Ch 11: HTN, Cor Pulmonale & Valvular Disease

Question 1

What part of the heart compensates for chronic HTN?

Answer 1

Left Ventricle

Hypertrophy occurs due to the volume overload

Question 2

True or false. The left ventricular free walls and interventricular septum become thickened uniformly & concentrically.

Answer 2

True

There is also an increase in heart weight with hypertrophy

Question 3

What is the appearance of the hypertrophic myocytes?

Answer 3

Increased diameter, hyperchromatic & rectangular “box car” nuclei

Question 4

60 year old Miley Cyrus had a smoking hx of 20 pack/year and 5 year history of chronic bronchitis that really ended her singing career. She expired from congestive heart failure and autopsy of the heart showed hypertrophy of the right ventricle. What was the most likely cause of the right ventricular hypertrophy?

Answer 4

Pulmonary HTN
Cor pulmonale is defined as right ventricular hypertrophy and dilation second to pulmonary HTN.
COPD & pulmonary fibrosis are the most common causes

Question 5

Old St. Nick has come to you because he is worried that he will not be able to deliver all the Christmas presents to the good girls and boys this year. He has been dypsneic in the workshop and has had to use 3 pillows to breathe while he sleeps. When you measure his vitals signs you notice that his heart rate is 115 bpm, bp 173/102. From indulging in too many Christmas cookies he has become obese and you also notice pitting edema, hepatosplenomegaly & rales at the bases of both lungs. ECG reveals left ventricular hypertrophy & CXR shows an enlarged heart. What is likely wrong with Old St. Nick?

Answer 5

Hypertensive Heart Disease

Intracerebral hemorrhage is often a frequent & fatal complication, so be sure to treat Old St. Nick!

Question 6

1. Valvular stenosis is due to _____ overload

2. Valvular insufficiency is due to _____ overload

Answer 6

1. Pressure

2. Volume

Question 7

12 year old boy in Uganda presents in the ED w/ tachycardia, chest pain, respiratory distress, pericarditis, increased CRP & increased ESR. CXR is significant for cardiomegaly. After he expires an autopsy was performed aschoff bodies anitschkow cells were found. What is the appropriate diagnosis?

Answer 7

Acute Rheumatic fever
Microscopic examination most often reveals aggregates of mononuclear cells arranged around centrally located deposits of eosinophilic collagen (inflammatory lesions).

Question 8

Exposure to what pathogen can cause rheumatic fever?

Answer 8

Group A Beta Hemolytic stretococcus

Surface antigens cross react w/ similar antigens found in the heart, joints & connective tissue of the skin

Question 9

What is the most common life threatening complication of rheumatic fever?

Answer 9

CHF
This is secondary to valvular stenosis/insufficiency
This is usually only in non-developed countires

Question 10

What are the 4 complications of Chronic Rheumatic fever?

Answer 10

1. Bacterial Endocarditis
   (Scarred valves provide attractive environment for bacteria—> murmor; common in IV Drug user)
2. Mural Thrombi
   (form in atrial & ventricular chambers—>thromboemboli—> infarcts)
3. CHF
   (assoc. w/ rheumatic disease of both mitral & aortic valves)
4. Adhesive Pericarditis
   (follows fibrinous pericarditis of acute attack)

Question 11

True or false? RA compromises cardiac function

Answer 11

False

RA does NOT compromise cardiac function

Question 12

Michelle Obama decided that she wanted to come to Syracuse for some dinosaur BBQ, but at dinner she noticed a concerning heart murmur. So she decides to come to Upstate and lucky you get to see her. She has a history of skin rashes & recurrent arthritis. She is positive for ant-dsDNA antibodies. Because you want to impress her so much you tell her right on the spot that her murmur is caused by what?

Answer 12

Libman-Sacks Endocarditis
This is the most striking cardiac lesion in SLE pts
Non-bacterial vegetations are seen on the mitral valve.
Fibrinoid necrosis is present in the small vessels w/ focal degeneration of interstitial tissue

Question 13

Ankylosing Spondylitis principally causes regurgitation of what valve?

