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Year 2 Clinical Pathology > Cardiovascular diseases 3 > Flashcards

Cardiovascular diseases 3 Flashcards

1
Q

What is endocarditis?

A

Inflammation of the endocardium of the heart with prototypical lesions/vegetations on heart valves

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2
Q

What are the 2 main types of endocarditis?

A

1) Infective endocarditis

2) Non-infective endocarditis

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3
Q

What is infective endocarditis?

A

Colonization or invasion of heart valves or heart chamber endocardium but a microbe

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4
Q

The vegetation of infective endocarditis are made up of what?

A

Mixture of thrombotic debris and organisms

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5
Q

What harmful effect do the vegetations found in infective endocarditis have?

A

They destroy the underlying cardiac tissue

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6
Q

Other than the heart valves or endocardium what other structures can become infected in infective endocarditis?

A

1) Aorta
2) Aneurysmal sacs
3) Blood vessels
4) Prosthetic valves

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7
Q

Most cases of infective endocarditis are caused by what kind of organism?

A

Mostly bacteria, fungi and other classes can however be a cause

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8
Q

What are the 2 types of infective endocarditis, how do they differ in severity?

A

1) Acute endocarditis - severe, medical emergency

2) Sub-acute endocarditis - less severe

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9
Q

What are the main differences between acute and sub acute infective endocarditis? 4

A

1) Acute can occur with infection of a previously normal heart valve whereas sub-acute tends to be insidious infections of deformed valves
2) Acute is caused by highly virulent organisms compared to the organisms of lower virulence in sub-acute
3) In acute get necrotizing, ulcerative, destructive lesions, sub acute is much less destructive
4) Sub-acute has a wax and wane course (flare ups)

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10
Q

What are the differences between acute and sub acute endocarditis in terms of treatment and prognosis?

A

Treatment - acute is difficult to cure with Abx and usually requires surgery, sub-acute is cured with Abx
Prognosis - in acute death is frequent within days to weeks despite treatment, subacute is cured

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11
Q

Infective endocarditis can occur in a normal heart but what are the 2 main risk factors?

A

1) Cardiac/valvular abnormalities

2) Rheumatic heart disease was a major cause

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12
Q

What 5 valvular abnormalities predispose to infective endocarditis?

A

1) MV prolapse
2) Valvular stenosis (calcification etc.)
3) Prosthetic valves
4) Unrepaired and repaired congenital defects
5) Biscuspid AV

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13
Q

Strep bovis infective endocarditis should prompt investigation for what?

A

Bowel cancer

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14
Q

Any route of bacteria into the bloodstream can lead to infection in the heart, name 4 routes into the blood stream?

A

1) Dental work abnormalities
2) IVDU
3) Wounds
4) Bowel cancer

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15
Q

Which bacteria from the mouth causes 50-60% of cases of infective endocarditis and what kind of valves does it infect?

A

Streptococcus viridans

Causes endocarditis in native but damaged or abnormal valves

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16
Q

Which bacteria from the skin causes 10-20% of cases of infective endocarditis, in which groups is it most common?

A

Staph aureus

Most common in IVDUs

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17
Q

Which bacteria commonly infects prosthetic heart valves?

A

Coagulase negative staphylococci (eg. staph epidermis)

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18
Q

What is culture negative endocarditis? What percentage of cases does it account for and how should it be treated?

A

Presents as infective endocarditis but no organism can be cultures
Accounts for 10-15% of cases
Treated as if infective endocarditis

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19
Q

Name 7 risk factors for infective endocarditis?

A

1) Dental disease or procedures
2) Prolonged indwelling vascular catheters
3) IVDU
4) Underlying genitourinary disease or procedures
5) Bowel malignancy
6) Prosthetic valves
7) Soft tissue infections

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20
Q

How would the vegetation in infective endocarditis be described?

A

Friable, bulky, potentially destructive (less destructive in sub acute IE)

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21
Q

Where do the vegetations tend to reside in infective endocarditis?

