Cardiovascular diseases 2 Flashcards by Eleanor Price

What is the pathogenesis behind left-sided (congestive) heart failure?

Hypertension = pressure overload

Valvular disease = pressure/volume overload

MI = regional dysfunction with volume overload

All can lead to increase cardiac work = increased wall stress = cell stretch = hypertrophy and/or dilatation

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What are the cellular pathological features of heart failure?

Increase heart size and mass

Increased protein synthesis

Induction of immediate-early genes

Induction of foetal gene programme

Abnormal proteins

Fibrosis

Inadequate vasculature

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What are the characteristics of cardiac dysfunction?

Heart failure (systolic/diastolic)

Arrhythmias

Neurohumoral stimulation

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What is the impact of low output left heart failure on the kidneys?

pre-renal azotemia

Salt and fluid retention

renin-aldosterone activation
natriuretic peptides

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What is the impact of low output left heart failure on the brain?

Brain: Irritability, decreased attention, stupor -> coma

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What are the general signs and symptoms of left-sided heart failure?

Dyspnea

Orthopnea

PND (Paroxysmal Nocturnal Dyspnea)‏

Blood tinged sputum

Cyanosis

Elevated pulmonary “WEDGE” pressure (PCWP) (nl = 2-15 mm Hg)

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What is the main cause of the signs/symptoms of left-sided heart failure?

Pulmonary congestion and oedema

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What is the aetiology of right-sided heart failure?

Left-sided heart failure

Cor pulmonale

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What is cor pumonale?

Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.

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What are the signs and symptoms of left heart failure?

Liver and spleen

passive congestion (nutmeg liver)‏
congestive splenomegaly
ascites

Pleura/Pericardium

pleural and pericardial effusions
transudates

Peripheral tissues
- Pitting oedema

Fatigue
GI distress
Distention of jugular veins
Elevation of peripheral venous pressure

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What might you find in the autopsy of a person with congestive cardiac failure?

Cardiomegaly

Chamber Dilatation

Hypertrophy of myocardial fibers, BOXCAR nuclei

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What are the two basic types of valvular heart disease

Opening problems: Stenosis

Closing problems: Regurgitation or Incompetence or “insufficiency”

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Aortic and mitral stenosis account for what percentage of valvular heart defects?

70%

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What is the aetiology of aortic stenosis?

Calcification of a deformed valve

“Senile” calcific AS
Rheum, Heart Dis.

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What is the aetiology of mitral stenosis?

Rheumatic heart disease

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What is the precursor to rhematic heart disease?

Follows a group A strep infection, a few weeks later.

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What is pancarditis?

Endocarditis
Myocarditis
Pericarditis

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What are the features of acute rheumatic heart disease?

Inflammation

Aschoff bodies

Anitschkow cells

Pancarditis

Vegetations on chordae tendinae at leaflet junction

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What are the features of chronic rheumatic heart disease?

Thickened valves

Commisural fusion

Thick, short chordae tendinae

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What are the pertinent features of aortic stenosis?

2X gradient pressure

LVH (but no hypertension), ischemia

Cardiac decompensation, angina, CHF

50% die in 5 years if angina present

50% die in 2 years if CHF present

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What is mitral annular calcification?

Calcification of the mitral “skeleton”

Usually NO dysfunction

Regurgitation usually, but Stenosis possible

More common in males

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What are the pathological valve regurgitations?

Aortic regurgitation

Mitral regurgitation

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What are the aetiologies of aortic regurgitation?

Rheumatic

Infectious

Aortic dilatations

Syphilis
Rheumatoid Arthritis
Marfan

What are the aetiologies of mitral valve regurgitation?

Mitral valve prolapse

Infectious

Fen-Phen (drug)

Papillary muscles, chordae tendinae

Calcification of mitral ring (annulus)

What are the features of mitral valve prolapse?

MYXOMATOUS degeneration (pathological weakening) of the mitral valve Associated with connective tissue disorders “Floppy” valve 3% incidence, F>>M Easily seen on echocardiogram

What are the clinical features of mitral valve prolapse?

- Usually asymptomatic - Mid-systolic “click” - Holosystolic murmur if regurg. present - Occasional chest pain, dyspnea - 97% NO untoward effects - 3% Infective endocarditis, mitral insufficiency, arrythmias, sudden death

What is the aetiology of congenital heart defects?

