Ch 12-Cardiac Path-Galbraith PDF's Flashcards
Describe morphologic changes of heart valves as you age:
Aortic and mitral valve annular calcification
Fibrous thickening
MV leaflets buckling toward LA —> increased LA size
Lambl excrescences
Describe the vascular changes in the heart as you age:
Coronary atherosclerosis
Stiffening of the aorta
Loss of myocardial contractile function is a __ dysfunction
Loss of ability to fill the ventricles during ventricular filling is a ___ dysfunction
Systolic
Diastolic
In the setting of pressure overload, myocytes become ___ and the LV wall thickness increases concentrically
In the setting of volume overload, myocytes ___, and ventricular dilation is seen
Thicker
Elongate
What is left-sided heart failure commonly a result of?
Myocardial ischemia
HTN
Left-sided valve disease
Primarily myocardial disease
In left ventricular dysfunction, you can get left atrial dilation which can lead to:
A fib, stasis, thrombus
What are some symptoms of pulmonary congestion and edema from left-sided heart failure?
Cough
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea (pillow orthopnea)
Describe what happens to glomerular perfusion in left-sided failure and its consequences:
Decreased ejection fraction may result in decreased glomerular perfusion –> stimulates release of renin –> increased volume
Prerenal azotemia
What is the most common cause of right-sided heart failure?
Left-sided heart failure
Isolated right-sided heart failures results from any cause of pulmonary HTN (parenchymal lung disease, primary pulm HTN, pulm vasoconstriction)
In primary right-sided heart failure, describe what happens to the following as the venous system becomes markedly congested:
Liver: __
Spleen: __
Peritoneal, pleural, and pericardial spaces: ___
Edema?
Renal: __
Liver congestion (NUTMEG liver) Splenic congestion (SPLENOMEGALY) Effusions Edema in dependent areas (ankle) Renal congestion
___ is described as a stenosis occlusion of a coronary artery with a “squeezing” or burning sensation (when walking up stairs/exercising), relieved by rest or vasodilators
Stable angina
__ is characterized as an episodic coronary spasm, relieved with vasodilators
Prinzmetal angina
__ is characterized by pain, increasing in frequency, duration, and severity, eventually at rest. There is usually a rupture of a plaque, with a partial thrombus. Up to 50% may have evidence of myocardial necrosis
Unstable or “crescendo” angina
Nearly 90% of infarcts are caused by ___
Atheromatous plaque
Other causes: embolus, vasospasm, ischemia secondary to vasculitis, shock ,hematologic abnormalities
Describe the classic presentation of an MI:
PROLONGED CHEST PAIN (>30 min) --> crushing, stabbing, squeezing, tightness; radiating down left arm or to left jaw DIAPHORESIS Dyspnea Nausea-vomiting Up to 25% are asymptomatic
Describe the levels of lactate and ATP during an MI
Lactate increases, ATP decreases
What are the areas of infarct with permanent occlusion of the LAD?
Apex, LV anterior wall, anterior 2/3 of septum
What are the areas of infarct with permanent occlusion of the RCA?
RV free wall, LV posterior wall, posterior 1/3 of septum
What are the areas of infarct with permanent occlusion of the LCX?
LV lateral wall
Describe the damage in a transient/partial obstruction non-transmural infarct:
Regional subendocardial infarct
Describe the damage in a global hypotension non-transmural infarct:
Circumferential subdendocardial infarct
Describe the damage in a small intramural vessel occlusion non-transmural infarct:
Microinfarcts
___ stains tissue containing lactate dehydrogenase red (after an MI)
Triphenyltetrazolium chloride
What are some gross and microscopic morphologic changes seen immediately after an MI?
Nothing
When will you see microscopic granulation tissue after an MI?
7-10 days it begins to form, can last up to 14 days
About how long does it take to form a dense collagenous scar following an MI?
~2 months
Contraction band necrosis is associated with ___
Reperfusion injury; dead myocytes contract d/t Ca influx
What is the most cardiac myocyte-specific lab test to determine an MI?
Troponin I and T
When does Troponin I typically peak after onset of chest pain in an MI?
About 24-30 hours
When does CK-MB usually peak after onset of chest pains with an MI?
About 18 hours
Half of all MI deaths occur within 1 hour of onset, and are usually secondary to a ___
Fatal arrhythmia
What are some more common complications of an MI?
