 8

smooth muscle cell migration

Altered matrix synthesis and degradation

Question 9

Plaque Disruption

Answer 9

Disrupted plaque integrity

Thrombus formation

Question 10

Role of Endothelial Cells (EC)

Answer 10

EC normally produce
antithrombotic molecules that prevent blood clots.
EC modulate the immune response
by resisting leukocyte adhesion and therefore inhibiting inflammation

Question 11

Endothelial Dysfunction

Answer 11

↑ Permeability
↑ Inflammatory cytokines
↑ Leukocyte adhesion molecules
↓ Vasodilatory molecules

Question 12

Lipoprotein Entry and Modification

Answer 12

↑ Permeability allows LDL entry
into the intima
LDL accumulate in the subendothelial space by binding to components of the extracellular matrix and become ‘trapped.’

Question 13

Evolution of Atherosclerotic Plaque: developmental stage Fatty streaks

Answer 13

Characterized by lipid-filling smooth muscle cells

potentially reversible

Question 14

Evolution of Atherosclerotic Plaque: developmental stage Fibrous plaque

Answer 14

Lipoproteins transport/deposits LDLs into the arterial intima

Fatty streak is covered by collagen and calcium deposits forming a fibrous plaque that appears grayish or whitish
resulting in narrowing of vessel

Question 15

Evolution of Atherosclerotic Plaque: developmental stage Complicated lesion/Unstable Plaques

Answer 15

Continued inflammation can result in plaque instability, ulceration, and rupture.

Lipid core is exposed to the blood stream, platelets accumulate, and thrombus forms.

Question 16

Complications of Atherosclerosis

Answer 16

acute coronary syndrome, myocardial infarction, Venous thromboembolism, stroke, Aneurysm, Hemorrhage

Question 17

Peripheral Vascular Disease (PVD)

Answer 17

A slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel.
PVD may involve disease in any of the blood vessels outside of the heart
Arteries (PAD)
Veins (CVI)

Question 18

Peripheral Arterial Disease causes

Answer 18

Structural changes in the vessel wall
Narrowing of the vascular lumen.
Spasm of vascular smooth muscle cell

Question 19

Claudication Walking Tests

Answer 19

Measure distance the patient can ambulate before stopping due to claudication pain.
Claudication pain of PAD occurs at predictable and reproducible durations if exercise intensity is kept consistent.

Question 20

Peripheral Arterial Disease Findings

Answer 20

Affected limb may show sings of cyanosis

Limbs may feel cool to the touch

Numbness or tingling reported in affected area

Skin may appear shiny, thin, pale, and hairless.

Nails become thickened and brittle.

Question 21

Clinical Implications for PAD

Answer 21

Exercise at least 3 x/week
Initial workload/intensity should induce claudication within 3-5 min
Continues at this workload until the pain is of mod severity (5/10)

Question 22

Raynaud’s Syndrome

Answer 22

Vasospasm causing reduced blood flow

Question 23

Aneurysms

Answer 23

Localized abnormal dilation by at least 50% compared to normal.

Question 24

Causes of aneurysms

Answer 24

atherosclerosis, congenital infections, Marfan’s

Question 25

Risk Factors aneurysms

Answer 25

``` Cardiovascular disease and Risk factors for CVD Especially smoking Male Genetics (Marfan’s) 40-60 yr old Hypertension prevalent ```

Question 26

Types of Aneurysms

Answer 26

Saccular aka Berry Fusiform Dissecting

Question 27

Saccular aka Berry Aneurysms

Answer 27

Small, spherical, 1-1.5 cm. | Most common in brain tissue

Question 28

Fusiform Aneurysms

Answer 28

Gradual more progressive

Question 29

Dissecting Aneurysms

Answer 29

Blood filled channel within vessel wall

Question 30

Abdominal Aortic Aneurysm symptoms

Answer 30

``` Dull, tearing ache/pain in low back, groin or mid abdominal left flank Chest Pain Weakness or transient paralysis of legs tachycardia ```

Question 31

Chronic Venous Insufficiency (CVI)

Answer 31

is a condition that occurs when the vein wall and/or valves in the leg veins do not work effectively, which impairs the ability for blood to return to the heart from the legs, resulting in venous-stasis

Question 32

Chronic Venous Insufficiency (CVI) may result from

Answer 32

Vein wall degeneration, post-thrombotic valvular damage, chronic venous obstruction, or dysfunction of the muscular pumps.

Question 33

Edema defined as

Answer 33

a clinically apparent increase in the interstitial fluid volume

Question 34

Edema causes

Answer 34

Due to Increase in capillary pressure usually results from an elevation of venous pressure caused by obstruction to venous and/or lymphatic drainage. Imbalance of the Startling Forces

Question 35

Pitting edema 1+

Answer 35

Barely detectable impression when finger is | presssed into skin.

Question 36

Pitting edema 2+

Answer 36

Slight indentation. | 15 seconds to rebound

Question 37

Pitting edema 3+

Answer 37

Deeper indentation. | 30 seconds to rebound.

Question 38

Pitting edema 4+

Answer 38

> 30 seconds to rebound.

Question 39

PT Implications for CVI

Answer 39

Exercise increases muscle pump for venous return and kidney function to clear fluid Short walks with occupations involving prolonged sitting, weight shift in standing

Question 40

Ulcers

Answer 40

A persistent discontinuity in the integrity | of skin despite sufficient time for healing

Question 41

3 types of ulcers

Answer 41

Arterial, Venous, Neuropathic.

Question 42

Arterial ulcers

Answer 42

Dorsal or Distal location (toes) Sharp margins Painful Pallor, loss of hair, nail dystrophy

Question 43

Venous ulcers

Answer 43

Malleolar location (usually Medial) Irregular margins Hemosiderin staining (browning) Varicose veins and pitting edema

Question 44

Neuropathic ulcers

Answer 44

``` Plantar location Metatarsal heads (especially 2nd ), sole of foot, balls of toes “Punched Out” margins, usually correspond to pressure point Insensate, patient often diabetic with peripheral neuropathy ```

Question 45

Patients with venous ulcers tend to have

Answer 45

CVI

Question 46

Patients with arterial ulcers tend to have

Answer 46

PAD

Question 47

Wells Score for DVT (Deep vein Thrombosis)

Answer 47

Score >2.0 — High probability Score 1.0 to 2.0 — Moderate Score <2.0 — Low

Question 48

Pulmonary Embolism (PE)

Answer 48

Usually occurs in patients with previous venous thrombosis or at risk Can lead to cor pulmonale and eventually death

Question 49

Pulmonary Embolism (PE) symptoms

Answer 49

Dyspnea, Sharp chest pain, pain with breathing, tachypnea, tachycardia hemoptysis

Question 50

Wells Score for PE

Answer 50

Score >6.0 — High probability Score 2.0 to 6.0 — Moderate Score <2.0 — Low

Question 51

Ischemia

Answer 51

Is a condition of imbalance between myocardial O2 supply and demand often caused by atherosclerosis of the coronary arteries.

Question 52

Causes of Increased demand in ischemia

Answer 52

Exercise, Cold weather (increased vascular resistance), mental/emotional stress, spontaneous changes in HR and BP

Question 53

Angina

Answer 53

``` Chest pain or discomfort caused due to cardiac ischemia Heaviness, tightness, pressure Discomfort gradually builds Gradually subsides Episode Lasts (1-15 minutes) ```

Question 54

3 Major Types of angina

Answer 54

Stable Unstable Printzemental

Question 55

Stable angina

Answer 55

``` Discomfort gradually builds Occurs with exercise at a predictable and consistent intensity Gradually subsides with rest Typically Lasts (2-5 minutes) Rarely more than 5-10 mins Improve with nitroglycerin ```

Question 56

Unstable angina

Answer 56

Recent or acceleration of angina threshold; New onset < 2 months Symptoms at rest > 15-20 minutes. Gradually worsens in a crescendo-like pattern May not respond to Nitro or Rest Often precursor to MI

Question 57

Acute coronary syndrome (ACS)/Myocardial Infarction

Answer 57

Cell death in the heart muscle caused by complete and prolonged occlusion of a coronary artery

Question 58

Type 1 MI

Answer 58

ST elevation and spike in troponin. The release of enzymes is used to see if someone has MI because people can have ST depression and still be having MI

Question 59

factors that increase likelihood of MI

Answer 59

does it have to do with exertion, does it spread to L arm and described as pressure

Question 60

factors that decrease likelihood of MI

Answer 60

sharp pain, not associated with exertion, if I poke your chest and it hurts, it is probably not MI, positional changes like if they have Chest pain while laying down but gets better after getting up.