CVSR 2. Pathology

Question 1

What is a Mural Thrombus and where do they most commonly occur?

Answer 1

Thrombus that adheres to the wall of a vessel.
Usually occur in larger vessels such as aorta + heart
May restrict blood flow but usually do not occlude it completely

Question 2

List 6 broad categories of Cardiac Dx

Answer 2

1. Ischemic Heart Dx
2. Arrythmias
3. Heart Failure
4. Hypertension
5. Valvular Heart Dx + Murmurs
6. Other

Question 3

List the subtypes of Ischemic Heart Dx

Answer 3

1. Chronic Angina Pectoris
2. Acute Coronary Syndrome (ACS)
   2a. Unstable Angina
   2b. STEMI
   2c. NSTEMI

Question 4

Define IHD

Answer 4

Imbalance b/w myocardial O2 supply + demand

Question 5

What is the most common Aetiology of IHD? List 3 others

Answer 5

• Atherosclerosis of coronary arteries (most common)
• Coronary artery spasm
• Emboli
• Coronary ostial stenosis (originating point of coronary arteries)
• Aortic stenosis
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Arrhythmias (→ ↓coronary perfusion pressures)
• Anaemia
• Microvascular Angina (Cardiac Syndrome X ) - due to ‘cardiac ischemia in the presence of normal coronary arteries’ thought to be due to abnormalities of small vessels = ↓ in blood flow

Non-coronary causes of angina: valvular Dx, anaemia

Question 6

List 3 non-modifiable RxFx for IHD

Answer 6

Non-Modifiable:
• Age: ↑age (?age associated accumulation of RxFx e.g. ↑serum cholesterol, HTN, cigarette smoking)
• Sex - when young: ♂ 6x >♀, (note: difference diminishes with age, ?women protected by hormonal status, diminishes progressively during & after menopause)
• FHx - affected relatives <50 yo (appears to be independent of other maj RxFx)
○ Cholesterol may cluster in families, only small proportion actually due to familial hyprcholesterolaemia
Race -

Question 7

List 3 modifiable RxFx for IHD

Answer 7

• Smoking: 3x Rx, directly related to # cigarettes smoked. | Quitting smoking = rapid ↓ in Rx, followed by tapering of Rx, rtn to almost same as non-smoker after ~10yrs
• Blood lipid level:
○ ↑Rx: LDL & Triglycerides (to small degree)
○ Protective: HDL
• HTN & other med cond:
○ Systolic & diastolic HTN = ↑Rx
○ Hypertensive heart Dx, stroke, renal failure = ↑Rx
○ Note: Tx with antihypertensives reduces Rx (esp. in elderly)
• Diabetes Mellitus: 3x ↑ Rx
• Weight: obesity = 2x ↑Rx
• OSA: has association with CVD & cerebrovascular Dx (despite being associated with obesity + HTN)
Psychological Fx:

Question 8

List the 7 stages of Artherosclerosis

Answer 8

Atherosclerosis - slowly progressive focal proliferation of connective tissue within the arterial intima. May begin as early as 2nd decade of life. Associated with high LDL levels.
• Endothelial dysfxn ICW high circulating cholesterol, inflammation & shear forces
• Macrophages enter arterial wall b/w endothelial cells taking up lipids + forming ‘foam cells’
• Accumulation of lipid- laden macrophages in subendothelial zone = formation of fatty streaks
• Toxins released from macrophages = PLT adhesion, smooth mm proliferation + thrombus formation
• Organisation of thrombus = development of atherosclerotic plaque surrounded by a fibrotic cap
• Progressive enlargement of lesion = segmental narrowing of lumen, once sufficient to be flow limiting on exercise = stable exertion-associated angina
• Liable to rupture = sudden thrombosis → ACS
RxFx for rupture: large lipid core, high monocyte density, low sm mm cell density

Question 9

List the S+S for IHD, how do they differ between Stable Angina Vs ACS?

Answer 9

S&S (For All IHD): Central chest pain, heaviness or discomfort commonly radiating to the jaw or arm, may be associated with SoB, sweating, nausea or faintness

* Stable Angina: 'predictable' mismatch brought on by exertion + relieved by rest
* ACS: 'unpredictable' sudden onset, may be at rest

Question 10

List Bedside, Bloods, Biochem, Micro INVs for IHD

Answer 10

• ECG - compare with previous where possible
• FBC
• Troponins
• Lipid Profile
• BGL

Question 11

List the imaging options for INV of IHD

Answer 11

Exercise ECG (Stress Test)
Echocardiography
Exercise or Pharmacological Stress Echo
CT Coronary Angiography
Nuclear Imaging
Coronary Angiography

Question 12

How does the Tx differ for stable angina Vs ACS?

Answer 12

Stable Angina: commonly managed in primary care w/ investigations as an outpatient (ie. Chronic Dx mgmt)

ACS: 🚩 Medical Emergency - for immediate admission + mgmt

Question 13

Non-Pharama Mgmt of IHD

Answer 13

• Minimise RxFx & optimal mgmt & Pt education
○ baseline BP mgmt, lipid profile
• smoking cessation
• healthy diet & lifestyle - weight loss,
exercise within Pt’s capacity (may aid collateral circulation in the heart as per PVDx)
Avoid precipitating factors: eg. Cold weather or extremes of emotion