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Year 2 clinical pathology > Week 8 Cardiovascular 3 > Flashcards

Week 8 Cardiovascular 3 Flashcards

1
Q

What is Endocarditis?

A

Inflammation of the endocardium of the heart

Prototypical lesion = “vegetation” on valves

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2
Q

What are the two main forms of endocarditis?

A

Infective endocarditis
Clinically important

Non-infective endocarditis
Nonbacterial thrombotic endocarditis (NBTE)
Endocarditis of SLE (Libman-Sacks Disease)

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3
Q

Is infective endocarditis serious?

A

Clinically serious infection!!!

Colonization / invasion of heart valves or heart chamber endocardium by a microbe

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4
Q

What caues the vegetation of the valves in endocarditis?

A

Mixture of thrombotic debris and microorganisms

Invade and destroy underlying cardiac tissues

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5
Q

What is the cause of infective endocarditiis?

A

Most cases caused by bacterial infection

Fungi

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6
Q

How does acute infective endocarditis occur and what is the cause?

A

Can occur with infection of a previously normal healthy valve
Caused by highly virulent organisms

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7
Q

What is the consequence of acute infetive endocarditis?

A

Necrotizing, ulcerative, destructive lesions

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8
Q

What is the treatment of acute infective endocarditis

A

Difficult to cure with antibiotics and usually require surgery

Death frequent days to weeks despite aggressive treatment

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9
Q

What is more common acute or sub acute infective endocarditis?

A

Sub-acute

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10
Q

What is the cause and outcome of sub acute infective endocarditis?

A

Organisms of lower virulence
Insidious infections of deformed valves
Vague symptoms –> fever and maybe a murmur
Less destructive

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11
Q

What is the treatment of sub-acute infective endocarditis?

A

Protracted “wax and wane” course of weeks to months

Cured with antibiotics

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12
Q

What are the causes of infective endocarditis?

A 
Mitral valave prolapse
Valvular stenosis (calcification etc)
Artificial (prosthetic) valves
Unrepaired and repaired congenital defects
Bicuspid AV
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13
Q

What disease use to be a major cause of infective endocarditis but not a problem as much any more?

A

Rheumatic heart disease

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14
Q

What are the different routes a bacteria can get into the blood stream and infected the heart?

A

Dental abnormalities, IVDU, wounds, bowel cancer

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15
Q

How does Streptococcus viridans affect the heart?

A

From the heart which cause damage/abnormal valves

50-60% cases

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16
Q

What bacteria on the skin can cause infection endocarditiis?

A

S.aureus–> 10% to 20% of cases overall esp in IVDU as they damage the skin

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17
Q

What bacteria commonly infects prosthetic heart valves?

A

Coagulase-negative staphylococci

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18
Q

What is appearance of vegetation in acute IE and what is effected?

A

Friable, bulky, potentially destructive

Often more than one valve –> AV,MV and the right heart (especially in IVDUS)

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19
Q

What effect does vegetation of acute IE have on the heart?

A

Can erode the myocardium and cause abscess

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20
Q

What are the clinical features of infective endocarditis?

A

Fever
Most consistent sign
Rapidly developing fever, chills, weakness
Can be slight or absent, particularly in the elderly

Non-specific symptoms
May be only presentation
Loss of weight / flu-like syndrome.

Murmurs
90% of patients with left-sided IE  can be a new defect or a pre-existing condition
New valvular defect or represent a pre-existing abnormality.

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21
Q

What are the complications of Infective endocarditis?

A

Immunologically mediated conditions e.g. glomerulonephritis

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22
Q

What are the clinical manifestations of infective endocarditis?

A

Splinter / subungual hemorrhages

Janeway lesions
Erythematous or haemorrhagic non-tender lesions on the palms or soles

Osler’s nodes
Subcutaneous nodules in the pulp of the digits

Roth spots
Retinal haemorrhages in the eyes

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23
Q

What type of patients will commonly have non-bacterial thrombotic endocarditis?

A

Occurs in debilitated patients (e.g. cancer or sepsis)

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24
Q

What is Non-bacterial thrombotic endocarditis (NBTE) assoicated with?

A

Assoicated with hypercoagulable state

Hence DVT, PE and mucinous adenocarcinomas!

Pro-coagulant effects of tumour-derived mucin or tissue factor

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25
Q

What predisposes people to NBTE?

