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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.

Contrast CT of iliac arteries


  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?

Soft plaque


  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?

CT Angiogram - RIA aneurysm


  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?

Coronary Artery - Stable plaque


  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?

Coronary Artery - Complete occlusion


  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?

CT Angiogram - RIA aneurysm


  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?

Coronary artery - soft plaque


  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?

Abdominal CT - Aortic calcification and thrombus


  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?

Aortic dissection


  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?

Fusiform aortic aneurysm


  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?

Abdominal CT - Aortic calcification and thrombus


  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?

Labelled Coronary Artery Microscopy


  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?

Contrast CT of iliac arteries


  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 gangrene


  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.

Coronary artery - stable plaque


  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?

Coronary artery - thrombotic occlusion


  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?

Aorta with fatty streaks


  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?

Severe aortic atherosclerosis


  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?

MI - less than 24 hours


  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 valve papillary muscle rupture


  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?

MI - 1 to 3 weeks


  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?

Healed MI with aneurysm and fibrosis


  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.