Heart Pathology Flashcards
Arteriosclerosis
Hardening of arteries
Medial calcific sclerosis – Monckeberg
- calcification in media of artery
- elderly
- arteries of extremities
- does not obstruct blood flow – benign
Arteriolosclerosis
Hyaline thickening of arterioles
Essential HTN and DM w/o hyperlipidemia
Atherosclerosis
Fibrous plaques and atheromas of intima of arteries
Accumulation of fatty materials in walls of arteries
Causes: HTN high LDL, low HDL DM Smoking FHx Sedentary lifestyle
Occlusion of RCA
-> arrhythmias
Occlusion of LAD
Anterior wall MI
Pathogenesis of atherosclerosis
- Endothelial dysfunction -> increased vascular permeability, leukocyte adhesion, and thrombosis
- Accumulation of lipoproteins – in vessel wall, mostly LDL
- Monocyte adhesion to endothelium – migration of monocytes into intima, transform to macrophages and foam cells (full of lipid)
- Factor release – activated platelets, macrophages, inflammatory mediators
- Sm.m. proliferation – migration of sm.m. cells into intima (normally only in media)
Lipid accumulation – extracellularly and w/in macrophages and sm.m. cells – if disrupted -> thrombi
Abdominal aortic aneurysm
Caused by atherosclerotic plaque compressing underlying media
Nutrient and waste diffusion compromised
Media generates and necroses -> atertial wall weakness
Mean over 50, smokers
Pulsating mass in abdomen
Complications:
- rupture -> fatal hemorrhage
- embolism from atheroma
- obstruction of branch vessel
- impingement on adjacent structure (ureter)
Known AAA – U/S every 6 mo
Tx: surgical repair if over 5.5 cm or if rapidly enlarging (0.5 cm in 6 mo or 1 cm in year)
Deadly causes of acute chest pain
“if you’re DUMPT you’re heartbroken”
aortic Dissection Unstable angina MI Tension pneumo PE
Ischemic heart disease
Inadequate O2 supply relative to demand
MC: atherosclerosis
Prinzmetal angina
Occurs at rest
Not assoc w/ exertion
d/t coronary artery spasm
younger
EKG change: ST segment elevation
Tx: dihydropyradine CCB (nifedipine)
Angina (except treatment)
Retrosternal pain, pressure, radiates to neck, jaw, shoulder
SOB, diaphoresis
Women may only have fatigue
Narrowing of at least 75% coronary a.
-can’t accommodate by dilating anymore
CP d/t myocardial ischemia
Primary cause atherosclerosis
Worse overtime
Stable vs unstable angina
Stable:
Predictable: with increased activity, resolves w/ rest
EKG change: ST depression or elevation
Unstable:
Increased frequency and increased severity
Unpredictable
Pain at rest
Targets to improve angina
Goal: decrease myocardial O2 demand
Factors increasing O2 demand: Preload BP Contractility Ejection time HR
Statins
HMG-CoA inhibitors
Lovastatin Pravastatin Simvastatin Atorvastatin Rosuvastatin
Best effect on LDL/cholesterol
Inhibit denovo cholesterol production
-> increased cell surface LDL receptors, causing LDL to be internalized out of circulation, dropping plasma LDL levels
Increases HDL
Lowers TGs
AE:
Hepatotoxicity – check LFTs before prescribing and as sx present
Myalgias -> myositis -> rhabdomyolysis
-measure CDK
Niacin
Increases HDL, lowers LDL
SE:
Flushing – 45%
-reduced w/ aspirin 30 min prior, remaining on drug and avoiding other causes (etOH, hot beverages)
Rash
Pruritis
Fibrates
Gemifibrozil
Fenofibrate
Lower TGs – best effect on TG/VLDL
AE: Myositis Myalgias Hepatotoxicity – elevated LFTs Increased cholesterol gallstones
Dangerous to use w/ statin -> increased risk of myositis
Omega 3 fatty acids