A

AV, MV, right heart (especially in IVDUs)

Can be single or multiple and often more than one valve

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22
Q

How can vegetations lead to abscesses?

A

Vegetations can erode the myocardium and produce ring abscesses
Emboli of vegetations can also break off which contain large numbers of virulent organsims and create abscesses at the sites where the emboli lodge

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23
Q

What 2 things can emboli of vegetations in infective endocarditis lead to?

A

1) Septic infracts

2) Mycotic aneurysms

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24
Q

What are the 3 main possible clinical features of IE?

A

1) Fever - most consistent sign, get a rapidly developing fever, chills and weakness, can be slight or absent particularly in the elderly
2) Non specific symptoms - may be the only presentation, loss of weight/flu-like syndrome
3) Murmurs - 90% of patients with left sided IE get this, this could also be a new valvular defect or represent a pre-existing abnormality

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25
Q

What are the main complications of infective endocarditis?

A

Immunologically mediated conditions eg. glomerulonephritis

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26
Q

What are the clinical manifestations of infective endocarditis (caused by micro-thromboemboli)?

A

1) Splinter/ subungual haemorrhages
2) Janeway lesions - erythematous or haemorrhagic non tender lesions on the palms or soles
3) Osler’s nodes - subcutaneous nodules in the pulp of the digits
4) Roth spots - retinal haemorrhages in the eyes

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27
Q

What is the pneumonic for remembering the clinical presentation of infective endocarditis?

A 
FROM JANE
Fever
Roth spots
Osler's nodes
Murmurs
Janeway lesions
Anaemia
Nail (splinter) haemorrhages
Emboli (Septic)
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28
Q

Name the 2 kinds of non-infective endocarditis?

A

1) Non bacterial thrombotic endocarditis (NBTE)

2) Libman-Sacks endocarditis

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29
Q

Non bacterial thrombotic endocarditis (NBTE) occurs in which patients and associated with what state?

A

Occurs in debilitated patients (Eg. cancer or sepsis) - AKA marantic endocarditis
Associated with a hypercoagulable state - hence DVT, PE and mucinous adenomas are associated with it, pro-coagulant effects of tumour-derived mucin or tissue factor

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30
Q

What is trousseau syndrome?

A

Syndrome associated with malignancy, involving episodes of thrombophlebitis which appear in different locations over time (migratory thrombophlebitis)

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31
Q

NBTE is part of what syndrome associated with malignancy?

A

Trousseau’s syndrome

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32
Q

Which 2 things predispose to NBTE?

A

1) Endocardial trauma

2) Indwelling catheter

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33
Q

What kind of vegetations occur in NBTE?

A
  • Small (1-5mm) sterile thrombi on valve leaflets

- Singly or multiple on line of closure of leaflets or cusps

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34
Q

How do the vegetations in NBTE potentially cause damage?

A

They are non invasive and don’t illicit and inflammatory reaction so have minimal local effects but can create systemic emboli which can cause infracts in the brain/heart etc.

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35
Q

Libman-sacks endocarditis is associated with what disease?

A

Systemic Lupus Erythematosis (SLE)

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36
Q

What are the symptoms/complications of Libman-sacks endocarditis?

A
  • Usually asymptomatic (other than the symptoms of SLE)

- Rarely cause cardiac failure or systemic emboli

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37
Q

Which valves tend to be affected in libman-sacks endocarditis, what is nature of the vegetations and where exactly do they commonly occur?

A 
Mitral and tricuspid (AV) valves affected
Get small (1-4mm) sterile pink warty vegetations, which can be single or multiple
Often occur on the AV valves under surfaces and on the chordae, valvular endocardium or mural endocardium of atria or ventricles
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38
Q

What is rheumatic fever?

A

Acute, immunologically mediated (auto-immune) multi system inflammatory disease following group A streptococcal pharyngitis

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39
Q

Why has rheumatic fever reduced in incidence, where is it most prevelant?

