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12 - Pathology: Heart 2


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Consequences of Left Sided Heart Failure
Pulmonary congestion and Edema
Consequences of Right-sided Heart Failure (4)
Increase in Systemic Venous pressure
-Pitting Edema
-Nutmeg liver
-Pleural effusions
What usually causes right sided heart failure?
Left-sided heart failure
What is Cor Pulmonale?
Pure right-sided heart failure due to chronic severe Pulmonary Hypertension
Histological cells of Left-sided Heart Failure
Hemosiderin-laden Macrophages = Heart Failure cells
Liver congestion in Right Sided Heart Failure first occurs in this part
Central Vein = centrilobular necrosis
Define Myocardial Ischemia
an imbalance between the supply (perfusion) and demand of oxygen in the heart
Causes 90% of Myocardial Ischemia
reduction in coronary blood flow due to Atherosclerotic coronary artery obstruction
An increased Myocardial metabolism could be due to this disease
Hyperthyroidism -> tachycardia -> increased O2 demand
Example of decreased oxygen transport resulting in Myocardial Ischemia
How is the dominant artery chosen?
the one that gives rise to teh Posterior Descending artery
-90% is the Right Coronary
Risk factors for Ischemic Heart Disease

Sex (Male>Female)
Increased weight
Pressure (Hypertension)
Ischemic Heart Disease can present in these 4 ways
1. Angina Pectoris
2. Chronic Ischemic Heart Disease
3. Myocardial Infarct
4. Sudden Cardian Death
Fixed obstruction occludes what percent of the lumen?
Soft atheromas are highly likely to result in what type of angina?
Unstable Angina
Most common form of angina
Stable angina is induced by __1__ and is caused by __2__
1. exercise
2. ischemia due to atherosclerotic narrowing of coronary arteries
Stable Angina is relieved by these 2 things

Explain Prinzmetal Angina (3)
-Coronary Artery SPASM at REST
- ST elevation = transmural ischemia
-Nitroglycerin helps
What characterizes Unstable (Crescendo) Angina
pain that is becoming more and more severe and is precipitated by less and less effort
What usually causes Unstable Angina
coronary atheromas that are prone to rupture
What is Myocardial Akinesis
where there are no contractions
What is Myocardial Dyskinasis
Where there are Abnormals contractions
3 consequences of Plaque rupture in Coronary Arteries
1. Healing
2. Embolism in downstream smaller mural vessels
3. Thrombosis -> unstable angina
Parts of the Heart that the Right Coronary Artery supplies

1. posterior wall of LV
2. Posterior part of Septum
3. RV
Parts of the Heart that the LAD supplies
1. anterior LV
2. Anterior septum
Parts of heart that Left Circumflex artery supplies
lateral wall of LV
Frequencies of Coronary Artery obstruction
LAD = 50%
RCA = 30%
LCX = 20%
Part of heart that is most susceptible to damage when principal blood flow is compromised (Hypotension)
Subendocardium (blood flows thru layers from outside to in)
Most coronary artery blood flow occurs during ventricular __________
Loss that occurs within seconds of Cardiac Ischemia
This is dimished in <2 minutes with Cardiac Ischemia
50% ATP depletion occurs within _____
10 minutes
90% ATP depletion occurs within ______
40 minutes
Irreversible Cell injury occurs within _________
20-40 minutes
Microvascular injury (endothelial damage of small terminal vessels) occurs after ________
1 hour
MI pathology:
4-24 hours = 1
1-2 days = 2
3-5 days = 3
5-7 days = 4
2-4 wks = 5
5-8 wks = 6
1. mottling or no apparent gross changes
2. pale-yellow, cell necrosis, PMN's
3. central yellow, red rim, necrosis peaks
4. mottled yellow-red, Macrophages
5. red-gray, granulation tissue, fibroblasts
6. scarring; collagen
When are the chances of Ventricular rupture the greatest after an MI
during the first week b/c collagen has not been put down yet
Characteristics of Transmural MI (4)
1. Q wave abnormality
2. Coronary Occlusion
3. limited to an ANATOMIC area
4. Epicarditis can occur
Characteristics of Subendocardial MI (4)
1. non-Q wave
2. Hypoperfusion
3. Circumferential
4. No Epicarditis
Irreversible injury of Ischemic Myocytes occurs first in this zone
Subendocardial zone
Preferred biomarker for diagnosing MI. Why?
Troponin I
-more specific for myocardial tissue
-increase in blood within 2-4 hours
-last for 7-10 days
Characteristics of CK-MB
1. elevated at 2-4 hours
2. lasts 72 hours (3 days)
After MI's, do most people have complications or not?
Complications arise in 80%
Most common complication after MI
What would cause an Infarct extension?
Retrograde movement of a thrombus
3 Types of Myocardial Rupture and their consequences
1. Ventricle Free wall rupture -> hemopericardium -> Cardiac Tamponade -> death

