Deck 1

Question 1

Q. Name two modifiable, two non-modifiable, two clinical and two psychosocial risk factors of atherosclerosis

Answer 1

A. Modifiable: diet (LDLs, sodium), tobacco smoking, obesity, sedentary lifestyle
B. Non-modifiable: gender, family history, genetics
C. Clinical: hypertension, lipids, diabetes
D. Psychosocial: behaviour patterns/traits (type A), depression/anxiety, work, social support – modifiable?

Question 2

Q. Name three features of an atherosclerotic plaque

Answer 2

Lipid, necrotic lesion, connective tissue, fibrous cap

Question 3

Q. Describe the three main layers of an artery

Answer 3

A. Tunica intima, tunica media, tunica adventitia
B. (endothelium, connective tissue, internal elastic membrane, involuntary muscle fibre, elastic fibre, external elastic membrane, connective tissue)

Question 4

Q. Name a blood test marker that is elevated in acute inflammation

Answer 4

A. C-reactive protein (CRP)

Question 5

Q. Which cell types are involved in A) Leukocyte capture/rolling/slow rolling, B) Firm adhesion, transmigration

Answer 5

A. Selectins

B. Integrins, chemoattractants

Question 6

1. Q. Which features (and cells) are involved in each of the following stages of atherosclerosis A) Fatty streaking B) Intermediate leisons C) Fibrous plaques or advanced leisons D) Plaque rupture E) Plaque Erosion

Answer 6

A. Fatty streaks: Earliest stage of atherosclerosis, appear at an eraly age (<10 years), consist of aggregations of lipid-laden macrophages and T-lymphocytes within the intima layer of the vessel wall
B. Intermediate lesions: Composed of layers of: lipid laden macrophages, vascular smooth muscle cells, T-lymphocytes, adhesion and aggregation of platelets to vessel wall, isolated pools of extracellular lipids
C. Fibrous plaques or advanced leisons: Impedes blood flow, prone to rupture.
Covered by a dense fibrous cap made of ECM proteins including collagen (Strength) and elastin (flexibility) laid down by smooth muscle cells that overlies lipid core and necrotic debris.
D. Plaque rupture: Haemorrhage of cells within the plaque, thrombus formation and vessel occlusion
E. Plaque Erosion: Leisons tend to be small early lesions, fibrous cap does not disrupt, luminal surface underneath the clot may not have endothelium present but is smooth muscle cell rich, they may be a prominent lipid core

Question 7

Define the following terms: A) Population attributable risk (PAR)

Answer 7

A. PAR indicates the number of cases of a disease among exposed individuals that can be attributed to that exposure: Incidence exposed – incidence unexposed

Question 8

Define the following terms: B) Population attributable fraction (PAF)

Answer 8

A. PAF is the proportion of cases of a disease among exposed individuals that can be attributed to that exposure (PAR but expressed as a fraction)

Question 9

Q. Define the following terms: C) Number needed to treat (NNT)

Answer 9

A. Number needed to treat: The NNT offers a measurement of the impact of a medicine or therapy by estimating the number of patients that need to be treated over a given period of time (usually over 5 years), in order to have an impact on one person (to save one life).

Question 10

Q. What is the ApoB/ApoA-1

Answer 10

ApoB/ApoA-1 ratio is a method of estimating the balance between plasma proatherogenic and antiatherogenic lipoproteins, this is a better estimation than cholesterol ratios – it is a strong predicator of cardiovascular risk

Question 11

Q. Briefly explain social inequality from the following philosophical views A) Absolutist B) Relativist

Answer 11

A. Absolutist: Absolute measures of socioeconomic deprivation – Townsend score (social/health inequality is all about poverty)
B. Relativist: Social inequality is all about relative differences (The larger the relative differences in society the poorer the outcomes or the worse off and for all of us)

Question 12

Q. Name the main coronary arteries – what part of the heart do they supply?

Answer 12

A. Left Main – LCx and LAD
B. Left Circumflex – supplies the left atrium and left ventricle
C. Left Anterior Descending (LAD) – supplies the right ventricle, left ventricle and interventricular system
D. Left Marginal – left ventricle
E. Right coronary – supplies the right atrium and right ventricle
F. Right marginal – right ventricle and apex

Question 13

Q. Why may pain (angina) felt in a patient with stable angina?

Answer 13

A. Pain is felt during exertion – vasodilation occurs during exercise in order to increase flow to meet metabolic demand. Epicardial disease causes the resistance of the epicardial vessel to increase – to compensate the microvascular resistance reduces. Epicardial resistance is high due to the stenosis.
B. This means that flow cannot meet metabolically demand, the myocardium because ischaemic and pain is experienced
C. By resting the demand for flow is reduced and pain ceases

Question 14

Q. Which conditions may cause a patient to have A) Decreased supply of blood B) Increasing demand for blood

Answer 14

A. Decreased supply: anemia, hypoxemia, polycythemia, hypothermia, hypovolaemia, hypervolaemia
B. Increased demand: hypertension, tachyarrhythmia, valvular heart disease, hyperthyroidism, hypertrophic cardiomyopathy, cold weather, heavy meal, emotional stress

Question 15

Q. Give three features of typical angina

Answer 15

A. Heavy, central, tight, radiation to arms (L), jaw, neck
B. Precipitated by exertion
C. Relieved by rest (s/l GTN)

Question 16

Q. Name and describe a tool used to access pain

Answer 16

A. OPQRST - Onset Position (site) Quality (nature / character) Relationship (with exertion, posture, meals, breathing and with other symptoms) Radiation Relieving or aggravating factors Severity Timing Treatment
B. SOCRATES - Site, Onset, Character, Radiation, Associated factors, Time, Exacerbating/relieving factors, Severity

