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Cardiovascualr System 2 Flashcards

1
Q

What is stenosis

A

Failure of a valve to open completely

This impedes the forward flow of blood

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2
Q

What is incompetent regurgitation

A

Failure of the valve to close completely

Allows the reverse flow of blood

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3
Q

What can valvular heart disease affect

A

Pure or mixed regurg or stenosis

Single or multiple valves

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4
Q

What is functional regurgitation

A

Valve becomes incompetent due to dilation of a ventricle

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5
Q

What does the clinical consequences of valvular heart disease depend on

A

Which valve
Degree of impairment
Rate of it’s development
Rate and quality of compensatory mechanisms
Can go from being physiologically unimportant to severe and rapidly fatal

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6
Q

What causes valvular incompetence

A 
Intrinsic disease of the valve cusps or damage to or distortion of the supporting structures 
Aorta 
Mitral valve annulus
Tendinous cords 
Papillary muscle 
Ventricular free wall 
\+/- underlying valve abnormality 
ACUTE OR CHRONIC
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7
Q

Valvular stenosis
Acute or chronic

Is the valve abnormal in this

A

Usually chronic

Almost always has an underlying valve abnormality

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8
Q

Where can valvular calcification occur

A

Calcific aortic stenosis
Calcification of a congenitally bicuspid aortic valve
Mitral annular calcification

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9
Q

What are heart valves subjected to

A

High repetitive mechanical stress especially at hinge points of cusp/leaflet
40 million cycles a year
Substantial tissue deformation
Transvalvular pressure gradients - aortic 120mmHg mitral 80mmHg
Cumulative damage is complicated by dystrophic calcification

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10
Q

Causes and epidemiology of calcific aortic stenosis

A

Age related wear and tear calcification
Clinically apparent 70-80 yo
Calcification of bicuspid valve occurs earlier

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11
Q

Most common cause of mitral stenosis

A

Rheumatic heart disease

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12
Q

Most common cause of mitral incompetence

A

Floppy mitral valve
Myxomatous degeneration
Mitral valve prolapse

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13
Q

Most common cause of aortic stenosis

A

Calcification of normal and congenitally bicuspid aortic valves

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14
Q

Most common cause of aortic incompetence

A

Dilation of ascending aorta related to hypertension and age

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15
Q

Mitral regurgitation facts

A

Most common form of valvular heart disease in the industrialised world
One or both mitral leaflets enlarged, hooded, redundant so prolapsed back into atrium during systole
Usually incidental finding on examination - mitral valve prolapse
Very rarely - sudden death

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16
Q

What is rheumatic fever

A

Acute immunologically mediated multisystem inflammatory disease
Occurs a few weeks after group A beta haemolytic streptococcal pharyngitis
Thought to be a hypersensitivity reaction induced by group A streptococci
Features:
Migratory polyarthritis of large joints
Carditis
Subcutaneous nodules
Skin rash
Syndenham chorea - neurological disorder (purposeless movements)

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17
Q

What is rheumatic heart disease

A 
Acute leads to pancarditis 
Endocardium --> vegetations
Myocardium --> Aschoff bodies 
Pericardium --> pericarditis 
Reactivation with subsequent pharyngeal infections 
--> cumulative damage
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18
Q

What is the most important complication of rheumatic fever

A

Chronic rheumatic heart disease
Characterised by
Deforming fibrotic valvular disease esp mitral stenosis
Fish mouth/button hole stenosis
Leaflet thickening, commissural fusion and shortening, thickening and fusion of chordea tendinea
Can cause permanent dysfunction
Most frequent cause of mitral stenosis
End stage of organisation of acute inflammatory damage

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19
Q

What is infective endocarditis

A

Serious infection
Colonisation/ invasion of the heart valves
Formation of friable bulky vegetations - composed of thrombotic debris and organisms
Often underlying tissue destruction
Most cases are BACTERIAL

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20
Q

Infective endocarditis types

A

Acute and subacute.

