Ischaemic Heart Disease Flashcards
What is ischaemic heart disease more commonly known as?
1 - hypertension
2 - heart failure
3 - coronary heart disease
4 - right ventricular failure
3 - coronary heart disease
- occurs when imbalance between O2 and nutrient supply and demand of myocardium
Ischaemic heart disease (IHD) is a group of clinical syndromes, generally due to atherosclerosis of the coronary arteries. Which of the following is NOT classed as IHD?
1 - angina
2 - MI
3 - heart failure (cardiomyopathy)
4 - hypertension
5 - arrhythmias
6 - mitral valve dysfunction
4 - hypertension
Coronary blood flow to a region of the myocardium may be reduced by a mechanical obstruction. Which of the following is not a cause of mechanical obstruction?
1 - atheroma
2 - thrombosis
3 - spasm
4 - embolus
5 - coronary ostial stenosis
6 - pulmonary embolism
7 - anaemia
8 - carboxyhaemoglobulinaemia
6 - pulmonary embolism
Coronary blood flow to a region of the myocardium may be reduced by a mechanical obstruction. One of these is called an atheroma. What is this?
1 - build up of fatty materials
2 - rupture of fatty plaque
3 - damage to epithelium
4 - over active coagulation cascade
1 - build up of fatty materials
- athera = greek for meaning gruel
- oma = greek for tumor or swelling.
Coronary blood flow to a region of the myocardium may be reduced by a mechanical obstruction. One of these is called an thrombosis. What is this?
1 - build up of fatty materials
2 - blood clot that blocks blood vessels
3 - damage to epithelium
4 - over active coagulation cascade
2 - blood clot that blocks blood vessels
- greek for curdling with clotting
Coronary blood flow to a region of the myocardium may be reduced by a mechanical obstruction. One of these is called an embolus. What is this?
1 - build up of fatty materials
2 - blood clot that blocks blood vessels
3 - mass that blocks blood vessels
4 - over active coagulation cascade
3 - mass that blocks blood vessels
- means plug in greek
Coronary blood flow to a region of the myocardium may be reduced by a mechanical obstruction. One of these is called an anaemia. What is this?
1 - build up of fatty materials
2 - blood clot that blocks blood vessels
3 - mass that blocks blood vessels
4 - insufficient RBCs to carry O2
4 - insufficient RBCs to carry O2
Incidence and prevalence of ischaemic heart disease both increase with age, but why does the prevalence decrease around the 90s?
1 - treatment is better as we age
2 - older people do not exert themselves as much
3 - they die so not as many people with disease
4 - incorrect the prevalence does not decrease at 90
3 - they die so not as many people with disease
In 2010, coronary artery disease (CAD) (same as IHD) was the largest single cause of death in the UK. How many deaths were attributed to CAD in 2010?
1 - 180 deaths
2 - 1800 deaths
3 - 18,000 deaths
4 - 180,000 deaths
4 - 180,000 deaths
- CAD responsible for 1 in 5 male deaths and 1 in 10 female deaths
In 2010, coronary artery disease (CAD) (same as IHD) was the largest single cause of death in the UK and was attributed to 180,000 deaths. Is CAD more common in men or women?
- men in a 2:1 ratio
Ischaemic heart disease is made up of a group clinical syndromes that occur due atherosclerosis. What are the 3 most common clinical syndromes of ischaemic heart disease?
1 - hypertension, angina and myocardial infarction
2 - hypotension, angina and myocardial infarction
3 - heart failure, angina and myocardial infarction
4 - hypertension, angina and heart failure
3 - heart failure, angina and myocardial infarction
Angina is a narrowing of coronary blood vessels. This reduces blood flow to the heart causes chest pain, which is one of the syndromes that make up ischaemic heart disease. There are 2 types of angina, stable and unstable. What is stable angina?
1 - angina that is present all the time
2 - angina that is predictable and manageable
3 - angina that can start randomly
4 - stopping of blood flow completely
2 - angina that is predictable and manageable
- comes on during exertion and stops with rest or nitrates
Angina is a narrowing of coronary blood vessels. This reduces blood flow to the heart causing chest pain, which is one of the syndromes that make up ischaemic heart disease. There are 2 types of angina, stable and unstable. What is unstable angina?
1 - angina that is present all the time
2 - angina that is predictable and manageable
3 - angina that can start randomly
4 - stopping of blood flow completely
3 - angina that can start randomly
- can occur during rest or exertion
In angina are troponin levels raised?
- no
In angina are there always changes on the ECG?
- no
- but there can be some changes
Which of the following is NOT a common descriptive terms patients with angina use to describe the pain?
1 - dull
2 - tight
3 - cold and sharp
4 - squeezing pain
5 - heavy
3 - cold and sharp
In angina is pain localised well?
- no
- generally felt across the chest, arms (left), neck and jaw
Typically angina pain is felt across the chest, neck, jaw and arms. Which vertebrae transmit pain from angina to the brain?