A

Rarer because of improved diagnosis/treatment

Commoner in developing countries or poor western populations

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40
Q

What microscopic signs in the heart are diagnostic of rheumatic fever?

A

Aschoff bodies - distinctive cardiac lesions

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41
Q

What are aschoff bodies and where can they be found?

A

Foci of T cells, plasma cells and macrophages

Can be found in all 3 cardiac layers

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42
Q

What is the term for inflammation in all 3 layers in the heart?

A

Pancarditis

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43
Q

What are the vegetations found in rheumatic fever called?

A

Veruccae

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44
Q

Other than verrucae and aschoff bodies, what are the 2 other main pathological features of rheumatic fever?

A

1) Mitral valve changes - virtually the only cause of mitral valve stenosis, leaflet thickening, virtually always involved in chronic rheumatic heart disease
2) Fibrous bridging of valvular commissures and calcification - fish mouth or buttonhole stenoses

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45
Q

What is the aetiological process of rheumatic fever?

A

1) Hypersensitivity reaction - combined Ab and T cell mediated response
2) Immune response to group A strep pharyngitis
3) Ab directed against the M proteins of streptococci cross react with self Ags in the heart
4) CD4+ cells specific for streptococcal peptides react with self proteins in the heart and produce cytokine which activate macrophages (hence aschoff body formation)

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46
Q

What is the name of the diagnostic criteria for rheumatic fever?

A

Jones criteria

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47
Q

What are 2 cardiac complications of rheumatic heart disease?

A

1) Left atrium dilatation (mural thrombi can form and embolise)
2) Right ventricular hypertrophy

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48
Q

What is pericarditis?

A

Inflammation of the pericardial sac

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49
Q

What are the 3 types of causes of pericarditis?

A

1) infections - viruses (Coxsackie B), bacteria, TB, fungi, parasites
2) Immunologically mediated processes
3) Miscellaneous conditions

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50
Q

What virus is commonly associated with infections of the heart?

A

Coxsackie B virus

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51
Q

Immunologically mediated processes associated with what 6 conditions?

A

1) Rheumatic fever
2) SLE
3) Scleroderma
4) Post-cardiotomy (surgical incision of the heart)
5) Late post MI = Dressler’s
6) Drug hypersensitivity

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52
Q

Name 6 non infective and non immunologically mediated conditions which can lead to pericarditis?

A

1) Post MI (Early)
2) Uraemia
3) Cardiac surgery
4) Neoplasia
5) Trauma
6) Radiation

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53
Q

What are the 5 forms of acute pericarditis?

A

1) Serous
2) Serofibrinous/fibrinous
3) Purulent/suppurative
4) Haemorrhagic
5) Caseous

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54
Q

What are the 3 forms of chronic pericarditis?

A

1) Adhesive
2) Adhesive mediastinopericarditis
3) Constrictive pericarditis

55
Q

What is the main difference between acute and chronic pericarditis?

A

Acute - inflamed

Chronic - pericardial sack is stuck down

56
Q

What is serous pericarditis?

A

Inflammation causes clear ‘serous’ fluid accumulation

57
Q

What aetiologies in serous pericarditis caused by?

A

Non infectious aetiologies - Although inflammation in adjacent structures can cause a pericardial reaction, rarely caused by viruses

58
Q

Name 6 specific aetiologies causing serous pericarditis?

A 
Immunologically mediated processes
1) Rheumatic fever
2) SLE
3) Scleroderma
Miscellaneous conditions
4) Uraemia
5) Neoplasia
6) Radiation
59
Q

What is Dressler’s syndrome, what clinical triad is it made up of?

A

Secondary pericarditis - AKA post MI syndrome
Clinical triad of:
1) Fever
2) Pleuritic chest pain - worse on inspiration
3) Pericardial effusion

60
Q

What is the aetiology of Dressler’s syndrome?

A

Autoimmune reaction to antigens released following an MI - it is not the same as acute pericarditis as there is a delay of weeks

61
Q

What causes a purulent/suppurative pericarditis?