Question 17

Q. Name three differential diagnoses for chest pain

Answer 17

A. Cardio – pericarditis, myocarditis
B. Resp – pulmonary embolism, pleurisy
C. Infectious – chest infection, pleurisy
D. Dissection of the aorta
E. GI – gastro-oesophageal (reflux, spasm, ulceration)
F. MSK – chest trauma
G. Psych

Question 18

Q. What investigations may be done for suspected MI?

Answer 18

A. ECG/ ECHO, pre-test probability
B. Anatomical: CT angiography, invasive angiography
C. Physiological: Exercise stress treadmill (scar/ischemia), stress echo, SPECT (nuclear perfusion), perfusion (stress) MRI

Question 19

Q. What occurs in a treadmill test and what does this diagnose?

Answer 19

A. Patients walk uphill on a treadmill, increasing speed
B. Look for ST segment depression on ECG
C. This indicates ‘late stage’ ischemia
D. (however many pts are unsuitable – can’t walk, very unfit, young females, BBB? –bundle branch block)

Question 20

Q. What do modern functional testing techniques used with angiogram measure?

Answer 20

A. Fractional flow reserve – pressure gradient across stenosis (if less than 0.8 suggestive of angina causing lesion)

Question 21

Q. How may stress ECHOs aid diagnosis?

Answer 21

A. Functional test using dynamic imaging with and without pharmacological stress (adenosine)
B. Look for regional wall motion abnormalities (RWMA) – this is when there is a small area of regional wall with abnormal motion
C. Highly sensitive and specific – but requires local expertise

Question 22

Q. How would you confirm the cause of an abnormal result in a SPECT scan?

Answer 22

A. When an abnormality is detected the test should be repeat under rest conditions in order to determine whether the abnormality is a fixed defect (scar, no change on repeat scar) or ischaemia causing angina (absent in repeat)
B. ExerciseSPECT MyoviewStress Test (Exercise stress test with real-time blood flow imaging) - This test is used to detect abnormalities in blood flow to the heart – radio-labelled tracer

Question 23

Q. Name two forms of primary and secondary prevention of CAD

Answer 23

A. Primary prevention: diet, smoking, exercise (risk factor modification), HTN – anti-hypertensives, hypercholesterolaemia – statins, diabetes therapy
B. Secondary prevention: i) lifestyle changes – behaviour modification, ii) pharmacological (to reduce events – aspirin/statins, to reduce symptoms – nitrates, CCBs, KCBs) iii) Interventional – PCI/surgery (to reduce events and symptoms)

Question 24

Q. Name three first line antianginals, describe the method of action. Give two drug names and two associated side effects for each

Answer 24

A. Beta-blockers: antagonise sympathetic nervous activation, they are negatively chronotropic and negatively inotropic (reduce HR and contractility)
e.g. Bisoprolol and Atenolol
Side effects: tiredness, nightmares, brady cardia, erectile dysfunction, cold hands and feet
Contra-indications: severe bronchospasm (asthma), excess bradycardia, severe heart block, coronary spasm
B. Nitrates: venodilators, reduces venous return to the heart, reducing preload on heart, therefore reducing work on heart and O2 demand
e.g.
Contra-indications : May antagonise spasm – as they dilate coronary arteries
C. Calcium channel blockers: artero-dilators, dilate systemic arteries, reducing BP and afterload of the heart
Non-dihydrpyridines are also negatively inotropic

Question 25

Q. What drug can be used in sinus rhythm as a negative chronotrope?

Answer 25

A. Ivabridine (2nd line antianginal), ‘funny’ sodium channel to slow pacemaker currents

Question 26

Q. How do antiplatelets reduce CVD events? What is the most commonly used?

Answer 26

A. COX inhibitors - decreased prostaglandin synthesis and platelet aggregation – antipyretic, anti-inflammatory, analgesic
B. Can cause gastric ulceration – P2Y12 can be used as an alternative
C. Aspirin
Contra-indications : May antagonise spasm – as they dilate coronary arteries

Question 27

1. Q. Describe the following terms A) pre-load B) after-load C) starlings law

Answer 27

A. Preloadis the end-diastolic volume (EDV) at the beginning of systole. The EDV is directly related to the degree of stretch of the myocardial sarcomeres. (starlings law)
B. Afterloadis the ventricular pressure at the end of systole (ESP).
C. Starlings law: The stroke volume of the heart increases in response to an increase in the volume of blood filling the heart (the end diastolic volume) when all other factors remain constant.

Question 28

1. Q. Which group of drugs inhibit HMGCoA reductase?

Answer 28

A. Statins – reduce LDL cholesterol

Question 29

Q. Name two forms of revascularisation – name two pros and two cons of each

Answer 29

A. Percutaneous coronary intervention – PCI – less invasive – repeatable – risk of stent thrombosis and risk of resentosis
B. Coronary artery bypass graft (CABG) surgery – improves prognosis, deals with complex disease – invasive, risk of bleeding, recovery time, may not be appropriate for elderly/frail
C. Used to restore patient coronary artery and increase blood flow reserve

Question 30

Q. Name two differences between stable and unstable angina

Answer 30

A. Stable angina is predictable, occurs during exertion and relived at rest – unstable angina is unpredictable and may occur at any time

Question 31

Q. How is angina diagnosed clinically?

Answer 31

A. History, ECG – crescendo pattern – troponin levels (no significant rise in unstable angina)