ࡱ> 5@ <bjbj22 %XX4ZZZZ[ 2,],],],],],],],]4666666$R9ZV_,],]V_V_Z,],]orrrV_,],]4rV_4rZrtr}T~,] ] Z8r"d}0~ 0r}ZrX~~ ,]]^r^LZ^,],],]ZZKMd r MCardiovascular Pathology HTN90% essential = 10 2nd m/c( renal dz inc w/ age, obesity DM, cigs, genetics black>white>asianLV hypertrophy (xray, echo) No valve, genetic, or aortic abnLs Myocyte hypertrophy and fibrosis, hyaline thickening & athersosclerosisPredisposes to CHD, CVA, CHF, RF, aortic dissection Atherosclerosis1. lower aorta/ iliac 2. proximal coronaries 3. femoral, popliteal, thoracic aorta 4. internal carotids 5. vertebral, basilar, Circle of WillisComplicaqted plaques: Advanced dz (calcification Ischemia of intima) thrombus( infarction, cholesterol emboli, hemorrhage into plaques, aneurysm Fatty streak, foam cell, collagen, lipid HTN, hyperlipidemia, smoking, DM cause endothelial injuryIschemic Heart Dz (IHD)Narrowed arteries (<75% XSA), dec. O2 capacity, inc. myocardial demand1. Angina 2. MI 3. sudden death 4. chronic IHDChronic IHD: +Brown-colored heart +myocyte atrophy +fribrosis +late CHFAnginaChronic: fibrosis + Inc. filling pressure + Dec. diastolic relaxation +pulm edema( dyspneaStable: +pain w/exertion +<10-20 min + responds to NTG +d/t atheroscl +ST depressionPrinzmetal = Paroxysmal vasospasm +pain at rest +ST elevationUnstable +at rest, prolonged, severe pain ( MI + unresponsive to NTGInfarcts: red vs paleREd=REperfusion Hemorrhagic infarcts occur in loose tissue w/ collaterals (lungs, intestines or following reperfusion)Pale infarcts( solid tissues w/ single blood supply (brain, heart, kidney, spleen)Evolution of MITransmural: usu d/t occlusion LAD > RCA > LCCASubendocardial: Inner of wall More vulnerable to hypoperfusion via ischemiaGross(Transmural): Day 1: pale, swollen 2nd day: well- demarcated, pale, soft 3-10 d: yellow, hyperemic rxn 2wk: granulation 2mo: scarMicro: 1 hr: edema 6 hr: wavy fibers (highly eosinophilic bands of necrotic myocytes) 1-3 d: PMN, eos 1 wk: coagulative necrosisDiagnosis of MI1st 6 hours: EKG is gold standard Cardiac troponin I used w/in 1st 8 hrs (for 7-10d); more specific CK-MB is test of choice in 1st 24hrs post-MI LDH1 also elevated 2-7 days post MIAST is nonspecific( found in cardiac, liver, skeletal muscle cellsEKG changes include ST elevation (transmural ischemia) Q waves (transmural infarct)MI complications+Arrythmias(90%) +LV failure, pulm edema (60%) w/ >20% vent. loss +thromboemboliz +Aneurysm+cardiogenic shock (>40% vent loss) +Fibrinous pericarditis (friction rub 3-5 d post MI)+Rupture of vent free wall, IV septum, papillary musc (4-10 d. post MI) cardiac tamponade +mitral insuffic fr. papillary infarct+Dresslers synd: autoimmune, results in fibrinous pericarditis (wks post MI)CardiomyopathiesDilated (DCM) = congestive +4 chamber cardiomegaly +Dec. contractility, stasis, mural thrombi +CHF ( systolic dysfxn ) +pregnancy, EtOH/ thiamine defic, genetic, viral **ABCDsHypertrophic (HCM) = IHSS (idiopathic hypertrophic subaortic stenosis) + L>R hypertrophy, LV outflow obstruction via asymmetric IV septum +genetic, catechol sens. + diastolic dysfxnRestrictive (RCM) = infiltrative/obliterative + amyloid (elderly) + sarcoid, granuloma (young) + endocardial fibroelastosis +endomyocardial fibrosis (Lofflers)See chart on 1st page of notes **ABCDs for DCM