A

Infections

62
Q

What are the main features of purulent or suppurative pericarditis?

A

Red, granular exudate - ie pus

Inflammation can extend causing mediastinopericarditis

63
Q

What is the most common outcome of suppurative pericarditis?

A
  • Complete resolution is rare

- Get organisation by scarring which can lead to restrictive pericarditis which is v serious

64
Q

What is haemorrhagic pericarditis?

A

Blood mixed with serous (watery) or suppurative (pus) effusion

65
Q

What are the 3 common causes of haemorrhagic pericarditis?

A

1) Neoplasia (see malignant cells in effusion)
2) Infections (inc TB)
3) Following cardiac surgery - get cardiac tamponade

66
Q

What are the 2 main causes of caseous pericarditis?

A

1) TB infection

2) Fungal infection

67
Q

What is constrictive pericarditis and how is it treated?

A

Heart encased in a fibrous scar which limits cardiac function
Treated by surgery to remove ‘shell’ around heart

68
Q

What is adhesive pericarditis?

A

Fibrosis/stringy adhesion obliterates the pericardial cavity

69
Q

Adhesive mediastinopericarditis commonly follows what?

A

Pericarditis caused by infection, surgery or radiation

70
Q

What is adhesive mediastinopericarditis and what heart abnormalities does it cause?

A

Obliterated pericardial cavity with adherence to surrounding structures
Causes cardiac hypertrophy/cardiac dilation

71
Q

How are pericardial effusion and pericarditis related?

A

Pericardial effusion can be a complication of pericarditis

72
Q

What are the 6 clinical features of pericarditis?

A

1) Sharp central chest pain
2) Pericardial friction rub- parietal and visceral layers of pericardium rub together
3) Fever
4) Leucocytosis
5) Lymphocytosis
6) Pericardial effusion

73
Q

What are the 2 main possible complications of pericarditis?

A

1) Pericardial effusion

2) Cardiac tamponade

74
Q

What is the classical pain in pericarditis?

A

Sharp central chest pain

1) Exacerbated by movement, respiration, lying flat
2) Relieved by sitting forwards
3) Radiating to the shoulders and neck

75
Q

What is a cardiomyopathy?

A

Disorder of the myocardium

76
Q

What are the 4 main types of cardiomyopathy?

A

1) Dilated
2) Hypertrophic
3) Restrictive
4) Arrythmogenic right ventricular cardiomyopathy

77
Q

What happens to the heart in dilated cardiomyopathy?

A

1) Progressive dilation leading to contractile (systolic) dysfunction
2) Heart enlarged, heavy and flabby (dilation of chambers)
3) Get myocyte hypertrophy with fibrosis

78
Q

Do you get diastolic or systolic dysfunction in dilated cardiomyopathy?

A

Systolic dysfunction

79
Q

What are the 2 main causes of dilated cardiomyopathy?

A

1) Genetic - autosomal dominant (mainly), cytoskeletal proteins gene mutation
2) Alcohol and other toxins eg. chemotherapy

80
Q

When does dilated cardiomyopathy commonly present?

A

Commonly 20-50

81
Q

What are the signs/symptoms of dilated cardiomyopathy?

A 
Slow progressive signs
Symptoms of congestive cardiac failure:
- SoB
-Fatigue
- Poor exertional capacity
82
Q

What is the 5 year survival rate of dilated cardiomyopathy, what are the most common causes of death?

A

5 year survival = 25%

Death due to CCF, arrhythmia/embolism (intra-cardiac thrombus)

83
Q

What are the 2 main treatments for dilated cardiomyopathy?

A

1) Cardiac transplantation

2) Long-term ventricular assist

84
Q

How is hypertrophic cardiomyopathy defined?

A

Myocardial hypertrophy in the absence of an obvious cause eg. hypertension

85
Q

What happens to the heart in hypertrophic cardiomyopathy?

