Difficult Exam Flashcards
What is histopathology of Aortic Aneurysm?
-Cystic Medial Degeneration
-Loss of Elastin
-Loss of smooth muscle cells
-Increased Collagen in the adventitia layer
3 Pathologic/Histologic abnormalities in MVP?
-Myxomatous proliferation of the mitral valve (Increased Spongiosum layer)
-Increased production of Mucopolysaccharide
-Fibrosis on the surface of the mitral leaflet
-Thinning and elongation of the chordae
Describe the histopathologic findings of IMH?
-Tear in the medial layer which leads to hemorrhage. No false lumen is created. Can be traumatic or atraumatic.
Histopathology of HoCM?
-Septal hypertrophy with sarcomere disarray and surrounding interstitial fibrosis.
-Additional findings: Large and bizarre nuclei, thrombosis and obliteration of the small vessels
What seen on Myocarditis biopsy?
-Inflammatory cell infiltrate or positive viral genome on EMB
What is seen on biopsy of Rheumatic Carditis?
-Aschoff bodies (Hallmark granulomatous lesions) in the Proliferative phase (1 to 6 months post illness)
-Inflammation of endocardium with macrophage and lymphocytic infiltration and fibroid degeneration of collagen and veruccous vegetations (Small uniformly sized thrombotic vegetations that don’t produce valve destruction) Exudative Phase (First few weeks)
What are the three characteristics disrupted in the failing myocyte?
Cellular membrane
Sarcoplasmic Reticulum
Contractile proteins
What are 3 anatomic hallmarks of LV remodeling?
-Alterations in cellular biology
-Myocardial changes: Necrosis, Apoptosis,
-Alterations in LV geometry: Dilation, wall thinning
What are two acute mechanisms by which smoking acutely increases risk of MI?
-Increases BP and sympathetic tone
-Reduction in myocardial oxygen supply
5 ways that smoking chronically results in more MI?
-Inflammatory effects (Increases levels of CRP, fibrinogen and homocysteine)
-Accelerates atherothrombosis and atherosclerotic progression
-Enhances oxidation of LDL cholesterol
-Impairs endothelium-dependent coronary artery vasodilation / Vasospasm
-Provokes spontaneous platelet activation
How to diagnose Takotsubo? By Mayo, ESC 2016 and INTERTak
Mayo Criteria
1) Transient LV dysfunction with RWMAs
2) No obstructive CAD
3) New ECG abnormalities or elevation in cardiac troponin
4) Absence of pheo/myocarditis
ESC 2016 Criteria
1) Transient RWMA/LV dysfunction usually but not always preceded by a stressful trigger.
2) RWMAs extend beyond single epicardial territory
3) Absence of culprit ASCVD
4) New and reversible ECG abnormalities
5) Elevated BNP
6) Positive troponin but small elevation
7) Recovery in 3-6 months
InterTAK (Preferred, will go with this on Exam)
1) Transient LV dysfunction beyond a single epicardial vascular distribution
2) An emotional/physical trigger is usual but no obligatory
3) Neurologic or Pheochromocytoma may serve as a trigger
4) New ECG abnormalities
5) Elevated biomarkers
6) Significant CAD can be present
7) No myocarditis
8) Post menopausal women are usually effected
3 Pathophysiologic features of microvascular angina?
Abnormal Vasodilation: Endothelial dysfunction is primarily due to imbalance in NO production and consumption
Pro thrombotic state: Increase platelet and leukocyte activation
Arterial remodelling: Endothelial dysfunction also increase activation of cytokines that increase the permeability of the vessel wall to oxidized lipoproteins and inflammatory mediators
What are the two mechanisms of SCAD?
-Intimal tear or bleeding into the Vasa vasorum with intramedial hemorrhage. This creates a false lumen by an enlarging hematoma
What are 3 histologic features of radiation induced coronary disease
-Diffuse interstitial fibrosis and collagen deposition
-Luminal narrowing of both arteries and arterioles due to accumulation of myofibroblasts and resultant intimal proliferation
-Intimal proliferation with aggregation of lipid-rich macrophages.
**Give 3 pathologic/Histopathologic findings in progressive calcified aortic valve stenosis
-Fibrous damage resulting in thickening
-Calcium deposition leading to thickening
-Atherosclerosis in valve tissue of patients resulting in cellular proliferation, inflammation, lipid accumulation and increased margination of macrophages and T lymphocytes
Histopathology of Giant Cell Myocarditis?
-Lymphocyte infiltration (predominantly CD4 T cells), myocyte necrosis/loss and viral inclusions on EMB, and large multinucleated cells. The cytoplasm of these cells can contain star shaped asteroid bodies.
What is histopathology of Sarcoidosis?
Noncaseating granulomas without myocyte necrosis
Review Coronary Artery Layers
What are histopathologic features of radiation induced coronary disease?
-Diffuse interstitial fibrosis and collagen deposition along with luminal narrowing of both arteries and arterioles due to accumulation of myofibroblasts and resultant intimal proliferation
You need 30 gray of radiation exposure and athero starts to develop 10-20 years post exposure
Review effects of Vaping on the Heart (AHA 2022) (7)
-Accelerated CAD
-Myocardial Fibrosis
-Decreased Myocardial blood flow
-Decreased Endothelial flow
-Decreaed NO production
-Increased Blood pressure and Arterial Tone
-Increased Oxidative Stress
What is Jones criteria for Rheumatic fever? What is treatment?