Faulty embryogenesis (week 3-8)‏ May not be evident till adulthood Usually monomorphic

What is the incidence of congenital heart defects?

1% of births

What percentage of congenital heart defects are seen with genetic abnormalities?

10%

Which of the aneuploidies are involved in congenital heart disease?

Trisomies 21, 13, 15, 18, XO

What environmental factors might contribute to the development of congenital heart disease?

Rubella Teratogens

What are the three types of congenital heart disease?

L -> R shunts: all “D’s” in their names (VSD, ASD, PDA, AVSD) - NO cyanosis - Pulmonary hypertension - significant pulmonary hypertension is irreversible R -> L shunts: all “T’s” in their names - cyanosi (i.e., “blue” babies) - venous emboli become systemic “paradoxical” OBSTRUCTIONS: aorta or pulmonary artery

Are left to right shunts cyanotic or non-cyanotic?

Non-cyanotic

What is the most feared consequence of left to right shunts?

Irreversible pulmonary hypertension

What are different kinds of atrial septal defects?

SECUNDUM (90%): - Defective fossa ovalis PRIMUM (5%): - Next to AV valves, mitral cleft ``` SINUS VENOSUS (5%): - Next to SVC with anomalous pulmonary veins draining to SVC or RA ``` Does not include PFO Usually asymptomatic until adulthood

What are the most common congenital heart disease defects?

Ventricular septal defects (VSDs)

What percentage of ventricular septal defects are isolated?

30%

What condition are ventricular septal defects often associated with?

Tetralogy of Fallot

What percentage of VSDs involve the membranous septum?

90%

What can happen if the muscular septum is involved in VSDs?

Can have multiple holes (Swiss cheese septum)

What often happens with small VSDs?

They close spontaneously

What often happens with large VSDs?

Often progress to pulmonary hypertension

What percentage of patent ductus arteriosus (PDA) are isolated?

90%

What other conditions are associated with PDA?

VSD Coarctation of aorta Pulmonary or aortic stenosis

What is the pathology of an atrioventricular septal defect?

Associated with defective, inadequate AV valves Can be partial, or complete (all 4 chambers freely communicate) More than 1/3rd with complete AVSD have Down syndrome‏

Which of the congenital heart defects cause a right to left shunt?

Tetralogy of Fallot Transposition of great arteries Truncus arteriosus Total anomalous pulmonary venous connection Tricuspid atresia - ALL THE Ts

What are the features of Tetralogy of Fallot?

1) VSD, large 2) OBSTRUCTION to RV outflow 3) Aorta OVERRIDES the VSD 4) Right Valve Hypertrophy

What does survival in Tetraology of Fallot depend on?

On severity of subpulmonic stenosis - the greater the onstruction the greater the right to left shunt

What is transposition of the great arteries?

- Abnormal formation of truncal and aortopulmonary septa - needs a shunt for survival, obviously - PDA or PFO (65%), “unstable” shunt - VSD (35%), “stable” shunt - RV>LV in thickness - Fatal in first few months without shunt - Surgical “switching”

What is truncus arteriosis?

Developmental failure of separation of truncus arteriosus - connection between aorta and pulmonary artery Associated VSD Produces systemic cyanosis as well as increased pulmonary blood flow

What is tricuspid atresia?

Lack of development of the tricuspid valve. Needs shunt, ASD, VSD ord PDA Very high mortality

What is a Total Anomalous Pulmonary Venous Connection (TAPVC)?

Pulmonary veins do not go into LA, but into L. innominate v. or coronary sinus Needs a PFO or a VSD Hypoplastic LA

What are the obstructive CHDs?

- COARCTATION of aorta - Pulmonary stenosis/atresia - Aortic stenosis/atresia

What chromosomal abnormality is frequently associated with coarctation of the aorta?

XO - Turner Syndrome

Which form of coarctation of the aorta is serious?

Infantile form - with PDA

What are the clinical features of pulmonic stenosis/atresia?

- If 100% atretic, hypoplastic RV with ASD | - Clinical severity ~ stenosis severity

What are the different types of aortic stenosis/atresia?

VALVULAR - If severe, hypoplastic LVfatal SUB-valvular (subaortic)‏ - Aortic wall THICK BELOW cusps SUPRA-valvular - Aortic wall THICK ABOVE cusps in ascending aorta