Hypertensive & Atherosclerotic CV Disease Flashcards
What are the functions of the normal vascular endothelium in the resting/basal state?
- maintain a permeability barrier
- provide a non-thrombogenic surface
- elaboration of mediators for hemostasis
- produce extracellular matriz
- modulate medial smooth muscle tone
- regulate inflammtion, immunity
- regulate cell growth
- metabolize some hormones (angiotensin)
- oxidize LDL
What happens when you have some kind or injury/stimulus to the endothelium?
- Activated State
- increased expression of procoagulants, adhesion molecules & proinflammatory factors
- altered expression of chemokines, cytokines, and growth factors
What situations can lead to injury/stimulate the endothelial cells to the activated state?
- turbulent flow
- hypertension
- cytokines
- complememt
- bacterial products
- lipid products
- advanced glycation end-products
- hypoxia, acidosis
- viruses
- cigarette smoke
What is the general response of the vascular wall to injury?
intimal thickening
recruitment of smooth muscles cells into the intima where they will proliferate (SM in the media will not be proliferating)
also end up recruiting macrophages & inflammatory cells into the intima as well
leads to deposition of lipids & elaboration of extracellular matrix
What blood pressure levels are considered:
normal
elevated
stage I
stage II
hypertensive crisis
- normal
- less than 120/80 mmHg
- elevated
- systolic between 120-129 mmHg
- diastolic less than 80 mmHg
- stage I
- systolic between 130-139 mmHg
- diastolic between 80-19 mmHg
- stage II
- systolic at least 140 mmHg OR
- diastolic at least 90 mmHg
- hypertensive crisis
- systolic over 180 mmHg and/or diastolic over 120 mmHg
What is the equation for blood pressure?
BP = CO x PVR
What factors directly influence cardiac output?
- Blood volume
- sodium
- mineralcorticoids
- atrial natruietic peptide
- Cardiac Factors
- heart rate
- contractility
What facrots directly impact peripheral resistance?
- Humoral factors
- constrictors
- angiotensin II
- catecholamines
- thromboxanes
- leukotrienes
- endothelin
- dilators
- prostaglandins
- kinins
- NO
- constrictors
- Neural factors
- constriction
- alpha-adrenergic
- dilators
- beta-adrenergic
- constriction
- Local factors
- autoregulation pH
- hypoxia
Check this out! Will be helpful to understand the pathologies
What are the two major types of hypertension? Which is most common?
- Essential hypertension (90-95%)
- Secondary hypertension
- renal
- endocrine
- cardiovascular
- neurologic
What factors are known to play a role in essential hypertension?
Have any specific factors been identified?
- Factors known to play a role
- genetic factors
- reduced renal sodium in the setting of normal arterial pressure
- vasoconstrictive influences
- increased peripheral resistance
- environental factors
- stress
- obesity
- smoking
- high salt intake
- inactivity
- No specific triggers are known
What hypertensive vascular diseases affect large to medium arteries?
Arteries larger than arterioles?
Small arteries / arterioles?
- Large to medium arteries
- degernative vascular wall changes
- accelerate atherogenesis
- Arteries larger than arterioles
- fibromuscular intimal hyperplasia
- Small arteries / arterioles (arteriolosclerosis)
- hyaline arteriolosclerosis
What pathology is shown in the provided image?
Describe the features of the vessel & in what conditions this pathology occurs.
Hyaline arteriolosclerosis
Thickened arteriolar wall with increased plasma protein deposition and narrowed luman
very homogenously pink
Congo red stain will be negative
occurs in chronic hypertension & diabetes mellitus
What pathology is shown in the provided image?
Describe the features of the vessel & in what conditions this pathology occurs.
Hyperplastic arteriolosclerosis
“onion-skinning” causes luminal obliteration. Laminations are composed of smooth muscle cells with reduplicated, thickened baement membranes
occurs in severe (malignant hypertension) – usually have a history of chronic hypertension
What pathology is shown in the provided image?
Monckeberg Medial Calcific Sclerosis
notice calcium deposits centered on internal elastic lamina in the muscularis (dark purple at top of image)
calcium deposits: agranular, amorphous, plate-like deposition
very rarely encroacing on the lumen
What is Monckeberg Medial Calcific Sclerosis?
It is most common in what demographics?
- calcium deposits centered on internal elastic lamina in the muscularis of medium-sized muscular arteries
- not usually severe enough to significantly narrow the lumen
- Demographics
- post-menopausal women
- can sometimes show up on mammograms but ahve to be fairly numerous
Describe the the process of atherosclerosis
- Smooth muscle cells become activated & migrate into the intima from the muscularis
- precursors to the smooth muscles can also be recruited to enter the intima when they will differentiate into smooth muscle cells & proliferate
- deposition of extracellular matrix in the intima
- deposition of extracellular lipids in the intima
- may have some necrotic & inflammatory cells – get recruitment of inflammatory cells
- macrophages (envibing lipids & will have foamy appearance) & lymphocytes
What conditions can lead to atherosclerosis?
