Week 8 Cardiovascular 3 Flashcards
What is Endocarditis?
Inflammation of the endocardium of the heart
Prototypical lesion = “vegetation” on valves
What are the two main forms of endocarditis?
Infective endocarditis
Clinically important
Non-infective endocarditis
Nonbacterial thrombotic endocarditis (NBTE)
Endocarditis of SLE (Libman-Sacks Disease)
Is infective endocarditis serious?
Clinically serious infection!!!
Colonization / invasion of heart valves or heart chamber endocardium by a microbe
What caues the vegetation of the valves in endocarditis?
Mixture of thrombotic debris and microorganisms
Invade and destroy underlying cardiac tissues
What is the cause of infective endocarditiis?
Most cases caused by bacterial infection
Fungi
How does acute infective endocarditis occur and what is the cause?
Can occur with infection of a previously normal healthy valve
Caused by highly virulent organisms
What is the consequence of acute infetive endocarditis?
Necrotizing, ulcerative, destructive lesions
What is the treatment of acute infective endocarditis
Difficult to cure with antibiotics and usually require surgery
Death frequent days to weeks despite aggressive treatment
What is more common acute or sub acute infective endocarditis?
Sub-acute
What is the cause and outcome of sub acute infective endocarditis?
Organisms of lower virulence
Insidious infections of deformed valves
Vague symptoms –> fever and maybe a murmur
Less destructive
What is the treatment of sub-acute infective endocarditis?
Protracted “wax and wane” course of weeks to months
Cured with antibiotics
What are the causes of infective endocarditis?
Mitral valave prolapse Valvular stenosis (calcification etc) Artificial (prosthetic) valves Unrepaired and repaired congenital defects Bicuspid AV
What disease use to be a major cause of infective endocarditis but not a problem as much any more?
Rheumatic heart disease
What are the different routes a bacteria can get into the blood stream and infected the heart?
Dental abnormalities, IVDU, wounds, bowel cancer
How does Streptococcus viridans affect the heart?
From the heart which cause damage/abnormal valves
50-60% cases
What bacteria on the skin can cause infection endocarditiis?
S.aureus–> 10% to 20% of cases overall esp in IVDU as they damage the skin
What bacteria commonly infects prosthetic heart valves?
Coagulase-negative staphylococci
What is appearance of vegetation in acute IE and what is effected?
Friable, bulky, potentially destructive
Often more than one valve –> AV,MV and the right heart (especially in IVDUS)
What effect does vegetation of acute IE have on the heart?
Can erode the myocardium and cause abscess
What are the clinical features of infective endocarditis?
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.
What are the complications of Infective endocarditis?
Immunologically mediated conditions e.g. glomerulonephritis
What are the clinical manifestations of infective endocarditis?
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
What type of patients will commonly have non-bacterial thrombotic endocarditis?
Occurs in debilitated patients (e.g. cancer or sepsis)
What is Non-bacterial thrombotic endocarditis (NBTE) assoicated with?
Assoicated with hypercoagulable state
Hence DVT, PE and mucinous adenocarcinomas!
Pro-coagulant effects of tumour-derived mucin or tissue factor
What predisposes people to NBTE?
Endocardial trauma / indwelling catheter (e.g. central line)
What type of vegetation occurs in NBTE?
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
What is Rheumatic fever?
Acute, immunologically mediated, multi-system inflammatory disease following group A streptococcal pharyngitis
Why has Rheumatic fever become rare?
Rare because of improved diagnosis / treatment
What is a diagnostic presentation of RF in the heart?
If Aschoff bodies are found
Distinctive cardiac lesions
Foci of T-cells, plasma cells and macrophages
Can be found in all three cardiac layers
What is the patholgical featrues of Rheumatic heart disease (RHD)
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”
What is the main cause of mitral stenosis?
Reumatic heart disease
What is the aetiology of RHD that presents Aschoff bodies?
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)
How is RHD diagnosed?
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
What is the cardiac complications of RHD?