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21
Q

Characteristics of acute infective endocarditis

A 
High virulence 
Valve previously normal
Acute onset 
50% mortality days to weeks
Lesion is necrotising, ulcerative and invasive
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22
Q

Characteristics of subacute infective endocarditis

A

Low virulence
Insidious onset
Most recover weeks to months
Less destructive

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23
Q

What causes a predisposition to infective endocarditis

A 
Abnormal valve - 
Floppy mitral valve 
Degenerative calcific valvular stenosis 
Bicuspid aortic valve 
Artificial valve 
(Vascular graft) 
Host factors - 
Immunosuppression - neutropenia, immunodeficiency, therapeutic

Diabetes
Alcohol
IV drug use

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24
Q

What are the organisms involved in infective endocarditis

A

Alpha-haemolytic strep - abnormal valve 50-60%, subacute
Staph aureus (skin) high virulence, normal valve, IV drug users
Mouth commensals - most of rest
Staph epidermidis - prosthetic valves

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25
How does the person get infected
Dental or surgical procedure Dirty needle Trivial injury
26
What should be done for those at risk
Prophylactic antibiotics
27
Morphology of infective endocarditis
Aortic and mitral valve most commonly affected Tricuspid valve in IV drug users Bulky friable vegetation May involve more this one valve
28
Complications of infective endocarditis
``` Myocardial abscess Valve rupture/perforation Systemic emboli- L sided body -kidney R sided - lungs Septic emboli Immune complexes ```
29
What is non bacterial thrombotic endocarditis
``` Deposition of fibrin/platelet thrombi on valve leaflets -SMALL Occur on either side of the heart Occurs on a previously normal valve Sterile Non-destructive Clinical importance = emboli Occurs in hypercoagulable state - Disseminated intravascular coagulation Cancer sepsis ```
30
What are the types of artificial valves
Mechanical Bioprostheses - homografts - chemically treated animal (porcine) valves
31
Complications of artificial valves
Thromboembolic - need long term coagulation Infective endocarditis Structural deterioration - esp bioprostheses
32
What is a cardiomyopathy
Heart disease resulting from a primary abnormality in the myocardium
33
What are the causes of a cardiomyopathy
``` Inflammatory Immunological Systemic metabolic disorders Muscular dystrophies Genetic abnormalities of the cardiac myocytes - cardiac energy metabolism - structural and contractile proteins Idiopathic ```
34
What are the 3 clinical pictures of cardiomyopathy
Dilated cardiomyopathy DCM 90% Hypertrophic cardiomyopathy HCM Restrictive cardiomyopathy least common Within each group - spectrum of diversity and overlap of features between groups Each pattern can be idiopathic , specific identifiable cause Or secondary to extramyocardial disease Diagnoses - endomyocardial biopsies of RV
35
What is dilated cardiomyopathy characterised by
``` Progressive - Cardiac hypertrophy Dilation Contractile Dysfunction Leads to congestive cardiac failure ```
36
Causes of dilated cardiomyopathy
``` Most idiopathic Alcohol Peripartum Genetic (ox phos, beta ox FFA, dystrophin) Myocarditis Haemochromatosis Chronic anaemia Drugs - doxorubicin, adriamycin Sarcoidosis ```
37
What is the morphology of dilated cardiomyopathy
``` Gross Heavy heart 2-3x normal Large flabby Dilation in all chambers Mural thrombi common - thromboemboli +/- secondary mitral/tricuspid regurg Normal coronary arteries Histology - Non specific Hypertrophied fibres Attentuated/ stretched fibres Interstitial and endocardial fibrosis ```
38
Clinical features of dilated cardiomyopathy
``` any age 20-60 Slowly progressive CCF But can be sudden compensated --> decompensated functional state EF 25% 50% mortality in 2 years Death - progressive CCF - arrhythmia Embolism Treatment cardiac transplant ```
39
What is hypertrophic cardiomyopathy characterised by
Myocardial hypertrophy Abnormal diastolic filling 1/3 intermittent left ventricular outflow obstruction Heavy muscular hyper contracting heart
40
What is the gross morphology of hypertrophic cardiomyopathy
Massive myocardial hypertrophy No ventricular disease Asymmetric septal hypertrophy (10% symmetric)
41
What is the histology of hypertrophic cardiomyopathy
Extensive myocyte hypertrophy Myocyte disarray Interstitial fibrosis
42
What is the pathogenesis of hypertrophic cardiomyopathy
``` 50% genetic 50% sporadic Genetic autosomal dominant with variable penetrance Many difference mutations in 4 genes that encode contractile proteins (sarcomeres) 1) B- myosin heavy chain 2) cardiac troponin T 3) alpha - tropomyosin 4) myosin binding protein C ```
