Cardiovascular Pathology Flashcards
T/F: In the case of vasculitis, the etiology is usually unknown, but most cases are not infectious
True
Large vessel vasculitides affect the aorta or its major branches. What are the 2 types of large vessel vasculitis?
Temporal (Giant Cell) Arteritis
Takayasu Arteritis
What is the most common form of vasculitis in older adults (>50); usually affects females?
Temporal (Giant Cell) Arteritis
The classic location for temporal arteritis is branches of the _____ artery, leading to symptoms of headache, visual disturbance, jaw claudication, flu-like symptoms (polymyalgia rheumatica) with joint and muscle pain. Classically, the _____ is elevated to >100
Carotid; ESR
Temporal arteritis is characterized as a _______ vasculitis, and biopsy will show an inflamed vessel wall wtih giant cells and intimal fibrosis.
Treatment is ________, which must be started promptly because there is high risk of blindness due to thrombosis of ophthalmic artery
Granulomatous
Corticosteroids
Granulomatous vasculitis that presents in adults <50 that affects aortic arch at the branch points, presenting with visual and neurologic symptoms, weak or absent pulse in upper extremity (“pulseless disease”), elevated ESR, and is treated with corticosteroids
Takayasu arteritis
Medium vessel vasculitides involve muscular arteries that supply organs. What are the 3 major medium vessel vasculitides?
Polyarteritis nodosa
Kawasaki disease
Buerger disease
Medium vessel necrotizing vasculitis that involves most organs, but lungs are spared
Polyarteritis nodosa
Polyarteritis nodosa presents in young adults with ______ (due to involvement of renal artery), abdominal pain with melena (due to involvement of _____ artery), neurologic disturbances, skin lesions, and is associated with serum ______
HTN; mesenteric; HBsAg
Polyarteritis nodosa presents with lesions of varying stage which have “string of pearls” appearance on imaging. Early lesions will show _______ inflammation characterized by ______ necrosis. These early lesions weaken the wall and can become aneurysms. These lesions will later be replaced by fibrosis.
Treatment for polyarteritis nodosa is _____ and ______
Transmural; fibrinoid
Corticosteroids; cyclophosphamide
T/F: Polyarteritis nodosa is fatal if not treated
True
Medium vessel vasculitis that classically affects Asian children <4 y/o, presenting with fever, conjunctivitis, erythematous rash of palms and soles, and enlarged cervical lymph nodes
Kawasaki disease
The preferential artery involved in Kawasaki disease is the _______ artery, which may lead to complications of thrombosis with myocardial infarction and/or aneurysm with rupture
Treatment is _____ and _____; the disease is self-limited
Coronary
ASA; IVIG
[Note that it may seem counterintuitive to give ASA when it appears initially as a viral illness]
Medium vessel necrotizing vasculitis involving digits; presents with ulceration, gangrene, and autoamputation of fingers and toes. Raynaud phenomenon is often present. Highly associated with smoking; tx is smoking cessation
Buerger Disease
Small vessel vasculitides affect the arterioles, capillaries, and venules. What are the 4 major small vessel vasculitides?
Wegener granulomatosis
Microscopic polyangiitis
Churg-Strauss syndrome
Henoch Schonlein purpura
Small vessel necrotizing, granulomatous vasculitis involving nasopharynx, lungs, and kidneys
Wegener Granulomatosis
Wegeners granulomatosis presents in middle-aged males with sinusitis or nasopharyngeal ulceration, hemoptysis with bilateral nodular lung infiltrates, hematuria due to _________, and serum _____ levels which correlate with disease activity.
Biopsy shows large necrotizing granulomas with adjacent necrotizing vasculitis. Key treatment is _______ and ________, and relapses are fairly common
RPGN; c-ANCA
Cyclophosphamide; corticosteroids
Small vessel necrotizing vasculitis involving multiple organs, especially lung and kidney that is similar to wegeners granulomatosis, but nasopharyngeal and granulomas are absent
Microscopic polyangiitis
With microscopic polyangiitis, ______ levels correlate with disease activity. Similar to Wegeners granulomatosis, treatment is _____ and _____, and relapses are common
p-ANCA
Corticosteroids; cyclophosphamide
Small vessel necrotizing granulomatous vasculitis with eosinophils involving multiple organs, especially lungs and heart; presents with asthma and peripheral eosinophilia, and p-ANCA levels correlate with disease activity
Churg-Strauss syndrome
Small vessel vasculitis due to IgA immune complex deposition; most common vasculitis in children. Self-limited but may recur; tx with steroids if severe
HSP
Clinical presentation of henoch schonlein purpura
Palpable purpura on buttocks and legs
GI pain and bleeding
Hematuria (IgA nephropathy)
Usually occurs following a URI
Systemic HTN can be divided into primary or secondary types based on etiology. In primary HTN, the etiology is unknown (90%), and risk factors include age, race, obesity, stress, lack of physical activity, and high-salt diet. Secondary HTN is due to an identifiable cause (5% of cases). What is a classic cause of secondary HTN?
Renal artery stenosis
Renal artery stenosis is associated with an increased plasma _____ and unilateral _____ of the affected kidney
Renin; atrophy
2 important causes of renal artery stenosis
Atherosclerosis (elderly males)
Fibromuscular dysplasia (young females)
HTN can be further subdivided into benign or malignant. Benign HTN involves mild or moderate elevation in BP that is clinically silent; vessels and organs are damaged over time. How does this differ from malignant HTN?
