Cardiac Pathology
Terms
undefined, object
copy deck
-
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