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Cardio Exam 1 > 12 - Cardiovascular Pathology III > Flashcards

12 - Cardiovascular Pathology III Flashcards

1
Q

What is the estimated prevalence of hypertension in the US?

A

Over 70 million

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2
Q

How do you diagnose hypertension??

A

Greater than 139/89

Three consecutive readings at least one week apart

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3
Q

What populations are at greater risk of developing hypertension?

A
  • Elderly (increases with age)

- African Americans

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4
Q

What can hypertension cause?

A

Hypertensive heart disease is the leading cause of illness and death from high blood pressure.

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5
Q

What are causes of secondary hypertension?

A
  • Acute glomerulonephritis
  • Chronic renal disease
  • Polycystic disease
  • Renal artery stenosis
  • Adrenocortical hyperfunction (Cushing’s, primary aldosteroism)
  • Pheochromocytoma
  • Hyperthyroidism
  • Pregnancy induce hypertension
  • Increased intracranial pressure
  • Sleep apnea
  • Acute stress (surgery)
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6
Q

What are some curable causes of systemic hypertension?

A
  • Cushing’s disease/syndrome
  • Adrenal cortical adenoma
  • Pheochromocytoma
  • Renal artery stenosis
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7
Q

What is optimal blood pressure?

A

Less than 120/80

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8
Q

What is prehypertension

A

120-139/80-89

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9
Q

What is stage I hypertension?

A

140-159/90-99

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10
Q

What is stage II hypertension?

A

Greater than 160/100

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11
Q

What is a hypertensive crisis? AKA malignant hypertension

A

Greater than 180/120

Medical emergency ***

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12
Q

What are the long term effects of hypertension on the brain?

A
  • Cerebrovascular accident (stroke)

- Hypertensive encephalopathy (confusion, headache, convulsion)

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13
Q

What are the long term effects of hypertension on the vessels?

A

Increased atherosclerosis

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14
Q

What are the long term effects of hypertension on the retina?

A

Hypertensive retinopathy

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15
Q

What are the long term effects of hypertension on the heart?

A
  • Myocardial infarction (heart attack)
  • Hypertensive cardiomyopathy
  • Heart failure
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16
Q

What are the long term effects of hypertension on the kidneys?

A
  • Hypertensive nephropathy

- Chronic renal failure

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17
Q

What would you actually see in hypertensive retinopathy?

A
  • Cotton wool spots (retinal cells have come together)
  • Exudates
  • Hemorrhage
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18
Q

What will you see in hypertensive damage of the kidney?

A

HTN kidney

  • Sclerosis of the kidney
  • Intimal thickening
  • Retraction of the surface
  • Can eventually lead to chronic renal failure
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19
Q

What will you see in hypertensive damage to the vasculature?

A
  • Buildup of hyaline

- Smooth muscle proliferation

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20
Q

What are you at risk for with malignant hypertension?

A

Intracranial hemorrhage

This is the very worst case

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21
Q

When BP levels are elevated in the long term, what are you at risk for?

A
  • Left ventricular hypertrophy
  • Accelerated coronary artery disease
  • Cardiac arrhythmias
  • Congestive heart failure
  • Sudden cardiac death
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22
Q

Give a brief description of right and left sided heart disease

A

Systemic hypertension –> Left sided heart disease

Pulmonary hypertension –> Right sided heart disease (Cor pulmonale)

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23
Q

How high does BP have to be to cause left-sided heart failure?

A

Even mild hypertension (levels only slightly above 140/90 mm Hg), if sufficiently prolonged, induces left ventricular hypertrophy.

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24
Q

Is the whole or part of the left ventricle typically affected?

A

Left ventricular hypertrophy (usually concentric – involves the entire left ventricle) in the absence of other cardiovascular pathology

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25
Q

What types of cells will we see in left-sided heart failure tissue?

A

Box car appearance cells packed full of proteins

The cells are producing more proteins and things to deal with the hypertrophy

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26
Q

What causes right sided hypertension?

A

Pressue overlaod of the right ventricle

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27
Q

What are the characteristics of right-sided hypertension?

A
  • Right ventricular hypertrophy
  • Dilation
  • Heart failure can develop
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28
Q

What is cor pulmonale?

A

When the pulmonary hypertension is due to lung disease, we call it cor pulmonale

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29
Q

What is the most common cause of right sided hypertension?

A

Lung disorders

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30
Q

Describe the effect of hypertensive heart disease on life expectancy

A
  • Even moderate elevation of arterial pressure leads to shortened life expectancy.
  • At severely high pressures, mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.
  • If you have an adverse event, you have an even higher chance of dying
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31
Q

What is valvular heart disease?

