Cardiovascular disease 3 Flashcards
What is endocarditis?
inflammation of the endocardium of the heart
caused by vegetation on the valves
what are the two main forms of endocarditits?
infective endocarditis - clinically important
non-infective endocarditis - non bacterial thrombolytic endocarditis, endocarditis of SLE (Libman sacks disease)
What is included in the vegetation in infective endocarditis and what does it cause?
thrombotic debris and organisms
mostly caused by bacteria
destroys underlying cardiac tissue
vessels, aneurysmal sacs and prosthetic valves may also be infected
what is acute infective endocarditis?
nasty!
infection of previously normal heart valve
caused by highly virulent organisms
necrotising, ulcerative and destructive lesions
difficult to cure - normally requires surgery
death is frequent
What is sub acute infective endocarditis?
organism of lower virulence infection of already deformed valves lasts from weeks to months cured with antibiotics most common on wards
what are the risk factors for endocarditis?
cardiac/valvular abnormalities used to be rheumatic fever, now: MV prolapse stenosis artificial valves congenital defects bicuspid AV
how does streptococcus viridans get to the heart?
mouth e.g. dental work
How does S. aureus get to the heart?
from the skin e.g. IVDU
What organism commonly causes infection of prosthetic heart valves?
coagulase-negative staphylococci e.g. S. epidermis
What should be investigated in any culture that is positive for strep. bovis?
bowel cancer
describe the vegetation of acute IE
friable (soft), bulky, potentially destructive
single/ multiple, often more than one valve
can erode and cause abscesses, sometimes via emboli
what are the clinical features of infective endocarditis?
fever, chills, weakness
weight loss?
murmurs in 90% of patients with left sides IE’s
what are the complications of infective endocarditis?
glomerulonephritis
splinter/subungual hemorrhages
janeway lesions - non tender lesions on the palms/soles
oslers nodes - nodules on the digits
roths spots - retinal haemorrhages in the eye
what is the pneumonic to remember the signs and symptoms of infective endocarditis?
F – Fever
R – Roth spots
O – Osler’s nodes
M – Murmurs
J – Janeway Lesions
A – Anaemia
N – Nail (splinter) haemorrhage
E – Emboli (septic)
What is non bacterial thrombotic endocarditis (NBTE) caused by?
occurs in chronically ill patients e.g. cancer, sepsis
associated with hypercoagulable state e.g. DVT, adenocarcinoma
Trousseau syndrome - acquired blood clotting disorder that results in migratory thrombophlebitis (inflammation of a vein due to a blood clot)
endocardial trauma and central lines predisposes to NBTW
What is the vegetation like in NBTE?
small, sterile thrombi on valve leaflets
single/multiple on border of leaflets of cusps
minimal local effect
When does Libman-Sacks endocarditis occur and what is the vegetation like?
associated with SLE
sterile pink warty vegetation
single or multiple
What is rheumatic fever?
acute, autoimmune inflammatory disease following a grouo A streptococcal pharyngitis
hypersensitivity reaction
antibodies from immune response to M proteins of group A strep occurs
cross reaction of antibodies with self antigens of the heart
CD4+ produces cytokines that activate macrophages = aschoff bodies
What are aschoff bodies?
seen in rheumatic fever histology slides
distinct cardiac lesions
consists of t cells, plasma cells and macrophages
can be found in all 3 cardiac layers = pancarditis
What is the vegetation in rheumatic fever called?
veruccae
What valve is most likely to change in rheumatic fever and how?
mitral valves, virtually only cause of mitral stenosis in chronic cases
leaflet thickening
fibrous bridging of valves and calcification - ‘fish mouth/buttonhole’ stenosis
what criteria is used to diagnosis rheumatic fever?
jones criteria
What are the complications of rheumatic fever?
left atrium dilates → mural thrombi → embolise
mitral stenosis → mechanical obstruction to emptying of the left atrium → increased pulmonary venous pressure → pulmonary hypertension → right ventricular hypertrophy, dilatation and failure
What is pericarditis?
