Cardiovascular Pathology - University of Kentucky



Cardiovascular Pathology

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|HTN |90% essential = 10 |LV hypertrophy (xray, echo) |Myocyte hypertrophy and fibrosis, |Predisposes to CHD, CVA, CHF, RF, aortic dissection|

| |2nd m/c( renal dz |No valve, genetic, or aortic abnL’s |hyaline thickening & athersosclerosis | |

| |inc w/ age, obesity DM, cigs, genetics | | | |

| |black>white>asian | | | |

|Atherosclerosis |1. lower aorta/ iliac |Complicaqted plaques: |Fatty streak, foam cell, collagen, | |

| |2. proximal coronaries |Advanced dz (calcification |lipid | |

| |3. femoral, popliteal, thoracic aorta |Ischemia of intima) thrombus( | | |

| |4. internal carotids |infarction, cholesterol emboli, |HTN, hyperlipidemia, smoking, DM cause | |

| |5. vertebral, basilar, Circle of Willis|hemorrhage into plaques, aneurysm |endothelial injury | |

|Ischemic Heart Dz |Narrowed arteries ( LCCA |More vulnerable to hypoperfusion via |2nd day: well- demarcated, pale, soft |6 hr: wavy fibers (highly eosinophilic bands of |

| | |ischemia |3-10 d: yellow, hyperemic rxn |necrotic myocytes) |

| | | |2wk: granulation |1-3 d: PMN, eos |

| | | |2mo: scar |1 wk: coagulative necrosis |

|Diagnosis of MI |1st 6 hours: EKG is gold standard |CK-MB is test of choice in 1st 24hrs |AST is nonspecific( found in cardiac, |EKG changes include |

| |Cardiac troponin I used w/in 1st 8 hrs |post-MI |liver, skeletal muscle cells |ST elevation (transmural ischemia) |

| |(for 7-10d); more specific |LDH1 also elevated 2-7 days post MI | |Q waves (transmural infarct) |

|MI complications |+Arrythmias(90%) |+cardiogenic shock (>40% vent loss) |+Rupture of vent free wall, IV septum, |+Dressler’s synd: |

| |+LV failure, pulm edema (60%) w/ >20% |+Fibrinous pericarditis (friction rub |papillary musc (4-10 d. post MI) |autoimmune, results in fibrinous pericarditis (wks |

| |vent. loss |3-5 d post MI) |cardiac tamponade |post MI) |

| |+thromboemboliz | |+mitral insuffic fr. papillary infarct | |

| |+Aneurysm | | | |

|Cardiomyopathies |Dilated (DCM) |Hypertrophic (HCM) |Restrictive (RCM) |See chart on 1st page of notes |

| |= congestive |= IHSS (idiopathic hypertrophic |= infiltrative/obliterative | |

| |+4 chamber cardiomegaly |subaortic stenosis) |+ amyloid (elderly) |**ABCD’s for DCM |

| |+Dec. contractility, stasis, mural |+ L>R hypertrophy, LV outflow |+ sarcoid, granuloma (young) |A: alcohol |

| |thrombi |obstruction via asymmetric IV septum |+ endocardial fibroelastosis |B: beri beri (wet) |

| |+CHF ( systolic dysfxn ) |+genetic, catechol sens. |+endomyocardial fibrosis (Loffler’s) |C: coxsackie B, cocaine |

| |+pregnancy, EtOH/ thiamine defic, |+ diastolic dysfxn | |D: doxorubicin toxicity |

| |genetic, viral | | | |

| |**ABCD’s | | | |

|Cardiac tumors |10 Atrial myxoma –mesenchyme, mostly |10 Rhabdomyoma— |Mets: bronchogenic and lymphoma | |

| |adults |striated muscle, m/c in kids (esp | | |

| |ball-valve obstruction, emboli |tuberous sclerosis) | | |

|CHF |L failure: pulm edema, congest’n, renal|R failure: hepato/ |Cor pulmonale = pulm HTN( RV failure | |

