quiz 2- CV 3-4 Flashcards
• what are usual causes of myocardial dysfunction? Cardiomyopathy?
- Common: IHD, HTN, valvular heart dz
- Less: intrinsic to myocardium itself: heart inflammatory dos of the heart, immunologic dzs, systemic metabolic dos, muscular dystrophies, myocyte genetic abnormalities, dzs of unknown etiology
- Cardiomyopathy: primary abnormality in myocardium
• What are the 3 major categories of cardiomyopathy, and the relative size of the 4 chambers??
- Dilated (90% of all cases of non-ischemic cardiomyopathy); all 4 enlarged
- Hypertrophic; very small LV, enlarged LA
- Restrictive; small LV, enlarged LA
• What causes dilated cardiomyopathy?
- Many unknown etio = idiopathic dilated cardiomyopathy
- Ischemic CM=most commonly identified (60% pts with sx HF)
- Common cause in US is chronic alcoholism
- Viral myocarditis
• What is pathophysiology of DCM? Laplace’s Law?
- <40% EF (despite enlarged LV vol) , may →systolic dysfunction
- Myocyte injury, necrosis, fibrosis →impaired mechanical function
- Cell failure → chambers dilate
- Laplace’s law: ↑diameter → ↑stress → mechanical disadvantage
- =vicious cycle (adverse ventricular remodeling)
• What is prevalence of DCM? Histology? In vivo?
- 0.4/1000
- Histo: nonspecific cellular abnormalities, variations in myocyte size, myocyte vacuolation, loss of myofibrillar material, fibrosis
- flabby, hypo-contracting heart
• What is shape of a very large heart?
• Globoid, bc all chambers are dilated
• What is hypertrophic cardiomyopathy (HCM)? Micro?
- Aka idiopathic hypertrophic sub-aortic stenosis, hypertrophic obstructive cardiomyopathy
- genetic dz, proteins of sarcomere
- thick-walled, heavy, hyper-contracting
- massive myocardial hypertrophy w/o ventricular dilation; usu only one ventricle
- classic: disproportionate thickening of ventricular septum, compared to free wall of ventricle.
- abnormal diastolic filling, intermittent ventricular outflow obstruction (1/3)
- Micro: hypertrophy of myocardial fibers (prominent dark nuclei) interstitial fibrosis
• What is restrictive CM? causes?
- Aka: infiltrative CM
- myocardium usu infiltrated w abnormal tissue → impaired/abn ventricular wall contraction/relaxation
- most common causes: amyloidosis and hemochromatosis
- Hemochromatosis (Prussian blue stain for iron): Excessive deposition of iron → heart enlargement and heart failure
- amyloidosis: amorphous deposits of pale pink material bw myocardial fibers
• what is Infectious endocarditis?
- inflammation on the valve leaflets, or endocardial lining of atrium and ventricles (surgery)
- begin on lines of closure (greatest P): atrial surfaces of AV valves, ventricular surfaces of the semilunar valves
- usu left-sided valves, A=M frequency
- Indwelling devices such as prosthetic valves and pacemakers can also become infected
• When is TC valve IE seen? Pulmonic?
- Suspicious of IV drug use
- Community-acquired (IV drug abuse)
- Hospital-acquired (implanted devices)
- P: rare, confusing sxs
• what are “vegetations” in IE?
- colonization by microbes =bulky masses
- =collections of infected thrombotic debris deposited on and around affected valve
- often → destruction of underlying valves and tissue
• What are gross and micro appearance of IE?
- Gross: aortic valve has large irregular, reddish tan vegetation
- Micro: valve has friable vegetations (easily break off, embolize, spread infxn) of fibrin and platelets (pink) mixed w inflammatory cells and bacterial colonies (blue).
- Gross Mitral: valve destruction and vegetation (destruction at commissure bw anterior and posterior leaflets)
• What organisms can cause IE?
- Many: all bacteria, fungi, Chlamydia and Rickettsiae.
* Most common is bacterial
• What organisms cause IE in community-acquired vs nocosomial?
- Staphylococcus aureus: (30-50%, minority MRSA) vs. (60-80%; majority MRSA)
- Alpha-hemolytic Strep (S. viridans): 10-35% vs. < 5%
- Enterococci: 5-10% vs. < 5%
- Culture negative: 5-30% vs. 5%
- Staphylococcus epidermidis (coagulase negative): ?? vs. < 5%
- Misc (Escherichia coli, Klebsiella sp., Corynebacterium) < 5% vs. 5-10%
- Fungi: < 5% vs. 10%
• What is culture-neg IE?
