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|  |USMLE Step 1 Web Prep — Cardiac Pathology |

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| |138520 >>> 0:00:00 |

| |SLIDE 1 of 42 |

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| |Chapter 12: Cardiac Pathology |

| |ISCHEMIC HEART DISEASE |

| |GENERAL |

| |Definition: ischemia due to CAD |

| |Most common cause of death |

| |Middle-age males + postmenopausal females |

| |[pic] |

| |138525 >>> 0:00:31 |

| |SLIDE 2 of 42 |

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| |3 MAJOR CATEGORIES |

| |Angina pectoris |

| |Myocardial infarction |

| |Sudden cardiac death |

| |[pic] |

| |138530 >>> 0:00:39 |

| |SLIDE 3 of 42 |

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| |ANGINA PECTORIS |

| |Definition |

| |Ischemia without cell death |

| |Substernal chest pain |

| |Stable angina |

| |Atherosclerosis |

| |Increased cardiac demand |

| |EKG: ST depression |

| |Relieved by rest or nitroglycerin |

| |Prinzmetal variant angina |

| |Coronary artery vasospasm |

| |Chest pain at rest |

| |EKG: ST elevation |

| |Relieved by nitroglycerin |

| |Unstable angina |

| |Non-occlusive thrombus |

| |Increasing episodes |

| |Occurs at rest |

| |Risk for MI |

| |[pic] |

| |138535 >>> 0:02:34 |

| |SLIDE 4 of 42 |

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| |MYOCARDIAL INFARCTION |

| |Definition |

| |Cardiac necrosis due to ischemia |

| |Most common cause of death |

| |Mechanism |

| |Atherosclerosis |

| |Plaque rupture |

| |Thrombus formation |

| |Distribution of thrombus |

| |LAD |

| |RCA |

| |LCA |

| |Transmural infarction |

| |Most common |

| |Most lethal |

| |Subendothelial infarction |

| |Clinical presentation |

| |“crushing” substernal chest pain |

| |radiation to left arm, jaw and neck |

| |diaphoresis, nausea and vomiting |

| |JVD |

| |“feeling of impending doom” |

| |[pic] |

| |138540 >>> 0:04:27 |

| |SLIDE 5 of 42 |

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| |SERUM MARKERS USED TO DIAGNOSE MI |

| |General |

| |cardiac cell death [pic]enzyme release |

| |CK-MB |

| |Troponin I & T |

| |More sensitive + specific |

| |LDH |

| |Remains elevated longest |

| |EKG |

| |ST elevation |

| |Q waves |

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| |[pic] |

| |[pic] |

| |138545 >>> 0:06:07 |

| |SLIDE 6 of 42 |

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| |GROSS CHANGES |

| |General |

| |Spectrum of changes |

| |Variable intervals |

| |Table XII-2. Gross Sequence of Changes |

| |Survival Time |

| |Predominant Finding |

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| |0-18 hrs |

| |No gross change |

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| |18-24  |

| |Vague pallor and softening |

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| |1-7 days |

| |Yellow pallor |

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| |7-24 days |

| |Central pallor with a red border |

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| |Months |

| |White, firm scar |

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| |Central pallor |

| |Red border |

| |7-14 days |

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| |[pic] |

| |[pic] |

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| |[pic] |

| |138546 >>> 0:08:53 |

| |SLIDE 7 of 42 |

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| |GROSS CHANGES |

| |old infarct |

| |white, pale |

| |months - years |

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| |[pic] |

| |138550 >>> 0:09:13 |

| |SLIDE 8 of 42 |

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| |MICROSCOPIC CHANGES |

| |*Insert table 12-3 |

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| |[pic] |

| |[pic] |

| |138555 >>> 0:10:47 |

| |SLIDE 9 of 42 |

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| |COMPLICATIONS OF MI |

| |• Sudden death |

| |• Arrhythmias |

| |• CHF |

| |• Cardiogenic shock |

| |• Thrombus [pic]thromboembolism |

| |• Pericarditis [pic]friction rub |

| |• Cardiac rupture |

| |• Ventricular aneurysm |

| |[pic] |

| |138560 >>> 0:12:18 |

| |SLIDE 10 of 42 |

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| |SUDDEN CARDIAC DEATH |

| |Definition |

| |Death within 1 hour |

| |Mechanism |

| |Fatal arrhythmia |

| |Etiology |

| |MI |

| |Hypertropic cardiomyopathy |

| |MVP |

| |AV stenosis |

| |Myocarditis |

| |[pic] |

| |138565 >>> 0:12:52 |

| |SLIDE 11 of 42 |

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| |CONGESTIVE HEART FAILURE |

