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Cardiovascular Pathology, Heart failure, vessels, ischemic heart disease,…
Cardiovascular Pathology
Heart failure
left HF
paroxysmal nocturnal dyspnea(発作性夜間呼吸困難症): breathless awaking from sleep
pulmonary edema
orthopnea(起坐呼吸): shortness of breath when supine(仰向け) (↑venous return
right HF
juglar venous distention
peripheral edema
hepatomegaly
↑ LV contractility
↓ CO
↑ sympathetic activity
↑LV contractility
↑preload
↑RAAS
↑renal and H₂O reabsorption
pulmonary venous congestion
↓ RV output
↑systemic venous return
peripheral edema
pulmonary edema
impaired gas exchange
right HF most often result from left HF
systolic dysfunction: reduced EF(左室駆出率), ↑EDV, ↓contractility to ischemia/MI, dilated cardiomyopathy
diastolic dysfunction: preserved EF, normal EDV, ↓compliance to myocardial hypertrophy
ACE inhibitors, angiotensin2 receptor blocker, β-blockers, spironolactone, thiazide, loop diuretics, hydralazine with nitrate
cor pulmonale(肺性心)
vessels
atherosclerosis(アテローム硬化)
risk factor: hypertension, smoking, dyslipidemia, diabetes, age, men, family history
angina, claudication(跛行)
abdominal>coronary>popliteal>carotid
inflammation, fatty streak, smooth muscle cell migration, proliferation, fibrous plaque
disease of elastic arteries and large- or mediam-sized muscular arteries
hypertension
hypertensive argency: severe(≧180/120mmHg) hypertension without acute organ damage
hypertensive emergency: severe hypertensionwith evidence of acute organ damage
90% is 1°, 10% is 2° to renal, renovascular disease
defined as systolic BP≧140mmHg, diastolic BP≧90mmHg
aortic aneurysm
abdominal aortic aneurysm: may present as palpable pulsatile abdominal mass, most common in infrarenal
thoracic aortic aneurysm: risk factors are hypertension, bicupsid aortic valve, connective tissue disease, may lead to AR
associated with atherosclerosis
pathologic dilatation, abdominal and back pain
hyperlipidemia signs
tendinous xanthoma: lipid deposit in tendon, especially Achilles
corneal arcus(角膜輪): lipid deposit in cornea, common in elderly
xanthomas(黄色腫): plaques or nodules composed of lipid laden histiocytes in skin, especially the eyelid
arteriosclerosis
arteriosclerosis
affect small arteries and arterioles
hyaline(硝子), hyperplastic
Mockeberg sclerosis(medial calcific sclerosis)
calcification→vascular stiffening without obstruction
affect medium-sized arteries
hardening of arteries, with arterial wall thickening and loss of elasticity
aortic dissection
types
stanford A: involves ascending aorta
stanford B: involves only descending aorta
associated with hypertension, bicuspid aortic valve, inherited connective tissue disease
longitudinal intimal tear forming a false lumen
traumatic aortic rupture
due to trauma and/or deceleration(減速損傷)
most common at aortic isthmus(大動脈峡部)
ischemic heart disease
angina
stable
usually 2° to atherosclerosis
exertional chest pain (usually with ST depression)
resolving with rest or nitroglycerin
vasospastoc
coronary artery spasm
transient ST elevation
treat with Ca blocker, nitrate, smoking cessation
chest pain due to ischemic myocardium 2° to coronary artery narrowing or spasm
unstable
frequency or intensity of chest pain or any chest pain at rest
thrombosis with incomplete coronary artery occlusion
coronary steal syndrome
vasodilator→dilate normal vessels→blood is shunted toward well-perfused area→ischemia
sudden cardiac death
associated with CAD, cardiomyopathy, heredotary ion channelopathies
lethal arrhythmia is most common
death from cardiac causes within 1 hours of onset of symptom
chronic ischemic heart disease
myocardial infarction
↑ cardiac biomarkers
types
ST segment elevation MI: full thickness of myocardial wall involved
non-ST segmented elevation MI: subendocardial infarct
most often due to rupture of coronary artery atherosclerotic plaque→acute thrombosis
evolution
LAD>RCA>circumflex
0-24hr: early coagulative necrosis
1-3days: extensive coagulative necrosis, accute inflammation
3-14days: macrophage, granulation tissue at margins