1 - C5-C8 and T1-T5
2 - C6-C8 and T1-T12
3 - C5-C6 and T1-T5
4 - C1-C5 and T1-T3
1 - C5-C8 and T1-T5
Why can cold temperatures and a large meal lead to angina?
- diverted blood flow
- cold = blood vessels vasoconstrict
- meal = blood diverted to GIT
Myocardial infarction is one of the syndromes that make up ischaemic heart disease. What is a myocardial infarction?
1 - angina that is present all the time
2 - angina that is predictable and manageable
3 - angina that can start randomly
4 - blocked coronary blood vessels
4 - blocked coronary blood vessels
- causes an ST elevation
Although troponin can be raised during an MI, that are circumstances when troponin is falsely raised. All of the following are false positives for rises in troponin, EXCEPT which one?
1 - Acute heart failure
2 - Major arrhythmias
3 - Aortic dissection
4 - NSTEMI
5 - Major PE
6 - Pericarditis
7 - Renal failure
8 - Sepsis
4 - NSTEMI
If a patient presents with angina, what medication can quickly relive the symptoms and is commonly given?
1 - heparin
2 - beta blockers
3 - glyceryl trinitrate GTN
4 - amlodipine
3 - GTN spray
- dilates arteries
When prescribing GTN spray for a patient with angina, what is the most common side effect?
1 - hypertension
2 - syncope
3 - tachycardia
4 - increased aldosterone
2 - syncope
- GTN dilates blood vessels and causes drop in BP
In a myocardial infarction, which types of pain sensations do the NOT experience:
1 - severe pain
2 - referred and poorly localised
3 - intermittent and dull
4 - persistent chest pain
3 - intermittent and dull
In a myocardial infarction, in addition to pain, which of the tell tail signs do NOT patients experience?
1 - nausea
2 - hypotension
3 - fever
4 - breathlessness
5 - malaise
2 - hypotension
What is the earliest stage of atherogenosis (atherosclerotic plaque formation, leading to coronary artery heart disease)?
1 - fatty streaks
2 - LDL infiltration
3 - cytokine release
4 - foam cells build up
1 - fatty streaks
Coronary atherosclerosis is a complex inflammatory process. Although the exact cause is unknown, the trigger is commonly linked with damage and/or dysfunction to the epithelium of blood vessels. Which of the following has not been identified as a trigger causing epithelium damage and/or dysfunction?
1 - morbid hypertension
2 - biochemical abnormalities (LDL)
3 - diabetes mellitus
4 -immunological factors (free radicals from smoking)
5 - inflammation
6 - genetic alteration
7 - biochemical abnormalities (HDL)
7 - biochemical abnormalities (HDL)
Following the initial damage/dysfunction to blood vessel epithelium, what is the first things that occurs leading to coronary atherosclerosis?
1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation
3 - LDL cross epithelium
Following the initial damage/dysfunction to blood vessel epithelium, LDL cross the epithelium. What then occurs leading to coronary atherosclerosis?
1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation
4 - macrophages phagocytose LDL through oxidation
- macrophages cross endothelium to get to LDLs
Following the initial damage/dysfunction to blood vessel epithelium, we have dead macrophages full of LDLs, called foam cells. What is the next thing that occurs leading to coronary atherosclerosis?
1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation
2 - foam cells build up
- foam cells are macrophages that have died and begin secreting cytokines
- attract more monocytes to area
What is a fatty streak, which is a term used in atherosclerosis?
1 - build up of HDL beneath epithelium
2 - build up of LDL beneath epithelium
3 - build up of foam cells beneath epithelium
4 - build up of macrophages beneath epithelium
3 - build up of foam cells beneath epithelium
Fatty streaks can occur in any patients throughout their life. Why are fatty streaks dangerous?
1 - thrombogenic
2 - increase blood pressure
3 - increase cytokine release
4 - decrease HDL levels
1 - thrombogenic
- susceptible to blood clotting on it
As fatty streaks form in the endothelium, platelets bind to damaged epithelium. They then release platelet derived growth factor that drives the development of what?
1 - more macrophages migrate to the area
2 - lymphocytes are activated
3 - smooth muscle cell proliferation
4 - increased cytokine secretion from fatty streak
3 - smooth muscle cell proliferation
- smooth muscle cells move from tunica media to tunica intima
Fatty streaks formed by dead macrophages containing LDL are thrombogenic, meaning they are susceptible to blood clotting. This causes the release of platelet derived growth factor, and then smooth muscle migration and proliferation to the tunica intima from the tunica media. Smooth muscle cells then secretes things that become the fibrous cap. Which of the following is NOT a component of the fibrous cap?
1 - collagen
2 - elastin fibrous cells
3 - elastic cartilage
4 - proteoglycans
3 - elastic cartilage
- purpose of the fibrous cap is to prevent blood clotting
Together the fibrous cap and fatty streak are called what?
1 - thrombosis
2 - embolus
3 - atheroma
4 - plaque
4 - plaque
In addition to secreting the contents that make up the fibrous cap, what else do smooth muscle cells secrete in the fatty streak?
