hi this is tom from zero define as calm in this video I'm going to be going through cardiovascular disease you can find written notes on this topic at zero define as calm slash CVD or in the cardiology section of the zeroD finals medicine book let's jump straight in so first let's talk about atherosclerosis a thorough basically means soft or porridge-like sclerosis is hardening and atherosclerosis is really a combination of a thorough m'as which have fatty deposits in artery wall and sclerosis which is the process of hardening or stiffening of the blood vessel wall atherosclerosis affects the medium and large arteries in the body and it's caused by chronic inflammation and activation of the immune system in the artery wall so this causes deposits of lipids in the artery wall followed by the development of fibrous atheromatous plaques these plaques cause a few different problems firstly they cause stiffening of the artery wall which leads to hypertension or raised blood pressure this is caused by the strain on the heart trying to pump blood against an artery wall that won't expand with the extra pressure so it pumps against that extra resistance and causes higher blood pressure the second problem is stenosis so this is a narrowing because of the plaques of the space that the blood can flow through in the blood vessel this would causes reduced blood flow in conditions like angina or peripheral vascular disease and the third problem is plaque rupture and this is where the plaque breaks off and gives off something called a thrombus that travels down the vessel and blocks a distal part of that blood vessel leading to ischemia and this is the main cause of acute coronary syndrome or heart attacks so what are the risk factors for developing atherosclerosis it's quite important to break down these risk factors into modifiable and non-modifiable risk factors there's nothing we can do about the non-modifiable risk factors but we can do something about the modifiable ones so the non-modifiable risk factors are stuff like older age family history and being male and the modifiable risk factors are smoking alcohol consumption poor diet things like eating high sugar or trans fat diets and not eating enough fruits vegetables and Omega threes low exercise obesity poor sleep and stress there's certain medical comorbidities that really increase the risk of atherosclerosis and these should be carefully managed to minimize the risk and this is stuff like diabetes type 1 and type 2 hypertension chronic kidney disease and then inflammatory conditions such as rheumatoid arthritis because remember atherosclerosis is an inflammatory process and atypical antipsychotics that might be used in schizophrenia so here's a bit of a Tom tip when you're taking a history from someone who you suspect has atherosclerosis disease you know somebody presenting with chest pain or intermittent claudication of their lower limbs ask them about their exercise tolerance diet past medical history family history occupation smoking and really think about what are their modifiable and non-modifiable risk factors this will score you really highly in exams and is useful when presenting to seniors or deciding what somebody's risk of having that condition actually is so what are the end results of atherosclerosis well this is really when somebody has established cardiovascular disease so as things like angina myocardial infarction transient ischemic attacks strokes peripheral vascular disease and chronic mesenteric ischemia when there's not enough blood flow to the bow how do we prevent cardiovascular disease where you can consider prevention of cardiovascular disease to fall into one of two main categories firstly primary prevention and thus trying to prevent cardiovascular disease in patients that have never had it and secondary prevention and this is when patients already have angina or they've had a heart attack or a TI a and you're trying to prevent it from happening again so the first thing is you want to optimize any modifiable risk factors so you figure out what their modifiable risk factors are and then try to improve them so you'd give them advice on diet exercise weight loss smoking alcohol and treating any of their comorbidities such as giving them really good control of their diabetes then you want to look at primary prevention of cardiovascular disease and the way we do this in general practice is we perform something called a Q risk score and at the moment we're on a Q risk three score and this calculates the percentage risk that the patient will have a stroke or an MI in the next 10 years if they have more than a 10% risk of developing a stroke or heart attack over the next 10 years ie their Q risk three score is above 10 percent then nice recommends that you should start a statin so the current recommendation is for atorvastatin 20 milligrams at night there's a slight exception in that all patients with chronic kidney disease or type 1 diabetes for more than 10 years should automatically be offered a torva statin 20 milligrams once a day the nice guidelines actually recommend checking lipids 3 months after starting a statin and increasing the dose in order to aim for at least a 40% reduction in the non HDL cholesterol but I would always check adherence carefully before increasing the dose because you might find out that the patient doesn't actually take their medication next let's talk about secondary prevention of cardiovascular disease and secondary prevention is after they've already had a heart attack and China a TI a stroke and so on and the way to remember this is with the four A's so the first day is aspirin the second a is atorvastatin and after somebody's had cardiovascular disease we try and get to eighty milligrams of at or statin compared to twenty in primary prevention the third a is at analog or any other beta blocker usually we use bisoprolol and you titrate that beta blocker to the maximum dose that they can tolerate and the fourth a is an ACE inhibitor quite often we use something like ramipril and again we titrate this to the maximum dose that they can tolerate based on their blood pressure and their symptoms just a final word on the side-effects of statins there's three major side effects that it's worth knowing about the first one is myopathy and this is where the statins cause some kind of problem with the muscle fibers in the body so the patient might complain of muscle pain or weakness and it's worth checking something called a creatine kinase which is a breakdown product from muscles and this will tell you whether they're suffering with myopathy or not the second is it can really cause type 2 diabetes or worse glucose control and the third thing is very very rarely statins have been linked with hemorrhagic strokes but usually the benefits of statins far outweigh the risks and the newer statin such as atorvastatin are usually very well tolerated and have little side effects so thanks for watching I hope you found this video helpful if you did don't forget there's plenty of other resources on the zero to finals website including loads and loads of notes on various different topics that you might cover in medical school with specially made illustrations there's also a whole test section where you can find loads of questions to test your knowledge and see where you're up to in preparation for your exams there's also a blog where I share a lot of my ideas about a career in medicine and tips on how to have success as a doctor and if you want to help me out on YouTube you can always leave me a thumbs up give me a comment or even subscribe to the channel so that you can find out when the next videos are coming out so I'll see you again soon