Contractile dysfunction Fibrinous pericarditis Myocardial rupture Infarct expansion Ventricular aneurysm
___ precipitates sudden cardiac death in 80-90% of cases
Coronary artery disease
Sudden cardiac death is due to a __ most often arising from ischemia-induced myocardial irritability
Fatal arrhythmia
Left-sided hypertensive heart disease is usually due to ___ HTN
Right-sided hypertensive heart disease is usually due to ___ HTN
Systemic
Pulmonary
In left-sided heart disease, pressure overload results in LV hypertrophy (LV wall is concentrically thickened). What happens to the LA and what type of dysfunction and arrhythmia can result?
Diastolic dysfunction can result in LA enlargement
Can lead to A fib
Acute cor pulmonale may arise from a large __
Pulmonary embolus
Chronic stenosis may cause ___ overload hypertrophy –> CHF
Chronic insufficiency (regurgitation) may cause ___ overload hypertrophy –> CHF
Pressure
Volume
___ is the most common valve abnormality. The prevalence increases with age (60-80 yrs), “wear and tear” is associated with chronic HTN, hyperlipidemia, inflammation. The bicuspid valves show an accelerated course and can get ossification of valves.
Calcification aortic stenosis
What type of “cells” can be found on affected valves in calcific aortic stenosis?
Osteoblast-like cell
Where do calcific deposits occur in mitral annular calcification?
Fibrous annulus (fibrous ring)
Normally does not affect valve function
What gender and age group is more likely to have mitral annular calcification?
F > M
> 60 years
When do valve leaflets prolapse back into the LA with a mitral valve prolapse?
Systole –> Mid-systolic click
Who is more likely to have a mitral valve prolapse?
F : M –> 7:1 ratio
What is the buzzword associated with leaflets becoming thickened and rubbery d/t proteoglycans deposits in mitral valve prolapse?
Myxomatous degeneration
Rheumatic fever is a multisystem inflamm disorder following pharyngeal infx with ___
Group A streptococcus
The pathogenesis of rheumatic heart disease is an immune response to streptococcal ___ proteins that cross react with cardiac self-ags.
M
What are other common features of rheumatic fever?
J-Joints (migratory polyarthritis) O-O supposed to look like a heart for heart problems (pancarditis) N-Nodules (subQ nodules) E-Erythema marginatum (rash) S-Syndenham chorea
What is the morphologic feature associated with pancarditis in acute RF?
Aschoff bodies
In chronic RHD, mitral leaflet thickening, fusion and shortening of commisures, fusion and thickening of tendinitis cords will result in __
Mitral stenosis
what type of valvular disorder is mostly associated with RF?
Mitral stenosis
__ is a rapidly progressive, destructive infx of a previously normal valve. It requires surgery in addition to ABx
Acute infective endocarditis
__ is a slower-progressing infx of a previously deformed valve (such as in RHD). It can often be cured with ABx alone
Subacute infective endocarditis
What are some predisposing conditions for infective endocarditis?
Valvular abnormalities: RHD, prosthetic valves, MV prolapse, calcific stenosis, bicuspid AV
Bacteremia: ANother site of infx, dental work/surgery, contaminated needles, compromised epithelium
Which valves are more commonly affected in infective endocarditis?
Left-sided valves more commonly affected
Right-sided valves often involved in IV drug abusers
What is the classic feature of infective endocarditis?
Friable, bulky, destructive valvular vegetations
Friability leads to septic emboli
Vegetations are mixtures of fibrin, inflamm cells, and orgs
What type of symptoms do infective endocarditis pts usually present with?
Nonspecific symptoms –> fever, weight loss, fatigue
Murmurs usually present with left-sided lesions
This org is often involved in infective endocarditis d/t dental work and valve abnormalities
Strep viridans
This org causes infective endocarditis of normal valves, abnormal valves, and IV drug abusers.
Staph aureus
This org is associated with infective endocarditis of prosthetic valves
Staph epidermidis
Aside from strep viridans, staph aureus, and staph epidermidis, what other orgs are associated with infective endocarditis?
H-Hemophilus A-Actinobacillus C-Cardiobacterium E-Eikenella K-Kingella
Describe what happens to the the following features of the myocardium and chambers as you age:
LV chamber size: ___
Epicardial fat: ___
Myocardial changes: ___
Decreased LV size
Increased epicardial fat
Lipofuscin and basophilic degeneration, fewer monocytes, increased collagen fibers
Nonbacterial thombotic endocarditis is associated with ___
MALIGNANCIES (Esp. mucinous adenocarcinomas)
Sepsis
Catheter-induced endocardial trauma
What is the most common type of cardiomyopathy?
Dilated (90%)
What type of dysfunction is associated with dilated cardiomyopathy?