1 - Ca2+
2 - Na+
3 - Mg+
4 - Cl-
1 - Ca2+
- normally deposited into vessel walls by LDL
- cholesterol crystals are also present
In addition to secreting the contents that make up the fibrous cap, smooth muscle cells secrete Ca2+ into the fatty streak, which is normally deposited into the vessel walls by LDL. Normally what then removes the Ca2+ to stop the hardening of blood vessel walls?
1 - lipoprotein lipase
2 - HDL
3 - VLDL
4 - albumin
2 - HDL
- plaques impair HDLs ability to remove Ca2+
Once Ca2+ has been deposited into the fatty streak and vessel walls, do the vessel walls become more elastic or stiff?
- stiff due to Ca2+ forming crystals
What generally causes a myocardial infarction that has been in the arteries for some time?
1 - low nitrates
2 - increased Na+ and K+
3 - fibrous cap of plaque becomes unstable and ruptures
4 - endothelium become damaged and leak collagen
3 - fibrous cap of plaque becomes unstable and ruptures
- rupture is due to thinning of the cap and core expansion
- thrombogenic contents (foam cells) of plaque leak out causing blood clot
When plaques rupture, what is the primary content that is very atherogenic that leaks out causing the formation of red thrombus?
1 - collagen
2 - Ca2+
3 - foam cells
4 - smooth muscle cells
3 - foam cells
- thrombus is blood clot
- embolism is clot moving in blood
During the rupture of fibrous cap or the expansion of a plaque, what % of blood vessel occlusion can lead to stenosis and lead to ischaemia given any increase in O2 demand?
1 - 10%
2 - 30%
3 - 50%
4 - 70%
3 - 50%
- 50% reduction in luminal diameter causes a 70% reduction in luminal cross-sectional area
Once a plaque ruptures a red thrombus is formed. This thrombus may cause the following:
- occlusion of the artery
- partial occlusion of the artery
- embolise distally
- plaque progression
Match the above with the following: ST elevated MI, Non-ST elevation MI, stable angina and unstable angina:
- ST elevated MI = occlusion of the artery
- Non-ST elevation MI = partial occlusion of the artery
- stable angina = embolise distally
- unstable angina = plaque progression
What is the earliest consequence of coronary artery occlusion?
1 - metabolic disturbance
2 - systolic dysfunction
3 - chest pain
4 - hypoperfusion
4 - hypoperfusion
The earliest consequence of coronary artery occlusion is hypoperfusion. What is the most common cause of acute heart failure following coronary artery occlusion?
1 - metabolic disturbance
2 - systolic dysfunction
3 - chest pain
4 - hypoperfusion
2 - systolic dysfunction
The earliest consequence of coronary artery occlusion is hypoperfusion. Which other consequence is the most common cause of arrhythmias?
1 - metabolic disturbance
2 - systolic dysfunction
3 - chest pain
4 - diastolic dysfunction
1 - metabolic disturbance
How quickly can development of coronary artery occlusion move from hypoperfusion to myocyte necrosis?
1 - 1 min
2 - <15 mins
3 - <1 hour
4 - <4.5 hours
2 - <15 mins
- detected after 15 minutes
- myocardium is salvageable <12 hours
In an acute occlusion of the coronary arteries we may see an STEMI. Which of the following are key features we would be able to detect in the >1hour on an ECG?
1 - wide T waves
2 - tall T waves
3 - ST elevation
4 - all of the above
4 - all of the above
In an acute occlusion of the coronary arteries we may see an STEMI. Which of the following are key features we would be able to detect in 6 hours to months on an ECG?
1 - wide Q waves
2 - T wave inversion
3 - ST returns to normal
4 - all of the above
4 - all of the above
In a STEMI and NSTEMI are troponin levels raised?
- yes
In a patient with an MI, which 2 of the following has been shown to significantly improve mortality?
1 - B-blockers
2 - Percutaneous coronary intervention
3 - Tissue plasminogen activator (tPA)
4 - ACE-I
2 - Percutaneous coronary intervention
3 - Tissue plasminogen activator (tPA)
Are patients with one identified manifestation of atherosclerosis in one vascular bed likely to be the only case of atherosclerosis in the patient?
- no
- often more advanced throughout other body parts. For example patients with peripheral vascular disease are 4 times more likely to have coronary artery disease
Which of the following can be caused by chronic ischaemic heart disease?
1 - heart failure
2 - arrhythmias
3 - mitral regurgitation
4 - all of the above
4 - all of the above
- essentially damages tissue
- heart failure = heart unable to contract effectively
- arrhythmias = electrical conductance pathway affected
- mitral regurgitation = inability to contract
- arrhythmias include AF, VF and VT
In addition to angina and myocardial infarction, heart failure is the 3rd common clinical syndrome of ischaemic heart disease. What is heart failure?
1 - inability of the heart to supply blood to the heart and body
2 - inability of heart to supply blood to itself
3 - inability of RBCs to carry O2
4 - inability to pump blood against peripheral resistance
1 - inability of the heart to supply blood to the heart and body
Heart failure has lots of causes, but what is the most common cause?