A

Poorly compliant left ventricular myocardium - thick walled, heavy and hypercontracting, with myocyte hypertrophy and disarray
Diastolic dysfunction with preserved systolic function
Intermittent ventricular outflow obstruction occurs in 1/3 cases

86
Q

What is the main cause of unexplained LV hypertrophy?

A

Hypertrophic cardiomyopathy

87
Q

Do you get diastolic or systolic dysfunction in hypertrophic cardiomyopathy?

A

Diastolic dysfunction

88
Q

What is the cause of hypertrophic cardiomyopathy?

A

100% genetic - mutations in sarcomeric proteins, can be sporadic

89
Q

What are the 4 main clinical features of hypertrophic cardiomyopathy?

A

1) Reduced stroke volume
2) Obstruction to LV outflow
3) Exertional dyspnoea due to the above
4) Systolic ejection murmur - ventricular outflow obstruction, anterior mitral leaflet moves towards the ventricular septum during systole

90
Q

What are the 5 main complication of hypertrophic cardiomyopathy?

A

1) AF
2) Mural thrombus formation - stroke
3) Cardiac failure
4) Ventricular arrhythmias
5) Sudden death especially in some affected families- most common cause of sudden death in athletes

91
Q

What are the 2 main treatments for hypertrophic cardiomyopathy?

A

1) Decrease heart rate and contractility - B-adrenergic blockers
2) Reduction of the mass of the septum which relieves the outflow tract obstruction

92
Q

Which 2 genes are commonly mutated in cardiomyopathies?

A

1) HCM
2) DCM
Can be both

93
Q

What is restrictive cardiomyopathy?

A

A primary decrease in ventricular compliance

Impaired ventricular filling during diastole

94
Q

What are the causes of restrictive cardiomyopathy?

A

1) Idiopathic

2) Secondary (infiltration) - fibrosis, amyloidosis, sarcoidosis, metastatic tumours or deposition of metabolites (IEMs)

95
Q

What is the morphology of the heart in restrictive cardiomyopathy?

A

1) Ventricles normal size/ slightly enlarged

2) Myocardium is firm and non compliant

96
Q

What is arrhythmogenic right ventricular cardiomyopathy?

A
  • Also called arrythmogenic RV dysplasia
  • AD genetic disorder of the cell-cell desmosomes
  • During exercise the cells detach and die
  • Get RV dilation/ myocardial thinning
  • Get fibrofatty replacement of RV
97
Q

What are the 4 main clinical features and the major complication of arrthmogenic RV cardiomyopathy?

A

Clinical features:
Silent, syncope, chest pain palpitations
Can cause sudden cardiac death in young people, particularly athletes

98
Q

What is myocarditis?

A

Infective or inflammatory process leading to myocardial injury

99
Q

Infections are the main causes of myocarditis, which 2 infectious agents are most common?

A

1) Coxsackie A&B viruses - most common in west

2) Chagas disease (trypanosome cruzi) protozoa - endemic in south america

100
Q

What are the 5 v broad clinical features of myocarditis?

A

1) Can be asymptomatic
2) Can lead to heart failure, arrhythmias and sudden death
3) Can produce non specific symptoms - fatigue, dyspnoea, palpitations, precordial discomfort and fever
4) Can mimic acute MI
5) DCM can develop

101
Q

There are various infectious causes of myocarditis, what are the 5 immune mediated causes?

A

1) Post viral
2) Post streptococcal (RF)
3) SLE
4) Drugs
5) Transplant rejection

102
Q

Other than the infectious and immune mediated causes of myocarditis, what are the 2 other causes?

A

1) Sarcoidosis

2) Giant cell myocarditis

103
Q

In what basic what can vasculitis be recognised histologically?

A

By blue dots in a blood vessel

104
Q

What is vasculitis?

A

Inflammation of vessel wall (20 Subtypes) - can affect any organ or any vessel

105
Q

How can the type of vasculitis be classified?

A

According to vessel size and then other features following that

106
Q

What is the most common form of vasculitis?

A

Giant cell arteritis

107
Q

What is the pathology of giant cell arteritis?

