cvs 2
DESCRIPTION
pathoTRANSCRIPT
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CARDIOVASCULAR SYSTEMDr. Atifa Shuaib
Associate Professor of Pathology
Rawalpindi Medical College
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CARDIOVASCULAR SYSTEM
Diseases of Blood vessels
Diseases of Heart
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Diseases of blood vessels
Congenital anomalies
Arteriosclerosis
Hypertensive vascular disease
Aneurysms & Dissections
Vasculitis
Tumors
CARDIOVASCULAR SYSTEM
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ARTERIOSCLEROSIS:
Atherosclerosis
Monckeberg medial calcific sclerosis
Arteriolosclerosis
CARDIOVASCULAR SYSTEM
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Fatty streaks Aortas of children
Risk factors Atheroma in adults
↓ ↓
Ischaemic Heart Disease
CARDIOVASCULAR SYSTEM
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ATHEROSCLEROSIS
CARDIOVASCULAR SYSTEM
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RISK FACTORS:
Non Modifiable
Modifiable
CARDIOVASCULAR SYSTEM
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NONMODIFIABLE:Age:
advancing ageSex:
males > femalespostmenopausal risk equal
Genetics:familial predisposition
CARDIOVASCULAR SYSTEM
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MODIFIABLE:
Hyperlipidemia:
hypercholesterolemia
LDL (bad cholesterol)
HDL (good cholesterol)
↓ by exercise
↑ by obesity & smoking
CARDIOVASCULAR SYSTEM
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Diet
↑ cholesterol egg yolk, butter, animal fat
↓ cholesterol omega 3 FA
Statins ↓ cholesterol
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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Hypertension:>169/95 mm Hg 5 fold ↑ risk
Smoking:200% ↑ death rate
Diabetes Mellitis:hypercholesterolemiatwice ↑ risk MIgangrene lower limbs (200% risk)
CARDIOVASCULAR SYSTEM
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Others:homocystinuriainflammationlipoprotein a (Lp a)lack of exercisestressful lifetype A personalityobesity
CARDIOVASCULAR SYSTEM
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Multiple risk factors Multiplicative effect
CARDIOVASCULAR SYSTEM
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participants had increases in HDL cholesterol averaging about 2.5 mg/dL. This increase in HDL cholesterol was only modest, but was statistically significant. Furthermore, since cardiac risk is thought to drop by two to three percent for each 1 mg/dL increase in HDL, a 2.5 mg/dL rise in HDL amounts to a substantial reduction in risk.
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Exercise is involved in increasing the production and action of several enzymes that function to enhance the reverse cholesterol transport system (Durstine & Haskell 1994). The precise mechanisms are unclear, but evidence indicates that other factors including diet, body fat, weight loss, and hormone and enzyme activity interact with exercise to alter the rates of synthesis, transport and clearance of cholesterol from the blood (Durstine & Haskell 1994).
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PATHOGENESIS:
“response to injury hypothesis”
A disease of intima
Chronic inflammation of arterial wall in
response to injury to endothelium
CARDIOVASCULAR SYSTEM
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Chronic endothelial injury activation Accumulation of lpoproteins (LDL) Oxidation of LP Monocyte migration macrophage
accumulation Foam cells
CARDIOVASCULAR SYSTEM
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Platelet adhesion Chemical mediator release Smooth muscle cells migration SMCs proliferation ECM deposition Lipid accumulation
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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1. Endothelial injury (repetitive):endothelial dysfunction ? injuryrepetetive non denudingtoxins, chemical mediators, infectionshemodynamic disturbance sites of ostia and bifurcationposterior wall of abdominal aortahypercholesterolemia
CARDIOVASCULAR SYSTEM
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2. Inflammation (chronic):initiation - complicationsendothelial cell adhesion moleculesVCAM-1monocyte adhesion & migrationmacrophage accumulation in intimafoam cell formationIL-1, TNFMCP-1
CARDIOVASCULAR SYSTEM
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Macrophages toxic oxygen species oxidation of lipids GF smooth muscle cell proliferationT lymphocytes cellular & humoral
3. Lipids:cholesterol & its esters in atheromasOxidized LDL in macrophages
CARDIOVASCULAR SYSTEM
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genetic defects hypercholesterolemia AS
MI at young age with ↑ cholesterol
DM, hypothyroidism ↑ cholesterolAS
high cholesterol diet AS
severity of AS levels of cholesterol
↓ing cholesterol levels risk of AS ↓
CARDIOVASCULAR SYSTEM