Answer 13

Aortic Valve

Question 14

Congenital heart disease is a predisposing factor for ______ endocarditis in children

Answer 14

Bacterial endocarditis

Question 15

A 63 year old man w/ a prosthetic valves presents with a 6 week history of fever, fatigue, a murmor, splenomegaly, petechiae & clubbing of his fingers. While in the ICU he develops neurologic dysfunction owing to what disease?

Answer 15

Bacterial endocarditis
(in majority of cases there will be no predisposing cardiac lesion)

Question 16

Vegetation of bacterial endocarditis are on what side of the atrioventricular valves and on what side for the semilunar valves?

Answer 16

AV Valves- atrial side

Semilunar Valves- ventricular side

Question 17

Chonic (recurrent) episodes of rheumatic fever cause diffuse fibrosis of valve leaflets. They also become thickened, shrunken and less pliable leading to stenosis. Which valves are the most commonly severely affected valves?

Answer 17

Mitral valve then Aortic valve
MacCallum Patch can form due to chronic regurgitation from the stenotic mitral valve, produces “jet” of blood directed at the post. aspect of the left atrium, which damages the atrial endocardium—> discrete focus of rough, wrinkled endocardium

Question 18

IV drug abusers most commonly develop insufficiency of what valve, leading to right sided heart failure?

Answer 18

Tricuspid Insufficiency

Most cases are cause by S. aureus from the skin

Question 19

45 year old woman w/ a hx of adenocarcinoma of the lung is likely to have which of the following

a) Inflammatory valvular disease
b) Marantic Endocarditis
c) Emobilization of destructive valve vegetations to the brain

Answer 19

b) Marantic Endocarditis

Presence of sterile vegetations (non-destructive, non-inflammatory) on apparently normal cardiac valves, almost always associated w/ cancer (adenocarcinoma of pancreas or lung is common) or other wasting disease.
This disease is attributed to increased blood coagulability & immune complex deposition
DANGER of emobilization to distant organs.

Question 20

What feature can distinguish Rheumatic Aortic Valve Disease from Degenerative (senile) calcific stenosis?

Answer 20

Commissural fusion (3 distinct cusps are not evident) & accompanied mitral valve disease are seen in rheumatic aortic valve disease

Both present w/ rigidly calcified valve cusps

Dystrophic calcification is due to the modulation of valvular interstitial cells to an osteoblastic phenotype

Question 21

Calcification of the mitral valve annulus is aggravated by the presence of what 3 disorders?

Answer 21

Aortic Stenosis
HTN
Diabetes

Question 22

A 23 year old male with a hx of Ehlers-Danlos Syndrome presents w/ a late systolic murmur. The murmur is due to what disorder, causing regurgitation of what valve and he is also at greater risk of sudden cardiac death due to what type of arrhythmia?

Answer 22

Mitral Valve Prolapse causing mitral regurgitation

Greater risk for sudden cardiac death from ventricular tachyarrhythmias.

Question 23

Pulmonary edema in a patients with rheumatic fever is due to what complication?

Answer 23

Stenosis of the mitral valve (most commonly & severely affected valve in chronic rheumatic disease). Irregular thickening & calcification of the leaflets w/ fusion of the commissures & chrodae tendinae—> “fish mouth” appearance of orifice of valve

Question 24

Left ventricular papillary muscles are susceptible to ischemic injury b/c of their blood supply. Angina can lead to transient ischemia leading to transient regurgitation of what valve?
What can lead to permanent regurgitation of this valve?

Answer 24

Mitral valve

Myocardial Infarction can lead to permanent mitral regurgitation

Question 25

This heart defect is seen in patients who have a hx of jejunal carcinoid tumors that have metastasized to their liver. It is thought that valvular & cardiac lesions are caused by production of what from the tumor in the liver? What is the heart defect?

Answer 25

High concentrations of serotonin (other vasoactive amines & peptides)

Right sided heart disease leading to tricuspid regurgitation.

The lesions are plaque-like, deposits of dense, pearly gray fibrous tissue on the tricuspid valve (assoc. w/ inflammation)