Valvular Disease, infections, vasculitis Flashcards
what is the most common mitral valve disease?
mitral valve prolapse?
who gets mitral valve prolapse?
young to middle aged women mostly
who gets mitral valve prolapse?
young to middle aged women mostly
what are some signs and symptoms of mitral valve prolapse?
cardiac arrhythmias, mitral regurgitation, valve incompetence, infective endocarditis, stroke from thrombus, chordae tendinae rupture
what are pathological findings in mitral valve prolapse?
myxomatous degeneration
associated with connective tissue diseases - marfans
what are auscultatory findings in mitral valve prolapse?
midsystolic click and late systolic murmur
what are treatments of mitral valve prolapse?
acute: diuretics, vasodilators, sodium nitroprusside, cardiogenic shock –> IABP, severe? –> MV repair/replacement
chronic: diuretics
hypertensive? –> vasodilator (sodium nitroprusside), MV replacement/repair
what are causes of mitral stenosis?
congenital deformities systemic disease (SLE, RA, carcinoid syndrome) pseudo mitral stenosis mitral annular calcification rheumatic valvular disease
what are signs and symptoms of mitral stenosis?
infective endocarditis, stroke from thrombus, cardiac arrhythmia, dyspnea and cough, orthopnea, chest pain, hoarseness, peripheral edema, fatigue, passively leads to RVH
what are pathological findings of mitral stenosis?
calcification of mitral valve
JVP wave shifted up
transvalvular gradient increased (magnitude tells you about severity)
what are auscultatory findings of mitral stenosis?
diastolic rumble
possible presystolic accentuation of murmur
with increased severity: holodiastolic murmur
OS (decrease in A2 to OS with increased severity)
what are treatments for mitral stenosis?
volume management rate control treat coexisting conditions percutatneous balloon valvulopathy mitral valve commisurotomy mitral valve replacement
what are pathological findings of rheumatic valvular disease?
chronic: thickening and fibrosis of valve –> stenosis and regurgitation (Dx w/ ultrasound)
what are auscultatory findings in rheumatic valvular disease?
transient regurgitant murmurs, mid-diastolic murmurs (Carey-Coons murmur)
what are causes of mitral regurgitation?
mitral valve prolapse rhemuatic valvular disease endocarditis dilated cardiomyopathy coronary ischemia trauma systemic disease
what is the effect of mitral regurgitation on JVP
prominent v waves and rapid y descent
what are auscultatory findings in mitral regurgitation
pan or holosystolic murmur
early diastolic murmur
possible S3
(5th ICS in anteroaxillary line and radiates to axilla)
what are causes of aortic stenosis?
congenital (bicuspid)
rheumatic valve disease: ARF –> valvulitis (concomitant MVD (esp women)
calcific degeneration from atherosclerosis, rheumatic fever or endocarditis
systemic disease
what are symptoms of aortic stenosis
pulmonary edema and hypertension angina syncope dyspnea and CHF, massive LVH mitral regurgitation aortic dissection aortic valve perforation MI cardiac arrhythmia
what are pathological findings in aortic stenosis?
inferolateral displacement of PMI
duration of apical impulse prolonged
contour of carotid pulse decreases in amplitude and delay in contour of carotid upstroke = pulsus parvus et tardus
auscultatory findings in aortic stenosis?
rhomboid SEM (peaks later with severity)
early systolic ejection click
splitting of S2 narrows (with possible paradoxical splitting)
S4 possible
what are treatments for aortic stenosis?
diuretics digoxin dopamine dobutamine aortic valve replacement percutaneous balloon valvuloplasty
what is the most common congenital CV abnormality
bicuspid aortic valve
what are signs and symptoms of bicuspid aortic valve
aortic dissection –> severe tearing chest pain radiating back
endocarditis
responsible for 50% of aortic stenosis cases
EKG shows LVH
causes of aortic regurgitation
acquired: RVD, endocarditis, aortic root disease, systemic diseases
congenital: bicuspid or quadricuspid, sinus of valsalva aneurysm, subaortic membranes, subaortic VSD
signs and symptoms of aortic regurgitation?