1 - hypertension
2 - hypotension
3 - ischaemic heart disease
4 - anaemia
3 - ischaemic heart disease
Which 2 of the following are the most common causes of chronic heart failure in IHD?
1 - multiple infarctions
2 - myocardial hibernation
3 - Large acute MI
4 - Extensive ischaemia (LMS disease)
1 - multiple infarctions
2 - myocardial hibernation
- myocardial hibernation = sufficient blood to stay alive, but not really function well
Which of the following are common causes of acute heart failure, which can also present with pulmonary oedema in IHD?
1 - Small MI with pre-existing reduced reserve
2 - Large acute MI
3 - Extensive ischaemia (LMS disease)
4 - all of the above
4 - all of the above
Heart failure (HF) is the 3rd common clinical syndrome of ischaemic heart disease. This can be divided into 2 main causes, what are they?
1 - hypertension and systolic HF
2 - hypertension and diastolic HF
3 - hypertension and myocardial infarction
4 - systolic and diastolic failure
4 - systolic and diastolic failure
- systolic = inability to pump blood effectively
- diastolic = inability to fill sufficiently
Heart failure (HF) is the 3rd common clinical syndrome of ischaemic heart disease. This can be divided into 2 main causes, systolic and diastolic failure. Irrespective of which is the cause, what happens to fluid in the lungs?
1 - no fluid is pumped into the lungs
2 - blood backs up into the lungs
3 - increased pressure enters the lungs
2 - blood backs up into the lungs
- often referred to as congestive heart failure
In heart faiilure fluid retention is common. Which of the following are NOT common clinical presentations of fluid retention?
1 - fatigue due to lack of cardiac output
2 - leg swelling
3 - breathlessness (cough) that is worse when lying down
4 - headaches
5 - waking in the night
4 - headaches
In heart failure why is breathing more difficult to breathe?
1 - no blood pumped to heart for O2 and CO2 exchange
2 - fluid build up in lungs and reduced perfusion
3 - lungs begin to fail in heart failure as well
2 - fluid build up in lungs and reduced perfusion
Heart failure can cause a decrease in blood flow to the kidneys triggering the angiotensin pathway to be activated and fluid retention. This is a protective mechanism causing the heart to fill more, increase preload and contractility (Frank-Sterling law). However, what is the main detrimental effect of this?
1 - blood pressure increases
2 - left ventricular hypertrophy
3 - oedema
4 - hypotension
3 - oedema
- fluid leaks into tissues
What is silent ischaemia?
1 - ischaemia where patients cannot talk
2 - ischaemia where patients experience constant symptoms
3 - ischaemia but patient is asymptomatic
4 - ischaemia but patient is unresponsive to treatment
3 - ischaemia but patient is asymptomatic
- can be very dangerous as patient can just drop dead
IHD can cause valvular dysfunction. Which valve is most commonly affected?
1 - aortic valve
2 - pulmonary valve
3 - tricuspid valve
4 - mitral valve
4 - mitral valve
IHD can cause valvular dysfunction, most commonly the mitral valve. In acute mitral regurgitation (blood leaks back into left atrium) which part of the heart can be damaged leading to mitral regurgitation?
1 - papillary muscles
2 - annulus
3 - chordae tendinae
4 - commisure
1 - papillary muscles
- Papillary muscle dysfunction (MI)
- Papillary muscle rupture (MI)
IHD can cause valvular dysfunction, most commonly the mitral valve. Which of the following are causes of chronic mitral regurgitation (blood leaks back into left atrium)?
1 - Annular dilation (LV dilation)
2 - LV distortion (scarring due to MI)
3 - Papillary muscle dysfunction (ischaemia
4 - all of the above
4 - all of the above
Which of the following is a mechanical complication of an MI?
1 - Cardiac rupture
2 - ventricular septal defect
3 - Mitral valve dysfunction
4 - LV aneurysm formation (True vs. Pseudoaneurym)
5 - all of the above
5 - all of the above
Which of the following is NOT a key risk of IHD?
1 - Age
2 - Female gender
3 - Smoking
4 - Hypertension
5 - Diabetes
6 - Family history of IHD
7 - Hyperlipidaemia
2 - Female gender
- male is a risk factor
Which of the following are causes of secondary hypertension, different from primary hypertension (unknown cause) in that we can identify a cause?
1 - glomerulonephritis
2 - diabetic nephropathy
3 - renal artery stenosis
4 - pyelonephritis
5 - Cushings Syndrome
6 - Conn’s syndrome
7 - steroid therapy
8 - phaeochromocytoma
9 - all of the above
9 - all of the above
Conns syndrome is a secondary cause of hypertenson secondary hypertension. What is the cause of conns syndrome?
1 - elevated renin levels
2 - primary hyperaldosteronism
3 - increased levels of ACE
4 - all of the above
2 - primary hyperaldosteronism
- aldosterone increases Na+ and H2O retention and thus increases BP
If we suspect a patient has secondary hypertension, in addition to all the standard tests, we can do some special tests. All of the following are blood tests, which is the only urine test we normally do?