Fish oil – Salmon, halibut – cold water fish
Flax seed oil
Lower TG
No SE
Bile Acid binding resins
Cholestyramine
Colestipol
Colesevelam
Prevent reabsorption of bile acids
Cause GI upset, decreased fat soluble vit absorption
-rarely cause cholesterol gallstones
Ezetimibe
Prevents cholesterol reabsorption at small intestine brushborder
SE: increased LFT, diarrhea
Effects of Nitrates and Beta blockers on EDV (preload)
Nitrates: decrease – relaxes venous system
B-blockers: no effect
Effects of Nitrates and Beta blockers on BP
Nitrates: decreases - preload
B-blockers: decreases - afterload
Effects of Nitrates and Beta blockers on Contractility
Nitrates: indirectly slight increase
B-blockers: decreases
Net effect – no change
Effects of Nitrates and Beta blockers on HR
Nitrates: increases
B-blockers: decreases (stronger)
Net effect - decreases
Effects of Nitrates and Beta blockers on ejection time
Nitrates: decreases
B-blockers: increases
Net effect – no change
Effects of Nitrates and Beta blockers on myocardial O2 demand or consumption
Nitrates: decreases - preload
B-blockers: decreases – HR, contractility, afterload
Hypertrophic obstructive Cardiomyopathy (aka hypertrophic cardiomyopathy, aka idiopathic hypertrophic subaortic stenosis)
MC sudden death in young healthy athletes
Hereditary - 50% AD
Disordered hypertrophy of LV - not parallel myocytes
Enlarged ventricular septum obstructs aortic valve leaflets - blood can’t get out
Apical impulse enlarged and diffuse
S4 heart sound - stiff ventricle
Systolic murmur - louder w/ valsava
-decreases preload –> worsening of LV outflow tract obstruction
softer w/ squatting - increased afterload, less obstruction
Volume depleted –> decreased preload –> death
Tx: b-blocker non-dihydropyridine CCB - verapamil --> prolonged diastole to increase ventricular filling Restrict physical exertion Avoid volume depletion
Dilated cardiomyopathy
MC 90%
heart dilates - myocytes in series instead of parallel
Round, globular shape
S3 herat sound
apical impulse displaced laterally
Causes: chronic myocardial ischemia hemachromatosis anthracyclines - Doxorubicin, daunorubicin Chronic cocaine and etOH use (B1 def) Wet beriberi (b1 def) Chagas dz - Trypanosoma cruzi Mycarditis from Coxsackie B virus
Restrictive cardiomyopathy
deposition in myocardium disrupts diastolic function
“LEASH”
Loffler syndrome - fibrosis, eosinophil infiltration (Ascaris lumbercoides)
Endocardial fibroelastosis - congenital, thick fibroelastic tissue
Amyloidosis
Sarcoidosis - granulomas
Hemochromatosis (MC w/ dilated CM)
Also radiation tx –> fibrosis
Myocarditis
generalized inflammation of the myocardium - not result from ischemia
MC cause: Coxsackie B virus
Histo: diffuse interstitial infiltrate of lymphocytes w/ myocyte necrosis
Causes of Infectious endocarditis - bacterial
BLOOD CX BEFORE ABX
75%:
S. aureus - 30% acutely ill
-large vegetations on previously normal valves
Viridans strep - 20-30% subacute illness
- smaller vegetations on previously damaged valves
- dental procedures
Enterococci - 10%
-some VRE
Coagulase neg Staph (S. epidermidis) 5-10%
-IV drug user
S. bovis - assoc w/ colon CA
Infectious endocarditis in IV drug user
Coagulase neg Staph (S. epidermidis) 5-10%
-IV drug user
More likely to have fungal endocarditis - Candida albicans
Culture negative endocarditis causes
HACEK Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella
Now MC causes are intracellular organisms:
Coxiella brunetti
Bartonella spp.
Brucella spp.
