Blood Vessels and CVS Flashcards
What are the Three patterns of arteriosclerosis?
- Atherosclerosis
- Medial Calcific Sclerosis
- Arteriolosclerosis
• Atheromatous plaques project
into and obstruct the lumen
and weaken the media
Atherosclerosis
• Chronic inflammatory response of the arterial wall initiated by injury to the endothelium • Atheromatous plaques located in intima obstruct vessel lumen and weaken vascular wall
Atherosclerosis
- Calcification of media
* Does not encroach on vessel lumen
MEdial calcific sclerosis
• Affects arterioles • Thickened walls reduce lumen diameter causing ischemic injury • Hyaline arteriolosclerosis – Benign hypertension – Diabetes mellitus • Hyperplastic arteriolosclerosis – Malignant hypertension (200/120 mm Hg) • Ischemia: reduced blood flow • Hypoxia: deficiency of oxygen • Infarct: complete loss of blood supply causes localized area of necrosis
Arteriosclerosis
What are the 3 Stages in the Progression of Atherosclerosis in order?
- Fatty streak
- Atheroma (plaque): covered by fibrous
cap - Complicated plaque: ulcerated
Lipid-filled foam cells (macrophages) within
the intima
Fatty streak
Plaque-like lesion that begins
in the intima and impinges on
the vessel lumen
Atheroma
Complications of \_\_\_\_\_\_: 1. Ischemic injury: Compromised blood flow to distal organs 2. Disruption: Exposes thrombogenic substances 3. Thrombosis: Clotting on surface of ulcerated plaque causes further narrowing 4. Embolization: Thrombus or plaque material may embolize (thromboembolus) 5. Hemorrhage: A hematoma may expand or rupture plaque 6. Aneurysm: Weak wall may dilate and rupture
Atheromas
Major Clinical Consequences of \_\_\_\_\_\_\_ • Myocardial infarct: Heart attack • Cerebral infarct: Stroke • Aortic aneurysm: Rupture • Peripheral vascular disease: Gangrene of legs
Atherosclerosis
Risk Factors for _______
Constitutional (non-modifiable) risk factors
– Age– Gender– Family history– Genetic abnormalities
Major (modifiable) risk factors
– Hyperlipidemia– Hypertension– Cigarette smoking– Diabetes mellitus
- Multiple risk factors
multiplies risk
Additional risk factors
– Obesity– Physical activity– Personality type– Alcohol– Trans fatty acids– Lipoprotein A – Hyperhomocystinemia– Systemic inflammatory state (C-reactive protein CRP)
Atherosclerosis
• Total Cholesterol < 200 mg/dl • Low Density Lipoprotein < 100 mg/dl – “Bad cholesterol” – Delivers cholesterol to peripheral tissues • High Density Lipoprotein > 40 mg/dl – “Good cholesterol” – Mobilizes cholesterol from atheromas and transports it to the liver for excretion
Hyperlipidemia
- Syphilitic aortitis of ascending aorta may occur in tertiary syphilis
- Obliterative endarteritis of the vasa vasorum
Syphilitic Aneurysm
• An intimal tear allows dissection of blood into media: may rupture leading to massive
hemorrhage
• Risk factors: hypertension, connective tissue abnormality (Marfan Syndrome)
Arteria dissection
• Cirrhosis of liver causes portal
hypertension
• Rupture producing massive upper
GI bleed
Esophageal Varices
• Prolonged increased intraluminal pressure and loss of vessel wall support produces dilated, tortuous veins
valvular incompetence
• Venous stasis - congestion, edema, pain,
Varicose veins
- Lymphatic spread of bacterial infection
* Painful red streaks and regional lymphadenopathy
Lymphangitis
• Compression of superior vena cava by neoplasm obstructing venous return
Superior vena cava syndrome
• Inflammation of the blood vessel wall
• Etiology unknown: most cases are not infectious
• Clinical features
– Systemic : non-specific symptoms of inflammation
• Fever, fatigue, weight loss, myalgias
– Local : symptoms of organ ischemia due to luminal narrowing or thrombosis
Vasculitis
• Most common form of vasculitis in older adults: Females over 50y • Granulomatous vasculitis • Flu-like symptoms with muscle and joint pain. ESR elevated • Branches of carotid artery – Headache – Visual disturbances 50% – Jaw claudication • Treatment: Anti-inflammatory – Corticosteroids
Large Vessel Vasculitis: Temporal (Giant Cell) Arteritis
