MT notes cardiovascular Flashcards
RHEUMATIC FEVER
⋅ Characterized by damage to the heart valves
– considered cardiovascular pathology rather than joint pathology
Rheumatic fever causes
-β-hemolytic Streptococcus group A (aka pyogenes)
β-hemolytic Streptococcus group A (strep pyogenes) causes what?
-glomerulonephritis
-rheumatic fever
- MOLECULAR MIMICRY
-
Lacunar Tonsillitis ⋅
– pockets form in tonsils where bacteria and pus collect; can be removed by gargling
Follicular Tonsillitis ⋅
– inflammation of follicles of lymphoid tissue, pus cannot be removed
Retrotonsillar Abscess
– formation of pus behind tonsils causing bulging of pharyngeal walls, if not treated enters
layers of mediastinum
– Must be surgically removed and pus evacuated – May be due to any tonsillitis
– Drinking cold water after excersing….BAD IDEA
Manifestations of Rheumatic Fever
- migratory arthritis
- molecular mimicry (due to beta group A strep pyogenes)
- erythema annulare (marginatum) circular skin rash
- subcutaneous nodules on knuckles
- syndenhams chorea
Syndenham’s Chorea
⋅ Age <15 y/o ⋅ Only in women ⋅ Mild vasculitis of cerebral vessels ⋅ Usually recover completely ⋅ Striatum neurons ⋅ Curable
Huntingdon’s Disease
⋅ Age over 30-35 ⋅ More common in males ⋅ Genetic ⋅ Incurable, inevitably results in profound dementia and death within 10-15 years ⋅ Destruction of striatal nuerons
rheumatic myocarditis
-occurs 100% of the time with myocardium
pericardium involvement in rheumatic fever
- 10-15% of cases
- fibrinous inflamation
- bread and butter pericarditis - heard as bruits
Rheumatic endocarditis
-involves heart valves (since valves are made of endocardium)
-80% of cases this occurs
-irreversible
-MC valve is the mitral
-2:aortic, 3tricuspid, 4th pulmonary
-vegetation
-
what is vegetation
-fibrin deposits on the margin of the cusps
what does vegetation cause
stricture of healed cusps resulting in valvular insufficiency or valvular regurgitation
-leads to adhesions of the cusps (stenosis)
adhesions due to valvular insufficiency lead to
stenosis of atrioventricular and mitral stenosis
Mitral stenosis
-narrowing of the mitral valve, usually develops with valvular insufficiency.
-Enlargement of left atrium occurs as a response to mitral stenosis. Leads to the compression of
bronchi, recurrent laryngeal artery (leading to hoarseness of voice).
-pulmonary edema
-hypertrophy of left atrium compresses bronchi and displaces esophagus
-RIGHT VENTRICLE HYPERTROPHY
-LEFT ATRIUM WILL FAIL
-ball thrombus
aortic stenosis
- left ventricular hypertrophy
- left heart deviation
- calcific stenosis
aortic insufficiency
-low diastolic pressure may be ZERO
aortic insufficiency causes
- Bacterial endocarditis (MC)
- rheumatic fever
- tertiary Syphilis
- ankylosing spondylitis
Bacterial Endocarditis
– most common cause of aortic stenosis and insufficiency
-Infectious disease of the heart valves – most commonly affecting the aortic valve followed by the mitral valve
⋅ Common, dangerous. 2 types:
-acute
-subacute
Rheumatic Fever
– most commonly affects mitral valve, followed by aortic valve, tricuspid valve
● NEVER Pulmonary!!!!!!