How long can this take to develop?
- Conditions
- hyperlipidemia
- hypertension
- smoking
- toxins
- hemodynamic factors
- immune reactions
- viruses
- years to decades to develop
What pathology is shownin the provided image?
Fatty streak
one of the first signs of atherosclerosis
What pathology is show in the provided image?
Intimal Foam Cells
early intimal thickening, don’t really see muscle cells – very subtle
Atherosclerosis
What pathology is shown in the provided image?
Mild atherosclerosis
Aorta with fibrous plaque (arrow)
Fatty yellow apearance, instead of streaks, you get plaques – can see some early streaks as well
What pathology is shown in the provided image?
Severe atherosclerosis:
Aorta with plaque rupture and thrombosis
b/c the aorta is such a large vessel, thrombus will not frequently occlude the vessel
“grungy” appearance rather than fatty yellow appearance
however, that thrombus product can break off & go to other organs
Describe the structure & components of an atherosclerotic plaque
- Plaque
- yellow area is thickened intima above the media
- lipid
- cholesterol crystals (pointy shapes)
- foam cells (macrophages)
- necrotic debris
- deposition of calcium
- typically will have a fibrous cap
- collagen (blue strands)
- smooth muscles cells
- macrophages
- yellow area is thickened intima above the media
What pathology is seen in the provided image?
identify the specific parts.
Atherosclerotic plaque
L indicates lumen
arrow = normal vascular wall
F= fibrous cap
C = central lipid core
this fibrous cap is very well developed (lots of collagen, lots of blue), so it is less likely to rupture
What pathology is shown in the provided image?
What is one of the majore complications with this type of pathology?
- Left ventricular hypertrophy
- thickness of left ventricular wall > 1.5 cm
- Cardiomegaly
- heart weight > 450 g, often > 500 g
- Something will eventually push the heart over the edge where it is no longer able to compensate by thickening the left ventricle
- this can lead to heart failure
- wall may become more thin & ventricle may become dilated
- atrium may become dilated
- will often have right heart failure due to back up in the pulmonary circulation
- causes pulmonary hypertension
What pathology is shown in the right image as compared the left?
Since myocytes cannot multiply, they undergo hypertrophy
- Left
- normal myocardium
- Right
- not a higher power view
- hypertrophied myocardium
- increase in both cell and nuclear size
What pathology is shown in the provided image?
What characteristic features of this pathology are visible in the image?
Right-sided (pulmonary) hypertensive heart disease
- Right ventricular hypertrophy
- > 0.5 cm thickness
- right ventricular dilation
- atrium look dilated as well
- loss of fat in the wall
- circumferential orientation of myocytes
- orderly hypertrophy
Which image is an example of systemic hypertensive heart disease & which is an example of pulmonary hypertensive heart disease?
What is the difference between true aneurysms & false aneurysms & dissection?
- Aneurysm
- widening of the vessel wall
- False aneurysm
- extravasation of blood into the blood vessel wall that is contained
- hematoma that can look from the outside like a hematoma
- lumen is not dilated
- Dissection
- when there is a tear in the intima so blood is able to enter it leading to dissection of the layers of the
- severe cases can cause closure of the lumen
- when there is a tear in the intima so blood is able to enter it leading to dissection of the layers of the
What pathology is shown in the provided image?
Abdominal aortic aneurysm
What pathology is shown in the provided image?
Identify specfic features
Abdominal Aortic Aneurysm
layer of fibrin
atherosclerosis
What pathology is shown in the provided image?
What is the most common cause?
Thoracic Aortic aneurysm
Most common cause is chronic hypertension & syphilis
What pathology is shown in the provided image?
Aortic Dissection
layers of the wall get splayed apart typically by some type of damage or Marfan’s syndrome
double barrel appearance
Aortic dissection occures most commonly in what two groups?
Additional risk factors?
- Middle-aged and elderly
- most often in setting of hypertension (90% of cases)
- Younger patients with generalized or focal abnormalities of connective tissue
- Marfan or Turner syndrome
- Other risk factors
- atherosclerosis
- pre-existing aortic aneurysm
- aortic valve defect
- coarctation of the aorta
- iatrogenic
What pathology is shown in the provided image?
What pathology is shown by the provided image compared to the normal adjacent image?
- Top image
- cross section or aortic medial from patient wiht Marfan syndrome
- asterisks mark the “cystic spaces” of elastic fragmentation (elastic trichrome stain)
- Bottom image
- normal aortic medial for comparison
- regular layed pattern of elastic tissue