43
Clinical features of hypertrophic cardiomyopathy
Basic abnormality - Dec chamber size + poor compliance + Dec stroke volume ``` Clinical problems Angina AF Cardiac failure Ventricular arrythmias Sudden death ```
44
What is restrictive cardiomyopathy
Primary Dec in ventricular compliance -> impaired ventricular filling
45
What are the causes of restrictive cardiomyopathy
Idiopathic Radiation fibrosis Amyloidosis Sarcoidosis Metastatic tumour Products of inborn errors of metabolism Endomyocardial fibrosis (children in tropical areas) Endocardial fibroelastosis (young children) Many of these can be diagnosed by endomyocardial biopsy
46
Features of restrictive cardiomyopathy
Normal sized ventricles Normal sized ventricular chambers Both atria dilated Firm myocardium
47
What is myocarditis
Inflammatory process of the myocardium which results in injury to the cardiac myocytes
48
Causes of myocarditis
Infection - esp viruses most common Immune - post viral, post strep (rheumatic fever), SLE, drug hypersensitivity, transplant rejection Unknown sarcoidosis
49
Clinical features of myocarditis
Asymptomatic could lead to dilated cardiac myopathy years later Or could lead to arrythmias, acute heart failure, sudden death
50
Types of Pericardial disease
Pericardial effusion- fluid variety of compositions e.g. Transudate and exudate Haemopericardium- blood Purulent pericarditis - pus
51
What is pericardial disease called when it is large and rapidly developing
Cardiac tamponade
52
How can a haemopericardium form
Ruptured MI Traumatic perforation Ruptured aortic dissection
53
What is pericarditis
Pericardial inflammation | Secondary to cardiac disease , thoracic or systemic disorders, or metastasis from distant site
54
Causes of pericarditis
``` Infection Virus Bacteria TB Fungi Immune mediated : Rheumatic fever SLE Scleroderma Post MI dressier syndrome Drug hypersensitivity Miscellaneous: MI Uraemia Post cardiac surgery. Neoplasia Trauma Radiation ```
55
What are the types of pericarditis
``` Serous Fibrinous Purulent/suppurative Haemorrhaging Caseous ```
56
What are the outcomes of pericarditis
Reabsorbed Resolve Organise -> obliterate pericardial space +/- constructive pericarditis = heart is surrounded by dense fibrous scar that limits diastolic expansion of the heart and restricts cardiac output
57
What is a neoplasm of the heart called and how common are they
Myxoma Rare 5% of people dying from cancer Most commonly a primary tumour
58
Where is the most likely location of a myxoma
90% are located in the atria -most left | Called an atrial myxoma
59
What is the gross morphology and what problems can it cause
Sessile or pedunculated Cause Half valve obstruction Injury to the valve Embolisation
60
What is congenital heart disease
Abnormalities of the heart or great vessels present at birth
61
What are the 3 main categories of congenital heart disease
1) left to right shunt 2) right to left shunt 3) obstructions
62
What is a shunt
Abnormal connection between chambers or blood vessels | Blood flows from high to low pressure
63
What is a right to left shunt and what are the consequences of this
Blood shunted from the pulmonary to the systemic circulation Therefore the blood is less oxygenated -> cyanosis Cyanosis congenital heart disease
64
Conditions associated with right to left shunts
Tetralogy of fallot - most common Transposition of the the great arteries Persistent truncus arteriosus Tricuspid atresia Total anomalous pulmonary venous connection Can get paradoxical embolus Veins bypass lungs to systemic circulation
65
What is a left to right shunt
Blood shunted from systemic to pulmonary army circulation
66
Consequences of a left to right shunt
Increased pulmonary blood flow -> pulmonary hypertension. Reversible initially but need early treatment With time -> reversal of shunt (high to low pressure) -> late cyanosis (eisenmengers syndrome) ASD VSD- most common PDA AV septal defect
67
What cause obstruction
Chamber Valve blood vessel Abnormal narrowing
68
What is vasculitis
Inflammation of wall of blood vessel
69
Cause of vasculitis
``` Immune : Immune complex Antineutrophil cytoplasmic antibodies Direct antibody mediated Cell mediated Inflammatory bowel disease Paraneoplastic Infectious: Unknown Giant cell (temporal) arteritis- most common Takayasu arteritis Polyarteritis nodosum ```
70
Consequences of vasculitis
affect specific blood vessels Different patterns Small vessel - skin - rash Kidney glomerulonephritis
71
Aetiology of vasculitis
``` Infection - acute or chronic, bacterial viral fungal Neoplasm benign, malignant Cardiovascular system Haematological Infiltrates e.g. Amyloid, sarcoid Autoimmune Drugs / chemicals Unknown idiopathic ```

Y3 (22 decks)

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