1 - angiotensin converting enzyme
2 - metadrenalines
3 - 9am cortisol
4 - aldosterone
5 - renin
2 - metadrenalines
- inactive metabolites of adrenalin and noradrenaline
Treating 3 ischaemia heart disease can be primary or secondary preventative. According to NICE guidelines, what is the main aim of primary prevention?
1 - reduce LDL
2 - increase HDL
3 - reduce QRISK
4 - reduce blood pressure
3 - reduce QRISK
- QRISK is a measure of the risk of a cardiovascular event in the next 10 years
- Q-risk >10% is indicator to start on statins
What is the precursor of cholesterol?
1 - Acetyl-CoA
2 - mevalonate
3 - bile acids
4 - vitamin-D
1 - Acetyl-CoA
Which of the following are causes of secondary dyslipidaemia?
1 - Diabetes mellitus
2 - Hypothyroidism
3 - Chronic kidney disease
4 - Chronic liver disease
5 - Obesity
6 - Smoking
7 - Medications (eg thiazide diuretics - bendroflumethiazide)
8 - Alcohol excess (increased TGs)
9 - all of the above
9 - all of the above
Central obesity is main cause behind the pathophysiology of metabolic syndrome. What can this then cause, which ultimately leads to a cascade of other problems?
1 - diabetes
2 - insulin resistance
3 - hypertension
4 - dyslipidaemia
5 - vascular inflammation
6 - endothelial dysfunction
2 - insulin resistance
- all caused by insulin resistance and can lead to atherosclerosis
All of the following are cut offs used in the diagnosis of metabolic syndrome.
- Hyperglycaemia: FG >5.6 mmol/L
- Low HDL <1.0 mmol/L
- High TG >1.7 mmol/L
- Obesity: Waist >102cm / 40” (men)
or >88cm / 34” (women) - Hypertension BP >135/85 mmHg
How many of these are needed to diagnosis metabolic syndrome?
1 - all of them
2 - 4
3 - 3
4 - 1
3 - 3
- or more
Hypertension is a risk factor for ischaemia heart disease. What is the primary group of medication given to patients in an attempt to reduce hypertension?
1 - beta blockers
2 - ACE inhibitors
3 - statins
4 - anti-thrombotic
2 - ACE inhibitors
- ACE = angiotensin converting enzymes
- converts angiotensin I into angiotensin II so stops vasoconstriction and reduces BP
Hypertension is a risk factor for ischaemia heart disease. The primary group of medication given to patients in an attempt to reduce hypertension are ACE inhibitors. Which of the following are drugs that come under the ACE inhibitor class?
1 - Ramipril, Lisinopril, Enalapril
2 - Ramipril, Bisoprolol, Enalapril
3 - Bisoprolol, Lisinopril, Enalapril
4 - Ramipril, Lisinopril, Bisoprolol
1 - Ramipril, Lisinopril, Enalapril
Hyperlipiaemiais a risk factor for ischaemic heart disease. What is the primary group of medication given to patients in an attempt to reduce hyperlipiaemia?
1 - beta blockers
2 - ACE inhibitors
3 - statins
4 - anti-thrombotic
3 - statins
Hyperlipiaemiais a risk factor for ischaemic heart disease. The primary group of medication given to patients in an attempt to reduce hyperlipiaemia are statins. Which of the following are drugs that come under the statin class?
1 - Ramipril, Simvastatin
2 - Simvastatin, Atorvastatin
3 - Bisoprolol, Atorvastatin
4 - Simvastatin, Bisoprolol
2 - Simvastatin, Atorvastatin
- Atorvastatin at 20mg prescribed to patients with 10% higher risk of 10 year cardiovascular event as PRIMARY preventative MEASURE
Patients with ischaemic heart disease (IHD) or at risk of IHD are more likely to form platelet thrombi due to plaque (fatty streak and fibrous cap) formation in atherosclerosis. What anti-platelet medications can be prescribed to reduce this risk?
1 - Aspirin, Clopidogrel, Ticagrelor, Prasugrel, Abciximab
2 - Aspirin, Clopidogrel, Ticagrelor, Prasugrel, Warfarin
3 - Aspirin, Clopidogrel, Ticagrelor, Warfarin, Abciximab
4 - Aspirin, Warfarin, Ticagrelor, Prasugrel, low molecular weight heparin
1 - Aspirin, Clopidogrel, Ticagrelor, Prasugrel, Abciximab
Patients with ischaemic heart disease (IHD) or at risk of IHD are more likely to have activation of the coagulation cascade due to the formation of platelet thrombi. In patients with a suspected thrombi following platelet clot formation patients are given anti-coagulation medications that are able to target coagulation factors 2a, 7, 9, 10, 11 and 12?
1 - DOACs
2 - heparins
3 - Warfarin
4 - Vitamin K antagonist
2 - heparins
- specifically low molecular weight heparin
If a patient presents with angina, what medication can quickly relive the symptoms and is commonly given?
