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JCU MB4 Term 1 Week 3 (PVD)
1
A 74-year-old man has diminished right femoral, popliteal, and dorsalis pedis pulses. A CT image of his pelvis below the aortic bifurcation is shown. Describe the findings.
Aneurysm of the aorta, thrombosis and wall calcification
RIA aneurysm, mural thrombosis and calcification
Aneurysm and rupture of RIA with haematoma
Large atheromatous plaque in RIA
Berry aneurysm of RIA and calcification
History indicates lesion of RIA (high level).
2
Picture shows opened aorta at autopsy. What is the arrow showing?
Ruptured plaque
Ulcerated plaque
Fatty plaque
Calcified plaque
Perforated plaque
Simple soft plaque (smooth and raised). In this case it is occluding an offshoot.
3
A 25-year-old man has a 2-year history of worsening right leg pain, exacerbated by walking even short distances. On examination, his right femoral popliteal, and posterior tibial arterial pulses are absent. His total cholesterol is 430 mg/dL (desirable ≤ 200 mg/dL), and his HDL cholesterol is 22 mg/dL (normal ≥ 35 mg/dL). His CT angiogram is shown. What is the diagnosis?
Atherosclerosis of RIA
Aneurysm of lower end of aorta
Dissecting aneurysm aorta
Aneurysm with thrombosis of RIA
Fusiform aneurysm of RIA
The absent pulses indicate obstruction, which means that thrombosis is likely.
4
Microscopy of a coronary artery is shown. What clinical feature would be associated?
Unstable angina
Variant angina
Myocardial infarction
Chronic heart failure
Stable angina
The thick cap means plaque is away from the lumen and no ulceration or other complication is visible and this is thus a stable plaque. This would give rise to stable angina.
5
Microscopy of a coronary artery is shown. What clinical feature would be associated?
Unstable angina
Variant angina
Myocardial infarction
Chronic heart failure
Stable angina
The lumen is totally blocked - it is a coronary artery, which means that this would likely lead to myocardial infarction.
6
A 25-year-old man has a 2-year history of worsening right leg pain, exacerbated by walking even short distances. On examination, his right femoral popliteal, and posterior tibial arterial pulses are absent. His total cholesterol is 430 mg/dL (desirable ≤ 200 mg/dL), and his HDL cholesterol is 22 mg/dL (normal ≥ 35 mg/dL). His CT angiogram is shown. What is the most likely underlying disease in this man?
Hypertension
Atherosclerosis
Diabetes
Burgers disease
Familial hypercholesterolaemia
All of the listed diseases can lead to aneurysm, but the extremely high LDL is indicative of FH (likely heterozygous). These patients often present with severe atherosclerosis at a very young age.
7
An autopsy specimen of a coronary artery is shown. What is the best description of the morphology?
Fatty dot
Fatty streak
Soft plaque
Ulcerated plaque
Complicated plaque
The picture shows plenty of fat, an obvious soft plaque.
8
A 65-year-old man has a 5-year history of post-prandial pain and intermittent claudication. His BMI is 35 (normal 18.5-25), fasting glucose 209 mg/dL (normal < 110 mg/dL) and creatinine 2.3 mg/dL (normal = 1.2 mg/dL). His abdominal CT scan is shown. What does his aorta show?
Plaques and dissecting aneurysm
Aneurysm, thrombosis, wall calficiation
Ruptured aneurysm and haematoma
Circular large soft plaque and aneurysm
Multiple plaques, ulcerations and calcifications
The history indicates that his underlying condition is T2DM leading to aortic atherosclerosis.
9
52-year-old male, sudden severe chest pain. Picture shows aorta at autopsy. What is the diagnosis?
Atheromatous plaque
Thrombosis on plaque
Fusiform aneurysm
Dissecting aneurysm
Berry aneurysm
10
58-year-old male, severe chest pain. Example gross specimen of his aorta is shown. What is the diagnosis?
Atherosclerosis of aorta
Haematoma of aorta
Berry aneurysm
Fusiform aneurysm
Dissecting aneurysm
11
A 65-year-old man has a 5-year history of post-prandial pain and intermittent claudication. His BMI is 35 (normal 18.5-25), fasting glucose 209 mg/dL (normal < 110 mg/dL) and creatinine 2.3 mg/dL (normal = 1.2 mg/dL). His abdominal CT scan is shown. What is the likely underlying condition?
Hypertension
Atherosclerosis
Diabetes
Smoking -> Buerger's disease
Multiple conditions
Atherosclerosis secondary to T2DM.
12
Microscopy of a coronary artery is shown. What is the feature shown my arrow C?
Cholesterol clefts
Smooth muscle hyperplasia
Inflammatory cells
Foamy macrophages
Thrombus over ulcer
A - soft/necrotic centre, B - fibrotic cap, C - clot/thrombus
13
A 74-year-old man has diminished right femoral, popliteal, and dorsalis pedis pulses. A CT image of his pelvis below the aortic bifurcation is shown. What is the pathogenesis of his disease?