A

A condition that results in stenosis, insufficiency (regurgitation or incompetence) or both

32
Q

What is stenosis?

A

Stenosis is the failure of a valve to open completely. Stenosis leads to pressure overload of the heart

33
Q

What is insufficiency?

A

Insufficiency, in contrast, results from failure of a valve to close completely, thereby allowing reversed flow. Valvular insufficiency leads to volume overload of the heart.

Valve can’t close properly

34
Q

What are the top four most frequent causes of valvular heart disease (VHD)?

A

1 - Aortic stenosis
2 - Aortic insuffiviency
3 - Mitral stenosis
4 - Mitral insufficiency

35
Q

What is aortic stenosis?

A

calcification of anatomically normal and congenitally bicuspid aortic valves

36
Q

What is aortic insufficiency?

A

dilation of the ascending aorta, usually related to hypertension and aging

37
Q

What is mitral stenosis?

A

Mitral stenosis: rheumatic heart disease

38
Q

What is mitral insufficiency?

A

myxomatous degeneration (mitral valve prolapse)

39
Q

What are the major causes of acquired heart valve disease?

A
  • Senile calcification, calcification of congenitally deformed valve, calcification of mitral ring
  • Postinflammatory scarring (rheumatic heart disease)
  • Mitral valve prolapse
  • Rupture or dysfunction of papillary muscle, rupture of chordae tendineae
  • Infective endocarditis (IV drug abuse)
  • LV enlargement (dilated cardiomyopathy, myocarditis)
  • Aortic Disease - (degenerative aortic dilation, Syphilitic aortitis, and Rheumatoid arthritis, reactive arthritis, aortitis)
  • Marfan syndrome
40
Q

What conditions lead to BOTH stenosis and regurgitation?

A
  • Calcification of congenitally deformed valve (bicuspid)

- Postinflammatory scarring (rheumatic heart disease)

41
Q

What conditions lead to ONLY stenosis?

A
  • Senile calcific aortic stenosis
42
Q

What conditions lead to ONLY regurgitation?

A
  • Idiopathic (spontaneous)
  • Infective endocarditis
  • Degenerative aortic dilation (Syphilis, rheumatoid arthritis, Marfans, Ehlers-Danlos)
43
Q

What do the clinical consequences of valvular heart disease depend on?

A

Depends on the valve involved, the degree of impairment, how fast it develops, and the rate and quality of compensatory mechanisms.

44
Q

What is the MOST COMMON of all valvular abnormalities?

A

Calcific aortic stenosis

45
Q

Why does calcific aortic stenosis usually develop?

A

Usually the consequence of age-associated “wear and tear” of either anatomically normal valves or congenitally bicuspid valves (∼1% of the population).

46
Q

Describe the age at which the valves affected usually calcify

A

Senile calcific aortic stenosis occurs seventh to ninth decades of life, whereas stenotic bicuspid valves tend to present in patients 50 to 70 years of age.

47
Q

What happens in aortic stenosis?

A
  • Valve can’t open completely
  • You get a jet stream coming out of the aorta
  • Left ventricle has to do more work in order to get the blood out
48
Q

What do we know about the development of calcific aortic stenosis?

A

Prior work attributed aortic valve calcification to wear and tear degeneration and dystrophic and passive accumulation of hydroxyapatite, the same calcium salt that is found in bone.

49
Q

What have recent studies suggested about calcific aortic stenosis?

A

More recent studies suggest that chronic injury due to hyperlipidemia, hypertension, inflammation, and other factors implicated in atherosclerosis may have a role and perhaps even precede the calcification.

50
Q

Is there fusion of the valves seen in calcific aortic stenosis?

A

No

51
Q

Where do we see the calcification in calcific aortic stenosis?

A

Within the sinuses of Valsalva

52
Q

What is the long-term effect of calcific aortic stenosis?

A

The left ventricular myocardium is exposed to progressively increasing pressure overload
as the stenosis gets worse resulting in LVH

53
Q

What are the clinical features of calcific aortic stenosis?

A
  • Left ventricular (pressure overload) hypertrophy.
  • The hypertrophied myocardium tends to be ischemic (as a result of diminished microcirculatory perfusion, often complicated by coronary atherosclerosis), and angina pectoris may appear.
  • Cardiac decompensation and CHF may ensue
54
Q

What is the prognosis of calcific aortic stenosis?

A

50% with angina will die within 5 years and 50% with CHF will die within 2 years if the obstruction is not alleviated by surgical valve replacement.

