06-10-22 - Pathology of Heart failure, Hypertension, Aneurysms and Neoplasia Flashcards
Learning outcomes
- Distinguish between pulmonary and systemic hypertension.Describe the causes of systemic hypertension.Describe the end-organ effects of systemic hypertension.Describe the causes of pulmonary hypertension.Describe the end-organ effects of pulmonary hypertension
- .Define cardiac failure.State the differences between the following pairs of terms: acute and chronic cardiac failure; systolic and diastolic cardiac failure; right and left ventricular failure.Describe the causes of left and right ventricular failure.Describe the clinical effects of left and right ventricular failure
- Read a little about aneurysms
- Heart tumours are rare
Define cardiac failure.
What does it result in?
What is acute heart failure?
What is chronic heart failure?
What is acute-on-chronic heart failure?
- Cardiac failure is failure of the heart to pump sufficient blood, and deliver sufficient oxygen, to satisfy metabolic demands
- Results in under-perfusion which may cause fluid retention and increased blood volume
- Acute heart failure – rapid onset of symptoms, often with definable cause e.g. myocardial infarction
- Chronic heart failure – slow onset of symptoms, associated with, for example, ischaemic or valvular heart disease
- Acute-on-chronic heart failure – chronic failure becomes decompensated by an acute event
What is systolic failure? What are causes, effects, and treatment?
1) Systolic failure is:
* Failure of the pump to move blood in systole
* Reduced ejection fraction
* Reduced ventricular contraction
2) Causes
* Myocardial ischaemia
* Myocardial infarction
* Myocardial scarring
* Myocarditis
* Drugs eg alcohol, anti-cancer cytotoxics (drugs toxic to cells), cocaine
* Muscular disorders eg DMD
3) Effects
* Reduced cardiac output
* Feedback to atria and right side of heart
* Pulmonary oedema then
* Peripheral oedema
4) Treatment
* Lifestyle changes
* Medication that treats systolic heart failure
* Medication that lessens symptoms
* Surgery
- Medications for treatment of systolic failure:
1) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) relax the blood vessels to lower blood pressure.
2) Beta blockers make the heart beat more slowly and with less force.
3) Aldosterone blockers help the body release sodium and water.
4) Angiotensin receptor– neprilysin inhibitors (ARNIs) reduce excess fluid in the body and relax blood vessels, making it easier for your heart to pump blood.
What is diastolic failure? What are causes, effects, and treatment?
1) Diastolic failure is:
* Failure of ventricular wall to relax
* Restrictive, stiff ventricle
* Reduced ventricular filling leads to reduced blood for systole
* Elevated end diastolic pressure
2) Causes
* Scarring plus most causes of systolic
* Infiltrative disease eg amyloid
3) Effects
* None
* Pulmonary and peripheral oedema
* Response to exercise
* Tachycardia and pulmonary acute oedema
4) Treatment
* Reduce AV conduction – what else?
* Medications may be prescribed to treat or reduce symptoms of diastolic heart failure.
- They include:
1) Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors) and Angiotensin Receptor Blockers (ARBs), which relax blood vessels to improve blood flow.
2) Beta-blockers, which can reduce blood pressure and slow a rapid heart rhythm.
3) Calcium-channel blockers and long-acting nitrates to relax blood vessels, especially those that feed the heart muscle.
4) Diuretics to reduce your body’s fluid content by promoting urination.
5) Vasodilators to open blood vessels if you cannot tolerate ACE inhibitors or ARBs
What are causes of left and right ventricular failure?
- Causes of left and right ventricular failure:
1) Coronary heart disease
2) Hypertension
3) Cardiomyopathies
* Familial/genetic or non-familial/non-genetic (including acquired, e.g. Myocarditis)
* Hypertrophic (HCM)
* dilated (DCM)
* restrictive (RCM)
* arrhythmogenic right ventricular (ARVC)
* Unclassified
4) Drugs
* Beta-Blockers
* Calcium antagonists
* Anti-arrhythmics
* Cytotoxic agents
5) Toxins
* Alcohol
* Medication
* Cocaine
* trace elements (mercury, cobalt, arsenic)
6) Endocrine
* Diabetes mellitus
* hypo/hyperthyroidism,
* Cushing syndrome – condition caused by too much cortisol
* adrenal insufficiency
* excessive growth hormone
* phaeochromocytoma – rare tumour of adrenal glands
7) Nutritional
* Deficiency of thiamine, selenium, carnitine.
* Obesity
* Cachexia - weakness and wasting of the body due to severe chronic illness.
8) Infiltrative
* Sarcoidosis
* Amyloidosis
* Haemochromatosis - Haemochromatosis is an inherited condition where iron levels in the body slowly build up over many years.