TERTIARY SYPHILIS
- 80% characterized by cardiovascular pathology
- de musset’s sign
- pulse pressure is visualized
Ankylosing Spondylitis
– systemic disease affecting the spine, also a cause of aortic insufficiency
BEAM
Bacterial
Endocarditis
Aortic
Mitral
rheuMATic fever
most commonly affects:
Mitral
Aortic
Tricuspid
Acute Bacterial Endocarditis
⋅ Sudden onset with high mortality rate
⋅ Most commonly caused by Staphylococcus aureus
Subacute Bacterial Endocarditis
- α-hemolytic strep viridans/mitis
- bacteremia
- chronic causes amyloids
- Aortic valves are most commonly involved
- aortic or mitral insufficiency
Subacute Bacterial Endocarditis areas of chronic infection
- teeth
- genital organs
- skin
- lungs
- gallbladder
- amyloidosis
- aortic valves (MC)
Subacute Bacterial Endocarditis valvular involvement
-aortic MC mitral #2
-results in aortic or mitral insufficiency
– Release of enzymes lead to destruction of valves, erosion and perforation of cusps
– 2nd Mitral Valve: conus of the valves may slip, forming an embolism
– Very often results in the development of stroke
Complications of Subacute Bacterial Endocarditis:
⋅ Congenital Heart Disease: Ductus Arteriosus
- Ischemic-Hemorrhagic stroke
- clubbing of fingernails
clubbing of fingernails aka’s
- drumstick syndrome
- hypertrophic pulmonary osteoarthropathy
- malignant cause is called “Paraneoplastic syndrome)
ARTERIOSCLEROSIS
⋅ Arteriosclerosis is a generic term reflecting arterial wall thickening and loss of elasticity ⋅ 3 types: 1)arteriolosclerosis 2)monckeberg medial sclerosis 3)atherosclerosis
ATHEROSCLEROSIS (ATHERA= MUSH, PORRIDGE)
⋅ Normal tissue is replaced by atheroma (atherosclerotic plugs/plaque), forming in the arteries
– Progression of atherosclerosis increases risk of stroke
-affecting small arteries and arterioles, may cause downstream ischemic injury
▪ Hyaline Arteriolosclerosis
▪ Hyperplastic Arteriolosclerosis
MOCKENBERG’S MEDIAL CALCIFIC SCLEROSIS
⋅ Ring-like calcification in the tunica media layer of medium to small arteries of obscure course, occurring in people
over 50
– Walls of arteries are completely filled with calcium, appears radiopaque on film
⋅ This does not lead to narrowing of the vascular lumen
⋅ Arteries commonly affected include: radial, ulnar, tibial, femoral, and the small arteries to the genitals
*Usually extremities
Hyaline Arteriolosclerosis
⋅ Associated with extracellular hyaline deposition in arteriole walls
– People with hypertension or diabetes mellitus are most vulnerable.
– Extracellular deposition of protein leads to dramatic narrowing of the lumen and thickening of the vessels
which may lead to ischemia
Hyperplastic Arteriolosclerosis
⋅ Associated with thickening of the basement membrane of arterioles (no deposition of protein)
– Duplication of basement membrane and smooth muscle cells lead “Onion skinning” (fibrinoid necrosis of the kidneys.)
⋅ Occurs with malignant hypertension, with a minimum 120 diastolic pressure ⋅
Hyperplastic Arteriolosclerosis
Complications:
– Thickening of vascular wall and narrowing of lumen is the most serious problem, resulting in loss of blood
supply to tissues, especially the kidneys – necrotizing arteriolitis
Hyaline Arteriolosclerosis Complications:
● Kidney is the most vulnerable tissue, resulting in the development of benign nephrosclerosis,
death of the glomeruli and development of glomerulonephritis.
– Walls become brittle, increasing the risk of arterial stroke
ISCHEMIC HEART DISEASE (AKA Coronary Heart Disease, Coronary Artery Disease)
⋅ Refers to a group of closely related syndromes caused by imbalance between the myocardial oxygen demand and
the blood supply.
⋅ A group of disorders characterized by a lack of blood flow and oxygen to the heart
⋅ Critical stenosis: clinical manifestations usually occur after the lumen of the coronary artery is 75% occluded.