Left atrium dilates
Right ventricular hypertrophy
What is pericarditis and the causes?
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
What are the two different forms of pericarditis?
Acute pericarditis (inflammed)
Chronic pericarditis ( stuck down)
What are the different types of acute pericarditis? (5)
Serous Serofibrinous / fibrinous Purulent / suppurative Haemorrhagic Caseous
What are the different type of chronic pericarditis? (3)
Adhesive mediastinopericarditis
Constrictive pericarditis
What disease is libman-sacks endocarditis assoicated with?
Associated with Systemic Lupus Erythematosis (SLE)
What are the common symptoms and signs of Libman sacks endocarditis?
Usually asymptomatic (other than features of SLE)
Rarely cardiac failure or systemic emboli
What valves are affected in Libman-Sacks endocarditis and what type of vegetation occurs?
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.
What is pericarditis?
What is the term for inflammation in all 3 layers in the heart?
What is vegetation in RHD called?
Veruccae
What is the criteries used for diagnosing RHD?
Jones criteria
What virus is commonly associated with infections of the heart?
Coxsackie B virus
What is the consequence of the inflammation caused by serious pericarditis?
Causes clear serious fluid accumulation
What is the common cause of serous pericarditis?
Caused by non-infectious aetiologie
What are less common causes of aetiologies of serious pericarditis?
Inflammation in adjacent structures can cause pericardial reaction
Rarely by viral pericarditis (Coxsackie B / echovirus)
What are the immunological mediated process that cause serous pericarditis?
Rheumatic fever, SLE, scleroderma
What are the Miscellaneous conditions that cause serous pericarditis?
Uraemia, neoplasia, radiation
What occurs in fibrinous pericarditis?
Serous fluid and / or fibrinous exudate in pericardial
What are the common causes of fibrinous pericarditis? (8)
Acute MI, Dressler’s syndrome
Uraemia, radation, rheumatic fever, SLE, trauma and surgery
What are the features of fibrinous pericarditis (without fluid)
Dry, granular, roughened surface
More intense inflammatory response sero-fibrinous
What is Dresslers syndrome?
Secondary pericarditis - AKA post MI syndrome Clinical triad of: 1) Fever 2) Pleuritic chest pain - worse on inspiration 3) Pericardial effusion
What is the aetiology of Dresslers syndrome?
Autoimmune reaction to antigens released following an MI - it is not the same as acute pericarditis as there is a delay of weeks
What is the cause of purulent/suppurative pericarditis?
infection
What are the features of purulent/suppurative pericarditis?
Red, granular, exudate i.e. pus (can be upto 500mls!)
Where can the inflammation of purulent/suppurative pericarditis extend into?
Extend into the mediastinum causing mediastino-pericarditis
What is the usual outcome of purulent/suppurative pericarditis?
complete resolution is rare
Organisation by scarring –> restrictive pericarditis – serious
What is Haemorrhagic pericarditis?
Blood mixed with serous (watery) or suppurative (pus) effusion
What are the common causes of haemorrhagic pericarditis?
Trauma to the chest
Neoplasia (malignant cells in effusion)
Infections (inc TB)
Following cardiac surgery
Why can cardiac surgery cause haemorrhagic pericarditis?
cardiac tamponade
compression of the heart by an accumulation of fluid in the pericardial sac.
What are the two causes of caseous pericarditis?
TB or fungal
Give 3 examples of chronic pericarditis?
Adhesive pericarditis
Adhesive mediastinopericarditis
Constrictive pericarditis
What is adhesive pericarditis?
Fibrosis / stringy adhesions obliterates pericardial cavity
What is the cause of adhesive mediastinopericarditis?
Follows pericarditis caused by infections, surgery or radiation
What occurs in adhesive mediastinopericarditis and what does it cause?
Obliterated pericardial cavity with adherence to surrounding structures
Causes cardiac hypertrophy / cardiac dilation
What is the pathology of constrictive pericarditis?