| |Definition |

| |Insufficient cardiac output to meet bodily demand |

| |General |

| |Final common pathway |

| |Increasing incidence |

| |Complications |

| |Forward failure |

| |Backward failure |

| |[pic] |

| |138570 >>> 0:13:36 |

| |SLIDE 12 of 42 |

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| |LEFT HEART FAILURE |

| |Etiology |

| |Ischemic heart disease- MI |

| |HTN |

| |Gross |

| |Increased heart weight |

| |LVH |

| |Edematous lungs |

| |Presentation |

| |Pulmonary symptoms |

| |S3 gallop |

| |Micro |

| |Myocyte hypertrophy- “boxcar” nuclei |

| |Intra-alveolar hemosiderin-laden macrophages |

| |Complications |

| |Pulmonary congestion and edema |

| |Cardiogenic shock |

| |Concentric hypertrophy |

| |Normal right heart |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138575 >>> 0:15:44 |

| |SLIDE 13 of 42 |

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| |RIGHT HEART FAILURE |

| |Etiology |

| |Left-sided heart failure |

| |Valvular disease |

| |Cor pulmonale |

| |Presentation |

| |JVD |

| |Hepatosplenomegaly |

| |Edema |

| |Ascites |

| |Gross |

| |RVH |

| |Complications |

| |“nutmeg liver” |

| |cardiac cirrhosis |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138580 >>> 0:16:54 |

| |SLIDE 14 of 42 |

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| |VALVULAR HEART DISEASE |

| |DEGENERATIVE CALCIFIC AORTIC VALVE STENOSIS |

| |Definition |

| |age-related calcifications |

| |General |

| |occurs in congenital bicuspid valves |

| |[pic]LVH and CHF |

| |risk of sudden death |

| |Treatment |

| |valve replacement |

| |[pic] |

| |138585 >>> 0:17:42 |

| |SLIDE 15 of 42 |

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| |MITRAL VALVE PROLAPSE |

| |Epidemiology |

| |young women |

| |common |

| |Marfan’s syndrome |

| |Presentation |

| |Asymptomatic |

| |mid-systolic click |

| |Gross |

| |floppy valves |

| |Micro |

| |myxomatous degeneration |

| |Complications |

| |infective endocarditits |

| |chordae rupture |

| |mitral insufficiency |

| |sudden death-rare |

| |[pic] |

| |138590 >>> 0:18:53 |

| |SLIDE 16 of 42 |

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| |RHEUMATIC VALVULAR HEART DISEASE |

| |Definition |

| |Gp A B-hemolytic strep.[pic] pharyngeal infection [pic]systemic disease (rheumatic fever) |

| |Mechanism |

| |Antibodies that cross-react with cardiac antigens |

| |Epidemiology |

| |Children |

| |Decreasing incidence |

| |Clinical findings |

| |2-3 weeks after pharyngeal infection |

| |Lab |

| |Elevated ASO titers |

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| |[pic] |

| |[pic] |

| |138595 >>> 0:20:59 |

| |SLIDE 17 of 42 |

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| |ACUTE RHEUMATIC HEART DISEASE |

| |• Myocarditis |

| |• Fibrinous pericarditis |

| |• Endocarditis |

| |[pic] |

| |138600 >>> 0:22:13 |

| |SLIDE 18 of 42 |

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| |CHRONIC RHEUMATIC HEART DISEASE |

| |Mitral and aortic valvular fibrosis |

| |thickened, fibrotic valve |

| |shortened, fused , thick chordae |

| |Complications |

| |Mitral stenosis |

| |CHF |

| |Infectious endocarditis |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138605 >>> 0:23:56 |

| |SLIDE 19 of 42 |

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| |INFECTIVE BACTERIAL ENDOCARDITIS |

| |Definition |

| |Valve infection |

| |Risk factors |

| |Rheumatic heart disease |

| |MVP |

| |Congenital heart disease |

| |Indwelling catheter |

| |Dental procedures |

| |IVDA (right side) |

| |[pic] |

| |138610 >>> 0:24:55 |

| |SLIDE 20 of 42 |

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| |INFECTIVE BACTERIAL ENDOCARDITIS CON’T |