A

Chronic granulomatous inflammation In large to medium sized arteries

108
Q

What arteries does giant cell arteritis commonly occur in?

A

Common in head - esp. temporal arteries- temporal arteritis

Also in vertebral and ophthalmic arteries

109
Q

What is the term for giant cell arteritis in the aorta?

A

Giant-cell aortitis

110
Q

What does giant cell arteritis in the ophthalmic artery lead to?

A

Permanent blindness - medical emergency requiring prompt recognition and treatment

111
Q

What are the 3 key features of the morphology of giant cell arteritis?

A

1) Intimal thickening - reduced luminal diameter
2) Granulomatous inflammation - elastic lamina fragmentation
3) Multinucleated giant cells

112
Q

What are the main clinical features of giant cell arteritis?

A

Vague symptoms such as fatigue and weight loss

113
Q

What are the 2 main symptoms in temporal arteritis?

A

1) Superficial temporal artery is painful on palpation

2) Jaw claudication

114
Q

How is diagnosis of giant cell arteritis carried out? 2

A

1) Biopsy - segmental disease (skip lesions) so 2-3cm needed

2) Histological examination

115
Q

What is the treatment for giant cell arteritis? 2

A

1) Corticosteroids are generally effective

2) Anti-TNF therapy in resistance cases

116
Q

What is an aneurysm?

A

Localised, permanent, abnormal dilatations of a blood vessel

117
Q

In which 2 ways can aneurysms be classified?

A

1) Shape

2) Aetiology

118
Q

What is the difference between a secular aneurysm and a fusiform aneurysm?

A

Sacular aneurysm - like a berry aneurysm

Fusiform aneurysm - whole thing dilated along one bit of length

119
Q

What is the main risk factor for rupture of AAA?

A

Size of aneurysm

120
Q

What is the most common type of aneurysm (classified by aetiology)?

A

Atherosclerotic aneurysm

121
Q

How is AAA detected?

A

Using US

122
Q

What are the 2 possible complications of AAA?

A

1) Rupture causing retroperitoneal haemorrhage

2) Embolisation causing ischaemia

123
Q

What is a dissecting aneurysm?

A

Tear in the wall - blood tracks between intimal and medial layers

124
Q

What is the classical symptoms of a dissecting aneurysm?

A

Tearing pain in chest radiating to upper left shoulder

125
Q

In which vessel does a dissecting aneurysm most commonly occur, what can it lead to?

A

Usually the thoracic aorta secondary to systemic hypertension
Leads to progressive vascular occlusion and haemopericardium (mortality without treatment)

126
Q

What are berry aneurysms?

A

Small saccular lesions which develop in the Circle of Willis - they develop at sites of medial weakness at arterial bifurcations

127
Q

In which patients are berry aneurysms commonly found and what does rupture lead to?

A

Commonly found in young hypertensive patients

Rupture leads to SAH

128
Q

Where and when do Charcot-Bouchard aneurysms (type of microaneurysm) occur, what do they cause?

A

Occur in intracerebral capillaries in hypertensive disease

Cause intracerebral haemorrhage (ie stroke)

129
Q

In which patients do retinal microaneurysms occur, what do they cause?

A

Can develop in diabetic patients

Cause diabetic retinopathy

130
Q

What are mycotic aneurysms?

A

Rare - weakening of arterial wall secondary to bacterial/fungal unfection
Organisms enter media from vasa vasorum (network of small vessels that supply large vessels)

131
Q

What is the most common underlying infection in mycotic aneurysms, which arteries are commonly affected?

A

Sub acute Bacterial endocarditis

Often in cerebral arteries

132
Q

What is a false aneurysm?

A

Blood filled space around a vessel usually following traumatic rupture or perforating injury
The adventitial tissue contains the haematoma

133
Q

When are false aneurysms commonly seen?

A

Commonly seen following femoral artery puncture during angiography/ angioplasty

Year 2 Clinical Pathology (64 decks)

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