Major:
-Sydenham’s chorea
-Carditis
-Migratory arthralgias
-Subcutaneous nodules
-Erythema Migrans
Minor:
-Fever
-Polyarthralgias
-ESR > 30
-Prolonged PR interval
Pen V 200 mg BID (As per AHA)
Sulfadiezine 1000 mg daily (As per AHA)
What is pathophysiology/criteria for Type 1 MI ? (4)
-Related to atherosclerotic plaque rupture
-Resulting intraluminal thrombus in 1 or more coronary arteries
-Leading to decreased flow or distal platelet emboli
-Ensuing myocyte necrosis
What is criteria for Type 1 MI?
-Rise and fall of troponin with at least one value above the 99th percentile URL with one of the following:
-Symptoms of ischemia
-New ST-T changes, LBBB, pathologic Q waves
-Loss of viable myocardium or RWMAs
-Angiography or autopsy showing intracoronary thrombus
What is the Dallas Criteria?
For diagnosing Myocarditis definitively:
-Inflammatory infiltrates of the myocardium with necrosis of adjacent myocytes not typical of the ischemic damage of coronary disease
What are 4 mechanisms for LV dysfunction in TCMO?
Depletion of myocardial energy stores
Abnormal Calcium handling
Oxidative stress in atrial and ventricular myocardium
downregulation and decreased responsiveness of beta adrenergic receptors
What are four pathogenic processes of NSTEACS?
-Rupture of unstable atheromatous plaque
-Coronary arterial vasoconstriction
-Imbalance between supply and demand of myocardium for oxygen
-Gradual intraluminal narrowing of an epicardial coronary artery because of progressive atherosclerosis or post stent restenosis
**What are three mechanisms for thrombus formation in setting of coronary plaque?
Rupture of Coronary Plaque fibrous plaque ->
Exposes thrombogenic material in the lipid rich core to blood and triggers platelet activation through exposure of subendothelial collagen and vWF -> thrombin generation ->
Tissue factor exposed at site of injury results in thrombin generation -> Thrombin converts fibrinogen to fibrin and potentiates platelet aggregation
Summary:
1) Platelet activation and aggregration
2) Thrombin activation
3) Coagulation cascade
What are 4 types of Takotsubo (Variants) ?
Apical
Midventricular
Basal
Focal Type
What are two mechanisms of SCAD?
-Spontaneous Hemorrhage
-Tear (No Hemorrhage)
What are 5 risk factors for pace maker post TAVR?
-Male
-RBBB
-LAFB
-First degree AV block
-Self expanding valve
-Depth of Implantation
3 things that can provoke Vasospasm?
-Hyperventilation
-Early morning (Higher Vagal Tone)
-Precipitated with Cocaine/Smoking
Name 5 changes on Echo in Pregnancy? (5)
-Increased LV mass
-LV dilation
-Increased stroke volume
-Increased Valvular gradients
-Increased regurgitation
What are risk factors for ICH with Lytic ?
Age
Female
Hypertension (SBP > 160mmhg)
Black
Prior Stroke
Use of Alteplase
What are 4 non pharm things in long term management of SCAD?
-CR Program with 50-70% HRR
-Weight lifting < 20 lbs women and < 50 lbs men
-BP control < 130/80mmhg
What are the high risk Aortopathy criteria in Pregnancy?
-BAV > 5
-MFS > 4.5
- Turners > 25mm/m2
- Vascular EDS
-LD with any Aortic dilation
What are three primary pericardial tumors? three most common mets?
-Mesotheliomas, Teratoma, Paraganglionomas
-Mets: Lung, Breast, Esophageal, Lymphoma
What are cardiac abnormalities associated with Freidrich’s Ataxia?
HCM, Conduction system disease
What is the cardiac abnormality associated with Tuberous Sclerosis?
Cardiac Rhabdomyoma
What is the cardiac abnormalities associated with HHT?
AV malformations resulting in high output HF
How many Korotkoff sounds are there? Describe them:
5 sounds
- Clear tapping sounds heard for at least 2 straight beats (this is SBP)
- Softening of the tapping sounds with the addition of a swishing sound
- Return of tapping sounds as heard with a phase 1 but with an increase in sharpness and intensity
- Abrupt muffling of sounds
- Disappearance of sounds (this is DBP)
Which populations is the 5 Korotkoff sound not interpretable? (So you have to use the 4th as a measure of DBP) (2)
-Pregnancy
-Severe AI
Label the following in descending O2 content
-Pulmonary vein, SVC, IVC, Coronary Sinus
-Pulmonary Vein (most oxygenated vessel in body)
-IVC (Renal shunting)
-SVC
-Coronary sinus (Heart extracts maximally at rest)
What is the NASPE code?
Note- 4th position is rate responsiveness
Review the Class 1 indications for LYTIC in STEMI
Name 3 differences between BNP and NT Pro BNP? Review metabolic pathway
-BNP is biologically active, NT-proBNP is inert.
-BNP has a shorter half life, NT-proBNP is more sensitive (circulates longer in the bloodstream).
-BNP levels may increase in patients taking neprilysin (neprilysin can break down BNP, but if inhibited, levels may increase). It has no effect on NT-proBNP
What are 5 stages of plaque progression?
Fatty streak -> Foam cell invasion -> Lipid pools -> Development of fibrous cap -> Increased calcification of fibrous cap