Systolic dysfunction
Progressive cardiac dilation and systolic dysfunction, usually with dilated hypertrophy
Dilated cardiomyopathy is thought to be familial in 30-50% of cases and due to ___ mutations and is autosomal dominant (usually)
TITIN
Alcohol strongly linked to DCM, so is myocarditis, cardiotoxic drugs/substances (Doxorubicin, cobalt Fe overload)
Describe the morphology of Dilated cardiomyopathy
Dilation of all chambers
Mural thrombi common
Functional regurgitation of valves
What is a classical presentation of Dilated cardiomyopathy?
Usually manifests between 20-50 yrs old
Progressive CHF –> dyspnea, exertional fatigue, decreased ejection fraction
Arrhythmias
Embolism
___ is due to excess catecholamines following extreme emotional of psychological stress. It appears > 90% women ages 58-75, the symptoms and signs resemble an acute MI and there is apical ballooning of the LV with abnormal wall motion and contractile dysfunction.
Takotsubo cardiomyopathy
BROKEN HEART SYNDROME
In Arrhythmogenic RV cardiomyopathy, RV failure and arrhythmias cause __ which can lead to sudden death
V tac and V fib
It is familial (usually autosomal dominant)
Desmosome and intercalated dysfunctions are associated with this cardiomyopathy:
Arrhythmogenic RV cardiomyopathy
__ is a genetic disorder leading to myocardial hypertrophy and diastolic dysfunction, leading to decreased stroke volume and often ventricular outflow obstruction
Hypertrophic cardiomyopathy
In Hypertrophic cardiomyopathy, numerous mutations are known involving sarcomeric proteins, most commonly ___
B-myosin heavy chain
Describe the morphology of hypertrophic cardiomyopathy:
Massive myocardial hypertrophy, often with marked septal hypertrophy
Microscopically, myocytes disarray
Consequences of extensive ___ can lead to foci of myocardial ischemia, LA dilation and mural thrombus, diminished CO and increased pulm congestion leading to exertional dyspnea, arrhythmias, and Sudden death
Hypertrophic cardiomyopathy
___ is due to decreased ventricular compliance (increased stiffness), leading to diastolic dysfunction. It may be secondary to depositio of material within the wall (amyloid) or increased fibrosis (radiation). The ventricles are usually normal size, but both atria can be enlarged
Restrictive cardiomyopathy
Amyloid is an EC deposition of proteins which form an insoluble B-pleated sheet. It may be systemic (due to myeloma) or restricted to the heart which is usually __
Transthyretin
When amyloid deposits in the interstitium of the myocardium of a ___ cardiomyopathy results
Restrictive
What is the most common causative agent/org responsible for myocarditis?
Coxsackie A and B viruses most common
What are some non-infectious causes of myocarditis?
Immune-mediated rxns, including RF, SLE, drug hypersensitivity
The single most common genetic cause of congenital heart disease is ___
Trisomy 21
What are the 3 left-to-right shunt congenital heart disorders (Galbraith slides)
ASD
VSD
PDA
___ is usually asymptomatic until adulthood. The L–>R shunting causes volume overload on the right side which may lead to pulmonary HTN, Right heart failure, paradoxical embolization, and may be closed surgically with normal survival
ASD
___ is the most common form of congenital heart disease. Many smaller defects close spontaneously but Large ones may cause significant shunting leading to RV hypertrophy, pulmonary HTN which can ultimately reverse flow through the shunt, leading to cyanosis
VSD
A ___ may fail to close when infants are hypoxic, and/or have defects associated with increased pulmonary vascular pressure (VSD). It produces a harsh, machinery-like murmur. Large shunt can increase pulm pressure and eventually shunt reversal and cyanosis
PDA
What type of murmur do you hear with a PDA?
Harsh, machinery-like murmur
What are the 3 R–>L shunts (Galbraith slides)?
Classic TOF
Transposition of great arteries W/ VSD
Transposition of great arteries W/O VSD
What are the 4 cardinal features of TOF?
VSD
Obstruction of RV outflow tract
Aorta overrides the VSD
RV hypertrophy
What does the heart look like in TOF?
“BOOT-SHAPED”–> heart is enlarged d/t RV hypertrophy
The clinical severity of TOF depends on the degree of ___
Subpulmonary stenosis
Which form of coarctation of the aorta generally has a PDA?
Infantile
What are the characteristics of a coarctation of the aorta with a PDA that manifests at birth?
May produced cyanosis in lower half of body
What are the characteristics of a coarctation without PDA?
Usually asymptomatic
HTN in UE’s, Hypotension in LE’s
Claudication and cold LE’s
May eventually see concentric LV hypertrophy
What is the greatest determinant of cyanosis in TOF?
Degree of pulmonary stenosis