* Connective tissue disease
9) Others
* Chagas’ disease - Chagas disease is caused by the parasite Trypanosoma cruzi
* HIV infection
* peripartum cardiomyopathy - weakness of the heart muscle that by definition begins sometime during the final month of pregnancy through about five months after delivery, without any other known cause
* end- stage renal fail
What are 2 common causes of left-ventricular failure?
What are 4 of the clinical effects of left ventricular failure?
What 2 complications can arise from left-ventricular failure?
What is combined left and right ventricular failure called?
- Common causes of left ventricular failure:
1) Cardiac ischaemia
2) Prolonged systemic hypertension - Clinical effects of left ventricular failure:
1) Cloudy lungs in the x-ray due to pulmonary oedema
2) Dilated blood vessels on the x-ray due to backlog of blood in the pulmonary circulation
3) Froth forming from breathing due to pulmonary oedema
4) Histologically, there is liquid in the alveoli instead of air - Complications that can arise from left-ventricular failure:
1) Pulmonary hypertension
2) Eventually right ventricular failure - Combined left and right ventricular failure often called congestive cardiac failure
What are 3 common causes of right ventricular failure?
What is another name for right sided heart failure?
What are 3 of the clinical effects of right ventricular failure?
What is right ventricular failure often secondary to?
- Common causes of right ventricular failure:
1) Secondary to left ventricular failure
2) Related to intrinsic lung disease - Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs
3) Pulmonary hypertension - Right-sided heart failure is also known as cor pulmonale or pulmonary heart disease.
- The clinical effects of right ventricular failure:
1) Congested ‘nutmeg’ liver du to backflow of hepatic vein in liver
2) Pitting oedema
3) Systemic hypertension - RV failure is often secondary to LV failure
What are 7 clinical changes of patients with heart failure?
- Clinical changes of patients with heart failure:
1) Appearance - alertness, nutritional status, weight
2) Pulse rate - rhythm, and character
3) Blood pressure - systolic, diastolic, pulse pressure
4) Fluid overload - jugular venous pressure
5) Peripheral oedema - (ankles and sacrum), hepatomegaly, ascites
6) Respiratory rate, crackles, effusion (transudate)
7) Apex displacement, gallop rhythm, third heart sound, flow murmurs suggesting valvular dysfunction
What is B-natriuretic protein (BNP)?
What is it produced by?
When is it released?
What receptor does it act on?
What are other proteins in the same family as BNP?
What are they produced by?
What are 7 functions of BMP?
- B-natriuretic protein (BNP) IS one of the natriuretic peptide hormone family
- BNP is produced by ventricular muscle
- It is released as a stress response protein to increases in heart failure
- BNP acts on the ANP receptor but with relatively lower affinity but longer half-life than other natriuretic proteins.
- Other proteins in the same family as BNP:
1) ANP produced in atrial muscle
2) CNP from large blood vessels
3) DNP present in blood probably originates from heart - Functions of BMP:
1) Vessel dilatation
2) Reduced load on heart
3) Changes in glomerular filtration
4) Inhibits renin secretion
5) Decrease aldosterone
6) Natriuresis
7) Reduction in blood pressure
What is cardiogenic shock?
- Cardiogenic shock, also known as cardiac shock, happens when your heart cannot pump enough blood and oxygen to the brain and other vital organs. This is a life-threatening emergency.
What is the definition of hypertension?
What are the 2 classifications of systemic hypertension?
What 4 conditions is hypertension a major risk factor for?
- Systemic hypertension by definition is persistent raised blood pressure above 140/90 mmHg
- Systemic hypertension can either be:
1) Primary (unknown cause) or secondary (caused by another disease)
* Primary hypertension makes up 95% of hypertension cases
2) Essential vs accelerated (based on clinical presentation)
* Essential hypertension is also known as primary or idiopathic hypertension
* Accelerated hypertension is defined as a recent significant increase over baseline BP that is associated with target organ damage
- Hypertension is a major risk factor for:
1) Cardiovascular disease
2) Ischaemic heart disease
3) Accelerated atherosclerosis
4) Alzheimer type dementia (not well understood)
What is epidemiology?
Epidemiology of hypertension?
- Epidemiology is the branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health.
- Epidemiology of hypertension:
- Hypertension is often symptomless, so screening is vital -before damage is done.
- About 30% of people aged 45-54 years have blood pressure (BP) that is at least 140/90 mm Hg.
- About 70% of people aged 75 years or older have BP that is at least 140/90 mm Hg
What is the optimal level for blood pressure?
What is considered to be hypertension?