55
Q

Is medical therapy effective?

A

Medical therapy is ineffective in severe symptomatic aortic stenosis.

56
Q

What is the prognosis of asymptomatic patients?

A

In contrast, asymptomatic patients with aortic stenosis generally have an excellent prognosis.

57
Q

Is it common to get calcific stenosis on congenitally deformed valves?

A

Yes

Bicuspid aortic valves are responsible for approximately 50% of cases of aortic stenosis in adults. Usually uncomplicated early in life.

Late complications of BAV include aortic stenosis or regurgitation, infective endocarditis, and aortic dilation and/or dissection.

58
Q

How common is aortic valve sclerosis?

A
  • Incidence: 29% of adults over 65yo and increases with age.
  • Leads to aortic valve stenosis in 2% of cases which warrants valve replacement.
  • 1.5X risk of cardiovascular death
59
Q

What is aortic valve insufficiency (AI)?

A

Leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.

60
Q

What causes aortic valve insufficiency?

A

This results in aortic backflow and massive LVH with dilatation and LV failure.

61
Q

What is the etiology of aortic valve insufficiency?

A
  • Rheumatic
  • Endocarditis
  • Aortic root dilatation
  • Degenerative aortic dilation
  • Syphilis
  • Rheumatiod Atheritis
  • Reactive Atheritis
  • Aortitis
  • Marfan’s syndrome
  • Ehlers-Danlos syndrome

A lot of this has to do with the aging population

62
Q

What is rheumatic fever?

A

Multisystem inflammatory disease that occurs a few weeks after an episode of group A streptococcal pharyngitis 3% of infected patients.

63
Q

What are the characteristics of rheumatic fever?

A

(1) migratory polyarthritis of the large joints
(2) pancarditis (affects ALL the tissues of the heart)
(3) subcutaneous nodules
(4) erythema marginatum of the skin
(5) Sydenham chorea, a neurologic disorder with involuntary rapid, jerky, purposeless movements

64
Q

Describe sydenham chorea

A

Jerky movements that start during the course of the disease - See this in children

65
Q

What is the Jones criteria for diagnosing rheumatic fever?

A

Two major symptoms or one major symptom and two minor symptoms

66
Q

What are the major symptoms of rheumatic fever?

A
  • Migratory polyarthritis
  • Carditis
  • Subcutaneous nodules
  • Erythema marginatum
  • Sydenham’s chorea
67
Q

What are the minor symptoms of rheumatic fever?

A
  • Fever
  • Arthralgia: Joint pain without swelling
  • Elevated ESR or CRP
  • Leukocytosis
  • Heart block
  • Elevated Antistreptolysin O titer or DNAase
  • Previous episode of rheumatic fever
68
Q

What causes rheumatic fever?

A

An immune reaction to post-streptococcal (Gp A, β- hemolytic) pharyngitis

69
Q

Describe the immune reaction

A

Antigenic mimicry between streptococcal antigens, mainly M-protein epitopes and human tissues, such as:

  • Heart valves
  • Myosin and tropomyosin
  • Brain proteins
  • Synovial tissue and cartilage

This has been proposed as the triggering factor leading to autoimmunity in individuals with genetic predisposition

70
Q

What kind of immune response does this initiate?

A

FULL IMMUNE RESPONSE

  • Humoral response AND…
  • T cell response (with killer and other cells)
  • You destroy the antigen, but also heart tissue, valvular tissue, skin, brain, joints, etc.
71
Q

What part of the heart does the initial infection affect?

A

Initial infection can effect the whole heart resulting in a pancarditis.

  • Pericarditis – fibrinous
  • Myocarditis – with Aschoff bodies
  • Endocarditis – inflammation of valves with verrucae, scarring, fibrosis and complications of rheumatic valve disease.
72
Q

If the valves are affected by rheumatic heart disease, which most likely to be affected?

A

1 - Mitral
2 - Aortic
3 - Tricuspid
4 - Pulmonic

73
Q

What is rheumatoid heart disease pancarditis?

A

Inflammation of the entire heart

This will be seen in ACUTE RHEUMATIC FEVER - This will not be seen way down the road

74
Q

What are verrucae?

A

Warts

  • Not destructive, but that’s where the inflammation starts
  • If the inflammation continues, you get thickening of the valvular material
  • Fusion of the commissures in late lesion AV in addition to sclerosis or calcification
75
Q

What does mitral valve stenosis look like in rheumatoid heart disease?

A

Fish mouth appearance

Cardio Exam 1 (15 decks)

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