A

Endocardial trauma / indwelling catheter (e.g. central line)

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26
Q

What type of vegetation occurs in NBTE?

A

Small (1 to 5mm) sterile thrombi on valve leaflets

Singly or multiple on line of closure of leaflets or cusps

Not invasive / no inflammatory reaction

Systemic emboli

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27
Q

What is Rheumatic fever?

A

Acute, immunologically mediated, multi-system inflammatory disease following group A streptococcal pharyngitis

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28
Q

Why has Rheumatic fever become rare?

A

Rare because of improved diagnosis / treatment

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29
Q

What is a diagnostic presentation of RF in the heart?

A

If Aschoff bodies are found

Distinctive cardiac lesions
Foci of T-cells, plasma cells and macrophages
Can be found in all three cardiac layers

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30
Q

What is the patholgical featrues of Rheumatic heart disease (RHD)

A

Vegetations called veruccae

Mitral valve changesare classical
Virtually ONLY cause of mitral stenosis

Virtually always involved in chronic disease
MV only in most cases cases
Aortic valve in 25% of cases
Tricuspid valve / pulmonary valves - uncommon

Fibrous bridging of valvular commissures & calcification
“FISH MOUTH”

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31
Q

What is the main cause of mitral stenosis?

A

Reumatic heart disease

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32
Q

What is the aetiology of RHD that presents Aschoff bodies?

A

Antibodies directed against the M proteins of Group A strep

Cd4 T cells specific for streptoccal peptides which react with self proteins in the heart

Produce cytokines that activate macrophages ( Aschoff bodies)

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33
Q

How is RHD diagnosed?

A

Diagnosis is made by the presence of:
One required criteria, two major criteria and zero minor criteria
Or
One required criteria, one major criteria, and two minor criteria

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34
Q

What is the cardiac complications of RHD?

A

Left atrium dilates

Right ventricular hypertrophy

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35
Q

What is pericarditis and the causes?

A

Inflammation of the pericardial sac can be caused by…..

Infections
Viruses (Coxsackie B), bacteria, TB, fungi, parasites

Immunologically mediated processes
Rheumatic fever, SLE, scleroderma, post-cardiotomy
Late post-MI = Dressler’s, drug hypersensitivity

Miscellaneous conditions
Post-MI (early), uraemia, cardiac surgery, neoplasia
Trauma, radiation

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36
Q

What are the two different forms of pericarditis?

A

Acute pericarditis (inflammed)

Chronic pericarditis ( stuck down)

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37
Q

What are the different types of acute pericarditis? (5)

A 
Serous
Serofibrinous / fibrinous
Purulent / suppurative
Haemorrhagic
Caseous
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38
Q

What are the different type of chronic pericarditis? (3)

A

Adhesive mediastinopericarditis

Constrictive pericarditis

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39
Q

What disease is libman-sacks endocarditis assoicated with?

A

Associated with Systemic Lupus Erythematosis (SLE)

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40
Q

What are the common symptoms and signs of Libman sacks endocarditis?

A

Usually asymptomatic (other than features of SLE)

Rarely cardiac failure or systemic emboli

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41
Q

What valves are affected in Libman-Sacks endocarditis and what type of vegetation occurs?

A

Mitral and tricuspid (AV) valves affected

Small (1–4 mm) sterile pink warty vegetations being either single or multiple.

Often occur on AV valves (often under-surfaces), on the chordae, vavular endocardium or mural endocardium of atria or ventricles.

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42
Q

What is pericarditis?

A

What is the term for inflammation in all 3 layers in the heart?

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43
Q

What is vegetation in RHD called?

A

Veruccae

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44
Q

What is the criteries used for diagnosing RHD?

A

Jones criteria

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45
Q

What virus is commonly associated with infections of the heart?

A

Coxsackie B virus

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46
Q

What is the consequence of the inflammation caused by serious pericarditis?

A

Causes clear serious fluid accumulation

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47
Q

What is the common cause of serous pericarditis?

A

Caused by non-infectious aetiologie

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48
Q

What are less common causes of aetiologies of serious pericarditis?

A

Inflammation in adjacent structures can cause pericardial reaction

Rarely by viral pericarditis (Coxsackie B / echovirus)

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49
Q

What are the immunological mediated process that cause serous pericarditis?

A

Rheumatic fever, SLE, scleroderma

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50
Q

What are the Miscellaneous conditions that cause serous pericarditis?