How does this differ for older people?
What is isolated systolic hypertension?
What age group is it most common in?
- Optimal Blood pressure is between 90/60mmHg to 120/80mmHg
- Hypertension is considered to be 140/90mmHg or higher (or 150/90mmHg or higher if you’re over the age of 80)
- Isolated systolic hypertension happens when the diastolic blood pressure is less than 80mmHg and the systolic blood pressure is 130 mmHg or higher e.g >130/<80mmHg
- This is most common in >65 years old
What is secondary systemic hypertension?
How many cases of hypertension does it make up?
In what age group does it typically occur in?
What are diseases/situations that cause secondary hypertension? (6 sections)
- Secondary systemic hypertension is high blood pressure that’s caused by another medical condition
- Makes up about 5% of systemic hypertension cases
- Secondary hypertension typically occurs in patients <25 years old
- Diseases/situations that cause secondary hypertension:
1) Renal system diseases
* Renal parenchymal disease:
* Glomerular nephritis,
* Diabetic nephropathy,
* Lupus nephritis,
* Polycystic kidney disease
- Renal vascular:
- Renal artery stenosis
- Vasculitis
- Fibromuscular dysplasia
2) Endocrine system diseases:
* Adrenal gland:
* Zona glomerulosa (increase aldosterone) – Conn’s syndrome
* Zona fasciculata (increased cortisol) – Cushing’s syndrome
* Adrenal medulla – Pheochromocytoma (too much epinephrine/norepinephrine)
3) Pregnancy - Eclampsia, pre-eclampsia (high blood pressures during/after labour)
4) Coarctation of aorta (narrowing)
5) Drugs - Contraceptive pill, cocaine, amphetamine, NSAIDs, alcohol
6) Obstructive sleep apnoea
What is end organ damage?
What are examples of end organs?
What are the end organ effects of systemic hypertension?
- End organ damage usually refers to damage occurring in major organs fed by the circulatory system
- Examples of end organs:
1) Brain
2) Heart
3) Kidneys
4) Arteries
5) Eyes - End organ effects of systemic hypertension:
1) Vessels
* Primary hypertension causes slow changes in vessels and heart with chronic end-organ dysfunction
* Accelerated hypertension causes rapid changes in vessels with acute end-organ dysfunction
* Acceleration of atherosclerosis
* Intimal hyperplasia – abnormal accumulation of cells in the tunica intima
* Hyalinisation of arteries and arterioles - Hyalinization of renal arterioles involves accumulation of an amorphous, eosinophilic, glassy substance within the vascular wall
* Accelerated and severe hypertension – fibrinoid necrosis
2) Heart
* Left ventricular hypertrophy – causes fibrosis and arrhythmias
* Myocardial fibrosis is a common final pathway in chronic myocardial disease and is the structural correlate of heart failure
* Coronary artery atheroma – Ischaemic heart disease
* Cardiac failure
3) Kidneys
* Nephrosclerosis (vascular narrowing of nephrons) – cause proteinuria (protein in urine) and haematuria (blood in urine)
* Chronic renal failure
* Acute renal failure can be associated with accelerated and severe hypertension
4) Brain
* Atherosclerosis
* Ischaemia
* TIA Infarct (transient ischaemic attack – mini stroke)
* Haemorrhage
5) Eyes
* Flame haemorrhages
* Papilledema - Papilledema is a term that is exclusively used when an optic disc swelling is secondary to increased intracranial pressure (ICP)
* Hard exudates - Exudate is fluid that leaks out of blood vessels into nearby tissues
* Cotton wool spots - are common retinal manifestations of many diseases
What is the difference between transudate and exudates?
What are exudates and transudates?
- Transudates are caused by disturbances of hydrostatic or colloid osmotic pressure not inflammation
- Transudates are fluids that pass through a membrane or squeeze through tissue or into the extracellular space of tissues
- Exudates are caused by inflammation
- Exudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues
What are aneurysms?
What are the different types of aneurysms?
What are the 4 different ways aneurysms present?
- Aneurysms are localised, permanent, abnormal dilatation of blood vessel or the heart
- Different types of aneurysms:
1) Atherosclerotic
2) Dissecting – often thoracic aorta, associated with Marfan syndrome
3) Berry – occur in young people
4) Micro-aneurysms
5) Syphilitic
6) Mycotic – can be caused by bacteria/fungi e.g can be associated with infective endocarditis - 4 different ways aneurysms present:
1) True aneurysm – saccular
2) True aneurysm – fusiform
3) False aneurysm – blood escapes from the lumen of the vessel and forms a haematoma
4) Dissection – tear between intima and media, leading to pooling of blood
