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Pathology 3001 > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

What is the subendocardial region?

A
  • Between the epicardium and endocardium
  • Least well supplied area for oxygen
  • First area to become ischaemic
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2
Q

What are the 3 main coronary artery imaging techniques?

A
  • Selective coronary angiography
  • CT
  • MR imaging
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3
Q

Describe the basic pathology of coronary artery disease

A
  • Fatty streak
  • Fibro-fatty plaque
  • Plaque disruption
    Plaque disrupture
    Plaque erosion
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4
Q

What do macrophages become in the sub-endothelial layer when they uptake oxidised LDL?

A

Foam cells

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5
Q

What is the hallmark cell of a fatty streak?

A

Foam cells

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6
Q

What do foam cells release?

A

Cytokines and growth factors that recruit smooth muscle cells which then produce collagen

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7
Q

What is the cause of angina?

A

Sub-endocardial ischaemia

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8
Q

What does angina appear like on an ECG?

A

ST depression

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9
Q

What is angina due to

A

When the coronary blood flow is not sufficient enough to meet the oxygen demands of myocardial tissue

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10
Q

What is the basis of angina pectoris?

A

Epicardial coronary artery stenoses. Atherosclerotic plaque limiting coronary blood flow.

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11
Q

What are the two broad regulatory features of the coronary system?

A
  • Autoregulation (myogenic control)

- Metabolic regulation

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12
Q

How much does coronary blood flow increase to accomodate a 20 fold increase in total body O2 consumption?

A

Can rise five fold (400 ml/min/100g)

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13
Q

What molecule is an extremely powerful coronary vasodilator?

A

Adenosine

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14
Q

What is the coronary flow reserve?

A

The maximum increase in blood flow through the coronary arteries above normal resting volume

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15
Q

What is the effect of angina on the coronary flow reserve?

A

Reduced

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16
Q

What determines myocardial oxygen consumption?

A
  • Tension development
  • Contractility
  • HR
  • Basal activity (10-20%)
  • Mass of tissue
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17
Q

What causes the variancy in stable angina (why on some days does it occur frequently and others not)?

A

The variable coronary flow reserve

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18
Q

What tests are performed to test inducible ischaemia?

A
  • Exercise stress test
  • Dobutamine stress echo
  • Myocardial perfusion imaging with either exercise or pharmacological stress
  • Cardiac magnetic resonance imaging (cMR) (flow)
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19
Q

When investigating chest pain what are you looking for?

A
  • Anatomical assessment
  • Test of inducible ischaemia
  • Measuring coronary flow reserve
20
Q

What artery is often used in a CABG oprocedure to bypass an occluded portion of the LAD artery?

A

The left internal mammary artery

21
Q

What are the two primary domains for treating angina?

A
  • Reduction in myocardial oxygen consumption

- Reduction in the variability of coronary flow reserve

22
Q

What are the main causes of myocardial infarction?

A
  1. Plaque rupture (~75%)
  2. Plaque erosion (~30%)
  3. Coronary embolism
  4. Coronary artery spasm (cocaine)
  5. Coronary anomaly
  6. Spontaneous coronary dissection
23
Q

What group of people are susceptible to spontaneous coronary dissection?

A

Pregnant women

24
Q

Describe how a plaque causes an MI (pathology)?

A
  • Cause coronary thrombosus
  • Plaque becomes exposed to blood
  • Platelets adhere to the plaque activating coagulation
  • This creates platelet rich thrombi which blocks the artery
  • Blocks artery creating a propogation thrombus down through the artery
25
Q

What are light bands through platelet rich thrombi called?

A

Bands of Zahn

26
Q

How is coagulation triggered inside arteries to create an MI at a molecular level?

A

Macrophages produce MMPs which digest the fibrous cap. Macrophages themselves produce tissue factor which triggers the activation of the extrinsic pathway of coagulation.

27
Q

What factors affect presentation of an AMI?

A
  • Time of day (morning)
  • Inflammatory activity (rheumatoid artheritis)
  • Infection (respiratory) (pneumonia)
  • Elevation of bp
  • Catacholamines
28
Q

How can MIs be classified?

A
  • Full thickness, transmural or sub enocardial (site)
  • STEMI or NSTEMI
  • Type 1 - 4 (Cause)
29
Q

What is the difference in affect of STEMIs and NSTEMIs?

A
  • STEMI inplies transmural MI

- NSTEMI will include subendocardial infarction but does not exclude transmural infarction in regions remote from ECG.

30
Q

What is a type 1 MI?

A
  • Spontaneous

- Related to ischaemia due to coronary event such as plaque erosion and/or rupture, tissuring or dissection

31
Q

What is a type 2 MI?

A
  • MI secondary to ischaemia due to either increased oxygen demand or decreased supply
32
Q

What is a type 3 MI?

A

Sudden unexpected cardiac death often with symptoms suggestive of MI

33
Q

What is a type 4 MI?

A

MI associated with percutaneous coronary intervention or stent thrombosis

34
Q

What is a type 5 MI?

A

MI associated with cardiac surgery

35
Q

Are STEMIs or NSTEMIs more common amongst older people?

A

NSTEMIs peak incidence rate is 10 years older than STEMIs

36
Q

What are the serum markers of Myocardial damage?

A
  • Troponin T or 1
  • Creatine kinase MB isoform (CKMB)
  • Creatine Phosphokinase (CPK)
  • AST
  • Myoglobin
37
Q

What medications are usually administered with a STEMI?

A
  • Aspirin + clopidogrel or other antiplatelet (P2Y12 inhibitor).
    Thrombolysis (streptokinase)
38
Q

What procedure is used to treat a STEMI?

A

Primary PCI for immediate vascularisation

39
Q

What medications are given after anti-platelets agnests and revascularisation?

A
  • Statin drugs
  • Ace inhibitors
  • Beta blockers
40
Q

What are the immeadiate complications of a STEMI?

A
  • Ventricular arrhythmia and death

- Acute left heart failure

41
Q

What are the early complications of a STEMI (day 2-7)

A
  • Myocardial rupture
  • Mitral valve insufficiency
  • VSD
  • Mural thrombus and embolisation
42
Q

What are the late (beyond day 7) complications of a STEMI?

A
  • LV dilation and HF
  • Arrhythmia
  • Recurrent MI
43
Q

What is an NSTEMI caused by?

A
  • Threatned STEMI
  • Small branch occlusion
    Occlusion of well collateralised vessel
  • Lateral STEMI in territory not well seen by ECG
  • Implies sub-endocardial ischaemia
44
Q

How does the treatment differ between an NSTEMI and a STEMI?

A

Same except angiography and revascularisation can be delayed slightly in NSTEMI

45
Q

When would an NSTEMI be treated early?

A
  • If symptoms continue
  • If roponin raised
  • Risk score (e.g GRACE)

Pathology 3001 (15 decks)

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