- 7-33%
- Hi in community-acquired dt abx tx prior to dx
- full work-up: serology and culture for esoteric organisms, PCR → etio dounf in >75% cases w initial negative culture (C burnetii and Bartonella species)
- no assoc bw cult neg and underlying etio
• what are the organisms commonly found in initially culture neg. IE?
- Fungi (10%)
- Enterococcus (5%)
- Alpha hemolytic streptococci (<5%)
- Misc. others including: E coli, Klebsiella, Corynebacterium; 5-10%
• What are portals of entry for organisms that may cause IE?
- Poor dental health, dental procedures, pharyngeal infxn
- GU infxns, instrumentation the GU tract
- Skin infections (impetigo)
- Pulm infxns
- IV drug use
- Any infx that can enter blood stream
• What is acute IE?
- rapidly developing, destructive infxn; usu previously normal heart valve
- usu dt infxn w highly virulent organism
- mb death in days to weeks in ~50%, even w vigorous tx with abx and surgery
- fever most common sign
• what is sub-acute IE?
- Mostly dt strep viridens
- generally slower and less severe course
- fever common, but not necessarily in elderly (can’t mount fever)
- valve usu already damaged, usu dt infxn w less virulent organism
- usu recover after appropriate tx
- vegetations frequently embolize
• what are splinter hemorrhages? Roth’s spots?
- S: Microemboli to skin, form petechiae I (mouth, under the tongue, feet, nail beds)
- R: retinal hemorrhages; white center of coagulated firbrin; dt immune complex mediated vasculitis; also seen in leukemia, DM, pernicious anemia, ischemic events, rare HIV
• what are sxs of acute IE?
- Dramatic onset fever, chills, weakness, fatigue
- Mb new murmur, dt flow over vegetations → commonly embolize
- abscesses in ring of tissue beneath leaflets of infected valve
• what are risk factors for IE, and corresponding organisms?
- Used to be rheumatic heart dz. Incidence now dec
- artificial valves- staph epidermitis
- damaged native valves: step viridens
- Immunocompromised
- IV drug abuse- staph aureus
- Alcoholics- anaerobes, oral cavity bugs
- indwelling catheters/cystoscopy/prostatectomy: Gram neg like E. coli
- vascular grafts
- colon CA: strep bovis
• what is follow-up for strep bovis culture?
• Colonoscopy is indicated if cultured from blood, to r/o colon CA
• What is follow-up/sig for culture neg IE?
- Etio not found on blood culture in 5 - 20% of all IE
- Mb dt abx prior to blood draw, organism not in blood stream at the time, or limitations in culture process in lab
- Mb an endocarditis that is inflammatory in nature rather than infectious
• What is Libman-Sachs endocarditis?
- =endocarditis of SLE (systemic lupus erythematosus)
- Inflammatory vegetations can occur w certain collagen vascular dzs like SLE
- Gross: flat, spreading vegetations over mitral valve surface and chordae tendineae.
• What is Marantic endocarditis?
- culture neg, vegetations dt hypercoagulable state (lung or pancreatic CA)
- Trousseau’s syndrome= paraneoplastic syndrome assoc w malignancies
- =not infectious
- Gross: small pink vegetation on cusp margin; rarely over 0.5 cm
- very prone to embolize
• what are outcomes of IE?
- successful tx: affected tissue becomes sterilized, valve more fibrotic and scarred
- cardiac decompensation (CHF dt endocarditis): affected valve must be removed and replaced w artificial/prosthetic valve
What is myocarditis?
- =inflammation of heart muscle
* Dt infxn of heart, or autoimmune (RHD, collagen vascular dzs, SLE, RA, drugs, transplant rejection)
• What Infectious agents can cause myocarditis?
- Viral most common
- Coxsackie virus (group B)- most common
- Borrelia burgdorferi (Lyme’s dz)
- Cytomegalic virus (CMV)
- HIV
- Meningococcus
- Rickettsia typhi (typhus)
- Toxoplasmosis
- Trichinosis
- Trypanosoma cruzi (Chaga’s dz)
• What is Coxsackie virus?
