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Glossary of Cardiac Pathology

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Congestive Heart Failure
physical exam
-tachycardia
-S3
-fine rales at lung bases
-lower exremity edema
-hepatojugular reflux
-cardiomegaly
Case:
72 yo man with a past medical history of HTN and coronary artery disease status post CABG complains of breathlessness
Congestive Heart Failure
Congestive Heart Failure
-multisystem derangement that occurs when the heart is not longer able to eject blood delivered to it by the venous system
What is forward failure?
inadequate cardiac output
What is backward failure?
increased congestion of the venous circulation
What are the neurohumoral reactions of CHF?
catecholamines (NEPI- inc. heart rate and contractility)
What are the morphological changes of CHF?
concentric hypertrophy and eccentric hypertorphy
Concentric hypertrophy
ventricular wall thickness inc. w/o an inc. in the chamber size
Eccentric Hypertrophy
ventricular wall thickness and chamber size inc.
Dilatation
chamber enlargment
Compensated Heart Failure
dilated ventricle that is able to maintain CO at a level that meets the needs of the body
Decompensated heart failure
failing myocardium in no longer able to maintain a CO that meets the needs of the body
What are the common causes of left-sided heart failure?
1. systemic HTN
2. ischemic heart disease
3. miral or aortic valve disease
4. primary disease of the mycardium
What does left-sided heart failure lead to?
1. pulm. congestion
2. pulm. edema
3. small alveolar space hemorrhage
What are the common causes of right-sided heart failure?
1. left-sided heart failure
2. pulm. disease
3. congenital abnormalities
What does right-sided heart failure lead to?
-congestion of abdominal viscera
-soft tissue edema
-pleural effusions
-pericardial effusions
-ascites
What is nutmeg liver?
from right-sided heart failure caused by congestion of abdominal viscera
How common is heart failure
-common
-5 million in US each yr
-1 million hospital
-300,000 deaths
Case:
65yo man with diabetes, HTN and hypercholesterolemia with crushing chest pain that radiates to the jaw
Ischemic Heart Disease
Ischemic Heart Disease physical exam
-tachycardia, diaphoretic
-EKG with abnormal Q-wave
-elevated troponin I and CK-MB
What is ischemic heart disease caused by?
narrowing of the lumina of the coronary arteries by atherosclerosis
What results from ischemic heart disease?
1. angina pectoris
2. acute MI
3. sudden cardiac death
4. chronic ischemic heart disease with congestive heart failure
What is the incidence of ischemic heart disease?
men > 60
women > 70
What are risk factors for ischemic heart disease?
1. HTN
2. diabetes
3. smoking
4. high levels of LDL cholesterol
critical stenosis
75% or greater reduction in the lumen of one or more coronary arteries
What is the pathology of Ischemic Heart Disease?
-severe atherosclerosis of the coronary arteries
-acute plaque changes
-coronary artery vasospasm
Angina Pectoris
intermittent chest pain caused by transient, reversible myocardial ischemia
Typical or stable angina
fixed critical stenosis
Prinzmetal or variant angina
coronary artery spasm
unstable angina pectoris
(preinfarction angina)
acute plaque change
Myocardial Infarction
-development of an area of myocardial necrosis caused by local ischemia
-1.5 mil/yr -500,000 deaths
-M>F until after 80yo
What causes an MI?
MIs are caused by coronary artery thrombosis
Where do most MIs originate?
in the subendocardium
Transmural Infarcts
involve most of the ventricular wall thickness
Subendocardial infarcts
involve the inner one third of the myocardium
What are the complications from a MI? (6)
1. papillary muscle dysfunction
2. external rupture of infarct
3. mural thrombi
4. acute pericarditis
5. ventricular aneurysm
6. cardiac arrhythmias
*most common cause of death from MI
Chronic Ischemic Heart Disease
development of progressive congestive heart failure as a consequence of long term ischemic myocardial injury
Case:
55yo man w/ poor controlled HTN complains of headache and breathlessness at night w/ high BP and lt. vent. enlargement
Hypertensive Heart Disease
What abnormality is observed in a heart with a history of HTN?
-left ventricular hypertrophy
->450g
-vent. wall thicknes >2cm
Cor Pulmonale
Disease of right sided heart chambers caused by pulmonary HTN resulting from pulmonary parenchymal or vascular disease
Acute Cor Pulmonale
-usually caused by pulmonary embolism (>50% vascular obstruction)
-rt. vent. dilation
Chronic Cor Pulmonale
progressive rt. vent. hypertrophy then dilation
Valvular Heart Disease
deformed valves may cause disease by two mechanisms:
1. impose a major hemodynamic burden on the cardiac chambers by causing obstruction (stenosis) or regurgitation (incompetence)
2. are more susceptible to infection
Case:
13yo boy tired and short of breath and had sore throat two weeks prior. Presents w/ tachycardia, pericardial rub and faint heart sounds, erythematous rash on extremities and trunk
rheumatic fever
Rheumatic Fever
an acute, immunologically mediated, multisystem inflammatory disease that follows an episode of group A streptococcal pharyngitis in 3% of patients after an interval of a few weeks
What is the peak incidence of rheumatic fever?