inflammation of the pericardial sac
What can cause pericarditis?
infections e.g. viruses (coxsackie B), bacteria, TB, fungi
immunologically mediated processes e.g. rheumatic fever, SLE, scleroderma, post MI (dresslers)
miscellaneous conditions e.g. neoplasia, trauma
What organism is the main cause of inflammation of the heart?
coxsackie B
What are the 2 types of pericarditis?
acute (inflammed) - serous, caseous, haemorrhagic
chronic (stuck down) - adhesive, constructive
what is serous pericarditis?
inflammation causes clear serous fluid accumulation (like in blisters)
caused by non infective causes i.e. inflammation in adjacent structures
What is dresslers syndrome?
pericarditis post MI by a few weeks autoimmune reaction to antigens from MI triad of: fever pleuritic chest pain pericardial effusion
What is the most common form of pericarditis?
serous fluid/ fibrinous exudate
What are the features of fibrinous pericarditis?
dry, granular, roughened surface
more intense inflammatory response
What causes purulent/suppurative (pus) pericarditis?
bacteria
red, granular exudate (pus)
can spread to mediastinum
leads to scarring
What is haemorrhagic pericarditis?
blood mixed with serous or suppurative effusion
What are the common causes of haemorrhagic pericarditis?
neoplasia - malignant cells in effusion
infections e.g. TB
following cardiac surgery - leads to a cardiac tamponade
What causes caseous pericarditis?
‘cheesy’
TB
fungal
What is adhesive pericarditis?
fibrosis, stringy adhesions
stuck to heart
What is adhesive mediastinopericarditis?
follows pericarditis
adherence to surrounding structures
causes cardiac hypertrophy/dilatation
What is constrictive pericarditis?
heart encased in fibrous scar = limits cardiac function
treated by surgery
What can be a complication of pericarditis?
pericardial effusion
cardiac tamponade
What are the clinical features of pericarditis?
sharp central chest pain
made worse by: movement, respiration, laying flat
radiates to: shoulders/neck
pericardial friction rub that is loudest with diaphragm, left sternal edge
fever
What does ‘cardiomyopathy’ mean?
heart muscle disease i.e. disorder of the myocardium
What are the 4 main types of cardiomyopathies?
Hypertrophic
Arrythmogenic right ventricular cardiomyopathy
Restrictive
Dilated
What is a dilated cardiomyopathy?
progressive dilatation → contractile (systolic) dysfunction
myocyte hypertrophy with fibrosis
What is the cause of dilated cardiomyopathy?
genetics - autosomal dominant cytoskeletal proteins gene mutation
alcohol/chemotheraphy
others e.g. SLE, scleroderma
What are the clinical features of dilated cardiomyopathy?
mostly ages 20-50
slow progressive signs
symptoms of congestive cardiac failure - shortness of breath, fatigue
5 year survival
treatment: cardiac transplant, ventricular assistance
What is a hypertrophic cardiomyopathy?
myocardial hypertrophy
preserved diastolic function but diastolic function affected
main cause of unexplained LVH
in absence of hypertension
What causes hypertrophic cardiomyopathy?
100% genetic
mutations of sacomeric proteins
can be sporadic - happens randomly for the first time in a family
What are the clinical features of hypertrophic cardiomyopathy?
reduced stroke volume
obstruction of LV outflow
exertional dyspnoea
systolic ejection murmur
What are the complications of hypertrophic cardiomyopathy?
AF mural thrombus formation → embolis cardiac failure ventricular arrhythmias sudden death - most common cause in athletes
What is the treatment for hypertrophic cardiomyopathy?