- Genus Enterovirus (also poliovirus and echovirus), common, fecal-oral
- Group A & B: non-specific fever, rash, UR dz, aseptic meningitis
- A: skin and mucous membrane → herpangia, acute hemorrhagic conjunctivitis, hand foot mouth dz
- B: heart, pleura, pancreas, liver→pleuritis, myocarditis, pericarditis, pericardial effusion, hepatitis
• What is Rickettsia typhi?
- Obligate parasite bacteria
* (Not “typhoid fever”)
• What is hallmark of viral myocarditis?
• interstitial lymphocytic infiltrates
• what is Valvular disease?
- Valves= CT of cardiac skeleton
- Congetical or acquired; isolated or combined
- stenosis, insufficiency (regurgitation or incompetence), or both
- Stenosis: doesn’t open completely, impedes forward flow
- Insufficiency: doesn’t close completely, allows reverse flow
- slight and physiologically unimportant to severe and rapidly fatal
- severe: Sudden destruction of aortic valve cusp by infxn (IE) → severe regurgitant blood flow → rapidly fatal
- benign: mitral stenosis dt RHD develops over years, well tolerated
- tx: mb meds, or repair/prosthetic
• what are the most common heart valve dzs? Rare?
- aortic stenosis (most common*, or mitral prolapse) and mitral regurgitation or insufficiency.
- Tricuspid valve dz rare, 2nd to other heart valve dz
- Mitral stenosis dt rheumatic fever, undeveloped countries
- Pulmonic valve dz is congenital, dx at birth
- Aortic and mitral stenosis: 2/3 of all cases
• What are sxs of heart valve dz?
- SOB, palpitations (irregular, rapid HR), weakness, dizziness, fainting, edema (ankles, feet), discomfort in chest
- Can progress slolwly
- Sxs don’t always reflect severity
- heart gradually adjusts, sxs may go unnoticed
- Abd heart sounds: Murmurs and clicks
• How is heart valve dz diagnosed?
- W echo
* St CT-angiography, cardiac MRI
• What are the murmurs attributable to left sided valvular dz?
- Normal: S1, softer S2
- Aortic stenosis: long loud systolic
- Mitral regurgitation: soft, holo-systolic
- Aortic regurgitation: holo-diastolic
- Mitral stenosis: S1 and S2 both soft
- PDA: holo-systolic and diastolic, tapers end diastole
• What are the most common of all the valve dzs?
- Most: aortic stenosis
- MVP
- Mitral regurg
• What causes tricuspid, mitral stenosis, and pulmonic valve dzs?
- T: rare, 2nd to other heat valve dz
- M: RF (unusual in developed countries)
- P: congetial, dx at birth
• What causes acquired aortic stenosis? Congenital?
- calcification w age; “wear and tear” of either previously anatomically normal aortic valves or congenitally bicuspid valves (3 is normal)
- 1% in US born w bicuspid aortic valve (raph=cusp w partial fusion at center)
- incidence increasing w rising avg age of pop
• what is mitral annular calcification?
- in fibrous ring (annulus) of mitral valve= hard, irregular, ulcerated nodules behind leaflets
- usu doesn’t affect valvular fxn
- but mitral stenosis can occur dt progressive dz
• what is Mitral valve prolapse?
- One of the most common forms of valvualr dz
- one or both mitral leaflets are “floppy” and prolapse, or balloon back into LA in systole
- ~3% or more of adults in US; F 20-40
- = “Myxomatous degeneration of the mitral valve”
• What is myxomatous degeneration?
- Weak CT, usu in MVP (most common cause of pure M insufficiency)
- Exact mechanism unknown
- CT degenerates, glycosaminoglycan accumulates
- Mb benign, or more severe in Marfan’s, etc
- In valves: mb insufficiency, regurg
• What causes MVP? Ssx? Dx?
- Mb cellular defect in CT
- Ssx: most asx, mid-sys click; if mitral regurg: late/holo-sys murmur
- Mb: chest pain (like angina, dyspnea, fatigue)
- Dx: Usu incidental on PE, Echo
• What are possible complications of MVP?
- Mostly benign, 3% develop:
- IE- high incidence
- Mitral insufficiency- requires surgery
- Stroke/other infarct: dt embolism or leaflet thrombi
- Arrhythmias: A and V (unknown mechanism for V); st sudden death
• What is rheumatic fever? Complications?