2weeks-: contracted scar complete
complex
0-24hr: arrhythmia, HF
1-3days: pericarditis
3-14days: tamponade, papillary muscle rupture(MR), septal rupture
2weeks-: Dressler syndrome, HF, arrythmias, true ventricular aneurysm
details
postinfarction fibrinous pericarditis
papillary muscle rupture
interventricular septal rupture
ventricular pseudoaneurysm formation
venticular free wall rupture
true ventricular aneurysm
Dressler syndrome: fibrinous pericarditis by autoimmune phenomenon
LV failure and pulmonary edema
cardiac arrhythmia
diagnosis
troponin 1 rises after 4 hours (peaks at 24 hr)
CK-MB rises after 6-12 hours (peaks at 16-24hr)
first 6 hours, ECG
treatment
unstable angina/NSTEMI: anticoagulation, antipalatelet, +ADP receptor inhibitor, β-blocker, ACE inhibitor, statin, nitroglycerin, morphine
STEMI: in addition to above, reperfusion therapy (percutaneous coronary intervention)
ECG localization
anterolateral: V₅-V₆
lateral: Ⅰ,aVL
anteroapical: V₃-V₄
inferior: Ⅱ,Ⅲ,aVF
anteroseptal:V₁-V₂
cardiac inflammation
rheumatic fever
mitral>aortic>>tricuspid
MR (early)→MS(late)
a consequence of pharyngeal infection with group A β-hemolytic streptococci
Aschoff bodies, Anitschkow cells, ↑anti-streptolysin O titers
migratory polyarthritis, carditis, nodules, erythema, sydenham chorea(舞踏)
type 2 hypersensitivity; antibodies to M protein cross-react with self antigens
bacterial endocarditis
fever, new murmur, Roth spot, Osler nodes, Janeway lesion, splinter hemorrhage on nail bed
mitral valve is most frequently involved
subacute: viridans streptococci, smaller vegetation on congenitally abnormal or diseased valve, dental procedures
acute: S.aureus, large vegetation on valve
acute pericarditis
friction rub, ST elevation, PR depression
idiopathic, confirmed infection, neoplasia, autoimmune, uremia, cardiovascular, radiation therapy
sharp pain, aggravated by inspiration, relieved by sitting up and learning forward
inflammation of pericardium
cardiac tamponade
low volatage QRS and electrical alternans
pulsus paradoxus: ↓ in amplitude of systolic BP by >10mmHg during inspiration
beck triad (hypotension, distended neck veins, distant heart sound), ↑HR, pulsus paradoxus
compression of heart bi fluid
myocarditis
may lead to SCD
viral, parasitic, bacterial, toxin, rheumatic fever, drug, autoimmune
inflammation of myocardium→global enlargement of heart and dilation of all chambers
syphilitic heart disease
3° syphilis disrupts the vasa vasorum of aorta with consequent atrophy of vessel wall and dilation of aorta and valve ring
shock
inadequate organ perfusion and delivery of nutrients necessary for normal tissue and cellular function
cardiogenic shock: acute MI, HF, valvular dysfunction, arrhythmia
distributive shock: sepsis, anaphylaxis, CNS injury
obstructive shock: cardiac tamponade, pulmonary embolism, tension pneumothorax
hypovolemic shock: hemorrhage, dehydration, burns
congenital heart disease
right to left shunt
early cyanosis; often diagnosed prenatally or become evident immediately after birth
usually require urgent surgical treatment or maintenance of PDA
D-transposition of great vessels
Ao leaves RV and Ap leaves LV
not compatible with life unless a shunt is present to allow mixing of blood
due to failure of the septum to spiral
tricuspid atresia
absense of tricuspid valve and hypoplastic RV
tetralogy of Fallot
pulmonary infundibular stenosis, RV hypertrophy, overriding aorta, VSD
caused by anterosuperior displacement of the infundibular septum
total anomalous pulmonary venous return
pulmonary vein drain into right heart circulation
Ebstein anomaly
associated with TR, accesory conduction pathway, right sided HF
by lithium in utero
displacement of tricuspid valve leaflets(三尖弁尖) downward into RV
persistent truncus arteriosus
luck of septum formation
most have accompanying VSD
fails to devide into Ap and Ao
left to right shunt
acyanotic
ventricular septum defect
asymptomatic at birth
most self resolve
most common
artrial septal defect
ostium secundum defect most common
lead to paradoxical emboli
fixed split S2