chronic: CHF, eccentric hypertrophy, progressive LV cavity dilation, increase in wall thickness, cardiomegaly, increased myocardial mass
LV wall stress, increased afterload mismatch and LV systolic dysfunction
widening of aortic pulse pressure
acute: pulmonary edema,
what are pathological findings in aortic regurgitation
long latent period without symptoms laterally displaced PMI Quinke's sign Corrigan's water hammer pulse Deroziez's sign Hill's sign
what are auscultatory findings in aortic regurgitation
diastolic murmur (3rd or 4th ICS at LSB) descrescendo appreciated along RSB if related to aortic root dilation (Harvey's sign) severity associated with duration rather than intensity austin-flint murmur: low frequency diastolic murmur
what are treatment options for aortic regurgitation?
valve replacements
echos: 1-2 yrs if asymptomatic and mild and normal LV
6-12 months if asymptomatic, moderate/severe aortic regurgitation, preserved LV
if preserved LV systolic function and diastolic hypertension –> diuretics, sodium restriction and vasodilator therapy (nifedipine or ACE inhibitors)
aortic root replacement in those with concomitant aortic pathology
NO IABP
what are causes of carcinoid heart disease?
tumor produces 5-HT or other vasoactive compounds
thickened valvular plaques made of smooth muscle collagen and matrix
thickened tricuspid valve and fusion of the chordae tendinae associated with the carcinoid tumors
why don’t GI carcinoids cause heart lesions?
metabolized by liver
how do you get left side lesions?
exogenous vasoactive peptide use, rare otherwise
what is unique about carcinoid heart disease?
right sided valve disease
what is rheumatic endocarditis?
fibrinous necrosis of cusps and cords
vegetations overlie areas of necrosis
inflammation of the heart
damage to heart tissues
what is the cause of rheumatic valvular disease?
antigenic cross reaction between streptrococcus and heart disease
direct invasion by bacteria
immune cross reaction to heart tissues
who commonly gets rheumatic valvular disease?
children from 5 to 15
what is the pathology of rheumatic valvular disease?
composed of fibrin, inflammatory cells –> scarring and deformity of valve results in valve stenosis and insufficiency
typical course of RF dose not involve rheumatic heart disease
What is non-bacterial thrombotic endocarditis?
a bland thrombus that sits on valve surface
no bacteria
no inflammation
can flick off clots to other organs
what are the clinical manifestations of NBTE?
valve stenosis or insufficiency
stroke
lower extremity ischemia
associated with hypercoagulable states
who gets NBTE?
people with debilitating diseases like cancer
who gets libman-sacks?
sle
what is libman sack endocarditis?
non-infectious small thrombi on outer and inner surgaces of mitral and tricuspid
may also occur on chrdae and ventricular wall
what is the pathology of libman-sacks?
valve lesions: composed of fibrin, cellular debris can become active with valvulitis
what is the most common cause of pulmonic stenosis?
congenital
what valves are most commonly affected?
mitral and aortic
what is the most common etiology of valve disease?
calcific degeneration
what are causes of LVH?
hypertension and hypertrophic myopathy
why can you get atrial fibrillation from mitral stenosis?
atrial chamber dilates resulting in improper electrical signal conduction when the mitral valve is narrowed or blocked
what is the most common acquired valvular heart disease?
aortic stenosis
what are three complications you see with any abnormal valve?
cardiac arrhythmia, thrombosis, infection
what is endocarditis?
inflammation of heart typically involve valves
what is myocarditis?
inflammation of heart muscle
caused by viruses, immune reactions (lupus, RF)
transplant rejection and drug reaction
what is pericarditis?
inflammation of the outside of the heart and heart sac, primary pericarditis is viral
typically see accompanying fluid collection
what are clinical findings of pericarditis?
chest pain, sharp retrosternal, radiates back
relieved by sitting up or leaning forward
worsened with lying down
friction rub
cardiac tamponade
Jugular venous distention, hypotension, muffled heart sounds
emergent treatment = pericardiocentesis
what are complications of pericarditis?
acute complications: cardiac tamponade, cardiac arrhythmia
chronic: scarring with adhesions
what are requirements for pathology diagnosis?
inflammatory infiltrates, myocyte damage and/or necrosis
what is the difference between acute and subacute bacterial endocarditis?
acute: normal valve, highly virulent organism, rapid course with high mortality
subacute: abnormal valve; less virulent organism, protracted course (weeks to months)
what are signs and symptoms of bacterial endocarditis?
