Cardiovascular diseases 3 Flashcards
1
Q
What is endocarditis?
A
- Inflammation of the endocardium of the heart
- Prototypical lesion = “vegetation” on valves
2
Q
What are the two main forms of endocarditis?
A
- Infective endocarditis
- Clinically important
- Non-infective endocarditis
- Nonbacterial thrombotic endocarditis (NBTE)
- Endocarditis of SLE (Libman-Sacks Disease)
3
Q
What is infective endocarditis?
A
Colonization / invasion of heart valves or heart chamber endocardium by a microbe (bacteria and fungi)
4
Q
What are the ‘vegetations’?
A
- Mixture of thrombotic debris and organisms
- Destroy underlying cardiac tissues
- Aorta, aneurysmal sacs, blood vessels, prosthetic
valves can also be infected
5
Q
What is acute infective endocarditis?
A
- Can occur with infection of a previously normal heart valve
- Caused by highly virulent organisms
- Necrotizing, ulcerative, destructive lesions
- Difficult to cure with antibiotics and usually require surgery
- Death frequent days to weeks despite treatment
6
Q
What is subacute infective endocarditis?
A
- Organisms of lower virulence
- Insidious infections of deformed valves
- Less destructive
- Protracted “wax and wane” course of weeks to months
- Cured with antibiotics
7
Q
What are the aetiologies of infective endocarditis?
A
- Cardiac/valvular abnormalities
- Rheumatic heart disease
- MV prolapse
- Valvular stenosis (calcification etc)
- Artificial (prosthetic) valves
- Unrepaired and repaired congenital defects
- Bicuspid AV
8
Q
What sort of investigation should you perform if you discover Strep. bovis AND endocarditis in a patient?
A
Investigation for bowel cancer
9
Q
How does an infection get to the heart?
A
- Any route of bacteria into the blood stream e.g.
- Dental abnormalities, IVDU, wounds, bowel cancer…..
10
Q
What organisms are commonly associated with endocarditis?
A
Streptococcus viridans from the mouth
- Endocarditis in native but damaged / abnormal valves
- 50-60% cases
S. aureus from the skin
- 10% to 20% of cases overall esp. IVDU
Coagulase-negative staphylococci (e.g. S. epidermidis)
- Commonly infect prosthetic heart valves
11
Q
What are the pertinent features of the vegetations of acute infective endocarditis?
A
- Friable, bulky, potentially destructive
- AV, MV, right heart (especially in IVDUs)
- Single, multiple and often more than one valve
- Can erode myocardium abscess (ring abscess).
- Emboli contain large numbers of virulent organisms
- Abscesses at the sites where emboli lodge
- Septic infarcts or mycotic aneurysms
- Abscesses at the sites where emboli lodge
Sub-acute IE – Less destruction
12
Q
What are the clinical features of infective endocarditis?
A
Fever
- Most consistent sign
- Rapidly developing fever, chills, weakness
- Can be slight or absent, particularly in the elderly
Non-specific symptoms
- May be only presentation
- Loss of weight / flu-like syndrome.
Murmurs
- 90% of patients with left-sided IE
- New valvular defect or represent a pre-existing abnormality.
13
Q
What are the complications of infective endocarditis?
A
- Immunologically mediated conditions e.g. glomerulonephritis
14
Q
What are the pathological signs of infective endocarditis?
A
- Splinter / subungual hemorrhages
- Janeway lesions
- Erythematous or haemorrhagic non-tender lesions on the palms or soles
- Osler’s nodes
- Subcutaneous nodules in the pulp of the digits
- Roth spots
- Retinal haemorrhages in the eyes
15
Q
What are Janeway lesions?
A
Janeway lesions are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis
16
Q
What are Osler’s nodes?
A
Painful, red, raised lesions found on the hands and feet
17
Q
What are Roth spots?
A
Retinal hemorrhages with white or pale centers
18
Q
What mnemonic is associated with infective endocarditis?
A
F – Fever
R – Roth spots
O – Osler’s nodes
M – Murmurs
J – Janeway Lesions
A – Anaemia
N – Nail (splinter) haemorrhage
E – Emboli (septic)
19
Q
What is non-bacterial thrombotic endocarditis (NBTE)?
A
Occurs in debilitated patients (e.g. cancer or sepsis)
- AKA “marantic endocarditis”
Associated with a hypercoagulable state
- Hence DVT, PE and mucinous adenocarcinomas!