A: alcohol B: beri beri (wet) C: coxsackie B, cocaine D: doxorubicin toxicityCardiac tumors10 Atrial myxoma mesenchyme, mostly adults ball-valve obstruction, emboli10 Rhabdomyoma striated muscle, m/c in kids (esp tuberous sclerosis)Mets: bronchogenic and lymphomaCHFL failure: pulm edema, congestn, renal hypoperfusion(RAAS, ATN, fluid retention, prerenal azotemia, cerebral hypoxia +d/t IHD, AS, HTN, cardiomyopathyR failure: hepato/ splenomegaly, nutmeg liver, JVD, renal hypoperfusion, ascites, edema, pleural effus, +d/t LHF, cor pulm, PS, cardio-myopathyCor pulmonale = pulm HTN( RV failure Acute( d/t pulm embolus( dilated RV(tricuspid regurg Chronic( gradual RVH d/t pressure overloadCardiogenic shockDec. bld vol or dec circ(inadeq perfusion +d/t dec cardiac fxn, dec bld vol, or pooling of bld (dec TPR)Results in cell hypoxia( anaerobic metab, inc. lactate( encephalopathy, MI, pulm edema/ ARDS, ATN Stages of compensation: 1. Compensated (reflex tachy, vasoconstriction) 2. Decompensated 3. IrreversibleTx: correction of initial metabolic and physiologic derangement (prior to irreversible stage)Embolus typesVenous( lungs Paradoxic R(L Arterial: 75% mural thrombi (lines of Zahn = clotted plasma/ rbc layers) Legs> brain, viscera, armsFAT BAT Fat, air, thrombus, , bacteria, amniotic fluid, tumor 95% of PEs from DVTs PE: CP, tachypnea, dyspnea Amniotic fluid emboli( DIC, esp post partumDeep venous thrombosisPredisposed by Virchows triad: stasis, hypercoagulalbility, endothelial damageVenous Dz 1. Thrombophlebitis 2. Venous occlusion 3. Varicose veinsThrombophlebitis = inflammation & thrombus in veins, esp. DVTBacterial Endocarditis+friable masses on valves: clot, fibrin, bacteria +often mitral valve +IVDA( R side valves +Non-bacterial 1. thrombotic/marantic fibrin, plts, sm vegetn ch. illness: CA, DIC 2. Libman-Sacks = SLE (verrucous)ABE: Staph aureus, some strep Janeway lesions (palms/soles) Splinter hemorrhages Hematuria, petechiae, F/C (fever/chills)SBE: Strp viridans Roths spots (retinal hemorrhages) Oslers nodes (fingers/toes), fatigue, low fever, hematuria Complic: valve perforation, myocardial/papillary abscess( MVP, R emboli to lung, L to brain, kidney, spleen; nephritis IgM, C3Rheumatic Fever/RHDARF 1-3 wks after pharyngitis (Grp A strep)( imm cross rxn of anti-strep Abs to host CT FEVERSS: fever, erythema marg, valve damage, inc. ESR, red-hot jts, subQ, St vitus danceMjr. Jones criteria -migratory polyarthritis -erythema marginatum -syndenhams chorea -subQ nodules w/ Aschoff bodies -carditisRHD: mitral +/- aortic stenosis or insuffic (hi press) Fibrosis( fish mouth or buttonhole MS( murmurs, LA dilation, RVH+Inc ASO titers +Chronic RHD( infective endocarditis, CHF +Aschoff bodies in myocardium = finrinoid necrosis w/ inflamm cellsPericarditisFibrinous: fibrin exudates/ deposits asstd w/ MI Serous: RF, SLE, viral Caseous: fibrocalcific constrictive pericarditis d/t TBSuppurative: pus + serosal erythema; organization( constrictive pericarditis +d/t bacterial, fungal, parasitic inf; friction rubHemorrhagic: blood mixed w/ suppurative or fibrinous material; asstd w/ TB or malignant neoplasm Organized( constrictiveChronic Pericarditis1. Adhesive mediastinopericarditis( parietal layer of heart fuses w/ pericardium( hypertrophy and dilation2. Constricitve( thick