1 - heparin
2 - beta blockers
3 - GTN spray
4 - amalodapine
3 - GTN spray
What are the two major coronary arteries coming from the main left coronary artery?
1 - left circumflex and left anterior descending artery
2 - left circumflex and right coronary artery
3 - right coronary artery and conus artery
4 - conus artery and left circumflex
1 - left circumflex and left anterior descending artery
- left circumflex supplies 20-30% of blood to heart
- left anterior descending artery supplies 45% of blood to heart
- in total they supply up to 70% of blood to heart so VERY HIGH RISK lesions
What are the major coronary arteries coming from the main right coronary artery?
1 - left circumflex
2 - right coronary artery
3 - conus artery
4 - right circumflex
2 - right coronary artery
- supplies 25-30% of blood to the heart
Which of the following coronary arteries is most dangerous if blocked?
1 - left anterior descending artery
2 - left circumflex artery
3 - right coronary artery
4 - conus artery
1 - left anterior descending artery
- supplies over 45% of blood to heart, so if blocked has a major effect
If a patient requires a coronary artery bypass, commonly internal mammary arteries (sometimes radial arteries) are detached from the proximal end and re-attached to the coronary circulation. Why is an artery better for this than a vein?
- arteries can withstand high pressures better and last longer
- saphenous vein (in leg) can be used as well
Percutaneous Coronary Intervention (PCI) can be used in patients with suspects atherosclerosis to improve blood flow to the heart. How long does it normally take before a patient is back to normal following the procedure?
1 - 1 hour
2 - 1 day
3 - 1 week
4 - 1 month
3 - 1 week
- performed under local anaesthetic where stent is placed in coronary artery
- rapid recovery
- home same day
DoesPercutaneous Coronary Intervention or CABG have better prognosis?
- CABG
- coronary artery bypass graft
Although Percutaneous Coronary Intervention (PCI), aka stenting does not appear to have any significant impact on prognosis in coronary artery elective surgery, does it have any impact on acute myocardial infarction?
- yes
- no treatment = 10% mortality
- PCI with ballooning = <1% mortality
How soon should Percutaneous Coronary Intervention (PCI) be offered from MI onset, before Tissue plasminogen activator (tPA) is offered?
1 - <30 minutes
2 - <60 minutes
3 - <90 minutes
4 - <2 hours
4 - <2 hours
In an acute myocardial infarct (MI) necrosis is detectable within 15 minutes. Where the MI is located, do all cells die equally?
- no cells closer to subendothelial are affected more
- collateral blood vessels provide protection
- even after 12 hours tissue can be saved
In patients with an increased QRISK score or with confirmed cardiovascular disease (CVD), what dosage of atorvastatin should they be prescribed?
1 - risk of CVD = 10mg and confirmed CVD = 20mg
2 - risk of CVD = 20mg and confirmed CVD = 40mg
3 - risk of CVD = 40mg and confirmed CVD = 200mg
4 - risk of CVD = 20mg and confirmed CVD = 80mg
4 - risk of CVD = 20mg and confirmed CVD = 80mg
- elevated QRISK = 20mg
- confirmed CVD = 80mg
UNLESS there are other drug interactions at higher doses
In a patient with stable angina who is experiencing symptoms, what might we expect to see on the ECG?
1 - prolonged PR interval
2 - no p waves
3 - ST-T changes
4 - inverted T wave
3 - ST-T changes
When managing IHD we can use the ABCDE x2 method. What are the 2 things we need to include associated with A?
1 - ACE-I inhibitors/AR2 blockers
2 - activity
3 - anti-platelet drugs
4 - angiogram
1 - ACE-I inhibitors/AR2 blockers
3 - anti-platelet drugs
When managing IHD we can use the ABCDE x2 method. What are the 2 things we need to include associated with B?
1 - BMI
2 - body weight
3 - BP
4 - Bisoprolol
3 - BP
4 - Bisoprolol
When managing IHD we can use the ABCDE x2 method. What are the 2 things we need to include associated with C?
1 - calcium supplements
2 - Ca2+ channel blockers
3 - cholesterol
4 - coagulation drugs
2 - Ca2+ channel blockers
3 - cholesterol
When managing IHD we can use the ABCDE x2 method. What are the 2 things we need to include associated with D?
1 - diet
2 - diabetes control
3 - diverticulitis
4 - drop in BP
1 - diet
2 - diabetes control
When managing IHD we can use the ABCDE x2 method. What are the 2 things we need to include associated with E?
1 - education
2 - eat less
4 - exercise
1 - education
4 - exercise
A 70 year old man sustains an acute lateral myocardial infarct. Angiography reveals a ruptured complex plaque in the circumflex coronary artery.
What physical processes underlie plaque rupture (select 2 answers)?
A. Calcium deposition
B. Cap thinning
C. Collagen deposition
D. Core expansion
E. Monocyte adhesion and migration
F. Platelet adhesion and aggregation
B. Cap thinning
D. Core expansion
A 55 year old man, previously well, is admitted with acute breathlessness. His chest X-ray shows pulmonary oedema. His ECG shows widespread ST depression and ST elevation in lead aVR. His symptoms and ECG/CXR changes resolve with oxygen and intravenous furosemide.