- Pro-coagulant effects of tumour-derived mucin or tissue factor
Part of trousseau syndrome of migratory thrombophlebitis
Endocardial trauma / indwelling catheter (e.g. central line)
- Predisposes
20
Q
What are the features of vegetations in NBTE?
A
- Small (1 to 5mm) sterile thrombi on valve leaflets
- Singly or multiple on line of closure of leaflets or cusps
- Not invasive / no inflammatory reaction minimal local effect
- Systemic emboli
- Infarcts in the brain, heart etc.
21
Q
What is rheumatic fever?
A
Acute, immunologically mediated, multi-system inflammatory disease following group A streptococcal pharyngitis
22
Q
What are Aschoff bodies?
A
- Distinctive cardiac lesions
- Foci of T-cells, plasma cells and macrophages
- Can be found in all three cardiac layers (pancarditis)
23
Q
What are the vegetations called in rheumatic fever?
A
Veruccae
24
Q
What mitral valve changes are seen in rheumatic fever?
A
- Virtually ONLY cause of mitral stenosis
- Leaflet thickening
- Virtually always involved in chronic disease
- MV only in most cases cases
- Aortic valve in 25% of cases
- Tricuspid valve / pulmonary valves - uncommon
- Fibrous bridging of valvular commissures & calcification
- “FISH MOUTH” or “buttonhole” stenoses
25
What is the aetiology of rheumatic fever?
- Antibodies directed against the M proteins of streptococci
- Cross-react with self antigens in the heart
- CD4+ T cells specific for streptococcal peptides
- React with self proteins in the heart
- Produce cytokines that activate macrophages (e.g. Aschoff bodies)
26
What are the possible causes of pericarditis?
- Inflammation of the pericardial sac can be caused by…..
- Infections
- Viruses (Coxsackie B), bacteria, TB, fungi, parasites
- Immunologically mediated processes
- Rheumatic fever, SLE, scleroderma, post-cardiotomy
- Late post-MI = Dressler’s, drug hypersensitivity
- Miscellaneous conditions
- Post-MI (early), uraemia, cardiac surgery, neoplasia
- Trauma, radiation
27
What are the features of acute pericarditis?
- Serous
- Serofibrinous / fibrinous
- Purulent / suppurative
- Haemorrhagic
- Caseous
28
What are the features of chronic pericarditis?
- Adhesive
- Adhesive mediastinopericarditis
- Constrictive pericarditis
29
What is serous pericarditis?
Inflammation causes serous fluid accumulation in pericardium.
30
What is usually the cause of serous pericarditis?
- Caused by non-infectious aetiologies (generally)
- Inflammation in adjacent structures can cause pericardial reaction
- Rarely by viral pericarditis (Coxsackie B / echovirus)
- Immunologically mediated processes
- Rheumatic fever, SLE, scleroderma
- Miscellaneous conditions
- Uraemia, neoplasia, radiation
31
What is Dressler's syndrome?
Secondary pericarditis - AKA – Post-MI syndrome
Clinical triad of…..
1. Fever
2. Pleuritic chest pain
3. Pericardial effusion
32
What is the cause of Dressler's syndrome?
Autoimmune reaction to antigens released following myocardial infarction
NOT acute pericarditis
33
What is the cause of purulant/suppurative pericarditis?
Infections
34
What are the features of purulent/suppurative pericarditis?
- Red, granular, exudate i.e. pus (can be upto 500mls!)
| - Inflammation can extend causing mediastino-pericarditis
35
What is the outcome of purulant/suppurative endocarditis?
Complete resolution is rare
- Scarring
- Restrictive pericarditis
36
What is haemmorhagic pericarditis?
Blood mixed with serous (watery) or suppurative (pus) effusion
37
What are the common causes of haemorrhagic pericarditis?
- Neoplasia (malignant cells in effusion)
- Infections (in TB/fungal preicarditis is caseous)
- Following cardiac surgery -> cardiac tamponade
38
What are the different forms of chronic pericarditis?
- Adhesive
- Adhesive mediastinopericarditis
- Constrictive
39
What are the features of adhesive pericarditis?
Fibrosis / stringy adhesions obliterates pericardial cavity
40
What are the features of adhesive mediastinopericarditis?
- Follows pericarditis caused by infections, surgery or radiation
- Obliterated pericardial cavity with adherence to surrounding structures
- Causes cardiac hypertrophy / cardiac dilation
41
What are the features of constrictive pericarditis?