| |hypoperfusion(RAAS, ATN, fluid |splenomegaly, nutmeg liver, JVD, renal|Acute( d/t pulm embolus( dilated | |

| |retention, prerenal azotemia, cerebral |hypoperfusion, |RV(tricuspid regurg | |

| |hypoxia |ascites, edema, pleural effus, |Chronic( gradual RVH d/t pressure | |

| |+d/t IHD, AS, HTN, cardiomyopathy |+d/t LHF, cor pulm, PS, |overload | |

| | |cardio-myopathy | | |

|Cardiogenic shock |Dec. bld vol or dec circ(inadeq |Results in cell hypoxia( anaerobic |Stages of compensation: |Tx: correction of initial metabolic and physiologic|

| |perfusion |metab, inc. lactate( encephalopathy, |1. Compensated (reflex tachy, |derangement (prior to irreversible stage) |

| |+d/t dec cardiac fxn, dec bld vol, or |MI, pulm edema/ ARDS, ATN |vasoconstriction) | |

| |pooling of bld (dec TPR) | |2. Decompensated | |

| | | |3. Irreversible | |

|Embolus types |Venous( lungs |Arterial: 75% mural thrombi (lines of |FAT BAT |95% of PE’s from DVT’s |

| |Paradoxic R(L |Zahn = clotted plasma/ rbc layers) |Fat, air, thrombus, , bacteria, |PE: CP, tachypnea, dyspnea |

| | |Legs> brain, viscera, arms |amniotic fluid, tumor |Amniotic fluid emboli( DIC, esp post partum |

|Deep venous thrombosis |Predisposed by Virchow’s triad: stasis,|Venous Dz |Thrombophlebitis = inflammation & | |

| |hypercoagulalbility, |1. Thrombophlebitis |thrombus in veins, esp. DVT | |

| |endothelial damage |2. Venous occlusion | | |

| | |3. Varicose veins | | |

|Bacterial Endocarditis |+friable masses on valves: clot, |ABE: Staph aureus, some strep |SBE: Strp viridans |Complic: valve perforation, myocardial/papillary |

| |fibrin, bacteria |Janeway lesions (palms/soles) |Roth’s spots (retinal hemorrhages) |abscess( MVP, |

| |+often mitral valve |Splinter hemorrhages |Osler’s nodes (fingers/toes), fatigue, |R emboli to lung, L to brain, kidney, spleen; |

| |+IVDA( R side valves |Hematuria, petechiae, F/C |low fever, hematuria |nephritis IgM, C3 |

| |+Non-bacterial |(fever/chills) | | |

| |1. thrombotic/marantic | | | |

| |fibrin, plts, sm veget’n ch. illness: | | | |

| |CA, DIC | | | |

| |2. Libman-Sacks = SLE | | | |

| |(verrucous) | | | |

|Rheumatic Fever/RHD |ARF 1-3 wks after pharyngitis (Grp A |Mjr. Jones criteria |RHD: mitral +/- aortic stenosis or |+Inc ASO titers |

| |strep)( imm cross rxn of anti-strep |-migratory polyarthritis |insuffic (hi press) |+Chronic RHD( infective endocarditis, CHF |

| |Ab’s to host CT |-erythema marginatum |Fibrosis( fish mouth or buttonhole MS( |+Aschoff bodies in myocardium = finrinoid necrosis |

| |FEVERSS: fever, erythema marg, valve |-syndenham’s chorea |murmurs, LA dilation, RVH |w/ inflamm cells |

| |damage, inc. ESR, red-hot jts, subQ, St|-subQ nodules w/ Aschoff bodies | | |

| |vitus dance |-carditis | | |

|Pericarditis |Fibrinous: fibrin exudates/ deposits |Serous: RF, SLE, viral |Suppurative: pus + serosal erythema; |Hemorrhagic: blood mixed w/ suppurative or |

| |asst’d w/ MI | |organization( constrictive pericarditis|fibrinous material; asst’d w/ TB or malignant |

