Hypertensive and Heart related disorders Flashcards
The major cardiac complications of HTN result from what?
- Pressure changes2. Ventricular Hypertrophy
What are the criteria for diagnosing systemic hypertensive heart disease?
- Left ventricular hypertrophy without any other CV pathology. AND 2. History or pathologic evidence of HTN
Can mild hypertension (140/90) cause systemic hypertensive heart disease?
Yes
What percentage of the U.S. population suffers from at least mild hypertension?
25%.
Describe the morphology of systemic hypertensive heart disease.
- Systemic HTN causes pressure overload on the heart, which will result in left ventricular hypertrophy. 2. As a result of increased left ventricular wall thickness, compliance decreases and diastolic filling will decrease. This can cause left atrial dilation. 3. Long standing systemic HTN will eventually cause left ventricular dilation too (in addition to already present hypertrophy).
Is hypertensive heart disease symptomatic?
Usually not, but it is suspected by evidence of HTN, on EKG, or by doing an echocardiogram (which would show left ventricular hypertrophy). As disease progresses, atrial fibrillation (secondary to left atrial enlargement) and/or CHF will develop. KNOW features of progression.
What are the 4 major types of hypertrophic heart disease?
- Hypertensive heart disease 2. Hypertrophic cardiomyopathy 3. Aortic stenosis 4. Cor pulmonale
Which is most common: Hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis, or cor pulmonale?
Hypertensive heart disease > Aortic stenosis > hypertrophic cardiomyopathy. Cor pulmonale statistics unknown.
T/F. All 4 types of hypertrophic heart disease present with dyspnea, angina, or sudden death?
False. Cor pulmonale does not present with angina
T/F. All 4 types of hypertrophic heart disease are chronic conditions?
False. Cor pulmonale can be acute or chronic
Epidemiology. Which of the 4 hypertrophic heart disease types presents in young patients?
ANS: Hypertrophic Obstructive Cardiomyopathy. Hypertensive heart disease, aortic stenosis, and chronic cor pulmonale present in OLDIES.
Epidemiology. Describe how sex relates to 4 hypertrophic heart diseases?
Hypertensive Heart disease: Male=Female
Hypertrophic Cardiomyopathy: Male = Female
Aortic Stenosis: MALES!
Chronic cor pulmonale: Males (?)
Epidemiology. Which of the 4 hypertrophic heart diseases is race related?
ANS: Hypertensive heart disease more common in blacks than whites. Other 3 types are not race specific
Which of the 4 hypertrophic heart diseases does not cause left ventricular hypertrophy?
ANS: Chronic cor pulmonale.
Which of the 4 hypertrophic heart diseases causes a murmur to develop?
Aortic Stenosis - YES
Hypertrophic cardiomyopathy - Sometimes
Hypertensive heart disease, Chronic for pulmonale - NO
What is the thickness of a normal left ventricular wall?
Usually 1.2 to 1.4 cm. Hypertrophy can cause left ventricular wall to exceed 2 cm.
Describe cardiac myocytes in hypertrophy?
Cardiac myocytes have expanded cytoplasm and enlarged nuclei. Nuclei are sometimes compared to boxcars
Some patients with hypertrophic heart disease develop myocardial fibrosis. Name major contributing cytokine to this
TGF-Beta
Describe why myocardialfibrosis is bad? Where does fibrosis develop (intracellularly, interstitially, etc)?
Fibrosis (which develops in the INTERSTITUM of the heart) will lead to increased wall thickness and stiffness, i.e.decreased compliance of the left ventricle. Decreased compliance causes blood to back up in atrium, causing atrial dilation. Atrial dilation eventually causes ventricular dilation. Again. Know progression.
What is the relationship between kidney disease and hypertensive heart disease?
Kidney diseases causes HTN (and vice versa). Therefore, patients with chronic renal failure are highly prone to developing hypertensive heart disease.
What exactly is hypertrophic cardiomyopathy?
Group of genetic conditions that is associated myocardial hypertrophy, defective diastolic filling, and ventricular outflow obstruction (in 1/3 of cases)
Is systolic or diastolic function affected by hypertrophic cardiomyopathy?