- Heart encased in fibrous scar – limits cardiac function
| - Treated by surgery to remove ‘shell’ around heart
42
What are the broad clinical features of pericarditis?
- Sharp central chest pain…characteristics?
- Exacerbated by : movement, respiration, laying flat
- Relieved : sitting forwards
- Radiating : shoulders / neck
- Differentials : angina, pleurisy
- Pericardial friction rub
- Loudest with diaphragm, left sternal edge
- Fever, leucocytosis, lymphocytosis, pericardial effusion
- Complications – pericardial effusion / cardiac tamponade
43
What is cardiomyopathy?
Literally 'heart muscle disease'?
44
What are the four types of cardiomyopathy?
- Dilated
- Hypertrophic
- Restrictive
- Arrythmogenic right venticular
cardiomyopathy
45
What are the pathological features of dilated cardiomyopathy?
- Progressive dilation -> contractile (systolic) dysfunction
- Heart enlarged, heavy, flabby (dilation of chambers)
- Myocyte hypertrophy with fibrosis
46
What are the causes of dilated cardiomyopathy?
Genetic
- 20 – 50% cases
- Autosomal dominant (mainly)
- Cytoskeletal proteins gene mutation
Alcohol and other toxins
- 10-20%
- chemotherapy
Others
- SLE
- scleroderma
- thiamine def
- acromegaly
- thyrotoxicosis
- diabetes
47
What are the clinical features of dilated cardiomyopathy?
Any age but commonly 20 – 50
Slow progressive signs / symptoms of
- CCF
- SoB
- fatigue
- poor exertional capacity
48
What is the 5 year survival for dilated cardiomyopathy?
~ 25% (like the ejection fraction!)
Death due to
- CCF
- arrhythmia / embolism (intra-cardiac thrombus)
49
What is the treatment for dilated cardiomyopathy?
Cardiac transplantation
Long-term ventricular assist (can induce regression)
50
What is hypertrophic cardiomyopathy?
Defined by myocardial hypertrophy
Poorly compliant (stiff) left ventricular myocardium
Diastolic dysfunction with preserved systolic function
Intermittent ventricular outflow obstruction (1/3 cases)
Thick-walled, heavy, and hyper-contracting
Main cause of unexplained LVH
(in the absence of any obvious cause)
51
What is the aetiology of hypertrophic cardiomyopathy?
100% genetic
- Mutations sarcomeric proteins
- Can be sporadic
52
What are the clinical features of hypertrophic cardiomyopathy?
↓Stroke volume
- Impaired diastolic filling - reduced chamber size / compliance of hypertrophied left ventricle
Obstruction to the left ventricular outflow
- 25% of patients
Exertional dyspnoea due to above
Systolic ejection murmur
- Ventricular outflow obstruction
- Anterior mitral leaflet moves toward the ventricular septum during systole.
53
What are the complications of hypertrophic cardiomyopathy?
Atrial fibrillation
Mural thrombus formation -> embolization / stroke
Cardiac failure
Ventricular arrhythmias
Sudden death, especially in some affected families
- Most common causes of sudden death in athletes
54
What is the treatment of hypertropic cardiomyopathy?
Decrease heart rate and contractility - β-adrenergic blockers.
Reduction of the mass of the septum, which relieves the outflow tract obstruction
55
What is restrictive cardiomyopathy?
Primary decrease in ventricular compliance
- Impaired ventricular filling during diastole
```
Idiopathic or secondary (infiltration)
- fibrosis
- amyloidosis
- sarcoidosis
- metastatic tumors
- deposition of
metabolites (inborn errors of metabolism)
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56
What is the morphology of restrictive cardiomyopathy?
- Ventricles normal size / slightly enlarged chambers normal
| - Myocardium is firm and noncompliant
57
What is arrythmogenic right ventricular cardiomyopathy?
AKA arrhythmogenic R.V. dysplasia
Genetic disease (A.D.), ~1 in 5000
RV dilation / myocardial thinning
Fibrofatty replacement of RV
Disorder of cell-cell desmosomes
Exercise -> cells detach and die
Silent, syncope, chest pain, palpitations
Sudden cardiac death – young / exercise
58
What are the most common causes of infective endocarditis?
Coxsackie A&B viruses
- most common cause in West
Chagas disease (Trypanosoma cruzi) protozoa
- important non-viral cause (endemic in South America)
- 10% die acutely
59
What are the broad clinical features of infective endocarditis?
