Cardio-Vascular Pathology Flashcards
1
Q
Define heart failure
A
Inability of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues
2
Q
How does heart failure develop
A
Slowly
- cardiac hypertrophy
actue
- MI
- acute valve dysfunction
3
Q
How common is heart failure
A
5 million in US
- commonest discharge diagnosis in under 65
- under 1 million hospitalised
4
Q
What are the two types of heart failure
A
- Systolic dysfunction
- Diastolic dysfunction
5
Q
Name the causes of systolic dysfunction
A
- Ischaemic heart disease
- pressure or volume overload such as systemic hypertension or aortic stenosis (AS)
- Cardiomyopathy
6
Q
Name the causes of diastolic dysfunction
A
- Inability to reflex/fill
- amyloid deposition
- myocardial fibrosis
- constrictive pericarditis - after radiotherapy particularly for breast, TB, connective tissue disorders
7
Q
How does amyloid deposition interfere with tissues function
A
- a collection of protein that are undigestible by the proteases therefore the protein when deposited in tissues interferes with the tissues function
8
Q
What are the two consequences of heart failure
A
Forward
Backward
9
Q
describe the forward and backward problem (consequence of heart failure)
A
Forward
- deliver the oxygen to the organs.
- The heart is not pumping out enough blood to satisfy the needs of the cells of the body. Thus, excess fluid retention and edema increase
backward
- hypoxic blood in the venous system
- One of the ventricles fails to pump out all of its blood that comes into it. Thus, the ventricular filling pressure and systemic or pulmonary edema increase.
10
Q
Name mechanisms that are used to cope with heart failure
A
- frank-starling
- hypertrophy +/- chamber dilation
- activation of neurohormonal systems such as noradrenaline, RAAS and atrial natriuretic peptide
- may eventually be exceeded
11
Q
What is the frank starling law
A
- this is the idea that increase in stretching of the heart causes an increase in contraction
- relation to EDV - as EDV increases this causes the heart muscle to stretch and increase in contraction to pump the EDV out
12
Q
What are the consequences of heart failure
A
- Heart size/weight increase
- hypertrophy
- pressure overload - concentric hypertrophy
- volume overload - cavitary dilation maybe without thickening
- hypertrophy - can cause capillary decrease - increase in fibrous tissue - increase metabolic needs - vicious circle that leads to failure
13
Q
Anything that does cause hypertrophy in the left ventricle is associated with…
A
Sudden death
14
Q
Why do people who have left sided heart failure present the way they do
A
Main features are due to decreased peripheral pressure and damming of blood in the pulmonary circulation
15
Q
What is the presentation of someone with left sided heart failure
A
- Lung congestion
- oedema
- accumulation of haemosiderin laden macros - leads to dyspneoa due to fluid build up on lungs, orthopnoea - fluid getting worse when you lie down, PND
- heart depends on cause - IDH, HT, Valves
- Brain and kidneys if severe suffer hypoxia (hypoxia - peripheral blood becomes hypoxic)
16
Q
Describe what causes the symptoms of right sided heart failure
A
- Usually secondary to LVF
- primary association with severe pulmonary hypertension
17
Q
What are the symptoms of right sided heart failure
A
Liver
- pure liver congested - nutmeg
- centrilobular necrossi and firbosis
- portal vein pressure increase - splenomegaly, ascities, kidneys and brain hypoxia, peripheral oedema
- biventricular - plus LVF
18
Q
What is hypertension defined as
A
- systolic greater than 140mmHg
- diastolic greater than 90mmHg
19
Q
What is hypertension as risk factor for
A
- IDH
- Cerebrovascular disease
- aortic dissection
- cardiac failure
- renal failure
20
Q
Name the types of hypertension
A
- Primary/essential (95%)
- secondary
- benign or malignant/accelerated (5%)(has severe end organ damage)
21
Q
Name the causes of secondary hypertension
A
Renal
- Chronic renal disease
- glomerulonephritis
- renal artery stenosis
Neurological
- stress including surgery
- psychogenic
- raised intracranial pressure
Cardiovascular
- coarctation of the aorta
- systemic vasculitis
- increased intravascular volume
Endocrine
- cushings
- conns
