30 - Cardiovascular Disease 3 Flashcards
Endocarditis is… + two types
inflammation of endocardium
prototypical lesion = vegetation on valves
infective and non-infective
Types of non=infective endocarditis
Nonbacterial thrombotic endocarditis
Endocarditis of SLE (Libman-Sacks disease)
Acute infective endocarditis
Highly virulent
Necrotising, ulcerative, destructive lesions
Difficult to cure and death occurs despite treatment
Sub-acute infective endocarditis
lower virulence
insidious infections of deformed valves
cured with antibiotics
Strep. bovis endocarditis indicates
Investigation into bowel cancer
Complications of infective endocarditis
immunologically mediated conditions e.g. glomerulonephritis
Clinical presentation of IE
splinter/subungual haemorrhages
Janeway lesions
Osler’s nodes
Roth spots
Janeway lesions
erythematous or haemorrhagic non-tender lesions
Osler’s nodes
Subcutaneous nodules in the pulp of the digits
Roth spots
Retinal haemorrhages in the eyes
FROM JANE
Fever
Roth spots
Oslers nodes
Murmurs
Janeway lesions
Anaemia
Nail - splinter haemorrhage
Emboli (septic)
Non-infective endocarditis abbreviation
NBTE
NBTE - who?
debilitated patients
those in hyper coagulable state
Trousseau syndrome
Endocardial trauma
Non-infective endocarditis libman-sacks endocarditis
associated with SLE usually asymptomatic
Rheumatic fever - what is it
acute, immunologically mediated multi-system inflammatory disease follow group A strep pharyngitis
Aschoff bodies
distinctive cardiac lesions
foci of T-cells, plasma cells and macrophages
Rheumatic fever - pathological features
Features of vegetations called veruccae
Mitral valve changes are classical - virtually ONLY cause of mitral stenosis
Leaflet thickening
Fibrous bridging of valvular commissures & calcification
Rheumatic fever - pathogenesis
antibodes against M proteins of Strep A cross react with self-antigens in the heart. CD4 cells specific for strep peptide react with proteins on heart.
Produce cytokines that activate macrophages e..g Aschoff bodies
Pericarditis - causes
inflammation of pericardial sac due to…
Coxsackie B, bacteria, TB, fungi, parasites
Rheumatic fever, SLE, scleroderma, post-cardiotomy
Late post-MI = dressler’s, drug hypersensitivity
Misc. conditions = post MI, uraemia, cardiac surgery, neoplasia, trauma, radiation
Acute pericarditis -
serous serofibrinous purulent haemorrhagic caseous
Chronic pericarditis -
adhesive
adhesive mediastinopericarditis
constrictive pericarditis
Serous pericarditis -
inflammation causes clear serous fluid accumulation
caused, generally, by non-infectious aetiologies - most common, inflammation of adjacent structures. rarely by viral pericarditis (coxsackie B/ echovirus)
Serous pericarditis - causes
Rheumatic fever, SLE, scleroderma
Uraemia, neoplasia, radiation
Dressler’s syndrome
2°pericarditis
aka - post-MI syndrome
Triad: fever, pleuritis chest pain, pericardial effusion
Autoimmune rxn to antigens released following myocardial infarction
Delay of weeks therefore not acute pericarditis
Pericarditis - clinical presentation
Exacerbated by: movement, respiration, laying flat
Relieved: sitting forward
Radiating: shoulders/neck
Differentials: angina, pleurisy
loudest pleural rub over diaphragm
fever, leucocytosis, pericardial effusion
Pericarditis - complications
pericardial effusion / cardiac tamponade
Types of cardiomyopathy
Dilated
Hypertrophic
Restrictive
Arrythmogenic right ventricular cardiomyopathy
Dilated cardiomyopathy - pathogenesis
progressive dilation -> contractile (systolic dysfunction)
heart enlarged heavy and flabby
Dilated cardiomyopathy - causes
genetic - AD
alcohol or chemo
SLE, scleroderma, thiamine def. , acromegaly, thyrotoxicosis, diabetes
Dilated cardiomyopathy - who?
