Vascular and Ischaemia Heart Disease

Question 0

What is infarction?

Answer 0

Ischaemic necrosis due to occlusion/reduction of blood flow

Question 1

What is Ischaemia?

Answer 1

Impaired vascular perfusion

Question 2

Why can slow, turbulent flow result in thrombus?

Answer 2

Platelets contact endothelium
Active clotting factors not diluted due to less flow
Anticoagulant inflow slowed

Question 3

When does slow, turbulent flow arise?

Answer 3

DVT
Fibrosed-myocardium post MI
Aneurysms
AF
MS and LV dilation

Question 4

What are lines of Zahn?

Answer 4

Alternating platelet + fibrin/RBC + WBC bands

Question 5

What occurs in a mural thrombus?

Answer 5

Forms in ventricles
- MI
- Arrhythmias
Forms in aorta

These adhere to the wall of large vessels and typically show lines of Zahn

Question 6

How do venous thrombi appear?

Answer 6

Reddish-blue and adhered to wall

Question 7

What types of embolism exist?

Answer 7

Thromboembolism
Fat
Marrow
Air
Septic
Amniotic fluid
Tumour

Question 8

What shape is a pulmonary infarct?

Answer 8

Wedge shaped

Question 9

How could a venous embolus infarct peripheral arteries? What would this phenomenon be called?

Answer 9

ASD/VSD

Paradoxical embolus

Question 10

When would a fat embolism occur?

Answer 10

Major soft tissue/bone injury

- Fat enters lung globules

Question 11

Arteriosclerosis is a general term for three conditions. What are they?

Answer 11

Atherosclerosis
Monckeberg Medial Calcific Sclerosis - Medium vessels
Arteriolosclerosis - Small vessels

Question 12

Where is atherosclerosis common?

Answer 12

Aorta
Coronary arteries
Cerebral arteries

Question 13

What is the basic structure of the atheromatous plaque?

Answer 13

Lipid core

Fibrous cap

Question 14

How can an atheromatous plaque lead to an aneurysm?

Answer 14

Media progressively degraded

Vessel wall weakens

Question 15

What are the key stages to atherosclerosis?

Answer 15

1. Chronic endothelial injury
2. Endothelial dysfunction
3. Macrophage activation
4. Lipoprotein oxidation
5. Foam cell formation
6. Plaque formation and growth
   (7. Distribution)

Question 16

What are some haematological risk factors for DVT and PE?

Answer 16

Polycythaemia rubra vera
Thrombocytosis
Hyperhomocysteinaemia
Antithrombin deficiency
Protein C/S deficiency

Question 17

Symptoms and signs of DVT?

Answer 17

Calf/leg

• Pain
• Swelling
• Redness
• Hot

Question 18

What investigations can be done into a DVT?

Answer 18

D Dimers - Rule out, not rule in

US Doppler

Question 19

What is venous plethysomography and how does it work?

Answer 19

Strain gauge around affected limb
Venous emptying by compression
If there is slow refill = clot

Question 20

Treatment for DVT

Answer 20

LMWH/Warfarin
Compression stockings (TEDs for 6 weeks)

Question 21

What is phlegmasia dolens?

Answer 21

A highly severe DVT
Results in reliance on superficial venous drainage
Blood gathers in limb
Blocks arterial inflow

Question 22

Symptoms of PE?

Answer 22

Dyspnoea
Syncope
Pleuritic chest pain
Haemoptysis
Sudden death

Question 23

Imaging for PE

Answer 23

CXR
V/Q scan
CTPA - Breath holding needed
Echo

Question 24

What is the BNF regimen for tPA?

Answer 24

- 10mg bolus over 2-5 minutes - 90mg infusion over 2 hours - Max 1.5mg/kg if <65kg

Question 25

What are some examples of oral anticoagulants?

Answer 25

Dabigatran (Antithrombin) | Apixaban, Rivaroxaban (anti-Xa)

Question 26

Which is the preferred therapy in pregnancy, warfarin, heparin or LMWH?

Answer 26

Heparin

Question 27

How is heparin dosing monitored?

Answer 27

Activated partial thromboplastin time (APTT)

Question 28

What is the duration of PE therapy?

Answer 28

``` If temporary risk factor present - 4-6 weeks If idiopathic PE - 3-6 months (longer the more distal) Second idiopathic event - Lifelong ```

Question 29

Common presentation of angina

Answer 29

``` Heavy chest pain Possible radiation Exacerbation by exertion/stress/cold wind Relieved by resting/GTN Risk factors present ```

Question 30

Presentation of aortic dissection/pericarditis

Answer 30

Pleuritic Focal pain No pattern - at rest No risk factors

Question 31

Central chest pain relieved by sitting forward is typically?

Answer 31

Pericarditis

Question 32

Sharp focal chest pain exacerbated by breathing?

Answer 32

Pleuritic pain - Aortic dissection (tearing) - PE (dull)

Question 33

What investigations can be done into chest pain (not MI)?

Answer 33

Exercise testing Perfusion imaging CT angiography Angiography

Question 34

What vessels are harvested during a CABG?

Answer 34

Long saphenous vein | Internal mammary artery

Question 35

What incision is made for a CABG?

Answer 35

Median sternotomy

Question 36

What is PCI and what is its alternate name?

Answer 36

Percutaneous Coronary Intervention | Coronary angioplasty

Question 37

When is PCI used?

Answer 37

In a STEMI

Question 38

What drug therapy is used during a PCI?

Answer 38

Dual antiplatelet therapy (aspirin and clopidogrel) | Anticoagulants

Question 39

What is claudication?

Answer 39

Intermittent leg pain due to muscle Ischaemia during exercise

Question 40

What is ABPI and what are the values in 1. A normal individual 2. A patient suffering from claudication 3. Patient with severe claudication

Answer 40

Ankle Brachial Pressure Index 1. 0.9-1.2 2. 0.4-0.85 3. <0.4

Question 41

What symptoms are indicative of critical limb Ischaemia?

Answer 41

Rest pain - toe/foot ischaemia while sleeping/lying down Ulcers and gangrene if very severe - due to trauma Worse at night Helped by putting dependence on leg/walking

Question 42

Pathogenesis of aortic aneurysm?

Answer 42

Elastin/Collagen regulation in wall Aneurysmal dilation Increased aortic wall stress Progressive dilation - Tension

Question 43

Symptoms of an abdominal aortic aneurysm?

Answer 43

Tachycardia Hypotension Pulsatile, expansile mass Transmitted pulses

Question 44

What investigations can be done into an AAA?

Answer 44

USS | CT Scan - Arterial phase

Question 45

What are varicose veins?

Answer 45

Dilated, tortuous superficial veins | Due to deep vein pressure

Question 46

What signs suggest varicose veins?

Answer 46

Visibility of veins - more prominent when standing Complications - Bruising - Thrombophlebitis

Question 47

Differential diagnoses for a stroke?

Answer 47

``` Hypoglycaemia Seizure Migraine Tumour Function hemiparesis ```

Question 48

Medical management of a stroke

Answer 48

Aspirin 75mg + Dipyridamole (modified release) 200mg twice daily Clopidogrel 75mg once daily Statins If in AF - Anticoagulants If hypertensive - Perindopril + Indapamide