fibrosis decreased filling volumePericardial EffusionHemopericardium: trauma, vent. rupture, aortic rupture No inflamm ( tamponade, deathSerous: d/t CHF, hypoproteinemia, develops slowly Chylous: lymphatic blockageSerosanguinous: usu. d/t trauma, tumor, TB Cholesterol: idiopathic/ myxedema v. uncommonVasculitities1. Buergers Dz (thromboangiitis obliterans)Segmental thrombosis in extremities PMN infiltrateSmokers <35 y/o Severe pain, ulcers, gangreneGangrene in young smoker2 Takayasus arteritis (pulseless dz)Medium, large artery granulomas, esp aortic archWeak carotid and UE pulsesOcular disturbances, neuroCheck BP in both arms in young Asian women (pressure difference)3 Temporal arteritis (giant cell)Extracranial arteries Focal Multinucleated giant cells w/ granulomaIntimal fibrosisHA & tenderness, Inc. ESR4 Polyarteritis nodosa (PAN)Small, medium arteries, systemic necrotizing, HepB Ag( Ag:Ab cmplxs P-ANCA AutoAbsAneurysmal dilations: GI, kidney, heart Acute: sharply demarcated fibroid necrosis, PMNsHealing: fibroblasts, monos Healed: fibrotic, lose elasticityChurg-Strauss synd (PAN variant) Small, medium arteries, veins, venules. Lung, spleen. Bronchial asthma. Extravascular granulomas.5. Wegeners granulomatosisTriad of lung-sinus-kidneyNecrotizing vasculitis of lungs and airwaysNecrotizing granulomas of URTNecrotizing glomerulitis Tx w/ immunosuppressives effective6. Hypersensitivity angiitisSmall vessels Crescentic GN Immune complexes PMN infiltrateA. Henoch-Schonlein purpura: skin, joints, abdominal pain, renal lesionsB. Vasculitides: infectious dz, neoplasm, CT d/os (common mech, different Ags)7. Kawasakis dz (mucocutaneous LN syndrome)Inflamm, necrosis of entire vessel wallfever, conjunctivitis, erythema, erosions of oral mucosa, rash, adenopathyUsually young (Japan) 1-2% die self-limitedCongenital Heart DzOccurs before week 16R( L shunts (Cyanotic)4 Ts TA, Tetralogy, TGA, TAPVRParadoxical embolismPersistant TA: Aorta/Pulm A dont separate(TA = Truncus arteriosis(often also has VSDL( R shunts (Acyanotic)VSD>ASD> PDARHF, pulm HTNTardive cyanosisVSD murmur = holosystolicObstructive Congenital Heart DZCoarctation of aortaPulm valve stenosis/ atresia (unequal truncus division)Aortic valve stenosis/atresia 1.Complete( dont survive 2. Biscuspid( endocarditis, LV overload, sudden deathM/C causes of aortic stenosis Rheumatic fever bicuspid aortic valvesASDOstium primum: 5%, inferior septum, AV valve problemsOstium secundum, 90% Foramen ovaleSinus venosus 5%, superior septumTetralogy of FallotVSD Overriding aorta RV hypertrophy Pulm. stenosisClinical manif. depends on 0 of RV outflow obstructionPDA permits survival if complete obstructionM/C cause of early cyanosisTransposition of Great Vessels Failure of truncoconal septum to spiralAorta off RV Pulm A off LV Survival via: PDA, VSD, ASD, patent foramen ovaleOffspring of diabetic mothersCoarctation of AortaPreductal = proximal to DA (ductus arteriosis) (infants) Postductal (adults) m/cUsu. no cyanosis M: F (3:1) but Common in TurnersPostductal: UE HTN, LE weak pulsesPatent Ductus Arteriosus (PDA)Oxy bld (aorta(PA) Complication: Pulm. HTN RV hypertrophy Eventual R(L Tardive cyanosisIndomethacin closes PGE/low O2 tension keeps openContinuous machine-like MurmurEisenmengers syndromeL(R to