| |Acute endocarditis |

| |S. Aureus- high virulence |

| |Colonize normal valve |

| |Destructive vegetations |

| |hemmorhagic vegetation |

| |S. Aureus |

| |Subacute endocarditis |

| |Low virulence |

| |Colonize damaged valve |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138615 >>> 0:26:35 |

| |SLIDE 21 of 42 |

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| |INFECTIVE BACTERIAL ENDOCARDITIS CON’T |

| |Clinical presentation |

| |Fever, chills + wt.loss |

| |Murmur |

| |Systemic emboli |

| |Roth spots |

| |Osler’s nodes |

| |Janeway lesions |

| |Splinter hemmorhages- under nails |

| |Diagnosis |

| |Blood cultures |

| |Complications |

| |Septic emboli |

| |Valvular damage |

| |Myocardial abscess |

| |Dehiscence of artificial valve |

| |[pic] |

| |138620 >>> 0:28:16 |

| |SLIDE 22 of 42 |

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| |MARANTIC ENDOCARDITIS |

| |NBTE |

| |Definition |

| |Sterile vegetations- fibrin |

| |Associated with debilitating disease |

| |Complication |

| |Embolism |

| |[pic] |

| |138625 >>> 0:28:54 |

| |SLIDE 23 of 42 |

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| |CONGENITAL HEART DISEASE |

| |General |

| |Most common cause of heart disease in childhood |

| |Etiology |

| |Idiopathic- 90% |

| |Genetic association |

| |Viral |

| |Drugs and alcohol |

| |[pic] |

| |138630 >>> 0:29:32 |

| |SLIDE 24 of 42 |

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| |COARCTATION OF THE AORTA |

| |Definition |

| |Narrowing of the aorta |

| |Types |

| |Preductal |

| |Postductal |

| |[pic] |

| |138635 >>> 0:29:41 |

| |SLIDE 25 of 42 |

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| |PREDUCTAL COARCTATION (INFANTILE- TYPE) |

| |General |

| |Turner’s syndrome |

| |Proximal to ductus arteriosis |

| |Presentation |

| |Upper extremity hypertension |

| |Lower extremity hypotension |

| |Weak pulses |

| |Cyanosis- lower extremities |

| |Right ventricular hyperplasia |

| |Prognosis |

| |Poor |

| |[pic] |

| |138640 >>> 0:30:24 |

| |SLIDE 26 of 42 |

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| |POSTDUCTAL COARCTATION (ADULT-TYPE) |

| |General |

| |Distal to ductus arteriosis |

| |Presentation |

| |Upper extremity hypertension |

| |Lower extremity hypotension + weak pulses |

| |Collateral circulation |

| |Chest X-ray |

| |Rib notching |

| |Complication |

| |CHF |

| |Intracerebral hemorrhage |

| |Dissecting aortic aneurysm |

| |[pic] |

| |138645 >>> 0:32:10 |

| |SLIDE 27 of 42 |

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| |COMPARISON OF LEFT VS. RIGHT SHUNT CONGENITAL DISEASE |

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| |[pic] |

| |[pic] |

| |138650 >>> 0:33:20 |

| |SLIDE 28 of 42 |

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| |TETROLOGY OF FALLOT |

| |Classic Tetrad |

| |Pulmonary stenosis |

| |Right ventricular hypertrophy |

| |Overriding aorta |

| |VSD |

| |Clinical |

| |Cyanosis |

| |SOB |

| |Clubbing |

| |Polycythemia |

| |Prognosis |

| |Increasing stenosis + cyanosis |

| |Treatment |

| |surgery |

| |[pic] |

| |138655 >>> 0:34:26 |

| |SLIDE 29 of 42 |

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| |TRANSPOSITION OF THE GREAT VESSELS |