- exogenous hormones
- pheochromocytoma
- acromegaly
- thyroid disease
- pregnancy
22
Q
How do you measure blood pressure
A
Cardiac output x peripheral resistance
23
Q
What influences cardiac output
A
Blood volume
- sodium
- mineralocorticoids
cardiac factors
- heart rate
- contractility
24
Q
What influences peripheral resistance
A
Constrictors
- angiotensin II
- catecholamines
- thromboxane
- leukotrienes
- endotheliin
- alpha adrenergic
Dilators
- prostaglandins
- NO
- Beta adrenergic
local factors
- autoregulation
- ionic (pH, hypoxia)
25
What do you see in the heart when someone has hypertension
- Left ventricular hypertrophy
26
What do you see in the vessels in someone who has hypertension
- atheroma
- aortic dissection,
- cerebrovascular haemorrhages,
- degenerative changes such as fibrointimal thickening
27
What do you see in the small vessels in someone who has hypertension
- hyaline arteriolosclerosis esp kidneys,
- hyperplastic arteriolosclerosis (onion-skinning)
- fibrinoid necrosis in accelerated
28
What is cor pulmonale
Heart disease as a consequence to lung disease
29
What is pulmonary hypertension
High blood pressure in the pulmonary circulation
30
What can cause pulmonary hypertension
- diseases of the lung parenchyma such as COPD, cystic fibrosis, diffuse interstitial fibrosis
- diseases of the pulmonary vessels such as recurrent, PEs, primary PH, severe vasculiits
- Disorders affecting chest movement such as kyphoscoliosis, neuromuscular disease
- disorders causing arterial constriction such as hypoxaemia, chronic altitude sickness
31
What are the two types of cor pulmonale
Acute - massive PE can cause this
| Chronic - most of the time
32
What changes do you see with cor pulmonale in the heart
- RV hypertrophy
- RA hypertrophy
- dilatation in both chambers
- due to the dilation the tricuspid valve ring may become expansive and this can lead to tricuspid regurgitation
- see the clinical features for RVF plus the primary disease
33
What is right ventricular hypertrophy defined as
Thickened right ventricle above 0.5cm
34
What is vasculitis
- inflammation of the vessel walls
| - can be infective or non infectious
35
What can cause non infectious vasculitis
- immune complex
- ANCA- mediated
- direct antibody mediated
- cell mediated
- paraneoplastic or idiopathic
36
What is classification of vasculitis based on
- pathogenesis
| - vessel size
37
Name some examples of
- Large vessel vasculitis
- medium vessel vasculitis
- ANCA - associated small vessel vasculitis
Large vessel vasculitis
- takayasu artertitis
- giant cell arteritis
Medium vessel vasculitis
- Polyarteritis Nodosa
- Kawasaki disease
ANCA - associated small vessel vasculitis
- Microscopic polyangitis
- granulomatosis with polyangitis
- eosinophillic granulomatosis with polyangitis
38
How does vasculitis show
- All show vascular injury with mural necrosis and haemorrhage
- localised, organ restricted or systemic
- some are granulomatous
- secondary ischaemia of down-stream tissue
- may cause infarction
39
What are granulomas
localised collections of epithelial macrophages
40
What is polyarteritis nodosa
- Systemic vasculitis
- small/medium sized arteries (not veins or smaller arteries)
- often spares the lungs
41
Describe what you see in polyarteritis nodosa
- Segmental necrotising inflammation of arteries especially renal, cardiac and GI tract
- branching sites particularly
42
What does polyarteritis nodosa lead to
- Aneurysms, infracts and haemorrhage
- microscopically transmural inflammation and fibrinoid necrosis
- possible thrombosis of vessel
- fibrosis later become nodular
- lesions of different ages
43
who does polyarteritis nodosa tend to effect
- Young adults
| - more common in men than in women
44
How does polyarteritis nodosa present
Episodic
acute, subacute, or chronic
- fever
- malaise
- weight loss
- hypertension
- abdominal pain
- malaena
- muscular pains
- renal involvement
- peripheral neuritis
45
What is the treatment of polyarteritis nodosa
- steroids
| - cyclophosphamide
46
What antigen presents along with polyarteritis nodosa
30% hep B antigen positive
47
What are ANCA related vasculitis
- 85% ANCA antibodies (60-95%)
| - group of vasculitis that can be systemic, renal limited or other