• Necrotizing arteritis involving multiple organs: lungs spared • Association with Hepatitis B • Classical presentation : young adults – Hypertension: Renal artery involvement – Abdominal pain with GI bleeding: • mesenteric artery involvement – Neurologic disturbances – Skin lesions
Medium Vessel Vasculitis: Polyarteritis Nodosa
• Necrotizing granulomatous vasculitis • Target organs: Nasopharynx, lungs, kidneys – Nasopharyngeal ulceration, sinusitis – Hemoptysis: Lung involvement – Hematuria: Renal involvement • Glomerulonephritis – ^ Middle-aged males • “Strawberry” gingiva • Antiproteinase-3 (PR3) • c-ANCA 95%
Small Vessel Vasculitis: Wegener Granulomatosis
• Optimal blood pressure:
<120 and <80
• Normal blood pressure
<130 and <85
• Stage I Hypertension
140-159 or 90-99
• The final common pathway of many forms of heart disease • Inability of the heart to pump a sufficient amount of blood through the body • Onset preceded by compensatory mechanisms (cardiac hypertrophy)
CHF
Left-sided heart failure: _____ edema
pulmonary
edema
Right-sided heart failure: _____ edema
peripheral
edema
______ dysfunction: Deterioration of
contractile function
– Ischemic heart disease
– Hypertension
Systolic
______ dysfunction: Inability to
relax, expand and fill
– Left ventricular hypertrophy
Diastolic
______ hypertrophy
• Concentrically increased wall thickness
• Seen in hypertension, aortic stenosis
Normal LV < 1.5 cm
Pressure-Overloaded Hypertrophy
_____ hypertrophy
• Dilation of chambers
• Valvular incompetence
Volume-Overloaded Hypertrophy
• Caused by: – Ischemic heart disease – Hypertension – Valvular disease: aortic and mitral valves • Clinical effects result from – Decreased peripheral blood pressure and flow – Backup of blood in pulmonary circulation • Pulmonary congestion • Pulmonary edema
Left sided heart failure
• Dyspnea : Shortness of breath
• Orthopnea: Difficulty breathing when lying flat
• Paroxysmal nocturnal dyspnea: Awakened by severe shortness
of breath and relieved by sitting up
Left sided heart failure
- Pure right-sided heart failure
- Right ventricular hypertrophy and dilation
- Pulmonary hypertension
Cor pulmonale
• Congestion in systemic and portal venous circulations • Congestive hepatomegaly: – Chronic passive congestion – “Nutmeg” liver • Congestive splenomegaly • Pleural effusion • Peripheral edema: pitting edema • Most common cause of right-sided heart failure is left-sided heart failure
Right sided heart failure
• Result of coronary artery atherosclerosis • Imbalance between myocardial oxygen supply and demand Angina pectoris Myocardial infarction
Ischemic heart diesease
Does primary or secondary hypertension have an identifiable etiology?
Secondary
• Compensatory mechanism to
– Pressure overload
– Volume overload
Cardiac hypertrophy
• Transient myocardial ischemia • Paroxysmal, recurrent pericardial chest discomfort, constricting, squeezing, choking, knife-like • May radiate to arm, mandible • Does not produce myocardial necrosis (infarction)
Angina pectoris
• Due to a fixed stenosis: an atherosclerotic plaque reduces coronary perfusion to critical level • Increased demand produces ischemia • Pain that is predictably reproducible & consistent over time • Precipitated by physical effort such as walking or climbing stairs but may also occur with eating or stress. • Pain is relieved by cessation of the precipitating activity, by rest, or by the use of nitroglycerin
Stable angina
• Due to a complicated plaque: a variable stenosis • New onset of pain • Pain that is increasing in frequency, more intense than before – Key feature is the changing character or pattern of the pain. • Pain that is precipitated by less effort than before, or pain that occurs at rest • Not readily relieved by nitroglycerin • Medical emergency: May evolve into MI
Unstable angina
• Coronary arterial spasm secondary to vascular hyper-reactivity • Occurs at rest • May be unassociated with atherosclerosis and coronary artery disease • Cocaine users -> vasospasm
Variant Angina (Prinzmetal Angina)
Pathogenesis of \_\_\_\_\_\_\_\_\_\_\_ • Coronary atherosclerosis • Complicated plaque • Platelet adhesion and activation • Thrombus formation • Vessel occlusion • Myocardial infarction (cellular necrosis)
Transmural Acute Myocardial Infarction
What are the 3 serum cardiac markers?