What is the most likely cause for his acute presentation?
Aortic stenosis
B. Atrial myxoma
C. Left main-stem disease
D. Right coronary artery disease
E. Renal artery disease
C. Left main-stem disease
- disease of the left main stem will cause global ST segment depression and ST elevation in lead aVR
A 48 year old woman attends the Emergency Department with chest pain. She is 28 weeks pregnant. She smokes 20 cigarettes per day. Her pulse is irregular and her BP is 170/90 mmHg. Her ECG shows sinus arrhythmia with 4 mm of inferior ST elevation.
What is the most likely pathology underlying her presentation?
A. Atherosclerotic coronary artery disease
B. Aortic dissection
C. Coronary artery embolism
D. Coronary artery spasm
E. Spontaneous coronary artery dissection
E. Spontaneous coronary artery dissection
- most likely
- tear in blood vessels of the heart
A 65 year old man is seen in the clinic with breathlessness. He smokes 10 cigarettes per day and drinks 20 units of alcohol per week. On examination his BP is 160/90 mmHg, he has a raised JVP, peripheral oedema and crackles in his chest. His ECG shows left bundle branch block.
What is the most likely cause for his symptoms?
A. Alcoholic dilated cardiomyopathy
B. Hypertensive heart disease
C. Ischaemic heart disease
D. Post-viral cardiomyopathy
E. Pulmonary fibrosis
C. Ischaemic heart disease
- all could cause, but given the number of risk factors he has and his age, this is the most likely
IHD can cause arrhythmias. Which valve is most commonly affected?
1 - aortic valve
2 - pulmonary valve
3 - tricuspid valve
4 - mitral valve
A 65 year old woman is seen by her GP for CV risk factor assessment. She is a non-smoker. Her blood pressure is 145/95 mmHg. Her serum cholesterol is 5.2 mmol/L, HDL cholesterol 0.8 mmol/L and triglyceride 3.1 mmol/L. Her waist measures 92 cm (36”) and her BMI is 35 kg/m2.
What is the name we give to this constellation of risk factors?
A. Adipem-Mulier syndrome
B. Bardet-Biedl syndrome
C. Metabolic syndrome
D. Pickwickian syndrome
E. Prader-Willi syndrome
C. Metabolic syndrome
- deadly quartet of:
1 - Obesity
2 - Hyperglycaemia
3 - Dyslipidaemia
4 - Hypertension
A 45 year old man is reviewed on the ward following a myocardial infarct. His total cholesterol is 7.9 mmol/L (<5.0), LDL cholesterol 6.6 mmol/L (<2.0), HDL cholesterol 1.0 mmol/L (>1.5), triglyceride 1.5 mmol/L (0.5-2.0).
What is the most likely cause of his lipid abnormalities?
A. Excess cholesterol absorption (high fat diet)
B. Excess lipoprotein production by the liver
C. Lipoprotein enzyme deficiency
D. Lipoprotein receptor deficiency
E. Lipoprotein structural abnormality
D. Lipoprotein receptor deficiency
- significant LDL levels are key here
A 55 year old man is seen by his GP for CV risk assessment. He is an ex-smoker. His blood pressure is 145/90 mmHg. Total cholesterol 5.9 mmol/L, LDL cholesterol 3.9 mmol/L, HDL cholesterol 1.0 mmol/L, HbA1c normal. His QRISK score is calculated at 11.1%. He is given lifestyle advice.
What is the most appropriate treatment?
A. No drug treatment required
B. Atorvastatin
C. Losartan
D. Atorvastatin and losartan
E. Atorvastatin, losartan and amlodipine
D. Atorvastatin and losartan
- high lipid profile = statin
- stage 1 hypertension WITH a Q-risk >10% = 1st line treatment ACE-I or AR2 blocker (losartan)
A 65 year old woman is attended by the ambulance service with chest pain. Her ECG is shown (see Image). She was taken to the local heart attack centre where she was found to have occluded one of her coronary arteries.
Which artery is most likely to have occluded?
A. Circumflex
B. Intermediate
C. Left anterior descending
D. Left main-stem
E. Right coronary artery
E. Right coronary artery
- ST elevation in leads III and aVF
- inferior infarct
A 70 year old man is seen in the clinic with palpitations. He is a smoker and has a strong family history of ischaemic heart disease (IHD). An ambulatory ECG recording reveals a variety of supraventricular arrhythmias.
Which arrhythmia would raise the greatest concern about underlying IHD?
A. Atrial fibrillation
B. AV nodal reentry tachycardia
C. AV reentry tachycardia
D. Frequent atrial ectopic beats
E. Sinus bradycardia
A. Atrial fibrillation
- common in older patients with IHD
A 46 year old woman is reviewed on the Coronary Care Unit with breathlessness. She was admitted the previous day with an anterior STEMI and underwent a primary PCI procedure. On examination she has a loud systolic murmur at the lower left sternal edge.