ISCHEMIC HEART DISEASE (AKA Coronary Heart Disease, Coronary Artery Disease)
Risk factors:
– Atheroma complications can directly lead to MI development
– arteriothrombosis is the most common
cause of MI, predisposed by disease and progression of atherosclerosis
-Atherosclerosis: narrowing of lumen and occlusion of blood vessels
– Smoking: coronary artery is very sensitive to nicotine; risks increase with hypercholesterolemia and hypertension
ISCHEMIC HEART DISEASE (AKA Coronary Heart Disease, Coronary Artery Disease)
pathogenesis
- calcification, cracking, ulceration, necrosis, emboli form from plaques
- platelette aggregation (forms thrombus)
- Coronary artery thrombosis – Coronary artery vasospasm (aka prinzemetal’s angina)
Coronary artery vasospasm aka
– prinzemetal’s angina
- vasoconstriction of SMOOTH muscle layer of blood vessels near an atheroma
- may be due to /\ of catecholamine in blood
Types of Ischemic Heart Disease (4 Major Diseases):
1) angina pectoris
2) acute MI
3) Chronic IHD with CHF
4) sudden cardiac death
Angina Pectoris
– Intermittent chest pain caused by transient, reversible myocardial ischemia
- no pinpoint spot
- manifests as Frogs Chest (squeezing heart)
- Radiation of pain into left arm traveling along ulnar side, left shoulder, scapula, entire left portion of chest
PRINZMETAL’S (VARIANT) ANGINA (NOT A GOOD DEVELOPMENT OF HEART DISEASE)
⋅ Occurs at rest, caused by coronary artery spasm
– Usually occurs on or near existing atherosclerotic plaque, though a completely normal vessel can be
affected
– Can occur in anyone, patient does not always have coronary artery occlusion
⋅ Responds to vasodilators such as nitroglycerin and calcium channel blockers
UNSTABLE ANGINA (AKA CRESCENDO ANGINA, PREINFARCTION ANGINA)
⋅ Stable may become unstable
⋅increasingly frequent pain at rest
–severe pain in the heart may wake patient in their sleep “nocturnal
angina”
– pain closer together, more severe
⋅ Ass w/plaque disruption, thrombosis, and/or
vasospasm
–occlusion of coronary artery, due to narrowing of lumen
⋅ MI> caused by complete vascular occlusion.
CHRONIC ISCHEMIC HEART DISEASE (AKA ISCHEMIC CARDIOMYOPATHY)
– heart cannot pump correctly
⋅ Type of IHD which develops in patients with prolonged ischemia of the heart that has not reached critical point
⋅ Myofibrils undergo degeneration due to ischemia and decrease in metabolism (lack o2 = atrophy = more scar tissue)
⋅ Connective tissue replaces damaged tissue, leading to myocardiosclerosis and decrease of functioning tissue
SUDDEN CARDIAC DEATH
⋅ Death occurs within 24 hours of the onset of cardiac pain (symptoms). May be the 1st & last manifestation of IHD.
⋅ 300,000 annual deaths, 50% have ischemic heart disease (coronary artery problem, coronary atherosclerosis,
developmental abnormalities, coronary artery embolism, vasculitis, dissection, etc.)
– Myocardial diseases – cardiomyopathies, myocardiditis, right ventricular dysplasia
– Valvular diseases – mitral valve prolapse
⋅ Causes include vasospasm and arrhythmia. Arrhythmia is the number one cause.
CONGESTIVE HEART FAILURE
⋅ Multisystem derangement that occurs when the heart is no longer able to eject blood delivered to it by the venous
system – heart fails to pump blood
CONGESTIVE HEART FAILURE ADAPTIVE RESPONSES
- Activity of the sympathetic nervous system
- hypertrophy of heart muscle
- dilation of heart chambers
CHF Activity of the sympathetic nervous system
⋅
⋅ Sympathetic division is responsible for
⋅ Increasing heart contractility = positive inotropic effect
⋅ Increase of heart rate = positive chronotropic effect
⋅ Hypertrophy- increased size (thickness) due to workload
⋅ Together, these two effects (inotropic and chronotropic) compensate for weakness of heart muscle
Inotropic effect:
increase heart contraction
chronotropic effect:
increase heart rate
Hypertrophy of heart muscle in CHF
⋅ Hypertension or stenosis (usually aortic) lead to increased loads of blood to heart muscle
⋅ Increased resistance causes myofibrils to increase in diameter (width) but not length
Concentric Hypertrophy in CHF
muscle enlargement with no change in size of heart chambers
– Usually in response to increased load to the heart and increased resistance to blood flow (e.g., aortic
stenosis, where normal flow of blood is prevented) – Normal ratio between L and R ventricular wall is 2:1 – this ratio is increased in hypertrophy, resulting in left
deviation
Eccentric Hypertrophy
– increase in heart muscle thickness with increase of heart chamber size
– Fluid creates hydrostatic pressure, causing distention to the area
– Eventually hypertrophy becomes ineffective and cardiac failure results
Dilation of heart chambers
⋅ Due to valvular problems, increased load and increased blood in the chambers.