| | |Caseous: fibrocalcific constrictive |+d/t bacterial, fungal, parasitic inf; |neoplasm |

| | |pericarditis d/t TB |friction rub |Organized( constrictive |

|Chronic Pericarditis |1. Adhesive mediastinopericarditis( |2. Constricitve( thick fibrosis | | |

| |parietal layer of heart fuses w/ |decreased filling volume | | |

| |pericardium( hypertrophy and dilation | | | |

|Pericardial Effusion |Hemopericardium: trauma, vent. rupture,|Serous: d/t CHF, hypoproteinemia, |Chylous: lymphatic blockage |Serosanguinous: usu. d/t trauma, tumor, TB |

| |aortic rupture |develops slowly | |Cholesterol: idiopathic/ myxedema |

| |No inflamm | | |v. uncommon |

| |( tamponade, death | | | |

|Vasculitities | | | | |

|1. Buerger’s Dz |Segmental thrombosis in extremities |Smokers ASD> PDA |RHF, pulm HTN |Tardive cyanosis |VSD murmur = holosystolic |

|(Acyanotic) | | | | |

|Obstructive Congenital Heart DZ |Coarctation of aorta |Pulm valve stenosis/ atresia |Aortic valve stenosis/atresia |M/C causes of aortic stenosis |

| | |(unequal truncus division) |plete( |Rheumatic fever |

| | | |don’t survive |bicuspid aortic valves |

| | | |2. Biscuspid( | |

| | | |endocarditis, LV overload, sudden death| |

|ASD |Ostium primum: |Ostium secundum, 90% |Sinus venosus 5%, superior septum | |

| |5%, inferior septum, AV valve problems |Foramen ovale | | |

|Tetralogy of Fallot |VSD |Clinical manif. |PDA permits survival if complete |M/C cause of early cyanosis |

| |Overriding aorta |depends on 0 of |obstruction | |

| |RV hypertrophy |RV outflow obstruction | | |

| |Pulm. stenosis | | | |

|Transposition of Great Vessels |Failure of truncoconal septum to spiral|Aorta off RV |Survival via: PDA, VSD, ASD, patent |Offspring of diabetic mothers |

| | |Pulm A off LV |foramen ovale | |

|Coarctation of Aorta |Preductal = proximal to DA (ductus |Postductal (adults) m/c |Usu. no cyanosis |Postductal: UE HTN, LE weak pulses |

| |arteriosis) (infants) | |M: F (3:1) but | |

| | | |Common in Turner’s | |

|Patent Ductus Arteriosus (PDA) |Oxy bld (aorta(PA) |Complication: |Indomethacin |Continuous “machine-like” |

| | |Pulm. HTN |closes |Murmur |

| | |RV hypertrophy |PGE/low O2 tension keeps open | |

| | |Eventual R(L | | |

| | |Tardive cyanosis | | |

|Eisenmenger’s syndrome |L(R to R(L d/t inc. pulm resistance |Late (tardive) |Clubbing, polycythemia | |

| | |Cyanosis | | |

|Cardiac defects ass’d with specific |Trisomy 13 |VSD/ASD/PDA |dextrocardia | |

|syndromes |18 |VSD/ASD |Polyvalvular dysplasia | |

| |21 |ASD/VSD |AV canal |(Endocardial cushion defect) |

| | |(ostium primum) | |ASD |

| |Marfan’s synd |Aortic dilation |Aortic dissection | |

| |Turner’s |Coarctation |Pulmonary stenosis | |

|Perinatal abnormalities |Rubella: ASD, VSD, PDA |FAS (fetal EtOH): VSD |Drugs: trimethadione, | |

| | | |isoretionin(retinA) | |

|Valvular heart dz | | | | |

|Mitral Valve Prolapse ( (MVP) |Mitral Stenosis (MS) |Mitral Annulus Calcification |Aortic Insufficieny (AR) |Aortic Stenosis (AS) |