Severe elevation in BP (>200/120 mm Hg); presents with acute end-organ damage — acute renal failure, headache, and papilledema. MEDICAL EMERGENCY!
May arise from preexisting benign HTN or de novo
3 pathologic patterns of arteriolosclerosis
Atherosclerosis — thickening of intima in medium and large vessels
Arteriosclerosis — thickening of wall in small vessels (hyaline or hyperplastic)
Monckeberg medial sclerosis — calcification of media of vessel wall
Atherosclerosis is characterized as an intimal plaque that consists of a necrotic lipid core with an overlying fibromuscular cap that obstructs blood flow. It involves large and medium-sized arteries — what are the 4 most common arteries involved?
Abdominal aorta
Coronary a.
Popliteal a.
Internal carotid a.
Risk factors for atherosclerosis are divided into modifiable (4) and nonmodifiable (3). What are some risk factors in each category?
Modifiable — HTN, hypercholesterolemia, smoking, diabetes
Non-modifiable — age, gender, genetics
Complications of atherosclerosis may include stenosis of medium-sized vessels which leads to what clinical features?
Peripheral vascular disease (e.g., popliteal a.)
Angina (coronary a.)
Ischemic bowel disease (mesenteric aa.)
[Note that symptoms don’t tend to arise until there is >70% stenosis]
Another complication with atherosclerosis is plaque rupture with thrombosis, leading to what 2 potential events?
Myocardial infarction (coronary a.)
Stroke (middle cerebral a.)
Another complication of atherosclerosis is plaque rupture with embolization, characterized by ______ ____ in emboli
Cholesterol clefts
Arteriolosclerosis is divided into hyaline and hyperplastic types. Hyaline is caused by proteins leaking into the vessel wall, producing vascular thickening, and is seen as pink hyaline on microscopy.
This is seen in the setting of what 2 conditions?
Benign HTN
Diabetes
Hyaline arteriolosclerosis results in reduced vessel caliber with end-organ ischemia. This classically produces what complication?
Glomerular scarring (arteriolonephrosclerosis) — progresses to chronic renal failure
Hyperplastic arteriolosclerosis involves thickening of vessel wall by hyperplasia of smooth muscle, which is described as “onion-skin” appearance.
What is this process typically a consequence of?
Malignant HTN
Hyperplastic arteriolosclerosis results in reduced vessel caliber with end-organ ischemia. This may lead to fibrinoid necrosis of vessel wall and classically to what complication?
Acute renal failure (with “flea-bitten”) appearance
Type of arteriosclerosis characterized by calcification of the media; non-obstructive and not clinically significant — often seen as incidental finding on x-ray or mammography
Monckeberg Medial Calcific Sclerosis
Aortic dissection is defined as a tear in the ______ with dissection of blood through the _____ of the aortic wall
Intima; media
Aortic dissection occurs in the proximal 10 cm of the aorta with pre-existing weakness of the ______. The most common cause is ______, but it is also associated with inherited defects of connective tissue
Media; HTN
The most common cause of death in aortic dissection is _____ _____
Pericardial tamponade
A thoracic aneurysm is a balloon-like dilation of the thoracic aorta due to weakness in the aortic wall. This is classically seen in what condition?
Tertiary syphilis (destruction of vasa vasorum results in “tree-bark” appearance of aorta)
Complications of thoracic aneurysm
Dilation of aortic valve root with insufficiency —> aortic insufficiency
Compression of mediastinal structures
Thrombosis/embolism
AAA is a balloon-like dilation of abdominal aorta, which usually arises below renal arteries but above aortic bifurcation. This primarily occurs due to ________ and is classically seen in male smokers >60 y/o with HTN; presents with pulsatile abdominal mass that grows with time
Atherosclerosis
The major complication of AAA is rupture, especially when size is ______ in diameter.
This will present with classic triad of _______, _____, and ______
> 5 cm
Hypotension, pulsatile abdominal mass, and flank pain
Benign tumor comprised of blood vessels commonly present at birth and often regresses during childhood; most often involves skin and liver
Hemangioma
Highly aggressive, malignant proliferation of endothelial cells; common sites include skin, breast, and liver
Angiosarcoma
______ angiosarcoma is associated with exposure to PVC, arsenic, and Thorotrast
Liver
Low-grade malignant proliferation of endothelial cells associated with HHV-8; presents as purple patches, plaques, or nodules on skin and may involve visceral organs
Kaposi Sarcoma
Kaposi sarcoma is classically seen in what 3 patient populations?
Older Eastern European males (usually localized to skin, tx is surgery)
AIDS (spreads early, give anti-retroviral agents)
Transplant recipients (decrease their immunosuppression)
Stable angina is chest pain that arises with exertion or emotional stress due to atherosclerosis of coronary arteries with _____% stenosis. It represents _______ (reversible/irreversible) injury to myocytes
Clinically presents as chest pain lasting <20 minutes that radiates to left arm or jaw, diaphoresis, and shortness of breath
> 70%; reversible (cellular swelling)
EKG findings and treatment for stable angina
EKG shows ST-segment depression (subendocardial ischemia)
Relieved by rest or nitroglycerin (vasodilation of veins, decreasing preload)
How is unstable angina different from stable angina?
Chest pain occurs at rest — and is often due to rupture of an atherosclerotic plaque with thrombosis and INCOMPLETE occlusion of a coronary artery
Still represents reversible injury to myocytes
EKG changes and treatment for unstable angina
EKG shows ST segment depression
Relieved by nitroglycerin
T/F: unstable angina has high risk of progression to MI
True