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Mechanism :1. Chronic hyperlipidemia EC activation2. Chronic hyperlipidemia LP accumulate in intima3. Oxidized LDL macrophages foam cells
monocyte accumulation GF, cytokine release Ecs, SMCs cytotoxicity
CARDIOVASCULAR SYSTEM
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4. Smooth muscle cells:SMCs migration proliferation & ECM deposition
↓Fatty streak fibrofatty atheromatous plaquePDGF, TGF-a, FGFFoam cellsECM (collagen) depositedSMCs apoptosis
CARDIOVASCULAR SYSTEM
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MORPHOLOGY:
Fatty streak:
children aortas
coronaries in adolescents
multiple, flat yellow dots
coalesce to streaks
lipid laden foam cells
CARDIOVASCULAR SYSTEM
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FATTY STREAK
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Atheromatous plaque:elastic & muscular arterieslower abdominal aorta > thoracic aortaostia and branchessymptomatic AS disease
MI heart attackcerebral infarction strokeperipheral vascular gangrene
CARDIOVASCULAR SYSTEM
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aorta > coronaries > popliteal > internal carotid > circle of willis
white – white yellow
variable size
eccentric lesions
obstruction of lumen
CARDIOVASCULAR SYSTEM
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Mild, Moderate, Severe AS
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Components:
1. Cells:
SMCs
macrophages
T lymphocytes
other leukocytes
CARDIOVASCULAR SYSTEM
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2. ECM:
collagen
elastic fibers
proteoglycans
3. lipids:
intracellular
extracellular
CARDIOVASCULAR SYSTEM
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Plaque change:enlargementulceration/erosionrupturethrombosisembolismhaemorrhagecalcificationaneurysmal dilation
CARDIOVASCULAR SYSTEM
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ARTEIOLOSCLEROSIS:Small Bv, arterioles
Hyaline homogenous pink hyaline thickeningnarrowed lumenelderlyHypertensionBenign nephrosclerosis
CARDIOVASCULAR SYSTEM
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microangiopathy of DM
Hyperplastic:
malignant HTN
onion skin
concentric, laminated thickening
SMCs & thickened BM
necrotizing arteriolitis
CARDIOVASCULAR SYSTEM
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ANEURYSM:
Localized abnormal dilation of a blood vessel or
heart.
True aneurysm
all layers of Bv or heart
False aneurysm (pseudoaneurysm)
extravascular hematoma
CARDIOVASCULAR SYSTEM
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Causes:AtherosclerosisCystic medial degenerationTrauma (A-V aneurysms)Congenital defects (berry aneurysms)Infections (mycotic)Vasculitis
CARDIOVASCULAR SYSTEM
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Types:SaccularFusiform
Sites:Abdominal aortacommon iliac AArch of aortadescending thoracic aorta
CARDIOVASCULAR SYSTEM
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Mycotic aneurysm:
septic embolus
direct extension
bacteraemia
CARDIOVASCULAR SYSTEM
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ABDOMINAL AORTIC ANEURYSMS(AAA):Atherosclerosis> 50 yrs> malesgenetic susceptibility ↓ connective tissue
strengthMMP TIMPHTN
CARDIOVASCULAR SYSTEM
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Morphology:
B/W bifurcation & renal arteries
saccular/fusiform
variable size
thromboemboli
occlusion of ostia
CARDIOVASCULAR SYSTEM
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Variants:
Inflammatory AAA
dense periaortic fibrosis
inflammatory cells (lymphos, plasma cells)
Mycotic AAA
AS AAA + bacteremia
Salmonella gastroentritis
CARDIOVASCULAR SYSTEM
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Complications:
Rupture
Obstruction adjacent BV
Embolism
Compression adjacent structures
Abdominal mass
CARDIOVASCULAR SYSTEM
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SYPHILITIC ANEURYSM:
Leutic
Obliterative endartritis
vasa vasorum
lymphocytes & plasma cells
syphilitic aortitis
CARDIOVASCULAR SYSTEM
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weakening of media
tree barking
aortic valve insufficiency
cor bovinum (cow’s heart)
CARDIOVASCULAR SYSTEM
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AORTIC DISSECTION
“Dissection of blood between & along laminar planes of media”
1. HTN 40-60 yrs males
2. CT defects young age
3. Iatrogenic
4. Pregnancy
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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Morphology:
intimal tear
10 cm from aortic valve
transverse / oblique
sharp edges
extension
dissecting hematoma
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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rupture out pericardial, pleural, peritonealdouble barreled aortacystic medial degeneration cystic medial necrosis
Classification:Type A: Proximal
III
Type B: Distal
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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VASCULITIS:
Inflammation of vessel wall.