5-15yo
Aschoff bodies
central focus of fibrinoid necrosis surrounded by a chronic mononuclear inflammatory infiltrate and occassional Anitschkow cells
Anitschkow cells
large macrophages w/ vesicular nuclei and abundant basophilic cytoplasm (pathognomonic for RF)
Acute Rheumatic Carditis
inflammatroy changes in all three layer of the heart:
1. pericardium- fibrinous pericarditis; effusions
2. myocardium- heart failure
3. endocardium- valvular damage
Verrucous Endocarditis
-resolve w/o sequalae
-irreversible deformity of one or more valves
1. mitral valve- most commonly affected, stenosis and/or regurgitation, predisposition for infective endocarditis
2. aortic valve- stenosis and/or regurgitation, predisposition for infective endocarditis, fusion of aortic valve commissures
Calcific Aortic Stenosis
-irregular calcium deposits behind valve cusps
-congenitally bicuspid valves
-normal valves as an age-related degenerative change
What is the most common cause of aortic stenosis?
calcific aortic stenosis
Case:
27yo woman presents for routine physical and has systolic murmur with a midsystolic click
mitral valve prolapse
What is the most frequent valvular lesion? (7%)
mitral valve prolapse
Mitral Valve Prolapse
-in young women
-stretching of post. mitral valve leaflet (systolic murmur w/ midsystolic click)
-can result in mitral insufficiency
-predisposes to infective endocarditis
Nonbacterial Thrombotic Endocarditis
-deposisiton of sterile small masses of fibrin, platelets, and other blood components on the leaflets of the cardiac valves
-can embolize
-usually resolve spontaneously
-infective endocarditis as a complication
What is the most common place for nonbacterial thrombotic endocarditis?
mitral valve then aortic valve
Libman-Sacks Endocarditis
sterile vegetations that develop on cardiac valves of patients with systemic lupus erythematosus
Where do Libman-Sacks endocarditis vegetations occur?
either surface of mitral and tricuspid valves
Case:
29yo man w/ fever and shaking chills and venopuncture sites on arms and sclerotic veins and one necrotic toe on each foot
temp104 HR140 BP90/50
Infective Endocarditis
Infective Endocarditis
-bacterial or fungal infectios of the endocardium particularly the valvular surfaces (mitral)
-soft friable vegetations composed of inflamm. cells and bacteria
What are risk factors for infective endocarditis?
1. preexisting cardiac abnormalities (alpha hemolytic strep)
2. prosthetic heart vlaves (coagulase neg. staph)
3. intravenous drug abuse (tricuspid- staph aureus)
What are complications from infective endocarditis? (2)
1. distal embolization
2. ring abscesses
What are complications from prosthetic valves? (5)
1. mechanical deterioration
2. thrombi
3. infective endocarditis
4. paravalvular leaks
5. hemolysis
Myocarditis
inflammation of the myocardium
What causes myocarditis? (3)
1. infection (virus, bacteria, fungi, parasites)
2. immune-mediated reactions (postviral, poststrep, SLE, drug, tx regection)
3. unknown (sarcoid, giant cell myocarditis)
Cardiomyopathies
primary abnormality of myocardium
Dilated Cardiomyopathy
*most common
progressive cardiac hypertrophy, dilation and contractile dysfunction
Hypertrophic Cardiomyopathy
-hypertrophy of vent. wall, particularly the septum w/ abnormal diastolic filling and lt. vent. outflow obstruction
-arrhythmias and sudden death (young athletes)
Restictive Cardiomyopathy
infiltrative process w/in the myocardium that results ina decrease in vent. compliance w/ impaired diastolic filling and cotractile dysfunction
Congenital Heart Disease
lt. to rt. shunts
rt. to lt. shunts
obstruction
Left to Right Shunts
-ASD
-VSD
-PDA
Right to Left Shunts
-tetralogy of fallot
-transposition of the great arteries
Congenital Obstruction
coarctation of the aorta
Tetralogy of Fallot (4)
1. VSD
2. dextraposed aortic root that overrides the VSD
3. RV outflow obstruction
4. RV hypertrophy
Pericardial Diseases (3)
1. pericarditis
2. pericardial effusions
3. hemopericardium
Pericarditis
-primary- viruses
-secondary- acute MI, cardiac surgery, uremia, acute rheumatic fever
Pericardial Effusions
-serous- heart failure
-serosanguinous- trauma, malignancy
-chylous
Hemopericardium
cardiac tamponade (usually trauma)
Cardiac Tumors- Metastic Neoplasms
lung and breast
Cardiac Tumors- primary neoplasms
1. myxomas *most common
2. cardiac rhabdomyomas

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