2. Ventricle Septum -> L to R shunt -> RV failure, Pulmonary HTN

3. Papillary Muscle rupture -> mitral regurgitation
When does free-wall rupture most frequently occur?
3-7 days post-MI = early complication
When do Ventricular Aneurysms typically occur?
Several Weeks-Months post-MI = Late Complication
The Lumen of Ventricular Aneurysms often contains?
Mural Thrombi
Rupture of the Septum causing L-to-R shunting is an early or late complication?
Early (3-7 days)
Papillary Muscle ruptures causes...
Mitral Valve Insuffiency
- Systolic Murmur
-Left-sided failure
-Pulmonary edema
3 treatments for Coronary Thrombosis
1. Thrombolytic Enzymes (Plasminogen Activator)

2. Coronary Angioplasty

3. Coronary artery bypass graft
Rheumatic Fever:
-Median age = 1
-Where common? = 2
-Immune response to: 3
1. 10 yoa
2. underdeveloped countries
3. S. pyogenes (Group A, beta-hemolytic)
Type of S. pyogenes infection that Acute Rheumatic Fever follows
Explain how S. pyogenes causes RF
S. pyogenes elicits an Immune response againsts its M protein that reacts with SELF
Most common manifestations of RF (2)
1. Joint pain
2. Carditis
Major Criteria for RF
1. Carditis
2. Polyarthritis
3. Chorea
4. Erythema Marginatum
5. Subcutaneous Nodules
4 minor criteria for RF
1. Previous history of RF
2. Fever
3. Lab findings
4. EKG (prolonged PR)
Criteria that must be met to Diagnose someone with RF
2 major, 1 minor
1 major, 2 minor
Most common cause of death in Acute RF
What are Aschoff Bodies?

granulomas that consist of:
-central area of fibrinoid necrosis
-surrounding M0 and lymphocytes
-M0 have "owl-eye" appearance
Type of Carditis that Acute RF causes
Pancarditis = effects the whole heart
RF Pericarditis has this appearance
"bread and butter"
Endocarditic Valve involvement in RF
Mitral > Aortic > Tricuspid
Are the verrucous lesions(fibrin vegetations) in RF sterile or septic?
Chronic Endocarditis from RF results in ________
Dystrophic Calcification -> Stenosis
Valvular Heart Disease can result in these 2 things
Valvular Stenosis

Valvular Insufficiency
Mitral Stenosis murmur
-opening snap
-mid-diastolic rumbling
Consequences of Mitral Stenosis
1. dilated/hypertrophy of L. Atrium
2. Pulmonary congestion
3. RVH
Mitral Insufficiency murmur
Systolic murmur
Consequences of Mitral Insufficiency
1. LA dilation/hypertrophy
2. Pulmonary congestion
3. RVH
4. *LVH* b/c it is receiving more blood
Most common stenosis of all Valvular abnormalities
Aortic Stenosis
Aortic Stenosis does not allow the outflow of blood from the LV into the Aorta during ________
Consequence of Aortic Stenosis
2. low peripheral arterial pressure
Aortic Stenosis murmur
high-pitched Systolic murmur
Most common cause of Mitral Stenosis
Rheumatic Fever
Most common cause of Mitral Insufficiency
Mitral Valve prolapse
-endocarditis and rupture
-or dysfxn of papillary muscle
Most common cause of Aortic Stenosis
Calcification due to old age

(or a congenital Bicuspid Aortic Valve)
Aortic insufficiency is due to .........
dilation of ascending aorta due Hypertension or Old Age
Mnemonic for most common Congenital Heart Diseases
-Patent ductus ateriosus
-Aortic Stenosis
-Tetralogy of Fallot
-Endocardial cushion defect
-Narrowing of Aorta (Coarctation)
-Transposition of great vessels

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