Systolic function usually remains preserved. Diastolic dysfunction occurs in that there is HYPERcontraction.
What is hypertrophic obstructive cardiomyopathy (HCOM)?
Condition that affects1/3 of patients with hypertrophic cardiomyopathy. Patients will haveasymmetric hypertrophy of upper septum, which will bulge out and block outflow tract.
GENETICS:Name mode of inheritence of Hypertrophic cardiomyopathy?
Autosomal dominant with variable penetrance
GENETICS: Mutations in which gene are most common in Hypertrophic cardiomyopathy (HCM)?
There are more than 400 different known mutations in 9 different genes, most being missense mutations. The most common mutation occurs inBeta-myosin heavy chains,then genes coding for cardiac Troponin T, alpha-tropomyosin, and myosin binding protein C. These 4 mentioned account for roughly 80% of all cases.
Morphology of hypertrophic cardiomyopathy
Massive myocardial hypertrophy, usually without ventricular dilation. Classically, have much thicker left ventricular septum than leftventricular free wall (ratio of 3:1 in size). Can have “banana like configuration” due to bulging of septum into left ventricle
Describe what happens with mitral leaflets in hypertrophic cardiomyopathy?
Septal hypertrophy causes mitral leaflets to hit at body, rather than at the tips. Part of anterior leaflet sticking out is carried anteriorly and superiorly, due to blood flow hitting it, causing subaortic obstruction and eventual mitral regurgitation. Fibrosis will eventually occur as a result of chronic damage and attempt to repair (Detail on another slide).
Treatment for hypertrophic cardiomyopathy?
Besides open heart surgery, inject ethanol into a septal coronary artery and infarct the inner part of the hypertrophied upper septum
Why is fibrosis seen inhypertrophic cardiomyopathy?
Contact between anterior leaflet of mitral valve and bulging septal wall causes a repair response, seen as fibrosis in both mitral valve and subaortic upper septum
Valvular disease results in what 2 common occurrences?
- Stenosis - failure of a valve to open completely, obstructing forward flow
- Insuffiency - failure of a valve to close completely, thereby allowing regurgitation (backflow) of blood
Aortic stenosis causes calcifications to occur where?
In the sinuses of Valsalva (the pockets formed between the cusps of the aortic valce and the aorta around them)
Pathophysiology of Degenerative calcific aortic stenosis?
In elderly patients with degenerative calcific aortic stenosis, the formation of rocks in the sinsuses of Valsalva has gradually stenosed the valve orifice
Pathophysiology of Rheumatic aortic stenosis?
In aortic stenosis due to Rheumatic valvulitis, inflammation and fibrosis start at the commissure (the point where the valve opening touches the valve annulus) and it moves inward from there
Pathophysiology of Bicuspid aortic stenosis?
In young and middle aged patients born with a bicuspid valve (1-2% of the US population) due to fusion of two cusps, aortic stenosis develops more rapidly
Cor pulmonale consists of what two common features in the right ventricle?
right ventricular hypertrophy and dilation, frequently accompanied by right heart failure.
Primary cause of cor pulmonale?
Pulmonary HTN from pulmonary disorders of lung parenchyma or pumonary vasculature
Acute cor pulmonale is most commonly caused by? Do you see hypertrophy, dilation, or both?
Acute cor pulmonale most commonly caused by a pulmonary embolism. Usually only see dilation of the right ventricle. If an embolism causes sudden death, you often won’t see dilation either.
Chronic cor pulmonale common cause? What morphologic changes do you observe
Due to chronic lung and pumonary vascular related diseases. Will see right ventricular (and often right atrial) hypertrophy. Size can often be comparable to left ventricle
What is often present in pulmonary arteries of patients with chronic cor pulmonale?
Because chronic cor pulmonale occurs in the setting of pulmonary HTN,the pulmonary arteries often contain atheromatous plaques and other lesions, reflecting long-standing pressure elevations.
Which is more common, right heart failure due to left heart failure or cor pulmonale?
Right heart failure is much more common due to left heart failure, not cor pulmonale. Most patients with cor pulmonale will compensate instead of develop right heart failure.