β-adrenergic blockers - Decrease heart rate and contractility
reduction of mass of septum
What is restrictive cardiomyopathy?
decrease in ventricular compliance - heart cannot fill up
can be caused by infiltration i.e. fibrosis, tumours, deposition of metabolites
ventricles are normal size
myocardium is firm/noncompliant
What is arrythmogenic right ventricular cardiomyopathy/right ventricular dysplasia?
right ventricle dilated and thinned out
filled with fibrofatty deposits
genetic defect in adhesion via cell-cell desmosomes
exercise = cell to cell adhesions fall apart → cell death/fibrosis
What are the signs/symptoms of arrythmogenic right ventricular cardiomyopathy/right ventricular dysplasia?
can be silent
chest pain
palpitations
cause of sudden cardiac death in the young/those that exercise
What is myocarditis?
infective/inflammatory process → myocardial injury
What is the most common infections to cause myocarditis?
coxsackie A&B virus
Chagas disease protazoa - more common abroad
What are the clinical features of myocarditis?
asymptomatic heart failure arrhythmias sudden death non specific i.e. fatigue, dyspnea, palpitations, fever can mimic acute MI dilated cardiomyopathy can develop
What is vasculitis?
inflammation of the vessel wall
affects any organ and any vessel size
What naming system is used to categorise specific types of vasculitis that affect specific vessels?
Chapel Hill nomenclature
What is the histological feature of vasculitis?
blue dots in a blood vessel
What is giant cell arteritis?
most common form of vasculitis elderly most affected chronic granulomatous inflammation large to med sized arteries temporal, vertebral, opthalmic arteries - permanent blindness medical emergancy!
What is the morphology of giant cell arteritis?
intimal thickening - reduces lumen diameter
granulomatous inflammation - elastic lamina fragmentation
multinucleated giant cells
What are the symptoms of giant cell arteritis?
vague symptoms for under 50’s
facial pain/headache - jaw claudication, superficial temporal artery painful to palpate
How is giant cell arteritis diagnoised?
biopsy of 2-3cm as segmental
histology
What is the treatment of giant cell arteritis?
corticosteroids e.g. prednisolone
anti TNF
What is an aneurysm?
localised, permanent, abnormal dilatations of a blood vessel
How can aneurysms be classified?
shape i.e. saccular, berry, fusiform
aetiology i.e. berry, atheroscleotic, dissecting etc.
What is an atherosclerotic aneurysm?
most common
often in elderly
AAA caused by athersclerosis
>6cm = 25% chance of rupture per year
What are the complications atherosclerotic aneurysm?
Rupture → retroperitoneal haemorrhage
Embolisation → limb ischaemia
What is an dissecting aneurysm?
tear in the wall
blood tracts between inimal and medial layers
tearing pain in chest radiating to upper left shoulder
secondary to systemic hypertension
What are the complications dissecting aneurysm?
vasscular occlusion
haemopericardium
↑↑ Mortality without treatment
What is a berry aneurysm?
Small, saccular lesions
develop in the Circle of Willis
At sites of medial weakness at arterial bifurcations
Small, saccular lesions that develop in the Circle of Willis
Develop at sites of medial weakness at arterial bifurcations/anastomosis
What are the complications berry aneurysm?
subarachnoid haemorrhage - thunderclap headache
What is a Charcot-Bouchard aneurysm?
Microaneurysm
occur in intracerebral capillaries in hypertensive disease
What are the complications Charcot-Bouchard aneurysm?
intracerebral haemorrhage (i.e. stroke)
What type of microaneurysm can develop in diabetes causing diabetic retinopathy?
Retinal microaneurysm
What is a Mycotic aneurysms?
rare
weakening of the arterial wall secondary to bacterial/fungal infection - suacute bacterial endocarditis most commonly
organisms enter media from the vasa vasorum
cerebral arteries mostly
What can infections of AAA cause?
rupture
What is a false aneurysm?
adventitial fibrous tissue contains the haematoma - blood around the vessel
Commonly seen following femoral artery puncture during angiography / angioplasty
resolves after a few days/weeks
What are the 6 P’s of acute ischemia?
Pale Pulseless perishingly cold paraethetic paralysed Painful