Infectious
direct invasion
immune mechanism
Immune mediated
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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PATHOGENETIC CLASSIFICATION:Direct infection:
Bacterial, Rickettsial, Spirochetal, Fungal, ViralImmunologic:
immune complex mediatedANCA mediatedDirect antibody mediatedCell mediated
Unknown
CARDIOVASCULAR SYSTEM
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CLASSIFICATION ACCORDING TO SIZE:
Large vessel
Medium sized vessel
Small vessel
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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TYPES:
Granulomatous
granuloma formation
giant cells
Necrotizing
fibrinoid necrosis
fibrous thickening of wall
CARDIOVASCULAR SYSTEM
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TUMORS OF BLOOD VESSELS:Vascular malformations
HamartomasReactive vascular proliferations
Bacillary angiomatosisBenign tumors:Blood/lymphatic filled channelsTransudateEndothelial lining without atypia
CARDIOVASCULAR SYSTEM
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Malignant tumors :
More solid & cellular
Atypia ++
Mitotic figures
No well formed vascular channels
CARDIOVASCULAR SYSTEM
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Benign:Hemangioma
capillarycavernouspyogenic granuloma
Lymphangiomasimplecavernous
CARDIOVASCULAR SYSTEM
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Glomus tumor
Vascular ectasias
nevus flamus
spider telangiectasia
hereditary haemorrhagic telangiectasia
reactive vascular proliferations
bacillary angiomatosis
CARDIOVASCULAR SYSTEM
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Intermediate grade tumors:
Kaposi sarcoma
Hemangioendothelioma
Malignant neoplasms:
Angiosarcoma
Hemangiopericytoma
CARDIOVASCULAR SYSTEM
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HEMANGIOMA:
localized
superficial
head & neck
internal
angiomatosis
7% of benign childhood tumors
CARDIOVASCULAR SYSTEM
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Capillary hemangioma:Gross:
skin, sub-cutaneous tissue, mucus membranesliver, spleen, kidneysvariable sizebright red – blueelevatedintact epithelium
CARDIOVASCULAR SYSTEM
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Histologically:lobulatedunencapsulatedclosely packedthin walled capillariesflat endotheliumscanty stromathrombosed lumen
CARDIOVASCULAR SYSTEM
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Strawberry hemangioma
newborns
grows and regresses
CARDIOVASCULAR SYSTEM
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Cavernous hemangioma:
less common
larger
less well circumscribed
deep structures
locally destructive
CARDIOVASCULAR SYSTEM
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Gross:red-bluespongy1-2 cm
Histologically:sharply definednot encapsulatedlarge cavernous vascular spaces
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blood filled
scanty stroma
intravascular thrombosis
dystrophic calcification
CARDIOVASCULAR SYSTEM
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GLOMUS TUMOR:Benign PainfulGlomus bodyDistal part of digitsSmall, elevated, roundRed-blue firm nodulesBranching vascular channelsAggregates/nests of glomus cells around BV
IOVCARDASCULAR SYSTEM
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KAPOSI’S SARCOMA:1. Chronic/Classic/European
Kaposi in 1872older mennot associated with HIVhomosexual menmultiple red – purple skin plaques/nodulesarms & legs
CARDIOVASCULAR SYSTEM
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gradual spread
asymptomatic & localized
visceral involvement 10%
2. Lymphadenopathic/African/Endemic:
Bantu children of SA
lymphadenopathy
aggressive
CARDIOVASCULAR SYSTEM
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3. Transplant associated/immunosuppression associated:
months-years post transplant
aggressive
lymph node, mucosa, viscera
internal involvement fatal
CARDIOVASCULAR SYSTEM
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4. AIDS associated:1/3rd AIDS patientswide dissemination
Morphology:3 stages: Patch
pink-red-purplesingle/multiple macules
CARDIOVASCULAR SYSTEM
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distal lower extremitiesdilated, irregular angulated BVendothelial cell linedlymphocytes, plasma cells, macrophages
Plaqueslarger, violaceousraiseddermal dilated vascular channels
CARDIOVASCULAR SYSTEM
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plump spindle cell lining
