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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 |
| | |
| |0-18 hrs |
| |No gross change |
| | |
| |18-24 |
| |Vague pallor and softening |
| | |
| |1-7 days |
| |Yellow pallor |
| | |
| |7-24 days |
| |Central pallor with a red border |
| | |
| |Months |
| |White, firm scar |
| | |
| |Central pallor |
| |Red border |
| |7-14 days |
| | |
| |[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] |
| | |
| |[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] |
| | |
| |[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 |
| | |
| | |
| |[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] |
| | |
| |[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] |
| | |
| |[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 |
| | |
| |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] |
| | |
| |[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] |
| | |
| |[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] |
| | |
| |[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 |
| | |
| |CARDIAC RHABDOMYOMA |
| |• Benign tumor |
| |• Tuberous sclerosis |
| |[pic] |
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