Essential Revision Notes for MRCP Third Edition - PasTest

Essential Revision Notes for MRCPSmoking and its relationship tocardiovascular diseaseSmokers have an increased incidence of the followingcardiovascular complications:• Coronary artery disease• Malignant hypertension• Ischaemic stroke• Morbidity from peripheral vascular disease• Sudden death• Subarachnoid haemorrhage• Mortality due to aortic aneurysm• Thromboembolism in patients taking oralcontraceptivesBoth active and passive smoking increase the risk ofcoronary atherosclerosis by a number of mechanisms.These include:• Increased platelet adhesion/aggregation andwhole-blood viscosity• Increased heart rate; increased catecholaminesensitivity/release• Increased carboxyhaemoglobin level and, as aresult, increased haematocrit• Decreased HDL cholesterol and vascularcompliance• Decreased threshold for ventricular fibrillation1.6.1 AnginaOther than the usual forms of stable and unstableangina, those worthy of specific mention include:• Decubitus: usually on lying down – due to anincrease in LVEDP or associated with dreaming,cold sheets, or coronary spasm during rapid eyemovement (REM) sleep• Variant (Prinzmetal): unpredictable, at rest, withtransient ST elevation on ECG. Due to coronaryspasm, with or without underlyingarteriosclerotic lesions• Syndrome X: this refers to a heterogeneousgroup of patients who have ST-segmentdepression on exercise testing butangiographically normal coronary arteries. Thepatients may have very-small-vessel disease and/or abnormal ventricular function. It is32commonly described in middle-aged femalesand oestrogen deficiency has been suggested tobe an aetiological factor• Vincent angina: nothing to do with cardiology;infection of the pharyngeal and tonsillar space!Causes of non-anginal chest pains• Pericardial pain• Aortic dissection• Mediastinitis• Associated with trauma, pneumothoraxor diving• Pleural• Usually with breathlessness in pleurisy,pneumonia, pneumothorax or a largeperipheral pulmonary embolus• Musculoskeletal• Gastrointestinal• Including oesophageal, gastric,gallbladder, pancreatic• Hyperventilation/anxiety• Reproduction of sharp inframammarypains on forced hyperventilation is areliable test• Mitral valve prolapse• May be spontaneous, sharp, superficial,short-lived painSymptomatic assessment of anginaThe Canadian cardiovascular assessment of chestpain is useful for grading the severity of angina:• Grade I: angina only on strenuous or prolongedexertion• Grade II: angina climbing two flights of stairs• Grade III: angina walking one block on thelevel (indication for intervention)• Grade IV: angina at rest (indication for urgentintervention)1.6.2 Myocardial infarctionConservative estimates suggest there are 113 000myocardial infarctions per year in the UK withsignificant pre-hospital mortality, and 5%–6% inhospitalmortality and 6%–7% 30-day mortality for