perivascular aggregates of spindle cells
red cells
hemosiderin laden macrophages
lymphocytes, plasma cells
pink hyaline globules in spindle cells
mitotic figures
CARDIOVASCULAR SYSTEM
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Nodulesneoplasticsheets of plump spindle cellsproliferate in dermis, sub-cutaneous tissueslit like spaces & small Bvhemosiderin , macrophagesmitotic figuresLN + viscera
CARDIOVASCULAR SYSTEM
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Pathogenesis:
HHV-8/KSHV latent infection
immunosuppression ↓ apoptosis endothelial cells (p53)
↑ cell proliferation
CARDIOVASCULAR SYSTEM
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DISEASES OF HEART:
Mechanisms of Cardiac dysfunction:
1. Pump failure
2. Outflow obstruction
3. Regurgitant flow
4. Conduction defects
5. Disruption of circulation
CARDIOVASCULAR SYSTEM
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Genetics environment
CARDIOVASCULAR SYSTEM
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HEART FAILURE (Congestive heart failure):Forward failure (↓ CO) orBackward failure (venous damming) orBothMyocardial hypertrophy:
permanent cellsno hyperplasiahypertrophy
CARDIOVASCULAR SYSTEM
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CARDIAC HYPERTROPHY:
Pressure overload hypertrophy
concentric hypertrophy
HTN, aortic stenosis
thickened left vent wall ↓ chamber
sarcomere deposition parallel
cross sectional area of myocyte ↑ not length
CARDIOVASCULAR SYSTEM
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Volume overload hypertrophy:
ventricular dilation
wall thickness chamber diameter
sarcomere deposition parallel & vertical
↑ thickness & length
CARDIOVASCULAR SYSTEM
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“ Structure of hypertrophied heart is not normal. It is a tight balance between adaptation and deleterious alterations ( ↓ capillary-to-myocyte ratio, ↑ fibrous tissue & synthesis of abnormal proteins). Thus sustained cardiac hypertrophy evolves into cardiac failure.”
CARDIOVASCULAR SYSTEM
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Molecular & cellular changes that initially mediate enhanced function later contributes to heart failure.
Physiologic hypertrophy.
Pathologic hypertrophy.
CARDIOVASCULAR SYSTEM
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Left sided heart failure:
Causes:
IHD
HTN
Aortic, mitral valvular disease
non ischemic MC disease
CARDIOVASCULAR SYSTEM
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Morphology:
Evidence of cause
enlarged size
↑ left vent wall thickness
secondary effects on atria
CARDIOVASCULAR SYSTEM
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Extracardiac effects:
1. Pulmonary congestion & edema
heavy, wet lungs
interstitial transudate Kerly’s B lines
widening of alveolar septa
edema in alveolar spaces
heart failure cells
CARDIOVASCULAR SYSTEM
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dyspnea
orthopnea
paroxysmal nocturnal dyspnea
2. Kidneys
↓ renal perfusion
pre renal azotemia
CARDIOVASCULAR SYSTEM
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3. Brainhypoxic encephalopathy
Right sided heart failure:Causes
left sided heart failurechronic severe pulmonary HTN
(cor pulmonale)
CARDIOVASCULAR SYSTEM
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Morphologyengorgement of systemic & portal venous systems
1. Liver & portal system:congestive hepatomegalycentrilobular necrosiscardiac sclerosis / cardiac cirrhosiscongestive splenomegaly
CARDIOVASCULAR SYSTEM
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2. Kidneys:severely affectedpronounced azotemia
3. Brain:venous congestion & hypoxia
4. Pleural & pericardial space:effusions
5. Subcutaneous tissues:edema (pedal)anasarca
CARDIOVASCULAR SYSTEM
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Heart disease:
Congenital heart disease
Ischemic heart disease
Hypertensive heart disease
Valvular heart disease
Myocardial disease
CARDIOVASCULAR SYSTEM
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ISCHEMIC HEART DISEASE (IHD):
↓ oxygen supply
↓ nutrient supply
↓ removal of waste
90% coronary atherosclerosis CAD
CARDIOVASCULAR SYSTEM
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4 clinical manifestations of IHD:
1. Myocardial Infarction
2. Angina Pectoris
3. Chronic IHD
4. Sudden cardiac death
Acute Coronary Syndromes (1, 2, 4)
CARDIOVASCULAR SYSTEM
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Leading cause of death
