Updated: 7/31/2018

Atherosclerosis

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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 
    • 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)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.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? Review Topic

QID: 100592
1

Fibroblasts

14%

(1/7)

2

Macrophages

71%

(5/7)

3

Endothelium

0%

(0/7)

4

T-cells

0%

(0/7)

5

Neutrophils

14%

(1/7)

M1

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PREFERRED RESPONSE 2

(M1.CV.33) A 65-year-old Caucasian male 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? Review Topic

QID: 100549
1

Cholesterol crystal presence

0%

(0/8)

2

Rate of formation

12%

(1/8)

3

Calcium content

25%

(2/8)

4

Presence of cytokines

25%

(2/8)

5

Amount of foam cells

38%

(3/8)

M1

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PREFERRED RESPONSE 2

(M1.CV.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? Review Topic

QID: 100563
1

Fibroblasts -- Foam Cells

9%

(1/11)

2

Smooth Muscle Cells -- ECM deposition

64%

(7/11)

3

Endothelial Cells -- Downregulation of VCAM-1

18%

(2/11)

4

Smooth Muscle Cells -- Migration from intima to media

9%

(1/11)

5

LDL chemical reduction -- Endothelial dysfunction

0%

(0/11)

M1

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PREFERRED RESPONSE 2

(M1.CV.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? Review Topic

QID: 100554
1

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

80%

(8/10)

2

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

20%

(2/10)

3

An ulcerated fibrous plaque in one of his coronary arteries

0%

(0/10)

4

A pulmonary embolism

0%

(0/10)

5

A ruptured atherosclerotic plaque in one of his coronary arteries

0%

(0/10)

M1

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PREFERRED RESPONSE 1

(M1.CV.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?
Review Topic

QID: 100569
1

Myocytes

9%

(7/74)

2

Fibroblasts

1%

(1/74)

3

Neutrophils

1%

(1/74)

4

Endothelial cells

81%

(60/74)

5

Smooth muscle cells

4%

(3/74)

M1

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PREFERRED RESPONSE 4
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