- acute, immune mediated, multisystem inflammatory dz
- occurs in few wks after GAS pharyngitis (strep pyogenes)-ONLY
- Acute rheumatic carditis in active phase may → chronic rheumatic heart disease (RHD)
- Mb AI response to anti-strep M protein Abs, cross react w cardiac myosin
- 1/3: →valve insufficiency, HF, pericarditis, or death
• What are the major and minor dx criteria for RF?
- Major: Carditis, Polyarthritis, Chorea (Sydenham’s), Subcutaneous nodules, Erythema marginatum
- Minor: Fever, Arthralgias, Prolonged PR interval on EKG , ↑WBC, ESR, CRP
• What is incidence of RHD?
- 100 yrs ago: leading cause of death in US, 5-20 yo
- markedly dec since 1940s (developed)
- still common in undeveloped (5-30 million kids, 90,000 die/yr)
- dt penicillin, change in virulence of strep
- median age 10 yrs, 20% in adults
- 2.5 million in US (many contracted 40-50 yrs ago)
• how does strep throat progress to RF/RHD?
- GAS spreads by direct contact with oral/resp secretions (↑crowded living)
- attach to epithelium of upper resp tract, make enzymes to invade and damage local tissue
- incubate 2-4 d → acute inflammatory response, 3-7 d of sxs (sore throat, fever, malaise, HA)
• how is strep throat diagnosed? Tx? Un-tx?
- Positive throat culture or rapid streptococcal antigen test
- hi strep Ab titer (antistrepotolysin O, ASO titer) (GAS make cytolytic toxins streptolysin S and O. O induces persistently high Ab titers= good marker)
- tx: abx shorten strep throat, reduce infectivity, reduce sequelae of heart damage, but don’t change course of acute RF
- Untx: remain infected/infectious for weeks after symptomatic resolution of pharyngitis
- 0.3-3% untx cases: get RF
• What are Aschoff bodies?
- nodules in heart w RF. dt inflammation in heart muscle, characteristic of RHD
- granulomatous: collagen, lymphocytes, plasma cells, M0s, surround necrotic center
- pathognomonic for pan-carditis in RHD (focal inflammation of all 3 layers of heart)
- found in other tissues in RF, but not called Aschoff
- M0s may →multinucleated giant cells, or Anitschkow cells (“caterpillar cells”, dt appearance of chromatin)
• what is most important cardiac related consequence of RHD?
- Mb chronic valvular deformities, particularly mitral stenosis (65-70%, then aortic valve at 25%)
- have deforming fibrosis → permanent dysfunction and severe, sometimes fatal, cardiac problems decades later
- gross: “fish mouth” shape with chronic rheumatic scarring.
- varying degrees of regurgitation, atrial dilation, arrhythmias, ventricular dysfunction.
- Chronic RHD= leading cause of MSV and valve replacement
- Chronic manifestations: 10-40%
- Fusion of valve develops 2-10 yrs after acute RF, more episodes more damage
• What is carditis?
o Inflammation of heart muscle
o 2nd most common complication of RF (50%)
o Sxs: like HF, dyspnea, chest discomfort, pleuritic chest pain, cough, pericarditis/rub
o Often w new murmur, tachycardia (out of proportion to fever)
• What are sxs of RF?
o Like HF o Difficulty breathing, exercise intolerance o Tachycardia (out of proportion to fever)
• What are Prosthetic heart valves? Complications?
- older ball and cage variety. last indefinitely, require continual anticoagulant tx because of the exposed non-biologic surfaces.
- Thrombosis: so need anticoagulant tx, doesn’t entirely precent
- Infection: vegetations of IE, septic embolization
- Structural failure: leaflets tend to become stiff and calcify
- Dehiscence: right after surgery, suture line leaks= valvular leakage
• What are non-cardiac ssx of acute RF?
- often diagnostic
- polyarthritis (most common; transient, large jts, from legs up)
- chorea (Sydenham’s, St. Vitus’ dance), erythema marginatum, subcutaneous nodules (bx if has Aschoff bodies)
- abdominal pain, arthralgias, fever, pneumonia
• what are subcutaneous nodules?
- Painless, firm, collagen, over bones or tendons
- back of wrist, outside elbow, front knees
- have Aschoff bodies w RF
• what is erythema marginatum?