Duke criteria (2M or !M +3m or 5m)
Pathology: bugs, histology
Major: blood, echo dx, new regurgitation
Minor: abnormal valve, IVDA fever, classic lesion, single unusual blood culture, echo suggestive
what histological findings do you see in bacterial endocarditis?
acute inflammation
inflammatory debris
bacteria colonies
s. epidermitis, s. aureus, p. aeruginosa in IV drug users or contaminated water supplies
what lesions do you see in bacterial endocarditis
septic emboli to other organs and issues splinter hemorrhages janeway lesions osler nodes roth's spots kidney abscesses brain infarcts
what are complications of bacterial endocarditis
destruction/rupture of valve heart failure valve insufficiency septic emolic events subacute: valve fibrosis and stenosis
what are histological findings in rheumatic myocarditis?
aschoff body: diagnostic myocardial lesion, composed of t cells, plasma cells and activated macrophages,
anitschow cells - diagnostic cell, activated macrophages with slender wavy chromatin “caterpillar cells”; multinucleated
what are complications associated with rheumatic myocarditis?
endocarditis, myocarditis (usually cause of death), pericarditis, pancarditis
what is the cause of viral myocarditis?
infection
viral: coxsackie, influenzae
chagas disease
lyme disease
what are signs and symptoms of viral myocarditis?
viral illness symptoms, cardiac arrhythmia, palpitations, dypnea, pre-cordial discomfort, can progress rapidly to heart failure and death
what are pathological findings in viral myocarditis?
gross pathology pale floppy myocardium
microscopic pathology: lymphocytic infiltrate
myocyte necrosis
clinical pathology: elevated CK-MB and troponins
what are complications of viral myocarditis?
chronic heart disease
dilated cardiomyopathy
can lead to death
what is eosinophillic myocarditis?
drug reaction (hypersensitivity) caused by antibiotics, chemotherapeutics typically have rash or other immune response chagas disease (protozoal infection) trypanosoma cruzi kissing bug achalasia in GI path
what is giant cell myocarditis
unusual variant of garden variety myocarditis
mixed infiltrate with giant cells
more extensive myocyte necrosis
aggressive course with poor prognosis
what is the gross pathology of myocarditis?
pale yellow discoloration of myocardium
what is the etiology of serous pericarditis?
SLE, rheumatic fever, viral infection
what are the types of pericarditis?
serous, fibrinous, purulent, hemorrhagic
what are pathological findings in serous pericarditis?
straw-colored pericardial effusion
protein rich exudate
what is the etiology of fibrinous pericarditis?
acute myocardial infarction
uremia - renal failure
post-pericardotomy syndrome - after coronary artery bypass graft syndrome
dressler’s syndrome
what are the pathological findings in fibrinous pericarditis?
sticky adherent fibrin strands on surface
fibrin rich exudate
what is the etiology of purulent pericarditis?
infection
what are pathological findings in purulent pericarditis?
thick yellow effusion (pus) inflammatory exudate
what is the etiology of hemorrhadic pericarditis?
tumor invasion of pericardium
tuberculosis
bacterial infection
what is the most common organism for infective endocarditis?
s. aureus
what are causes of myocarditis?
viral, RF, chagas disease
what are pathologic criteria for diagnosis of myocarditis?
lymphocyte infiltrate and myocyte necrosis
what are the etiologies of the four types of pericarditis?
serous - RF, viral myocarditis
fibrinous - renal failure and post-coronary graft surgery
purulent - infection
hemorrhagic - tumor
what are the clinical signs of pericarditis?
jugular venous distension, hypotension, muffled heart sounds
what are the types of large vessel vasculitis?
giant cell arteritis
takayasu arteritis
what are the types of medium vessel vasculitis?
polyarteritis nodosum
kawasaki disease
beurger
what are the types of small vessel vasculitis?
microscopy polyangitis, chrug-strauss, wegners
what is c- anca
serum Ab to neutrophils that binds proteinase 3 within cytoplasm
what is p-anca?
serum Ab to neutrophils that binds myeloperoxidase located at perinuclear area
what are pathological findings of hemorrhagic pericarditis?
bloody inflammatory effusion