Heart encased in fibrous scar due to inflammation – limits cardiac function
What is the treatment of constrictive pericarditis?
Treated by surgery to remove ‘shell’ around heart
What are the clinical features of pericarditis?
Sharp central chest pain –> pleuritic
Pericardial friction rub
Fever, leucocytosis, lymphocytosis, pericardial effusion
When is pericardial friction rub the loudest?
Loudest with diaphragm, left sternal edge
How is pleuritic pain, Exacerbated, relieved, radiated and differentiated?
Exacerbated by: movement, repiration, lying flat
Relieved: sitting forwards
Radiating: shoulders/neck
Differentials: angina, pleurisy
What is the complications of pericarditis?
pericardial effusion / cardiac tamponade
What type of disease is cardiomyopathy and what are the 4 main types?
Heart muscle disease
Four main types are:
Dilated
Hypertrophic
Restrictive
Arrythmogenic right venticular
cardiomyopathy
What is the pathology of dilated cardioyopathy?
Progressive dilation –> contractile dysfunction
Heart enlarged, heavy, flabby (dilation of chambers)
Myocyte hypertrophy with fibrosis
What is the cause of dialted cardiomyopathy?
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….
What is the clinical presentation of dilated cardiomyopathy?
Any age but commonly 20 – 50
Slow progressive signs / symptoms of CCF
SoB, fatigue, and poor exertional capacity
Dilated cardiomyopathy has a common survival rate of 5 years what is the death due to?
Death due to Congested Cardiac Failure, arrhythmia / embolism
What is the treatment for cardiomyopathy?
Cardiac transplantation
Long-term ventricular assist
What is the pathology of hypertropic cardiomyopathy?
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
How would you define hypertropic cardiomyopathy?
Defined as myocardial hypertrophy with absence of an obvious cause such as hypertension.
What is the main cause of unexplained left ventricular hypertrophy?
Hypertrophic cardiomyopathy
What is the cause of hypertrophic cardiomyopathy?
100% genetic
Mutations sarcomeric proteins
Can be sporadic
What are the clincal features of hypertrophic cardiomyopathy?
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.
What is the complications of hypertorophic cardiomyopathy?
Atrial fibrillation
Mural thrombus formation embolization / stroke
Cardiac failure
Ventricular arrhythmias
Sudden death, especially in some affected families
What is the treatment for hypertrophic cardiomyopathy?
Decrease heart rate and contractility - β-adrenergic blockers.
Reduction of the mass of the septum, which relieves the outflow tract obstruction
What is the common cause of sudden death in atheletes?
Hypertrophic cardiomyopathy
What is the morphology of restrictive cardiomyopathy?
Ventricles normal size / slightly enlarged
chambers normal
Myocardium is firm and noncompliant –> it has been infiltrated so cannot enlarge
What are secondary causes of restrictive cardiomyopathy?
fibrosis, amyloidosis, sarcoidosis,
metastatic tumors or deposition of
metabolites
What is the primary cause of restrictive cardiomyopathy?
Decrease in ventricular compliance
Impaired ventricular filling during diastole
What type of genetic disease is Arrythmogenic right ventricular cardiomyopathy?
Autosomal dominant disease
What is another name for Arrythmogenic right ventricular cardiomyopathy?
Arrhythmogenic R.V. dysplasia
What is the morpholy of arrhythmogenic R.V. cardiomyopathy?
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
What is the signs and symptoms of Arrythmogenic right ventricular cardiomyopathy?
Silent, syncope, chest pain, palpitations
Sudden cardiac death – young / exercise
What are the infectious causes of myocarditis?
Coxsackie A&B viruses most common cause in West
Chagas disease (Trypanosoma cruzi) protozoa
What are the clinical features of myocarditis?
Asymptomatic
Heart failure, arrhythmias and sudden death
Non-specific symptoms - fatigue, dyspnea, palpitations, precordial discomfort, and fever
Can mimic acute MI
DCM can develop
What are the immune mediated causes of myocarditis?