- Myoglobin
- Cardiac-specific Troponin (T or I)
- Creatine kinase (MB fraction): CK-MB
- Aneurysm
- Wall rupture
- Mural thrombus
- Papillary muscle rupture
Post MI complications
\_\_\_\_\_\_\_\_ diseases • Stenosis: Doesn’t open completely – Impedes forward flow • Insufficiency/incompetence: Doesn’t close completely – Allows reverse flow Abnormalities of flow produce murmurs
Valvular heart diseases
• Aortic stenosis • Aortic insufficiency • Mitral stenosis – rheumatic heart disease • Mitral insufficiency - myxomatous degeneration (mitral valve prolapse)
Major valvular lesions
• Acute rheumatic fever is a complication of
Group A streptococcal pharyngitis
• Antibodies to Strep cross react with
cardiac antigens
• Inflammation leads to fibrotic valvular
disease
Type II Hypersensitivity Reaction
Acute rheumatic fever
The following molecules are associated with _______:
• Anitchkow cells (macrophages)
• Aschoff body
Acute Rheumatic fever
• Pericardium: fibrinous pericarditis • Myocardium - myocarditis • Valves – Mitral vegetations – Thickened leaflets – Fused commissures • ARF is the most frequent cause of mitral stenosis
Rheumatic heart disease
• Most frequently bacterial – Strep viridans (50-60%) – Staph aureus: IV drug abusers • Virulence of organism determines course • Thrombus formation on damaged endothelium (vegetations) • Bacteremia results in microbial colonization of vegetations • Septic emboli
Infective endocarditis
• Left side of heart affected most
commonly (aortic valve)
• Right side: for IV drug abusers
• Mortality due to heart failure
Infective endocarditis
Prevention of ________:
• Antibiotic prophylaxis for procedures causing
bacteremia: dental, gastrointestinal,
genitourinary, upper respiratory tract
• Dental procedures that involve manipulation of
gingival tissue, manipulation of the periapical
region of teeth, or perforation of the oral
mucosa
Infective endocarditis
• Abnormalities of the heart and great vessels that are present at birth • = 20-30% of all birth defects • Faulty embryogenesis: weeks 3 to 8 • Most cases: – Atrioventricular, ventricular or atrial septal defect – Pulmonary stenosis – Patent ductus arteriosus – Tetralogy of Fallot – Coarctation of aorta – Aortic stenosis – Transposition of great arteries • 90% have no identifiable cause
Susceptibility to infective endocarditis: antimicrobial prophylaxis
Congenital Heart Disease
Etiology of \_\_\_\_\_\_" • Most have no identifiable cause: multifactorial environmental, genetic and maternal factors • Genetic – Trisomy 21 – Turner syndrome • Environmental – Infectious • fetal rubella or cytomegalovirus infection – Drugs • accutane, lithium, anti- seizure medications, cocaine, alcohol
Congenital heart disease
• Malformations causing
Right-to-Left Shunts:
_________
Cyanosis
• Malformations causing
Left-to-Right Shunts:
________
– Most common
\_\_\_\_\_\_\_ shunts: • Pulmonary blood flow is decreased poorly-oxygenated blood enters the systemic circulation • Cyanotic Congenital Heart Disease • May be associated with paradoxical embolism – Septal defect allows venous emboli to bypass the lungs and enter systemic arterial circulation • Begin with “T” – Tetralogy of Fallot – Transposition of the Great Vessels
Right to left shunts
• Most common form of cyanotic congenital heart disease • Right-to-Left Shunt 1. Ventricular septal defect (VSD) : most common form of congenital Heart Disease 2. Sub-pulmonary stenosis 3. Right ventricular hypertrophy 4. Aorta overides VSD
Tetralogy of fallot
\_\_\_\_\_\_\_\_ Shunts • Most common • Pulmonary blood flow increased – Pulmonary hypertension – Shunt reversal -> cyanosis (Eisenmenger syndrome) All contain a “D” • Ventricular Septal Defect • Atrial Septal Defect • Atrial-Ventricular Septal Defect • Patent Ductus Arteriosus
Left-to-Right Shunts
• Normal fetal blood vessel that allows blood to bypass the lungs • Left-to-right shunt from the aorta to the pulmonary artery • When pulmonary hypertension develops, shunt reverses and cyanosis develops – (Eisenmenger syndrome)
Patent Ductus Arteriosus: Connects Pulmonary Artery and Aorta
• Obstructive defect located in the area of the ductus that may be asymptomatic until adulthood • Rib notching due to collateral circulation • Males 2:1
Coarctation of the Aorta
Is there hypo or hypertension proximal to coarction?
Hypertension
Is there hypo or hypertension distal to coarction?
Hypotension