A

Uraemia, neoplasia, radiation

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51
Q

What occurs in fibrinous pericarditis?

A

Serous fluid and / or fibrinous exudate in pericardial

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52
Q

What are the common causes of fibrinous pericarditis? (8)

A

Acute MI, Dressler’s syndrome

Uraemia, radation, rheumatic fever, SLE, trauma and surgery

53
Q

What are the features of fibrinous pericarditis (without fluid)

A

Dry, granular, roughened surface

More intense inflammatory response  sero-fibrinous

54
Q

What is Dresslers syndrome?

A

Secondary pericarditis - AKA post MI syndrome Clinical triad of: 1) Fever 2) Pleuritic chest pain - worse on inspiration 3) Pericardial effusion

55
Q

What is the aetiology of Dresslers syndrome?

A

Autoimmune reaction to antigens released following an MI - it is not the same as acute pericarditis as there is a delay of weeks

56
Q

What is the cause of purulent/suppurative pericarditis?

A

infection

57
Q

What are the features of purulent/suppurative pericarditis?

A

Red, granular, exudate i.e. pus (can be upto 500mls!)

58
Q

Where can the inflammation of purulent/suppurative pericarditis extend into?

A

Extend into the mediastinum causing mediastino-pericarditis

59
Q

What is the usual outcome of purulent/suppurative pericarditis?

A

complete resolution is rare

Organisation by scarring –> restrictive pericarditis – serious

60
Q

What is Haemorrhagic pericarditis?

A

Blood mixed with serous (watery) or suppurative (pus) effusion

61
Q

What are the common causes of haemorrhagic pericarditis?

A

Trauma to the chest
Neoplasia (malignant cells in effusion)
Infections (inc TB)
Following cardiac surgery

62
Q

Why can cardiac surgery cause haemorrhagic pericarditis?

A

cardiac tamponade

compression of the heart by an accumulation of fluid in the pericardial sac.

63
Q

What are the two causes of caseous pericarditis?

A

TB or fungal

64
Q

Give 3 examples of chronic pericarditis?

A

Adhesive pericarditis

Adhesive mediastinopericarditis

Constrictive pericarditis

65
Q

What is adhesive pericarditis?

A

Fibrosis / stringy adhesions obliterates pericardial cavity

66
Q

What is the cause of adhesive mediastinopericarditis?

A

Follows pericarditis caused by infections, surgery or radiation

67
Q

What occurs in adhesive mediastinopericarditis and what does it cause?

A

Obliterated pericardial cavity with adherence to surrounding structures

Causes cardiac hypertrophy / cardiac dilation

68
Q

What is the pathology of constrictive pericarditis?

A

Heart encased in fibrous scar due to inflammation – limits cardiac function

69
Q

What is the treatment of constrictive pericarditis?

A

Treated by surgery to remove ‘shell’ around heart

70
Q

What are the clinical features of pericarditis?

A

Sharp central chest pain –> pleuritic

Pericardial friction rub

Fever, leucocytosis, lymphocytosis, pericardial effusion

71
Q

When is pericardial friction rub the loudest?

A

Loudest with diaphragm, left sternal edge

72
Q

How is pleuritic pain, Exacerbated, relieved, radiated and differentiated?

A

Exacerbated by: movement, repiration, lying flat

Relieved: sitting forwards

Radiating: shoulders/neck

Differentials: angina, pleurisy

73
Q

What is the complications of pericarditis?

A

pericardial effusion / cardiac tamponade

74
Q

What type of disease is cardiomyopathy and what are the 4 main types?

A

Heart muscle disease

Four main types are:
Dilated
Hypertrophic
Restrictive
Arrythmogenic right venticular
     cardiomyopathy
75
Q

What is the pathology of dilated cardioyopathy?

A

Progressive dilation –> contractile dysfunction

Heart enlarged, heavy, flabby (dilation of chambers)

Myocyte hypertrophy with fibrosis

76
Q

What is the cause of dialted cardiomyopathy?

A 
Genetic (20 – 50% cases)
Autosomal dominant (mainly)

Cytoskeletal proteins gene mutation
Alcohol (10-20%) and other toxins
E.g. chemotherapy

Others
SLE, scleroderma, thiamine def., acromegaly, thyrotoxicosis, diabetes….

77
Q

What is the clinical presentation of dilated cardiomyopathy?