Hypercholesterolaemia, diabetes
Intimal injury, cholesterol deposits
Inflammation, proteases, destruction
Obstruction, ischaemia, infarction
Streak, soft plaque, hard plaque
Picture shows complicated plaque resulting in thrombosis and occlusion. This indicates inflammation with lysis and destruction of the plaque.
14
A 69-year-old man has sudden sever abdominal pain. On exam his abdomen is distended and no bowel sounds are auscultated. Doppler ultrasonography shows absent superior mesenteric artery flow. An exploratory laparotomy is performed, and the results are shown in the picture. What has happened here?
Intestinal haemorrhage
Thrombosed intestines
Gangrene of small intestine
Atherosclerosis of abdominal arteries
Large aneurysm of aorta
Aortic atherosclerosis may have been the initial cause, but the necrotic appearance of the intestines clearly indicates gangrene. Haemorrhage is not consistent with the provided history.
15
A 65-year-old man reliably gets chest pain after climbing a single flight of stairs; the pain is promptly relieved by nitroglycerin. If we sampled his left anterior descending artery at this point, it would have the appearance shown. What term describes his symptoms.
Unstable angina
Myocardial infarction
Stable angina
Atherosclerosis of coronary artery
Prinzmetal angina
Classic description of stable angina.
16
A 47-year-old woman has sudden chest pain radiating to her neck. An ECG shows Q waves and ST-segment elevation in two anatomically contiguous leads. She has a sudden arrhythmic even and, despite intervention, dis. The microscopic appearance of her left circumflex artery is shown. What cells contribute to this lesion?
Smooth muscle cells
Neutrophils
Fibroblasts
T lymphocytes
Macrophages
Q waves indicate infarction, ST elevation indicates ischaemia. The picture shows a block due primarily to thrombus. Pathogenesis is ulceration and thrombus formation (macrophage and metalloprotease involvement).
17
The coronary artery shown is from a 22-year-old man who died in a motor vehicle accident. What laboratory test findings indicate increased risk of progression to myocardial infarction or cardiac-related death?
High HDL
Low HDL
Raised CRP
High homocysteine
Raised Factor VII
Young energetic man with no known risk factors for cardiovascular disease, which rules out all except CRP which are risk factors. The only reliable indicator of progression in this case would be inflammation indicated by elevated CRP. Inflammatory mediates indicate the atherosclerotic plaque is undergoing change, i.e. breakdown, ulceration, rupture, thrombosis.
18
A 61-year-old woman with lower extremity claudication, abdominal angina, and hypertension dies as a result of bowel infarction and resulting sepsis. The gross appearance of her aorta at autopsy is shown. How can these problems be treated?
Life style modification
Treat diabetes
Thrombolysis / stent
Folate and vitamins
Platelet inhibitors (e.g. aspirin)
With acute complications, lifestyle modifications come last.
19
A 63-year-old man has severe substernal chest pain radiating to his left jaw. He is hypotensive and tachycardic. He has elevated creatine phosphokinase and troponin I, and is admitted to the cardiac intensive care unit. He dies 24 hours later of intractable tachycardia. His myocardium at autopsy is shown. What is the diagnosis?
Acute infarction (MI new)
Acute Rheumatic Fever
Viral myocarditis
Old infarction (MI old)
Atherosclerotic changes
20
A 54-year-old man with hypertension and a 60-pack-year smoking history has prolonged chest pain radiating to his neck. He abruptly develops severe dyspnoea 3 days later. Examination reveals hypotension and tachycardia, with diffuse rales and a high-pitched holosystolic murmur radiating to the axilla. He dies in florid pulmonary oedema. His heart is shown at autopsy.
Mitral stenosis
Mitral regurgitation
Myocardial rupture
Ventricular aneurysm
Cardiac tamponade
Holosystolic (pan-systolic) murmur is indicative of mitral regurgitation, distinguished from tricuspid regurtiation by the fact that it radiates to the axilla. The image shows papillary muscle rupture, which usually happens within the first 9-10 days after a myocardial infarction.
21
A 56-year-old male smoker with hypertension and type 2 diabetes has a 3-hour episode of chest discomfort attributed to heartburn from shovelling snow too soon after a large beer and pizza repast. The discomfort abates, but he dies suddenly 5 days later while watching television. His myocardium at autopsy is shown. What life-threatening complication of this disease may now have happened?
Mitral stenosis
Mitral regurgitation
Myocardial rupture
Ventricular aneurysm
Cardiac tamponade
Picture shows evidence of recent MI. A possible acute complication (within 10 days) of myocardial infarction is myocardial rupture. This may or may not lead to cardiac tamponade.
22
One year after a myocardial infarction, a 65-year-old woman has congestive heart failure with an ejection fraction of 25% (normal 50% to 75%). She has a sudden embolic stroke and dies; her heart is shown at autopsy. What is the cause of her death?
Myocardial infarction
Restrictive cardiomyopathy
Hypertension
Thrombosis secondary to ventricular dysfunction
Carotid stenosis
Picture shows aneurysm and fibrosis resulting from the patient's previous MI. This would have caused ventricular dysfunction (evidenced by the reduced ejection fraction) and encouraged thrombus formation. The thrombus sequently embolised resulting in cerebrovascular occlusion.