|mitral leaflets balloon into LA( mitral |+ d/t scarring, calcification, fusion of |+deposition of Ca2+ at base of mitral |Acute( LV failure, often fr. infective |+90% calcific |

|insufficiency |mitral valve |valve( mitral regurg |endocarditis |+often bicuspid |

|+ young women, Marfan’s |+ RHD |+elderly | |+thickening/fibrosis of valve cusps w/o |

|+m/c valvular lesion |+ Inc. LA press., dilation ( possible |+ asst’d with IHD |Chronic( LVH, wide pulse pressure |fusion |

|+mid-systolic click |Afib | |(bounding pulses), reflex tachycardia |(AS d/t RHD( fusion) |

|high-pitched murmur |+ diastolic opening snap | |+ d/t congenital bicuspid AV, RHD, or |+angina, syncope, CHF, systolic ejection |

| |+ rumbling later diastolic murmur w/ | |syphilis |click |

|MR murmur: high-pitched “blowing” |presystolic accentuation | |+ high-pitched blowing murmur. |+death via CHF, arrythmia |

|holosystolic murmur |LA>>LV pressure during diastole | |+bounding pulses = Waterhammer/Corrigans |+cresc-decrescendo midsystolic ejection |

| |S1 | |Bisferens pulse |murmur w/ LV>> aortic pressure during |

| | | | |systole |

| | | | |+LVH, S4, pulsus parvus et tardus |

|Prosthesis |+Valve replacement in MS, AS |Complications: | | |

| |mixed MS+MR |Thromboembolism, infective endocarditis, | | |

| |MR, AR |microangiopathic hemolysis (see | | |

| | |schistocytes on PBS) | | |

|Myocarditis |Inflamm of myocardium, may ( necrosis |Viral( Coxsackie B |Bacterial( Diphtheria*, meningococcus |Protozoa( T. cruzi = |

| |+4 chamber dilation and hypertrophy |+mononuclear infiltrate w/ necrosis |+ PMN w/ abscess or granuloma |Chagas |

| |+ diffuse hemorrhage | | | |

| | | | |+eos’s w/ giant cell, granuloma ( |

| | | | |Fiedler’s myocarditis ? |

|Congenital Vessel Prob’s |Berry Aneurysm—cerebral vessel walls, |AV Fistula— | | |

| |esp. Circle of Willis & MCA bifurcation( |Inc. venous return causing RHF | | |

| |SAH | | | |

| | | | | |

|Arteriosclerosis |Hyperplastic: HTN, necrotizing vasculitis|Hyaline: DM, HTN, elderly, eosinophilic | | |

| |“onion skin hyperplasia” |material | | |

|Aneurysms |Atherosclerotic |Syphilitic |Microaneurysms |Dissecting |

| |+Abdominal aorta |+vasa vasorum damage of aortic media( |HTN( cerebral vessels |Tunica media degeneration |

| |+ elderly |endarteritis, , ischemia, sm. muscle |DM( retina |Marfan’s, HTN |

| |+HTN |atrophy | | |

| | |+ascending aorta( impinge AV( AR | | |

|Benign vascular neoplasms |1. Hemangioma |Von Hippel Lindau: |Vascular Ectasias (Telangiectasia) |*Sturge Weber syndrome |

| |Capillary: unencapsulated, skin, mucous |Multiple cavernous h’s in cerebellum, |Nevus flammeus: flat, head/neck |trigeminal area, glaucoma, nevus, |

| |memb |brainstem, liver, pancreas, eyes |Portwine stain: SW synd* |meningeal angioma, MR |

| |Cavernous: sponge-like, skin, mucous |Renal cysts, RCCA |Spider: pregnant, cirrhosis | |

| |memb, viscera |Auto dominant | | |

|Malignant vascular neoplasms |1. Hemangiosarcoma |2. Hepatic angioma( toxins |3. Kaposi’s Sarcoma: | |

| |skin, breast, liver | |AIDS | |

| |red nodules(large, soft, pale masses | |Multiple violaceous nodules | |

|EKG | | | | |

|Enzymes | | | | |

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