A

Any age but commonly 20 – 50

Slow progressive signs / symptoms of CCF
SoB, fatigue, and poor exertional capacity

78
Q

Dilated cardiomyopathy has a common survival rate of 5 years what is the death due to?

A

Death due to Congested Cardiac Failure, arrhythmia / embolism

79
Q

What is the treatment for cardiomyopathy?

A

Cardiac transplantation

Long-term ventricular assist

80
Q

What is the pathology of hypertropic cardiomyopathy?

A 
Poorly compliant (stiff) left ventricular myocardium 
Diastolic dysfunction with preserved systolic function
Intermittent ventricular outflow obstruction (1/3 cases)

Thick-walled, heavy, and hyper-contracting

81
Q

How would you define hypertropic cardiomyopathy?

A

Defined as myocardial hypertrophy with absence of an obvious cause such as hypertension.

82
Q

What is the main cause of unexplained left ventricular hypertrophy?

A

Hypertrophic cardiomyopathy

83
Q

What is the cause of hypertrophic cardiomyopathy?

A

100% genetic
Mutations sarcomeric proteins
Can be sporadic

84
Q

What are the clincal features of hypertrophic cardiomyopathy?

A

Decrease in stroke volume –> Impaired diastolic filling - reduced chamber size / compliance of hypertrophied left ventricle

Obstruction to the left ventricular outflow

Exertional dyspnoea

Systolic ejection murmur due to:

Ventricular outflow obstruction

Anterior mitral leaflet moves toward the ventricular septum during systole.

85
Q

What is the complications of hypertorophic cardiomyopathy?

A

Atrial fibrillation
Mural thrombus formation embolization / stroke
Cardiac failure
Ventricular arrhythmias
Sudden death, especially in some affected families

86
Q

What is the treatment for hypertrophic cardiomyopathy?

A

Decrease heart rate and contractility - β-adrenergic blockers.
Reduction of the mass of the septum, which relieves the outflow tract obstruction

87
Q

What is the common cause of sudden death in atheletes?

A

Hypertrophic cardiomyopathy

88
Q

What is the morphology of restrictive cardiomyopathy?

A

Ventricles normal size / slightly enlarged
chambers normal

Myocardium is firm and noncompliant –> it has been infiltrated so cannot enlarge

89
Q

What are secondary causes of restrictive cardiomyopathy?

A

fibrosis, amyloidosis, sarcoidosis,
metastatic tumors or deposition of
metabolites

90
Q

What is the primary cause of restrictive cardiomyopathy?

A

Decrease in ventricular compliance

Impaired ventricular filling during diastole

91
Q

What type of genetic disease is Arrythmogenic right ventricular cardiomyopathy?

A

Autosomal dominant disease

92
Q

What is another name for Arrythmogenic right ventricular cardiomyopathy?

A

Arrhythmogenic R.V. dysplasia

93
Q

What is the morpholy of arrhythmogenic R.V. cardiomyopathy?

A

RV dilation / myocardial thinning  get fat in the wall as there is a defect in cell adhesion
Fibrofatty replacement of RV
Disorder of cell-cell desmosomes
Exercise –> cells detach and die

94
Q

What is the signs and symptoms of Arrythmogenic right ventricular cardiomyopathy?

A

Silent, syncope, chest pain, palpitations

Sudden cardiac death – young / exercise

95
Q

What are the infectious causes of myocarditis?

A

Coxsackie A&B viruses most common cause in West

Chagas disease (Trypanosoma cruzi) protozoa

96
Q

What are the clinical features of myocarditis?

A

Asymptomatic
Heart failure, arrhythmias and sudden death

Non-specific symptoms - fatigue, dyspnea, palpitations, precordial discomfort, and fever

Can mimic acute MI

DCM can develop

97
Q

What are the immune mediated causes of myocarditis?

A

Post-viral

Post steptococcal (RF)

SLE

Drugs

Transplant rejection

98
Q

What is Vascuilitis

A

Inflammation of the vessel walls

Any organ and any vessel size

99
Q

What is the clinical features of vasculitis

A

Clinical features depend on vascular bed

100
Q

What is the most common form vasculitis?

A

Giant cell arteritis

seen in elderly individuals in west

101
Q

What is the pathology of Giant cell arteritis?

A

Chronic granulomatous inflammation

Large to medium-sized arteries

102
Q

What arteries are commonly effected by giant cell arteritis?

