Updated: 10/6/2020

Atherosclerosis

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https://upload.medbullets.com/topic/108038/images/041218xwstep1cardasplaque_anatomy.jpg
Snapshot
  • A 54-year-old man presents to the emergency department 30 minutes after developing crushing sternal chest pain that radiates down the left arm and to the jaw. His symptoms are accompanied by anxiety. Medical history is significant for hypertension, hypercholesterolemia, and type II diabetes mellitus. On physical exam, the patient appears restless and is diaphoretic. An electrocardiogram is performed, which shows ST-segment elevated in leads V1-4. The cardiac catheterization lab is activated and the patient is awaiting stenting after appropriate acute management for acute coronary syndrome. 
Introduction 
  • Definition
    • a pathological process that causes damage to the
      • aorta
      • cerebrovasculature
      • coronary arteries
      • peripheral arteries
  • Epidemiology
    • risk factors
      • modifiable
        • hypertension
        • cigarette smoking
        • hyperlipidemia
          • especially hypercholesterolemia
      • nonmodifiable
        • age
        • male gender
        • family history
        • genetic abnormalities (e.g., LDL receptor gene mutations)
  • Pathophysiology 
    • background
      • LDL transports cholesterol into peripheral tissues and HDL mobilizes cholesterol from the periphery and into the liver for excretion via bile
    • pathogenesis 
      • injury (e.g., smoking, hypertension, and hypercholesterolemia) to the endothelium leads to endothelial dysfunction resulting in 
        • increased vessel permeability
        • monocyte adhesion and emigration
      • macrophages become activated within the vessel intima and smooth muscles are recruited  
        • smooth muscle cells migrate to the intima via FGF and PDGF
      • smooth muscle cells and macrophages engulf lipids (e.g., LDL), forming foam cells, along with recruitment of T lymphocytes forming a fatty streak 
        • smooth muscle cells proliferate and there is deposition of the extracellular matrix, resulting in the fatty streak becoming a fibrofatty atheroma 
          • slow forming plaques allow for the formation of collateral circulation 
    • location
      • abdominal aorta > coronary artery > popliteal artery > carotid artery
Presentation
  • Symptoms
    • angina
      • if > 75% obstruction 
      • myocardial demand ischemia 
        • type of stable angina where individuals with known atherosclerotic coronary disease experience relative myocardial ischemia during episodes of high metabolic demand
        • subendocardial vessels are susceptible to ischemia during systole due to high resistance and systolic back flow from endocardial to epicardial vessels 
          • left ventricular subendocardial muscle most likely due to left coronary vessel systolic compression 
        • supply/demand mismatch can cause anginal pain and ischemic changes on EKG
    • claudication
    • can be asymptomatic
Complications
  • Aneurysms
  • Myocardial infarction
  • Ischemic stroke
  • Peripheral vascular disease
  • Atheromatous plaque disruption can result in thrombosis
    • thrombus fragments can break off and result in an embolism 
Abdominal aorta > coronary artery > popliteal artery > carotid artery
 

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Questions (8)
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(M1.CV.14.76) A 14-year-old Caucasian female commits suicide by drug overdose. Her family decides to donate her organs, and her heart is removed for donation. After removing the heart, the cardiothoracic surgeon notices flat yellow spots on the inside of her aorta. Which of the following cell types predominate in these yellow spots? Tested Concept

QID: 100592
1

Fibroblasts

11%

(8/75)

2

Macrophages

75%

(56/75)

3

Endothelium

1%

(1/75)

4

T-cells

1%

(1/75)

5

Neutrophils

8%

(6/75)

M 1 D

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(M1.CV.13.47) A 65-year-old man presents to the Emergency Department complaining of substernal chest pain. An acute coronary event is suspected and a coronary catheterization procedure reveals an atherosclerotic plaque in the patient's left anterior descending artery. In the formation of an atherosclerotic plaque, which of the following pairings is correct? Tested Concept

QID: 100563
1

Fibroblasts -- foam cells

6%

(4/69)

2

Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

59%

(41/69)

3

Endothelial cells -- downregulation of VCAM-1

7%

(5/69)

4

Smooth muscle cells -- migration from intima to media

7%

(5/69)

5

LDL chemical reduction -- endothelial dysfunction

20%

(14/69)

M 1 D

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(M1.CV.12.38) A 50-year-old Caucasian male notices substernal chest pain while walking his dog uphill in Central Park on a sunny Saturday morning. The pain disappears after 5 minutes of rest, and he continues to enjoy his weekend. As he smokes a cigarette later in the day, he wonders: which of the following pathologies were most likely responsible for his chest pain that morning? Tested Concept

QID: 100554
1

A fixed atherosclerotic plaque obstructing 80% of one of his coronary arteries

89%

(85/96)

2

A fixed atherosclerotic plaque obstructing 50% of one of his coronary arteries

10%

(10/96)

3

An ulcerated fibrous plaque in one of his coronary arteries

0%

(0/96)

4

A pulmonary embolism

0%

(0/96)

5

A ruptured atherosclerotic plaque in one of his coronary arteries

0%

(0/96)

M 2 E

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(M1.CV.12.33) A 65-year-old Caucasian man presents to the emergency room with chest pain. Coronary angiography reveals significant stenosis of the left anterior descending (LAD) artery. Which of the following represents a plausible clinical predictor of myocardial necrosis in this patient? Tested Concept

QID: 100549
1

Cholesterol crystal presence

4%

(3/70)

2

Rate of plaque formation

21%

(15/70)

3

Calcium content

31%

(22/70)

4

Presence of cytokines

20%

(14/70)

5

Amount of foam cells

23%

(16/70)

M 1 D

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(M1.CV.12.53) A 60-year-old male painter with severe chest pain is found to have atherosclerosis of his coronary arteries. What type of cells were most likely injured in the initial stage of his disease?
Tested Concept

QID: 100569
1

Myocytes

6%

(8/136)

2

Fibroblasts

1%

(1/136)

3

Neutrophils

1%

(1/136)

4

Endothelial cells

89%

(121/136)

5

Smooth muscle cells

2%

(3/136)

M 1 E

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