patent ductus arteriosus
continuous murmur
patancy is maintained by PGE synthesis and low O₂ tension
shunt becomes left to right→progressive RV and LV hypertrophy and HF
Eisenmenger syndrome
cause late cyanosis, clubbing, and polycythemia
Ap hypertension and RV hypertrophy→shunt becomes right to left
other anomalies
coarctation of the aorta(大動脈縮窄症)
hypertension of upper, weak and delayed pulse in lower extremities
risk of HF, hemorrhage, aortic rupture, possible endocarditis
aortic narrowing near insertion of ductus arteriosus
cardiomyopathy
dilated cardiomyopathy
HF, S3, systolic regurgitant murmur, dilated heart
treatment: Na restriction, ACE inhibitor, β-blocker, diuretics, digoxin, ICD, heart transplant
idiopathic or familial
Takotsubo cardiomyopathy (likely due to sympathetic stimulation)
most common cardiomyopathy(90%)
hypertrophic obstructive cardiomyopathy
S4, systolic murmur, MR
treatment: β-blocker, Ca channel blocker, ICD(to high risk)
may lead to sudden death (ventricular arrhythmia)
concentric hypertrophy, myofibrillar disarray and fibrosis
60-70% of cases are familial, AD
restrictive/infiltrative cardiomyopathy
Loffler endocarditis: associated with hypereosinophilic syndrome; infiltrale in myocardium
diastolic dysfunction
postradiation fibrosis, Loffler endocarditis, endocardial fibroelastosis, amyloidosis, sarcoidosis, hemochromatosis
vasculitides
small-vessel vasculitis
Behcet disease
HSV, parvovirus
immune complex
recurrent aphthous ulcers, genital ulcerations, uveitis, erythema nodosum
HLA-B51
eosinophilic granulomatosis with polyangiitis (EGPA)
MPO-ANCA/p-ANCA
eosinophilia
asthma, sinusitis, skin nodules or purpura, peripheral neuropathy
microscopic polyangiitis
without nasopharyngeal involvement
MPO-ANCA/p-ANCA
necrotizing vasculitis involving lung, kidney, skin
treat with cyclophosphamide, corticosteroids
immunoglobulin A vasculitis
IgA immune complex deposition
skin, arthralgias, GI
childhood systemic vasculitis
Henoch-Schonlein purpura
granulomatosis with polyangiitis(多発血管炎性肉芽腫症); Wegener
PR3-ANCA/c-ANCA
treat with cyclophosphamide, corticosteroids
triad; focal necrotizing vasculitis, necrotizing granulomas in lung and upper airway, necrotizing glomerulonephritis
perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis(乳突蜂巣炎), hemoptysis(喀血), cough, dyspnea, hematuria, red cell casts
medium-vessel vasculitis
Kawasaki disease
may develop coronary artery aneurysms
treat with IV immunoglobulin and aspirin
conjunctival injection, rash, adenopathy, strawberry tongue, hand-foot change, fever
asian children
Buerger disease
segmental thrombosing vasculitis with vein and nerve
treat with smoking cessation
intermittent claudication, gangrene, superficial nodular phlebitis(静脈炎), Raynaud phenomenon
heavy smoker, male<40age
polyarteritis nodosa(結節性多発動脈炎)
associate with hepatitis B
transmural infalammation with fibrinoid necrosis, coexisting of different stages of inflammation, innumeral renal microaneurysms and spasm
middle aged man, typically involve renal and visceral vessels, not pulmonary arteries
treat with corticosteroids, cyclophosphamide
large vessel vasculitis
giant cell arteritis
headache, jaw claudication, blindness
focal granukomatous inflammation
eldery female, most commonly carotid artery
treat with high dose corticosteroids
Takayasu arteritis
weak pulse, fever, night sweat, arthritis, myslgias, skin nodules, ocular disturbance
granulomatous thickening nad narrowing of aortic arch and proximal great vessels
young female
treat with corticosteroids
cardiac tumor
myxomas(粘液腫)
early diastolic tumor plop sound
gelatinous material, immersed in glycosaminoglycans
most common 1° cardiac tumor, mostly LA
rhabdomyomas(横紋筋腫)
children
Kussmaul sign
↑ in JVP(内頸静脈圧) on inspiration
constrictive pericarditis, restrictive cardiomyopathy, right atrial and ventricular tumor
hereditary hemorrhagic telangiectasia(遺伝性出血性末梢血管拡張症)
telangiectasias(毛細血管拡張症) on skin and mucous membranes, recurrent epistaxis(鼻出血), skin discoloration, arteriovenous malformation, GI bleeding, hematouria