Typical S/S of endocarditis
Fever, chills, weakness, anorexia
New regurgitation murmur or HF
- MV most common - left sided
- Tricupsid MC in IV drug users –> septic pulmonary infarcts
Splinter hemorrhages in fingernails
Osler nodes - painful red nodules on finger and toe pads
Janeway lesions - painless erythematous macules on palms and soles
Roth spots - retinal hemorrhages w/ clear central area - rare
Signs of embolism
Brain infarct -> focal neuro defects
Renal infarct –> hematuria
splenic infarct –> abdominal or shoulder pain
Systemic immune reaction to endocarditis
glomerulonephritis
arthritis
Complications of infective endocarditis
Embolic glomerulonephritis structural damage to valves valvular regurgitation or stenosis rupture chordae tendinae acute MR or TR Suppurative pericarditis
Libman-sacks endocarditis
SLE causes LSE
sterile vegetations on BOTH sides of valve simultaneously
Marantic endocarditis
Metastatic cancer cells
platelet-fibrin aggregates in hypercoaguable states
Cardiac tamponade
excessive fluid in space between myocardium and pericardium
- blood, pericardial effusion
- -> compresses heart, can’t fill during diastole
Causes decreased CO, equilibration of pressures in all chambers
Leads to: Hypotension increased venous pressure, JVD distant heart sounds increased HR Pulsus paradoxus
EKG: electrical alternans - alternating amplitude of QRS complexes - tall –> tiny –> tall
(can’t r/o tamponade if not present on EKG)
Pulsus paradoxus
Exaggerated decrease in amplitude of SBP during inspiration - >10mmHg
-decreased capacity of LV
Normal up to 10 mmHg
Causes: Cardiac tamponade Asthma Croup OSA Severe COPD Rarely pericarditis
Causes of fibrinous pericarditis
uremia
RA
Dressler syndrome
Causes of serous pericarditis
noninfectious inflammatory dz
lupus
rheumatic fever
Suppurative pericarditis
infection of pericardium
Causes of hemorrhagic pericarditis
TB
melanoma - mets to heart
Acute pericarditis
Pleuritic CP
- sharp
- worse w/ inspiration
- better sitting up and leaning forward
distant heart sounds
friction rub
diffuse ST elevation
diffuse PR depression
can either resolve w/o scarring or cause chronic constrictive pericarditis
Chronic constructive pericarditis
Lupus
Kussmaul sign - JVD w/ inspiration
Diagnostic criteria for rheumatic fever
- evidence of grp A strep infection - elevated ASO titer
- 2 major criteria or 1 major and 2 minor criteria
“Jones Criteria”
Major criteria for Jones criteria
Joints - migratory polyartheritis
Heart - pancarditis - peri/myo/endocarditis
Nodules - subcutaneous, painless
Erythema marginatum - serpiginous skin rash - ring like, comes and go
Sydenham chorea - chorea of face, tongue, upper limb
Minor criteria for Jones criteria
“PEACE”
Prolonged PR interval
Elevated temperature (fever)
Arthralgia
elevated Crp or Esr (counts as 1)
Rheumatic heart disease
autoimmune
d/t Grp A beta-hemolytic strep (S. pyogenes)
–> type II HSR - Ab attack heart
Scarlet fever
widespread sandpaper rash all over body
toxin mediated
active infection
Post-strep glomerulonephritis
type III HSR - immune complexes
hematuria, proteinuria, renal insufficiency
1-6 wks after
Acute rheumatic fever
Type II HSR
2-4 weeks after pharyngitis
Kussmaul’s sign
JVD during inspiration d/t decreased capacity of RV
caused by constrictive pericarditis»_space;tamponade
Syphilitic heart disease
disrupt vasovasorum
dilation of aorta and aortic valve ring
Aortic regurg d/t dilation of aortic root
Aortic stenosis
Thoracic aortic aneurysm
Calcification of aorta
-tree bark appearance of inner surface of aorta
Tuberous sclerosis tumor associations
Rhabdomyoma
angiomyolipoma - renal tumor
Astrocytoma
Metastatic tumors to heart
MC overall type of cardiac tumors
Melanoma
lymphoma
Myxoma
MC primary cardiac tumor in adults
Left atrial myxoma
- ball of tissue in atrium acts as ball valve
- -> obstruction of mitral valve –> syncopal episodes
can flip into LV during diastole –> early diastolic sound
-“tumor plop”
Rhabdomyoma
MC primary cardiac tumor in kids
assoc w/ tuberous sclerosis