⋅ Eccentric hypertrophy results, with elongated hypertrophied fibers
– Eventually results in dilation, based on Frank-Starling law (elongation of heart myofibril results in increased
heart contractility)
– Most common adaptive response
⋅ If the dilated ventricle is able to maintain cardiac output at a level that meets the needs of the body, the patient is
said to be in compensated heart failure
⋅ If further dilation no longer results in increased contractility, but instead leads to a progressive decrease in
myocardial contractility and a decline of cardiac out, the patient is said to be in decompensated heart failure.
LEFT-SIDED CONGESTIVE HEART FAILURE
Causes: resulting in weakness of left ventricle, left atrium, or both, manifested by lung edema
⋅ systemic hypertension,
⋅ mitral/aortic valve disease
– stenosis or insufficiency depending on the degree of involvement,
⋅ ischemic heart disease – including myocardial infarction, affects function of heart muscle, and
⋅ primary diseases of the myocardium
– myocardiopathies (idiopathic), myocarditis
MitraL stenosis
left sided issues
- excess blood in L atrium
- eccentric hypertorphy
- hypertrophic dilation
- pulmonary edema
Brown induration of the lungs (pulmonary hemosiderosis)
– lungs will be heavy and filled with brown fluid
– Lung edema is always a result of left heart failure
The most common causes of left-sided heart failure:
- systemic hypertension
- Mitral or aortic valve disease
- Ischemic heart disease
- Primary diseases of myocardium
Right sided heart failure
-blood backs up into the R Ventricle causing hypertrophy of the R Ventricle and increased hydrostatic
pressure
– Blood backs up into the R Atrium, then Vena Cava, and increases hydrostatic pressure here as well
– Congestion of the venous system develops in the liver
● Increase intrahepatic pressure compresses hepatocytes and leads to atrophy and nutmeg-like
appearance of the liver
-pitting or pedal edema
pitting edema in other cavities
● Abdominal cavity – ascites
● Pleural cavity – pleural effusion
● Pericardial cavity – pericardial effusion
RIGHT-SIDED CONGESTIVE HEART FAILURE
- L Ventricular failure
- Cor Pulmonale
⋅ Cor Pulmonale due to primary lung disease such as emphysema or interstitial lung disorders
RIGHT-SIDED CONGESTIVE HEART FAILURE organs effected
-Liver (MC) nutmeg liver
anasarca
total swelling of the body (everything swollen, including cavities) in all soft tissues and cavities
Most common causes of right ventricular heart failure
- Left ventricular failure
- Cor pulmonale- enlargement of right heart.
the most common manifestation of LEFT ventricular failure is
- dyspnea (breathlessness)
- tachycardia
Clinical manifestations of congestive heart failure
-Dyspnea
-▪ Muscle fatigue
▪ Enlarged heart
▪ Tachycardia
▪ Fine rales in lung bases (rales are rattle sounds)
▪ High pitched systolic murmur
▪ Atrial fibrillation- lacks specific
▪ Enlargement of heart ▪ Distended neck veins (congestion is vena cava superior)
▪ Enlarged and sometimes tender liver ▪ Edema of the feet and lower legs
▪ Accumulation of fluid in the body cavities
▪ Cyanosis
▪ Muscle fatigue (not adequate supply of oxygen)
▪ Elevated venous pressure
▪ Dilation of the right ventricle
▪ Mitral valve disease
▪ Prolonged circulation time