R(L d/t inc. pulm resistanceLate (tardive) CyanosisClubbing, polycythemiaCardiac defects assd with specific syndromesTrisomy 13 18 21 Marfans synd Turners VSD/ASD/PDA VSD/ASD ASD/VSD (ostium primum) Aortic dilation Coarctation dextrocardia Polyvalvular dysplasia AV canal Aortic dissection Pulmonary stenosis (Endocardial cushion defect) ASD Perinatal abnormalities Rubella: ASD, VSD, PDAFAS (fetal EtOH): VSDDrugs: trimethadione, isoretionin(retinA) Valvular heart dzMitral Valve Prolapse ( (MVP) mitral leaflets balloon into LA( mitral insufficiency + young women, Marfans +m/c valvular lesion +mid-systolic click high-pitched murmur MR murmur: high-pitched blowing holosystolic murmurMitral Stenosis (MS) + d/t scarring, calcification, fusion of mitral valve + RHD + Inc. LA press., dilation ( possible Afib + diastolic opening snap + rumbling later diastolic murmur w/ presystolic accentuation LA>>LV pressure during diastole S1 Mitral Annulus Calcification +deposition of Ca2+ at base of mitral valve( mitral regurg +elderly + asstd with IHDAortic Insufficieny (AR) Acute( LV failure, often fr. infective endocarditis Chronic( LVH, wide pulse pressure (bounding pulses), reflex tachycardia + d/t congenital bicuspid AV, RHD, or syphilis + high-pitched blowing murmur. +bounding pulses = Waterhammer/Corrigans Bisferens pulseAortic Stenosis (AS) +90% calcific +often bicuspid +thickening/fibrosis of valve cusps w/o fusion (AS d/t RHD( fusion) +angina, syncope, CHF, systolic ejection click +death via CHF, arrythmia +cresc-decrescendo midsystolic ejection murmur w/ LV>> aortic pressure during systole +LVH, S4, pulsus parvus et tardusProsthesis+Valve replacement in MS, AS mixed MS+MR MR, ARComplications: Thromboembolism, infective endocarditis, microangiopathic hemolysis (see schistocytes on PBS)MyocarditisInflamm of myocardium, may ( necrosis +4 chamber dilation and hypertrophy + diffuse hemorrhage Viral( Coxsackie B +mononuclear infiltrate w/ necrosis Bacterial( Diphtheria*, meningococcus + PMN w/ abscess or granulomaProtozoa( T. cruzi = Chagas +eoss w/ giant cell, granuloma ( Fiedlers myocarditis ?Congenital Vessel ProbsBerry Aneurysmcerebral vessel walls, esp. Circle of Willis & MCA bifurcation( SAHAV Fistula Inc. venous return causing RHFArteriosclerosisHyperplastic: HTN, necrotizing vasculitis onion skin hyperplasiaHyaline: DM, HTN, elderly, eosinophilic materialAneurysmsAtherosclerotic +Abdominal aorta + elderly +HTNSyphilitic +vasa vasorum damage of aortic media( endarteritis, , ischemia, sm. muscle atrophy +ascending aorta( impinge AV( ARMicroaneurysms HTN( cerebral vessels DM( retinaDissecting Tunica media degeneration Marfans, HTNBenign vascular neoplasms1. Hemangioma Capillary: unencapsulated, skin, mucous memb Cavernous: sponge-like, skin, mucous memb, visceraVon Hippel Lindau: Multiple cavernous hs in cerebellum, brainstem, liver, pancreas, eyes Renal cysts, RCCA Auto dominantVascular Ectasias (Telangiectasia) Nevus flammeus: flat, head/neck Portwine stain: SW synd* Spider: pregnant, cirrhosis*Sturge Weber syndrome trigeminal area, glaucoma, nevus, meningeal angioma, MR Malignant vascular neoplasms1. Hemangiosarcoma skin, breast, liver red nodules(large, soft, pale masses2. Hepatic angioma( toxins3. 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