A

Large and medium sized arteries in the head (e.g. temporal arteries – AKA temporal arteritis)
Also vertebral and ophthalmic arteries

Vessels of the aorta

103
Q

What is the consequence if there is ophthalmic arterial involvement in Giant cell arteritis?

A

Ophthalmic arterial involvement is a medical emergency.

Permanent blindness

Giant-cell arteritis is a medical emergency requiring prompt recognition and treatment – early recognition is VITAL!

104
Q

What is the morphology of giant cell arteritis?

A

Intimal thickening
reduces the lumenal diameter

Med. granulomatous inflammation
elastic lamina fragmentation

Multinucleated giant cells
75% of adequately biopsied

105
Q

What are the clinical features of Giant cell arteritis?

A

Rare

106
Q

How do you diagnose giant cell arteritis?

A

biopsy and histologic
Segmental disease

Hence 2- to 3-cm length of artery

107
Q

What is the treatment for Giant cell arteritis?

A

Corticosteroids is generally effective –>prednisolone

Also anti-TNF therapy in refractory cases

108
Q

What is a aneurysm?

A

Localised, permanent, abnormal dilatations of a blood vessel

109
Q

What are the two ways aneurystms can be classified?

A

Shape

Aetiology

110
Q

What are the different caues of a aneurysm?

A 
Atherosclerotic
Dissecting
Berry
Microaneurysms
Syphilitic
Mycotic
False
111
Q

What is risk factor for rupture of atherosclerotic aneurysms?

A

Nil 6cm

Risk of surgery is big –> so only do it when the risk of rupture is more than surgery

112
Q

What is a common sight of atherosclerotic aneurysm?

A

Abdominal aortic aneurysm

113
Q

How is atherosclerotic aneurysm detected and treated?

A

Detected by ultrasound scan

Can be repaired endovascularly

114
Q

What are the complications of atherosclerotic aneurysms?

A

Rupture causing retroperitoneal haemorrhage

Embolisation causing limb ischaemia.

115
Q

What is dissecting aneurysm?

A

Tear in the wall

Blood tracks between intimal and medial layers

116
Q

What is the classical symptoms of dissecting aneursysm?

A

Tearing pain in chest radiating to upper left shoulder

117
Q

Where does dissecting aneurysm commonly effect?

A

Usually thoracic aorta secondary to systemic hypertension

Progressive vascular occlusion and haemopericardium which is the chambers filling up with blood

118
Q

What is a berry Aneurysm and where does it occur?

A

Small, saccular lesions that develop in the Circle of Willis

Develop at sites of medial weakness at arterial bifurcations or anastomoses

Commonly found in young hypertensive patients

119
Q

What is the consequence of rupture of Berry Aneurysms?

A

Rupture causes subarachnoid haemorrhage (SAH)

Thunder clap headache

120
Q

Give a example of microaneurysm?

A

Charcot-Bouchard aneurysms

121
Q

Where does Charcot-Bouchard aneurysms occur?

A

It ocurs in the intracerebral capillaries in hypertensive disease.

122
Q

What can Charcot-Bouchard aneurysms cause?

A

Causes intracerebral haemorrhage (i.e. stroke)

Retinal microaneurysms can develop in diabetes causing diabetic retinopathy

123
Q

What is syphilitic aneurysms?

A

Syphilitic aneurysm is associated with tertiary state of syphilis infection which causes ascending (thoracic) aorta aneurysms.

124
Q

What is mycotic aneurysms?

A

Rare
Weakening of arterial wall secondary to bacterial / fungal infection
Often in the cerebral arteries

125
Q

What causes mycotic aneurysms?

A

Organisms enter media from the vasa vasorum

Subacute bacterial endocarditis is the most common underlying infection

126
Q

What is false aneurysm?

A

Blood filled space around a vessel, usually following traumatic rupture or perforating injury

The adventitial fibrous tissue contains the haematoma

127
Q

When do you see false aneurysms? What is the treatment?

A

Commonly seen following femoral artery puncture during angiography / angioplasty

Resolves few days or week

128
Q

What are the 3 main causes of acute arterial occlusion?

A

Embolus

Thrombosis

Trauma

129
Q

What are the 6ps when investgiating acute ischaemia?

A 
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing Cold

Year 2 clinical pathology (21 decks)

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