20-50
slow progressive signs
Dilated cardiomyopathy - 5 yr survival
25%
death due to CCF, arrythmia / embolism
Dilated cardiomyopathy - treatment
cardiac transplantation
long-term ventricular assist
Hypertrophic cardiomyopathy -
stiff LV myocardium
diastolic dysfunction with preserved systolic function
Hypertrophic cardiomyopathy - causes
100% genetic
Hypertrophic cardiomyopathy - clinical features
low stroke volume due to impaired diastolic filling
obstruction to LV outflow in 25% of patients
exertional dyspnoea
systolic ejection murmur
Hypertrophic cardiomyopathy - complication
AF mural thrombus formation cardiac failure ventricular arrythmias sudden death in some familes and sudden death in athletes
Hypertrophic cardiomyopathy - treatment
decreased heart rate and contractility - B-adrenergic blockers
reduction of the mass of the septum
Restrictive cardiomyopathy -
1°decrease in ventricular compliance due to impaired vent filling during diastole
Restrictive cardiomyopathy - idiopathic or 2°
fibrosis, amyloidosis, sarcoidosis, metastatic tumours or deposition of metabolites
Restrictive cardiomyopathy - morphology
ventricles normal size but with slightly enlarged chambers.
myocardium is firm and non-compliant
Arrythmogenic right ventricular cardiomyopathy -
aka arrhythmogenic RV dysplasia
AD - 1in5k
Arrythmogenic right ventricular cardiomyopathy - morphology
RV dilation / myocardial thinning
Fibrofatty replacement of RV
Disorder of cell-cell desmosomes
Exercise causes cells to detach and die
Arrythmogenic right ventricular cardiomyopathy - clinical presentation
silent, syncope, chest pain, palpitations, sudden cardiac death in the young during exercise
Myocarditis - cause
infections (most) - Coxsackie A&B viruses; Chagas disease (Trypanosoma cruzi - protozoa)
Myocarditis - clinical features
asymptomatic
heart failure, arrhythmias and sudden death
non-specific - fatigue, dyspnoea, palpitations, precordial discomfort and fever
can mimic acute MI
DCM can develop
maybe steal slide 57 of 82
for causes of myocarditis
Vasculitis -
inflammation of vessel walls
any organ and any vessel
GCA stands for
giant cell arteritis
GCA - who?
elderly in west
GCA - pathology
chronic granulomatous inflammation
large -> med arteries
esp. head art. e.g. temporal also vertebral and ophthalmic arteries
aorta = giant cell aortitis
ophthalmic arterial involvement: permanent blindness
MEDICAL EMERGENCY
GCA - morphology
intimal thickening
med. granulomatous inflammation -> elastic lamina fragmentation
multinucleated giant cells
GCA - clinical presentation
Rare
GCA - diagnosis
biopsy
GCA - treatment
corticosteroids
anti-TNF therapy in refractory cases
Aneurysms -
localised, permanent, abnormal dilatations of a blood vessel
Aneurysms - aetiology
atherosclerotic dissecting berry microaneurysms syphilitic mycotic false
What is a dissecting aneurysm?
Tear in the wall
blood tracks between intimal and medial layers
Dissecting symptoms
Tearing pain in chest radiating to upper left shoulder
Most common dissecting aneurysm
thoracic aorta 2°to systemic hypertension.
progressive vascular occlusion and haemopericardium. High mortality w/o treatment
Dissecting aneurysm
Aim to reduce arterial pressure / surgery
Berry aneurysm -
small, saccular lesions that develop in the circle of willis
develop at sites of medial weakness at arterial bifurcations
Berry aneurysm - who?
young hypertensive patients
Berry aneurysm - what does rupture cause?
subarachnoid haemorrhage (SAH)
Charcot-Bouchard aneurysms -
occur in intracerebral capillaries in hypertensive disease, causing intracerebral haemorrhage
retinal microaneurysms can develop in diabetes
Mycotic aneurysms -
rare
weakening of arterial wall 2°to bacterial/fungal infection
organisms enter media from the vasa vasorum
SBE is the most common underlying infection
often in cerebral arteries
infections of AAAs -> risk rupture
What is a false aneurysm?
Blood filled space around a vessel, usually following traumatic rupture or perforating injury
False aneurysm morphology
adventitial fibrous tissue contains the haematoma
commonly seen following femoral artery puncture during angiography/plasty
6 Ps
Pale Pulseless Painful Paralysed Paraesthetic Perishing cold