Asymptomatic
Heart failure, arrhythmias and sudden death
Non-specific symptoms - fatigue, dyspnea, palpitations, precordial discomfort, and fever
Can mimic acute MI
DCM can develop
60
What are the other viral causes of infective endocarditis?
ECHO
Influenza
HIV
CMV
61
What are the bacterial causes of infective endocarditis?
C.diptheriae
N.meningococcus
Borrelia (Lyme)
Chlamydiae
Rickettsiae
62
What are the fungal causes of infective endocarditis?
Candida
Histoplasma
(Immunosuppressed)
63
What are the protozoan causes of infective endocarditis?
Trypanosoma cruzi (Chagas disease)
64
What are the helminths that can cause infective endocarditis?
Trichonosis
65
What are the immune-mediated causes of myocarditis?
Post-viral
Post-Strep (grp A) - rheumatic fever
SLE
Drugs
- methyldopa
- sulfonamides
Transplant rejection
66
What are the other causes of myocarditis?
Sarcoidosis
Giant cell myocarditis
67
What is vasculitis?
Inflammation of the vessel walls
68
How is vasculitis classified?
Chapel Hill Classification
By size first
Small vessel then split to ANCA/non-ANCA
69
What is the most common form of vasculitis?
Giant cell arteritis
| - elderly individuals in the west
70
What is the pathology of giant cell arteritis?
Chronic granulomatous inflammation
Large to medium-sized arteries
Esp. in the head (e.g. temporal arteries
- AKA temporal arteritis)
Also vertebral and ophthalmic arteries
Ophthalmic arterial involvement
- Permanent blindness
- Giant-cell arteritis is a medical emergency requiring prompt recognition and treatment – early recognition is VITAL!
Also occurs in other vessels the aorta (giant-cell aortitis).
71
What is the morphology of giant cell arteritis?
Intimal thickening
- reduces the lumenal diameter
Med. granulomatous inflammation
- elastic lamina fragmentation
Multinucleated giant cells
- 75% of adequately biopsied
72
How is giant cell arteritis diagnosed?
biopsy and histologic
- Segmental disease
- Hence 2- to 3-cm length of artery
73
What is the treatment of giant cell arteritis?
- Corticosteroids is generally effective
| - anti-TNF therapy in refractory cases
74
What is an aneurysm?
Localised, permanent, abnormal dilatations of a blood vessel
75
How can aneurysms be classified?
Shape
Aetiology
- Atherosclerotic
- Dissecting
- Berry
- Microaneurysms
- Syphilitic
- Mycotic
- False
76
What are atherosclerotic aneurysms?
Most common, often in the elderly
Commonly - AAA secondary to atherosclerosis
77
How are atherosclerotic aneurysms detected?
USS
78
What are the complications of atherosclerotic aneurysms?
Rupture causing retroperitoneal haemorrhage
Embolisation causing limb ischaemia
79
What is a dissecting aneurysm?
Tear in the wall
Blood tracks between intimal and medial layers
80
What are the classical features of a dissecting aneurysm?
Tearing pain in chest radiating to upper left shoulder
81
What are the pathological features of dissecting aneurysms?
Usually thoracic aorta secondary to systemic hypertension
Progressive vascular occlusion and haemopericardium
↑↑ Mortality without treatment (aim to reduce arterial pressure / surgery)
82
What are berry aneurysms?
Small, saccular lesions that develop in the Circle of Willis
Develop at sites of medial weakness at arterial bifurcations
Commonly found in young hypertensive patients
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Rupture causes
subarachnoid haemorrhage (SAH)
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83
What are Charcot-Bouchard aneurysms?
Occur in intracerebral capillaries in hypertensive disease
Causes intracerebral haemorrhage (i.e. stroke)
84
What are microaneurysms?
Retinal microaneurysms can develop in diabetes causing diabetic retinopathy
85
What are mycotic aneurysms?
Rare
Weakening of arterial wall secondary to bacterial / fungal infection
Organisms enter media from the vasa vasorum
SBE is the most common underlying infection
Often in the cerebral arteries
Infection of AAAs risk rupture
86
What is a false aneurysm?
Blood filled space around a vessel, usually following traumatic rupture or perforating injury
The adventitial fibrous tissue contains the haematoma
Commonly seen following femoral artery puncture during angiography / angioplasty
87
What are the 6 Ps of acute ischaemia?
```
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing Cold
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