- Aka erythema annulare
- Rash in 5-13% of acute RF
- Begins trunk/arms 1-3 cm , pink-to-red nonpruritic macules or papules, rarely face
- spread outward → serpiginous ring w red raised margins and central clearing
- worse w heat
• Describe presentation of 8 yo boy with RF, chorea, subcutaneous nodules:
- Difficulty writing dt chorea in arms
- Mild sore throat, resolved w/o abx; lo fever, no chills
- Friction rub over heart
- subQ nodules over hands
- bloodword unremarkable, ↑ESR
• what are causes of pericarditis/pericardial dz?
- Idiopathic – most common
- Infectious – all microbes, esp viruses
- Inflammatory – post-MI, secondary to uremia
- AI – RF, RA, SLE,
- Drugs: procainamide, hydralazine
- Trauma – penetrating/blunt trauma, post-catheterization, post-cardiac surgery
- Misc. – tumors
• What are the types of pericarditis?
- Serous
- Fibrinous
- Hemorrhagic
- Purulent
- Caseous
• What are features of Serous pericarditis?
- Usu non-infectious, mb viral
- Uremia (acute)
- AI – RA, SLE
- Normally, minimal fluid in pericardium and less inflammatory response. Often has complete resolution.
• What is Fibrinous pericarditis?
- Post-MI or Dressler’s syndrome; Post-cardiac surgery; Trauma; Uremia (chronic); AI– RA, SLE
- Pericardial fluid is mixture of fibrinous exudate in serous fluid
- Pericardial friction rub mb audible
- Gross: surface looks rough, not normal glistening (dt fibrin strands)
- “bread and butter” pericarditis
• What is Hemorrhagic pericarditis?
- TB; Tumor; Bacterial; Bleeding dos; Trauma
- =fibrinous pericarditis w blood (w/o inflammation, would be called hemopericardium)
- Pericardial fluid w blood mixed with fibrin, st pus exudate
- Gross: rough and red surface
- usu with metastatic tumors, TB
• what is Purulent pericarditis?
- from adjacent infection, septic embolism, septicemia, iatrogenic after heart procedure
- exudative, yellow pericardial fluid, w pus and fibrin.
- Resolution w scarring, may → constrictive pericarditis.
• What is incidence of heart tumors?
- Primary: rare, 70% benign, 30% malignant
- Metastatic also uncommon, but most common malignancy in heart
- most common: atrial myxoma (benign)
• what are the types of benign and malignant heart tumors?
- B: Fibroma, Hemangioma, Lipoma, Lymphangioma, Myxoma, Neurofibroma, Rhabdomyoma, Teratoma,
- M: Angiosarcoma, Extraskeletal Osteosarcoma, Fibrosarcoma, Leiomyosarcoma, Liposarcoma, Neurogenic Sarcoma, Rhabdomyosarcoma, Malignant Lymphoma, Malignant Teratoma, Mesothelioma, Thymoma,
• What is atrial myxoma? Dx?
o benign masses, attached to atrial wall, or valve, ventricle (in chambers)
o usu LA, 80-90%l usu septum
o 1-15 cm, usu 5-6
o 29% all heart tumors
o “ball valve” effect: intermittently occlude valve orifice
o Can embolize (metastasize); esp be careful on surgical removal
o Dx: echo, further confirmation by MRI
• What is gross and micro appearance of atrial myxoma?
o Gross: gelatinous ball into LA
o Hypocellular myxoid mass, polygonal/elongated cells
o Mono- or multinuclear
o finely vacuolated eosinophilic cytoplasms.
• What is Cardiac rhabdomyoma?
o most common primary pediatric tumor of the heart.
o benign, can’t metastasize, but certain position may cause lethal arrhythmias, chamber obstruction.
o spontaneous regression.
o Mild atypical histology
o Gross: clear cells (not normal myocardium, dt glycogen loss in staining), round/polygonal, enlarged
• Which neoplasm has greatest propensity to metastasize to heart? Others?
o Melanoma (64%), but not most common cardiac malig
o Dt hematogenous invasion (like lymphoma, dt myocardium involvement)
o Gross: See brown-black pigment
o Met to heart: 10-12% of autopsies w malignancy, dt hematogenous dissemination
o Bronchogenic 36%, nonsolid 20%, breast 7%, esophagus 6%
• What is the most common cardiac malignancy?
o Carcinoma of lung (bronchogenic, 36%)
o involves heart dt proximity/extension or hematogenous spread
o dt lymphatic invasion (dt peri/endocardium involvement)
o Also bc lung CA is so common