| |Definition |

| |inversion of the aorta + pulmonary arteries |

| |Risk |

| |infants of diabetic mothers |

| |Clinical |

| |cyanosis + RVH |

| |Must have mixing of blood to survive |

| |Prognosis |

| |poor (without surgery) |

| |[pic] |

| |138660 >>> 0:35:47 |

| |SLIDE 30 of 42 |

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| |TRUNCUS ARTERIOSIS |

| |Definition |

| |No septum between aorta + pulmonary artery [pic]common trunk |

| |Clinical |

| |Early cyanosis |

| |CHF |

| |Prognosis |

| |Poor (without surgery) |

| |[pic] |

| |138665 >>> 0:36:34 |

| |SLIDE 31 of 42 |

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| |TRICUSPID ATRESIA |

| |Definition |

| |No communication between R. atrium + R. ventricle |

| |Associated with R. ventricular hypoplasia + an ASD |

| |Prognosis |

| |Poor (without surgery) |

| |[pic] |

| |138670 >>> 0:37:10 |

| |SLIDE 32 of 42 |

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| |COMPARISON OF LEFT VS. RIGHT SHUNT CONGENITAL DISEASE |

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| |[pic] |

| |[pic] |

| |138675 >>> 0:38:20 |

| |SLIDE 33 of 42 |

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| |VENTRICULAR SEPTAL DEFECT (138675) |

| |General |

| |Most common congenital heart defect |

| |Definition |

| |Ventricular communication |

| |Small VSD |

| |Asymptomatic + may spontaneously close |

| |Jet stream [pic]endothelial damage [pic]infective endocarditis |

| |Large VSD |

| |Eisenmenger’s complex |

| |Auscultation |

| |Systolic murmur |

| |Treatment |

| |Surgery |

| |[pic] |

| |138680 >>> 0:39:20 |

| |SLIDE 34 of 42 |

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| |ATRIAL SEPTAL DEFECT |

| |Definition |

| |Atrial communication |

| |Most common type |

| |Ostium secundum |

| |Complications |

| |Eisenmenger’s complex |

| |Paradoxical emboli |

| |[pic] |

| |138685 >>> 0:40:14 |

| |SLIDE 35 of 42 |

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| |PATENT DUCTUS ARTERIOSIS |

| |Definition |

| |Communication between aorta and pulmonary artery |

| |Associated with prematurity |

| |Clinical |

| |Machinery murmur |

| |Late cyanosis |

| |Complication |

| |Eisenmenger’s complex |

| |Treatment |

| |Prostaglandins (To keep ductus open) |

| |Indomethacin (To close ductus) |

| |[pic] |

| |138690 >>> 0:41:13 |

| |SLIDE 36 of 42 |

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| |THE CARDIOMYOPATHIES |

| |DILATED CARDIOMYOPATHY |

| |Most common form |

| |Etiology |

| |Idiopathic |

| |Alcohol |

| |Adriamycin |

| |Coxsackievirus B |

| |Chagas disease (S. America) |

| |Pregnancy |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138695 >>> 0:42:35 |

| |SLIDE 37 of 42 |

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| |DILATED CARDIOMYOPATHY CON’T |

| |Echo |

| |Decreased EF |

| |Presentation |

| |Progressive CHF |

| |Complications |

| |Mural thrombi |

| |Prognosis |

| |Poor |

| |Treatment |

| |Heart transplant |

| |[pic] |

| |138700 >>> 0:43:08 |

| |SLIDE 38 of 42 |

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| |HYPERTROPHIC CARDIOMYOPATHY (IHSS) |

| |Etiology |

| |Hereditary |

| |Clinical |

| |Sudden death in athlete |

| |Gross |

| |Hypertrophied ventricular septum |

| |Micro |

| |Disorganized myofibers |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138705 >>> 0:44:15 |

| |SLIDE 39 of 42 |

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| |RESTRICTIVE CARDIOMYOPATHY |

| |Uncommon |

| |Etiology |

| |Amyloidosis (Congo red) |

| |[pic] |

| |138710 >>> 0:44:47 |

| |SLIDE 40 of 42 |

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| |CARDIAC TUMORS |

| |Cardiac myxoma Benign tumor |

| |Left atrium |

| |Micro- stellate cells |

| |[pic] |

| |[pic] |

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| |[pic] |

| |138715 >>> 0:45:06 |

| |SLIDE 41 of 42 |

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| |MYXOMA VS. VEGETATION VS. THROMBUS |

| |Tumor |

| |Stellate cells |

| |Myxoid background |

| |Vegetation |

| |Bacterial colonies |

| |Thrombus |

| |Lines of Zahn |

| |[pic] |

| |138720 >>> 0:45:32 |

| |SLIDE 42 of 42 |

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| |CARDIAC RHABDOMYOMA |

| |• Benign tumor |

| |• Tuberous sclerosis |

| |[pic] |

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