Post-viral
Post steptococcal (RF)
SLE
Drugs
Transplant rejection
What is Vascuilitis
Inflammation of the vessel walls
Any organ and any vessel size
What is the clinical features of vasculitis
Clinical features depend on vascular bed
What is the most common form vasculitis?
Giant cell arteritis
seen in elderly individuals in west
What is the pathology of Giant cell arteritis?
Chronic granulomatous inflammation
Large to medium-sized arteries
What arteries are commonly effected by giant cell arteritis?
Large and medium sized arteries in the head (e.g. temporal arteries – AKA temporal arteritis)
Also vertebral and ophthalmic arteries
Vessels of the aorta
What is the consequence if there is ophthalmic arterial involvement in Giant cell arteritis?
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!
What is the morphology of giant cell arteritis?
Intimal thickening
reduces the lumenal diameter
Med. granulomatous inflammation
elastic lamina fragmentation
Multinucleated giant cells
75% of adequately biopsied
What are the clinical features of Giant cell arteritis?
Rare
How do you diagnose giant cell arteritis?
biopsy and histologic
Segmental disease
Hence 2- to 3-cm length of artery
What is the treatment for Giant cell arteritis?
Corticosteroids is generally effective –>prednisolone
Also anti-TNF therapy in refractory cases
What is a aneurysm?
Localised, permanent, abnormal dilatations of a blood vessel
What are the two ways aneurystms can be classified?
Shape
Aetiology
What are the different caues of a aneurysm?
Atherosclerotic Dissecting Berry Microaneurysms Syphilitic Mycotic False
What is risk factor for rupture of atherosclerotic aneurysms?
Nil 6cm
Risk of surgery is big –> so only do it when the risk of rupture is more than surgery
What is a common sight of atherosclerotic aneurysm?
Abdominal aortic aneurysm
How is atherosclerotic aneurysm detected and treated?
Detected by ultrasound scan
Can be repaired endovascularly
What are the complications of atherosclerotic aneurysms?
Rupture causing retroperitoneal haemorrhage
Embolisation causing limb ischaemia.
What is dissecting aneurysm?
Tear in the wall
Blood tracks between intimal and medial layers
What is the classical symptoms of dissecting aneursysm?
Tearing pain in chest radiating to upper left shoulder
Where does dissecting aneurysm commonly effect?
Usually thoracic aorta secondary to systemic hypertension
Progressive vascular occlusion and haemopericardium which is the chambers filling up with blood
What is a berry Aneurysm and where does it occur?
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
What is the consequence of rupture of Berry Aneurysms?
Rupture causes subarachnoid haemorrhage (SAH)
Thunder clap headache
Give a example of microaneurysm?
Charcot-Bouchard aneurysms
Where does Charcot-Bouchard aneurysms occur?
It ocurs in the intracerebral capillaries in hypertensive disease.
What can Charcot-Bouchard aneurysms cause?
Causes intracerebral haemorrhage (i.e. stroke)
Retinal microaneurysms can develop in diabetes causing diabetic retinopathy
What is syphilitic aneurysms?
Syphilitic aneurysm is associated with tertiary state of syphilis infection which causes ascending (thoracic) aorta aneurysms.
What is mycotic aneurysms?
Rare
Weakening of arterial wall secondary to bacterial / fungal infection
Often in the cerebral arteries
What causes mycotic aneurysms?
Organisms enter media from the vasa vasorum
Subacute bacterial endocarditis is the most common underlying infection
What is false aneurysm?
Blood filled space around a vessel, usually following traumatic rupture or perforating injury
The adventitial fibrous tissue contains the haematoma
When do you see false aneurysms? What is the treatment?
Commonly seen following femoral artery puncture during angiography / angioplasty
Resolves few days or week
What are the 3 main causes of acute arterial occlusion?
Embolus
Thrombosis
Trauma
What are the 6ps when investgiating acute ischaemia?
Pale Pulseless Painful Paralysed Paraesthetic Perishing Cold