48
How does ANCA vasculitis present
- flu like illness
- fever
- arthralgia
- myalgia
- purpura
- peripheral neuropathy
- gastro-intestinal involvement
49
What can provoke ANCA vasculitis
- propylthiouracil
- penicillamine
- hydralazine
50
What are the two staining patters for somone with ANCA related vasculitis and what antibody do they stain
- Cytoplasmic by IMF - c-ANCA is usually proteinase 3 (PR3)
- perinuclear by IMF - usually myeloperoxidase (MPO)
- can have ANCA circulating in patients who do not have vasculitis
51
What is granulomatosis with polyangitis
- effects upper and lower respriatory tract
- particular the eyes and ear
- see necrotising grnauloma
- vasculitis
- target is proteinase 3 (PR3) - you see c-ANCA usually
52
How do you treat ANCA
- aggressive immunosupression with cyclophosphamide (IV, V oral) and steroids if patient an tolerate
53
what are the prognosis for ANCA with and without treatment
- Untreated 80% 1 year mortality
| - Treated 75% 5 year survival (kidney involvement and patient)
54
What is cardiomyopathy
cardiac disease that arises from a primary intrinsic myocardial abnormality
55
what are the causes of cardiomyopathy
- Idiopathy
- Secondary to known cause
- Primary
56
Name the 4 types of cardiomyopathy
• dilated
• hypertrophic
• restrictive
- arrhythomogenic right ventricular cardiomyopathy
57
Describe what dilation cardiomyopathy look like
4 chamber dilation
| - bigger heart
58
Describe what hypertrophic cardiomyopathy looks like
- septum thickening
59
Describe what restrictive cardiomyopathy look like
- heart looks normal and only able to diagnose it on functional analysis, ECG, biopsy or autopsy
60
describe what happens in dilated cardiomyopathy
* Progressive cardiac dilatation and contractile dysfunction
* valves/arteries not significantly abnormal
* may be thrombi
* micro - myocardial hypertrophy/fibrosis
61
What is the cause of dilated cardiomyopathy
* Idiopathic
* Genetic (~30%)
* Post myocarditis
* Alcohol or other toxicity eg doxorubicin
* Pregnancy associated
* Haemochromatosis
* Sarcoidosis
62
What age does dilated cardiomyopathy occur in
- any age but especially 20-50
63
what are the signs of dilated cardiomyopathy
* progressive CCF
* signs of LVF+RVF
* death from failure or sudden death (arrhythmia)
64
What is the treatment of dilated cardiomyopathy
Transplantation
65
What happens in hypertrophic cardiomyopathy
- Heart muscle is abnormal
- fills poorly in diastole
- often an outflow obstruction due to thickened septum
- little or no dilatation
- classically disproportionate thickening of septal myocardium epsically subarotic
- micro hypertrophy, disarray and fibrosis
66
What is the most common genetic problem associated with hypertrophic cardiomyopathy
* Mutation of muscle protein esp beta-myosin heavy chain
* most familial
* many different mutations found
* leads to poor compliance and reduced LV chamber size +/- outflow obstruction
* clinically heterogeneous, may need surgery
67
What is the most common genetic problem associated with hypertrophic cardiomyopathy
Beta myosin heavy chain
68
Describe restrictive cardiomyopathy
- Primary disease in ventricular compliance
- idiopathic
- firm ventricles with normal dilated atria
- microscopy may reveal cause
69
What can cause secondary restrictive cardiomyopathy
- irradiation fibrosis
- amyloid
- sarcoid
- tumour metastases
70
What is myocarditis
- inflammation causing myocardial injury and not a response to it
71
What infections can cause myocarditis
- viruses such as Coxackieviruses, enteroviruses, other viruses including HIV; chlamydia, rickettsiae, bacteria, fungi, protozoa, Helminths
72
What immunological reactions can cause myocarditis
– post-viral, SLE, drug reactions, transplant rej
73
What can also cause myocarditis
sarcoidosis, giant cell myocarditis
74
what can cause direct damage to the myocarditis
May be direct damage or T cell mediated injury to antigens on myocyte surface
• Inflammation and myocyte necrosis
75
How do the patients present in myocarditis
- fatigue
- fever
- chest discomfort
- heart failure
- arrhythmias
- sudden death
76
myocarditis and
acute infract can be confused due to similar symptoms
77
What does myocarditis lead onto
- dilated cardiomyopathy