Which is the most likely source of her murmur?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral regurgitation
D. Tricuspid regurgitation
E. Ventricular septal defect
E. Ventricular septal defect
- located in lower left sternal edge
- important complication of MI
A 69 year old woman was found to have dyslipidaemia and started on a drug which blocked the rate limiting enzyme for cholesterol synthesis.
Which is the rate limiting enzyme?
A. Acetyl CoA carboxylase
B. Carnitine palmitoyltransferase
C. Fatty acid synthase
D. HMG CoA reductase
E. Lipoprotein lipase
D. HMG CoA reductase
A 44 year old woman is brought to the Emergency Department. She has a long history of chest pain but has learning difficulties and is not able to give a coherent history. The automated interpretation of her ECG (see Image) suggests an MI of undetermined age.
Which is the best estimate of the timing of her MI?
A. <1 hour
B. 1 - 6 hours
C. 6 - 48 hours
D. 2 days – 3 months
E. >3 months
C. 6 - 48 hours
In patients <80 y/o with hypertension, what are the NICE guidelines for BP?
1 - 130/85
2 - 140/90
3 - 150/90
4 - 160/90
2 - 140/90
- 130/85 in diabetes
- 150/90 in >80 y/o
A 74 year old women attends A&E with left-sided chest pain radiating to her arms, breathlessness and fatigue which had started 36 hours earlier. She has recently stopped smoking and has a history of type-2 diabetes and hypertension.
Observations:
Pulse: 75 bpm BP: 165/95 mmHg
RR: 14 /min SO2: 95% (air)
Hb 135 g/L, Creatinine 110 mcg/L
Troponin T: 8509 ng/L
CXR: Normal
The patient is diagnosed with a late presentation anterior ST-elevation MI. Which of the following medications would NOT be given to the patient immediatley?
1 - morphine
2 - metoclopramide
3 - aspirin 300mg
4 - LMW heparin
5 - GTN spray
6 - ACE-I or ARB-II
6 - ACE-I or ARB-II
A 74 year old women attends A&E with left-sided chest pain radiating to her arms, breathlessness and fatigue which had started 36 hours earlier. She has recently stopped smoking and has a history of type-2 diabetes and hypertension.
Observations:
Pulse: 75 bpm BP: 165/95 mmHg
RR: 14 /min SO2: 95% (air)
Hb 135 g/L, Creatinine 110 mcg/L
Troponin T: 8509 ng/L
CXR: Normal
The patient is diagnosed with a late presentation anterior ST-elevation MI. Which 2 of the following investigations should be performed?
1 - CT angiogram
2 - chest X-ray
3 - LDH levels
4 - echocardiogram
1 - CT angiogram
4 - echocardiogram
A 74 year old women attends A&E with left-sided chest pain radiating to her arms, breathlessness and fatigue which had started 36 hours earlier. She has recently stopped smoking and has a history of type-2 diabetes and hypertension.
Observations:
Pulse: 75 bpm BP: 165/95 mmHg
RR: 14 /min SO2: 95% (air)
Hb 135 g/L, Creatinine 110 mcg/L
Troponin T: 8509 ng/L
CXR: Normal
The patient is diagnosed with a late presentation anterior ST-elevation MI. Which of the following is NOT part of the long term management in patients following an MI?
1 - Lifestyle
2 - B-blockers
3 - Dual anti-platelet therapy
4 - Bisoprolol
5 - Ramipril
6 - Atorvastatin
2 - B-blockers
A 67 year old man presents to his GP with intermittent headaches and fatigue for the three months. Cardiovascular and neurological examinations are normal.
Observations:
Pulse: 89 bpm BP: 189/115 mmHg
RR: 16 /min SO2: 95% (air)
ECG: sinus rhythm, voltage criteria for LVH (SV2 19, RV5 28)
What is the diagnosis?
1 - hypertension
2 - chronic heart failure
3 - atrial fibrillation
4 - hypotension
1 - hypertension
How do we calculate BP?
1 - EDV - ESV
2 - Q x HR
3 - Q x SVR
4 - HR x SV
3 - Q x SVR
- BP = cardiac output x systemic vascular resistance
A 35 year old man presents to A&E complaining of headaches, visual disturbances, nausea and vomiting. His wife says that he is intermittently confused. He had recently been prescribed amlodipine and ramipril by his GP but had not taken the medication. He is obese (BMI 33) and his femoral pulses are difficult to feel.
Observations:
Pulse: 110 bpm BP: 215/117 mmHg
Apyrexial SO2: 99% (air)
ECG: Sinus tachycardia and LV hypertrophy by voltage (SV1: 27, RV6: 44)
Urinalysis: +2 protein +2 blood
Hb 135 g/L, WBC 6.1 x109/L, Platelets 256 x1012/L
Na+ 142 mmol/L, K+ 2.9 mmol/L, Creatinine 176 mcmol/L.
What is the diagnosis?
1 - hypertension
2 - chronic heart failure
3 - atrial fibrillation
4 - hypertensive encephalopathy
4 - hypertensive encephalopathy