50% reduction in IHD related mortality in USA
Prevention
Early diagnosis (advanced facilities)
Therapeutic intervention (effective, safer)
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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PATHOGENESIS:
Demand supply
↑↑ ↓↓
↓ ISCHEMIA
CARDIOVASCULAR SYSTEM
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AS obstruction fixed / stable obstruction
plaque change ↓
↓ ↓
ISCHEMIA
75% obstruction symptomatic on ↑ demand
90% obstruction symptomatic at rest
CARDIOVASCULAR SYSTEM
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Role of acute plaque change:Rupture/ulcerationErosion/fissuring thrombosisHaemorrhageIntrinsic influences
structure & composition of plaqueextrinsic influences
blood pressure, Plt reactivity
CARDIOVASCULAR SYSTEM
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Structure of plaqueVulnerable plaque
↑ foam cells↑ extracellular lipidsthin fibrous capsfew SMCsinflammatory cell clusters
Junction of fibrous cap & adjacent endothelium
CARDIOVASCULAR SYSTEM
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Collagen deposition degradationmetalloproteinases by macrophages
Adrenergic stimulation systemic HTN & plt reactivity stress on plaques
Early morningEmotional stress
CARDIOVASCULAR SYSTEM
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Role of inflammation:
All stages of AS
Macrophages & T lymphocytes
IL-1, IL-6, TNF, INF g
Metalloproteinses weaken plaque
Inflammation destabilizes plaque
CARDIOVASCULAR SYSTEM
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Role of coronary thrombus:
Partial / total acute coronary syndromes
Mural branch thrombus embolize
Microinfarcts
Role of vasoconstriction:
Potentiate plaque change
CARDIOVASCULAR SYSTEM
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ANGINA PECTORIS:
“A symptom complex of IHD cahracaterized by recurrent attacks of substernal/precordial chest discomfort caused by transient MC ischemia that falls short of inducing infarction.”
CARDIOVASCULAR SYSTEM
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TYPES:
Stable / typical
Unstable / crescendo
Prinzmetal / variant
CARDIOVASCULAR SYSTEM
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STABLE ANGINA:
Chronic stenosing atherosclerosis ↓ coronary perfusion
↑ demand MC ischemia
Triggered by exercise, stress
Relieved by rest, nitroglycerine
CARDIOVASCULAR SYSTEM
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UNSTABLE ANGINA:
Progressively ↑ing frequency
At rest
Prolonged duration
Disruption of stable atheroma thrombosis
Embolization, vasospasm
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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PRINZMETAL ANGINA:
Uncommon
Episodic
At rest
Coronary vasospasm
Responds to vasodilators
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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MYOCARDIAL INFARCTION:
“Heart attack”
Death of cardiac muscle due to ischemia.
Transmural infarction
Subendocardial infarction
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEMTRANSMURAL SUBENDOCARDIAL
Full thickness of MC Inner 1/3rd or half
AS plaque change thrombosis
As plaque change thrombosis recanalized
Hypotension / shock on chronic stenosing AS
Limited to area of supply Can extend beyond
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Incidence & risk factors:
Any age
Risk factors of AS
Pathogenesis:
Coronary artery occlusion
Acute plaque change thrombosis VC
↑ size of thrombus complete occlusion
CARDIOVASCULAR SYSTEM
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10% MI not associated with AS plaque change. Vasospasm Emboli (paradoxical emboli) Unexplained (vasculitis, Hg defects, amyloid)
CARDIOVASCULAR SYSTEM
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Myocardial response:
Biochemical
Functional
Morphological
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM FEATURE TIME
ATP depletion Seconds
Loss of contractility < 2 min
ATP reduced to 50%
10%
10 min
40 min
Irreversible cell injury 20 – 40 min
Microvascular injury > 1 hr
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Early identificationReperfusion
30 min reversible injuryMC ischemia subendocardial zoneWavefront progression transmural Necrosis within 6 hrsGrossly visible after 12 hrs
CARDIOVASCULAR SYSTEM
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Factors influencing MI:1. Site, size, rate of development of AS2. Size of vascular bed3. Duration4. