Causes and Complications

Question 1

Primary Hypertension

Risk Factors

Answer 1

• Family history of hypertension or heart disease
• High sodium diet
• Obesity
• Smoking
• Diabetes
• Excess alcohol intake
• Physical inactivity
• Ethnicity (blacks > whites)
• Advanced age

Question 2

Secondary Hypertension

Causes

Answer 2

• Primary renal disease (often unilateral parenchymal)
• Renal artery stenosis (fibromuscular dysplasia [young patients] or atherosclerosis [old patients])
• Chronic use of OCPs
• Pheochromocytoma
• Conn’s syndrome (hyperaldosteronism)
• Cushing’s syndrome
• Coarctation of the aorta

Question 3

Hypertension

Complications

Answer 3

• Cardiovascular:
• Left ventricular hypertrophy
• Congestive heart failure
• Coronary artery disease
• Atrial fibrillation (AF)
• Accelerated atherosclerosis (major risk factor)
• Aneurysm formation and rupture
• Dissection
• Brain:
• Stroke (ischemic or hemorrhagic [major risk factor])
• Impaired cognition (dementia)
• Hypertensive encephalopathy (severe headache, nausea, vomiting [often projectile], focal neurological signs and altered mental status)
• Eyes: hypertensive retinopathy
• Kidneys: hypertensive nephropathy and end-stage renal disease

Question 4

Atherosclerosis

Major or Modifiable risk factors

Answer 4

• Hyperlipidemia
• Hypertension
• Smoking
• Diabetes
• Obesity

Question 5

Atherosclerosis

Minor or Non-modifiable risk factors

Answer 5

• Male gender
• Sedentary lifestyle
• Stress (type A personality)
• Elevated homocysteine
• Oral contraceptive use
• Increasing age
• Familial/genetic factors

Question 6

Atherosclerosis

Complications

Answer 6

• Aneurysms
• Ischemia
• Infarcts
• Peripheral vascular disease
• Thrombus
• Emboli

Question 7

Aortic Dissecting Aneurysms

Complications

Answer 7

• Organ ischemia due to obstruction of aortic branches by pressure like renal or coronary arteries
• Aortic rupture
• Death

Question 8

Superficial Varicose veins of lower extremities

Causes

Answer 8

• Lack of structural support from superficial fat

- Incompetent valves

Question 9

Superficial Varicose veins of lower extremities

Risk factors

Answer 9

• Pregnancy

- Prolonged standing or sitting

Question 10

Superficial Varicose veins of lower extremities

Complications

Answer 10

• Edema
• Thrombosis
• Stasis dermatitis
• Ulceration
• Source of emboli (rarely)

Question 11

Esophageal Varices

Causes

Answer 11

Portal hypertension

Question 12

Esophageal Varices

Complications

Answer 12

Life-threatening hemorrhage

Question 13

Hemorrhoids

Risk factors

Answer 13

• Constipation

- Pregnancy

Question 14

Hemorrhoids

Complications

Answer 14

• Bleeding

- Thrombosis (painful)

Question 15

Stable Angina

Cause

Answer 15

Coronary artery atherosclerosis with luminal narrowing greater than 75%, so the pain is brought up by increased cardiac oxygen demand (stress or exercise). It is a subendocardial ischemia

Question 16

Prinzmetal variant angina

Cause

Answer 16

Coronary artery vasospasm (invoked usually by cocaine or smoking) that produces episodic pain at rest. It is a transmural ischemia

Question 17

Unstable (Crescendo) angina

Cause

Answer 17

Formation of non-occlusive thrombus in an area of coronary atherosclerosis (due to recurrent atherosclerotic plaque rupture)

Question 18

Myocardial Infarction (MI)
(Cause)

Answer 18

• Coronary artery atherosclerosis with plaque rupture and superimposed occlusive thrombus formation
• Unrelieved coronary artery spasm

Question 19

Myocardial Infarction (MI)
(Complications according to time line)

Answer 19

• 0-24 hr: Cardiac arrhythmias especially VF [most common cause of death], HF and cardiogenic shock (> 40-50% myocardium is necrotic)
• 1-3 days: Fibrinous pericarditis
• 3-14 days: Free ventricular wall rupture –> cardiac tamponade, Interventricular septum rupture –> left to right shunt, Papillary muscle rupture –> mitral insufficiency
• 2 weeks to several months: Congestive heart failure, Dressler syndrome, arrhythmias, true ventricular aneurysm ( risk of mural thrombus and thromboembolism)

Question 20

Sudden Cardiac Death

Causes

Answer 20

• Fatal cardiac arrhythmias (usually VT) with 80% being coronary artery disease as the underlying cause
• Hypertrophic and dilated cardiomyopathy
• Mitral valve prolapse
• Aortic valve stenosis
• Congenital heart abnormalities
• Hereditary ion channelopathies (e.g., long QT syndrome and Brugada syndrome)
• Myocarditis

Question 21

Coronary Artery Disease (CAD)

Risk factors

Answer 21

• Diabetes mellitus
• Tobacco smoking
• Hypertension
• Hyperlipidemia
• Abdominal obesity
• Family history of premature CAD (under 55 in male and under 65 in women)
• Age above 45 in men and above 55 in women
• CAD risk equivalents are DM, symptomatic carotid artery disease, peripheral artery disease and abdominal aortic aneurysm

Question 22

Myocardial Infarction (MI)
(Complications according to presentation)

Answer 22

All of them cause hypotension

• Bradycardia: either sinus bradycardia (vascular insufficiency to SA node) or third degree AV block (cannon A waves). Rx: atropine first then pacemaker
• Tachycardia:
• RV infarction (associated with inferior MI [40%] and clear lungs). Dx: ST elevation in RV4. Rx: high volume fluid replacement and avoid nitroglycerin
• Tamponade: “sudden loss of pulse” and clear lungs
• VT and VF: also cause loss of pulse and should be diagnosed with ECG
• Valve or septal rupture: both cause new onset murmur and pulmonary congestion (septal rupture cause step-up in oxygen saturation on entering RV)
• Extension of infarction or reinfarction (inferior or anterior MI)
• Aneurysm or mural thrombus: most aneurysms need no specific therapy while mural thrombi are treated with heparin followed by warfarin

Question 23

Dyslipidemia

Causes

Answer 23

• Obesity
• DM
• Alcoholism
• Hypothyroidism
• Nephrotic syndrome
• Hepatic disease
• Cushing’s syndrome
• OCP use
• High dose diuretic use
• Familial or hereditary

Question 24

Preductal Coarctation of aorta (infantile type)

Complications

Answer 24

Congestive heart failure

Question 25

Postductal Coarctation of aorta (adult type) | Complications

Answer 25

- Congestive heart failure - Intracerebral hemorrhage - Dissecting aortic aneurysm

Question 26

Transposition of great arteries | Risk factors

Answer 26

Infants of diabetic mothers

Question 27

VSD | Complications

Answer 27

- Eisenmenger complex (as all other left to right shunt defects) - Infectious endocarditis (small defect only due to jet stream that may damage the endocardium)

Question 28

ASD | Complications

Answer 28

- Eisenmenger complex (as all other left to right shunt defects) - Paradoxical emboli (the most common cause is patent foramen ovale)

Question 29

PDA | Risk factors

Answer 29

- Prematurity | - Congenital rubella infections

Question 30

Dilated Cardiomyopathy | Causes

Answer 30

- Idiopathic - Alcoholism (B1 deficiency) - Wet Beriberi - Medications like doxorubicin and cocaine - Viruses like Coxsackievirus B and enteroviruses - Parasites like Chagas disease - Hemochromatosis - Sarcoidosis - Pregnancy (peripartum cardiomyopathy)

Question 31

Dilated Cardiomyopathy | Complications

Answer 31

- Congestive heart failure (systolic) - Mural thrombi - Arrhythmias

Question 32

Hypertrophic Cardiomyopathy | Causes

Answer 32

- Autosomal dominant (> 50% of cases, the most common mutation is beta-myosin heavy chain) - Idiopathic - Can be associated with Friedreich ataxia

Question 33

Restrictive Cardiomyopathy | Causes

Answer 33

- Amyloidosis - Sarcoidosis - Post-radiation fibrosis - Endomyocardial fibroelastosis (thick fibroelastic tissue in endocardium of young children) - Loeffler endomyocarditis (fibrosis with prominent eosinophilic infiltration) - Hemochromatosis (although dilated cardiomyopathy is more common)