Cardiovascular Disease (Andrews) Flashcards
What represents 2/3 of all valve diseases?
Acquired stenosis of the aortic or mitral valve (LEFT side valve problems)
What is the major pathogen of Rheumatic fever
Post Group A Beta-hemolytic streptococcus..
Describe what Rheumatic fever is…
It is a post group A Beta-hemolytic Strep pharyngitis, immune mediated, multisystem inflammatory disease
Describe the pathogenesis of Rheumatic fever
It’s a hypersensitivity reaction induced by Group A -Beta strep. The M protein on the antibody on the GAS looks like proteins on the heart valve, joints and other tissue. so the immune system gets ‘faked out’ and M protein attacks the proteins on the heart valve. Continued attacks leave lesions and necrosis.
What is the morphology of acute Rheumatic fever
The lesions that appear on the heart valve have a bubble gum look called fibrinoid necrosis. Also has ‘Aschoff bodies’, (inflammatory cells). It’s also not just a valvular disease. but a (fibronous) pan-carditis meaning that all 3 layers (endo, myo and pericardium are affected.
What is the sound affiliated with pericarditis (pericardial effusion)?
“leather on leather”.
What is the endocardial involvement with acute Rheumatic fever?
It’s left sided, the mitral and aortic valves are most commonly affected. Also swollen, edematous and have crusts of fibrin.
What are manifestations in the skin that can be seen in acute Rheumatic fever?
Subcutaneous nodules and a maculopapular rash (Erythema marginatum)
What is happening with chronic rheumatic heart disease?
You have ongoing alterations of the valve structure (scarring) to the point where the valve becomes thickened and rolled. Commissures of valves leaflets join together (good ddx from others). You also see a thickening and fusing of the chordae tendonae
Where does chronic rheumatic heart disease present the most?
About 70 percent of cases are seen in the mitral valve.
What can be seen at end stage rheumatic heart disease ?
Right ventricular dilation and hypertrophy due to the back up of flow.
What is the lag period for acute rheumatic fever
Usually 10 days to 6 weeks post GAB hemolytic strep pharyngitis it because clinically evident but the peak incidence is about 5-15 years
What is the clinical diagnostic criteria for acute rheumatic fever?
The Jones criteria
What is the criteria for the Jones criteria
You need to have 2 major or 1 major and 1 minor
Major: PECCS Polyarthritis, Erythema marginatum, Acute Carditis,Chorea (involuntary slow muscle movement) and Subcutaneous nodules
Minor - Fever, arthralgia, prolonged PR interval, previous rheumatic fever and leukocytosis.
What are manifestations in chronic rheumatic carditis that could lead to a valve transplant
1) A new murmur
2) Cardiac hypertrophy - CHF
3) Arrhythmia, especially A fib w- Mitral stenosis
4) Thromboembolic complications
5) ineffective carditis
What is the claim to fame of Calcific aortic stenosis.
It’s the most common valvular disorder in adults and most common cause of isolated Aortic stenosis in the US
Where can Calcific aortic stenosis occur?
It’s commonly associated with bicuspid valves (more congenital) but can develop in normal valves (more due to age).
Describe the morphology of Calcific aortic stenosis.
Valves become rigid and deformed by irregular calcified masses but there is no fusion or commisures… they are still distinct but stiff and non-compliant. Due to this they develop a resistance of emptying to the left ventricle, LV becomes hypertrophic and eventually dialated
What kind of symptoms would you expect to see in someone who has Calcific aortic stenosis.
Angina pectoris (due to increased demand and decreased aortic outflow), syncope, a harsh systolic murmur Eventually can get CHF
What is the age of onset for both types of Calcific aortic stenosis.?
Normal valve - in 70s- 80s
Bicuspic valve - in 40s-50s
What is the general treatment for someone with Calcific aortic stenosis?
Surgical valve replacement (if not 50% mortality in 2 years)
What is the most common cause of isolated mitral valve regurgitation?
Myxomatous degeneration or Mitral valve prolapse.
Who is most likely to get Myxomatous degeneration or Mitral valve prolapse
Peak age 20-40, Females outnumber males 7:1. Associated with those with Marfans and other connective tissue diseases but many who don’t get it.
What is the morphology of Myxomatous degeneration or Mitral valve prolapse?
Its the ballooning of redundant cusps especially the posterior leaflet. Chordae tendonae can get elongated and fragile (can rupture) due to polysaccharide mucus build up on valves.
What are the possible symptoms of Myxomatous degeneration or Mitral valve prolapse?
Palpations, Fatigue, chest pain, click murmur syndrome (click is chordae tendonae pulled tight
What does Myxomatous degeneration or Mitral valve prolapse increase the risk of?
1) Ineffective endocarditis
2) Stroke from emboli
3) Arrythmias and sudden death
What are the two types of prosthetic heart valves?
1) Bioprosthetic - From pigs or other humans
2) Mechanical - Artificial (no tissue component)
What are the 2 types of mechanical heart valves
1) Star Edwards - “Ping-Pong ball in a birdcage” - Fills and floats ball that gets sucked in annulus and closes valve
2) Tilting disc - has 2 trap doors. Hydrodynamic valve, reach a critical volume it opens up.
What are some complications that can happen with prosthetic heart valves?
1) Gradual wear - more of a problem in bioprosthetic, can stiffen
2) Thrombi- more with mechanical
3) Ineffective endocarditis (bioprosthetic)
4) Paravalvular leaks (both)
5) Hemolysis - more in mechanical (tilting disc)
What are the two types of pericarditis?
Primary - (usually viral) uncommon
Secondary - Most
What are the causes of secondary pericarditis?
1) MI
2) Cardiac surgery
3) Mediastinal radiation
4) Systemic disorders (Rhu fever, uremia)
What is morphology of secondary pericarditis?
Shaggy fibrinous membrane
What are the clinical features of pericarditis
1) atypical chest pains (worsened by reclining)
2) Friction rub
3) Tamponade (faint distant heart sounds, distended neck veins, reduced CO)
What are the 3 types of pericardial effussion
1) Serous - CHF, hypoalbuminemia
2) Serosanguineous - d/t blunt chest trauma and malignancy
3) Chylous - d/d mediastinal lymphatic obstruction.
Where do you find metastatic cardiac tumors and (what do they metastasized from)
Most commonly in the pericardium
Metastasized from lung, breast, melanoma, lymphoma/leukemia most common primaries
Are primary cardiac tumors rare?
Yes
What are 3 types of primary cardiac tumors
1) Myxoma - on the valve. Ball valve AV obstruction
2) Rhabdomyoma - associated with tuberous sclerosis and may see polygonal spider cells
3) Lipoma - on interatrial septum
