13 cardiovascular pathology ii color
TRANSCRIPT
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Cardiac Pathology 2: Heart Failure, Ischemic Heart
Disease and other assorted stuff
Kris=ne Kra>s, M.D.
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• Blood Vessels • Heart I • Heart II
Cardiac Pathology Outline
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• Blood Vessels • Heart I
• Heart Failure • Congenital Heart Disease • Ischemic Heart Disease • Hypertensive Heart Disease
Cardiac Pathology Outline
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• Blood Vessels • Heart I
• Heart Failure
Cardiac Pathology Outline
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• End point of many heart diseases • Common!
• 5 million affected each year • 300,000 fatali=es
• Most due to systolic dysfunc=on
• Some due to diastolic dysfunc=on, valve failure, or abnormal load
• Heart can’t pump blood fast enough to meet needs of body
Heart Failure
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• System responds to failure by • Releasing hormones (e.g., norepinephrine) • Frank-‐Starling mechanism • Hypertrophy
• Ini=ally, this works
• Eventually, it doesn’t • Myocytes degenerate • Heart needs more oxygen • Myocardium becomes vulnerable to ischemia
Heart Failure
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R L
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Clinical consequences of le> and right heart failure
peripheral edema
ascites
hepatomegaly
cyanosis
pulmonary edema
splenomegaly
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• Le> ventricle fails; blood backs up in lungs
• Commonest causes • Ischemic heart disease (IHD) • Systemic hypertension • Mitral or aor=c valve disease • Primary heart diseases
• Heart changes • LV hypertrophy, dila=on • LA may be enlarged too (risk of atrial fibrilla=on)
Le> Heart Failure
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• Dyspnea
• Orthopnea, paroxysmal nocturnal dyspnea too
• Enlarged heart, increased heart rate, fine rales at lung bases
• Later: mitral regurgita=on, systolic murmur
• If atrium is big, “irregularly irregular” heartbeat
Le> Heart Failure
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• Right ventricle fails; blood backs up in body
• Commonest causes • Le> heart failure • Lung disease (“cor pulmonale”) • Some congenital heart diseases
• Heart changes • right ventricular hypertrophy, dila=on • right atrial enlargement
Right Heart Failure
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• Peripheral edema • Big, congested liver (“nutmeg liver”)
• Big spleen
• Most chronic cases of heart failure are bilateral
Right Heart Failure
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Hepa=c blood flow
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“Nutmeg” liver Nutmeg
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• Blood Vessels • Heart I
• Heart Failure • Congenital Heart Disease
Cardiac Pathology Outline
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• Abnormali=es of heart/great vessels present from birth
• Faulty embryogenesis, weeks 3-‐8 • Broad spectrum of severity • Cause unknown in 90% of cases
Congenital Heart Disease
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• Le>-‐to-‐right shunts • atrial septal defects • ventricular septal defects • Patent ductus arteriosus
• Right-‐to-‐le> shunts • tetralogy of fallot • transposi=on of the great arteries
• Obstruc=ons • aor=c coarcta=on
Congenital Heart Disease
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• Ini=ally, le>-‐to-‐right shunt (asymptoma=c)
• Eventually, pulmonary vessels may become constricted (“pulmonary hypertension”), leading to right-‐to-‐le> shunt (“Eisenmenger syndrome”)
• Surgical repair prevents irreversible pulmonary changes and heart failure
Atrial Septal Defects
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ASD
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• Most common congenital cardiac anomaly
• Most close spontaneously in childhood
• Small VSD: asymptoma=c
• Large VSD: big le>-‐to-‐right shunt, may become right-‐to-‐le>
Ventricular Septal Defects
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VSD
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• Ductus: allows flow from PA to aorta
• Closes spontaneously by day 1-‐2 of life
• Small PDA: asymptoma=c
• Large PDA: shunt becomes right-‐to-‐le>
Patent Ductus Arteriosus
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PDA
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• Most common cause of cyano=c congenital heart disease
• Four features: • VSD • obstruc=on to RV oublow tract • overriding aorta • RV hypertrophy
• Cyanosis, erythrocytosis, clubbing of finger=ps, paradoxical emboli
Tetralogy of Fallot
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Tetralogy of Fallot
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Clubbing of finger=ps
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Normal (L) and clubbed (R) finger=ps
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• Aorta arises from R ventricle; pulmonary artery arises from L ventricle
• Outcome: separa=on of systemic and pulmonary circula=ons
• Incompa=ble with life unless there is a big shunt (VSD)
Transposi=on of Great Arteries
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• Coarcta=on = narrowing
• “Infan=le” (preductal) and “adult” (postductal) forms
• Cyanosis and/or low blood pressure in lower extremi=es
• Severity depends on degree of coarcta=on
Aor=c Coarcta=on
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Coarcta=on of the aorta
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• Blood Vessels • Heart I
• Heart Failure • Congenital Heart Disease • Ischemic Heart Disease
Cardiac Pathology Outline
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• Myocardial perfusion can’t meet demand
• Usually caused by decreased coronary artery blood flow (“coronary artery disease”)
• Four syndromes: • angina pectoris • acute MI • chronic IHD • sudden cardiac death
Ischemic Heart Disease
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• Intermigent chest pain caused by transient, reversible ischemia
• Typical (stable) angina • pain on exer=on • fixed narrowing of coronary artery
• Prinzmetal (variant) angina • pain at rest • coronary artery spasm of unknown e=ology
• Unstable (pre-‐infarc=on) angina • increasing pain with less exer=on • plaque disrup=on and thrombosis
Angina Pectoris
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• Necrosis of heart muscle caused by ischemia
• 1.5 million people get MIs each year
• Most due to acute coronary artery thrombosis • sudden plaque disrup=on • platelets adhere • coagula=on cascade ac=vated • thrombus occludes lumen within minutes • irreversible injury/cell death in 20-‐40 minutes
• Prompt reperfusion can salvage myocardium
Myocardial Infarc=on
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Time Gross changes Microscopic changes
0-‐4h None None 4-‐12h Mogling Coagula=on necrosis 12-‐24h Mogling More coagula=on necrosis;
neutrophils come in 1-‐7 d Yellow infarct center Neutrophils die, macrophages
come to eat dead cells 1-‐2 w Yellow center, red borders Granula=on =ssue 2-‐8 w Scar Collagen
Morphologic Changes in Myocardial Infarc=on
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Acute Myocardial Infarc=on
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MI: day 1, day 3, day 7
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• Clinical features • Severe, crushing chest pain ± radia=on • Not relieved by nitroglycerin, rest • Swea=ng, nausea, dyspnea • Some=mes no symptoms
• Laboratory evalua=on • Troponins increase within 2-‐4 hours, remain
elevated for a week. • CK-‐MB increases within 2-‐4 hours, returns to
normal within 72 hours.
Myocardial Infarc=on
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• Complica=ons • contrac=le dysfunc=on • arrhythmias • rupture • chronic progressive heart failure
• Prognosis • depends on remaining func=on and perfusion • overall 1 year mortality: 30% • 3-‐4% mortality per year therea>er
Myocardial Infarc=on
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Rupture of papillary muscle a>er MI
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• Blood Vessels • Heart I
• Heart Failure • Congenital Heart Disease • Ischemic Heart Disease • Hypertensive Heart Disease
Cardiac Pathology Outline
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• Can affect either L or R ventricle
• Cor pulmonale is RV enlargement due to pulmonary hypertension caused by primary lung disorders
• Result: myocyte hypertrophy
• Reasons for heart failure in hypertension are poorly understood
Hypertensive Heart Disease
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Le> ventricular hypertrophy (L) and cor pulmonale (R)