Ischaemic heart disease

Question 1

Mockenberg atherosclerosis

Answer 1

Arterosclerosis with dystrophic calciculation of internal/ middle layer of blood vessels
- Affects medium sized vessels

Causes- DM, kidney disease
Pipestem appearance of XR

Question 2

Causes of hyaline arteriosclerosis

Answer 2

Chronic essential hypertension
Diabetes
Normal aging

H&E stain: hyaline deposits (pink) within arteriolar walls

Question 3

Hyperplastic arterioscleorosis is most associated with…

Answer 3

Malignant hypertension

H&E stain: onion skin arteriole
- Caused by proliferation of subendotherlial smooth muscle cells due to high BP

Question 4

ASCVD patient risk factors

Answer 4

Premature menopause
Hypertensive pregnancy disorder
CKD
Chronic inflammatory disease- RA, HIV, psoriasis
Metabolic syndrome/ obesity

Question 5

ASCVD diagnostic risk factors

Answer 5

High LDL
Persistent hypertriglyceridaemia
Rashied lipoprotein A +/- B
Riased hsCRP
Low resting ABPI

Question 6

Tools for calculating ASCVD risk

Answer 6

PREVENT equations
- includes kidney function

PCE (pool cohort equations)
- underestimates risk in chronic inflammatory conditions and socioeconomic disadvantage

Question 7

When to assess patients for ASCVD risk

Answer 7

From age 20-75 every 4-6 years
More frequently from age 40

Question 8

Indications for statins as primary intervention for CVD

Answer 8

Age 20-39
- Moderate-intensity statin: LDL >160mg + family history of early ASCVD
- long standing diabetes/ complications of diabetes

Age 40-75
AHA:
- 10-year risk >20%
- DM = moderate intensity. 1+ ASCVD risks= consider high intensity
- ASCVD risk 5-19.9%= consider moderate intensity using risk-enhancing factors +/- CAC score

USPSTF:
- 1+ modifiable ASCVD risk factor + >10% risk= moderate intensity statin + consider low dose aspirin.
- intermediate risk= consider moderate intensity

Question 9

Pathophysiology of: Unstable angina, STEMI, NSTEMI

Answer 9

Unstable angina- partial coronary vessel occlusion. Ischaemia without infarction

NSTEMI: partial coronary vessel occlusion causing subendocardial infarction

STEMI: complete coronary occlusion causing transmural infarction

Question 10

STEMI/ NSTEMI troponin definition

Answer 10

Elevation > 99th percentile + >20% change on repeat testing.

Question 11

Indications of TTE in ACS

Answer 11

cardiogenic shock

infarct-like symptoms but inconclusive ECG

complications of MI (MV regurg, pericardial effusion, HF, aneurysms)

Question 12

Purpose of GRACE score in ACS

Answer 12

Predicts death / further myocardial infarction following an initial acute coronary syndrome

Question 13

HEART score

Answer 13

Risk assessment for major adverse CV events in patients presenting to ED with chest pain:
- History
- ECG findings
- Age
- Risk factors
- Troponin levels

Question 14

Purpose of TIMI score

Answer 14

Estimates risk of mortality/ new/ recurrent MI or need for revascularization in NSET-ACS
- Score 2+ favors invasive strategy

Question 15

Definition of significant STE in STEMI

Answer 15

Absence of LVH and LBBB

All leads except V2, V3: 1mm+
V2-3, men age <40: 2.5mm+
V2-3, men age >40: 2mm+
Women any age, v2-3: >1.5mm+

Question 16

Definition of pathological Q waves

Answer 16

Q wave >0.04s (1 small square) + >1/4 R wave amplitude

Question 17

Sagging ST depression is associated with _____ toxicity

Answer 17

Digoxin

Question 18

Upsloping ST depression is associated with what physiological activity?

Answer 18

Physical activity

Question 19

Management of STEMI

Answer 19

Emergency revascularisation- <120 mins
- Antiplatelet + anticoagulation

> 120 mins from PCI facility + symptom <12 hours
- Fibrinolytics
- antiplatelet and anticoagulation

Question 20

Modified Sgarbossa criteria

Answer 20

Identifies STEMI in LBBB
- STE 1mm+ in any lead
- STD 1mm+ V1-3
- Discordant STE 1mm+ and 25%+ of preceeding S wave

Question 21

Medication for STEMI

Answer 21

DAPT- asprin 325mg + ADP receptor inhibitor (prasugrel 60mg, ticegrelor 180mg , clopidogrel 600mg)
- clopidogrel if having PCI

Anticogulation
- Unfractionated heparin
- Bivalirudin
- PCI- enoxaparin 30mg bolus + 1mg/kG BD, fondaparinux 2.5mg bolus then 2.5mg daily, unfractionted heparin

Adjuvant- IIb/IIIa inhibitor
- Abcixmiab
- Eptifibatide
- Tirofiban

Question 22

criteria for urgent revascularisation
in NSTEMI

Answer 22

HD unstable
Life threatening arrhythmia
Refractory ischaemic pain
Acute HF
Mechanical complication

Question 23

criteria for early revascularisation
in NSTEMI (<24 hrs)

Answer 23

GRACE >140
Dynamic ST/ T changes
Dynamic trop changes

Question 24

Medical therapy for NSTE-ACS

Answer 24

DAPT
- aspirin + Ticagrelor / clopidogrel

Anticoagulation
- Enoxapain
- UFH
- Fondaparinux
- Early invasive- bivalirudin

High risk/ intermediate
- Eptifibatide
- Tirofiban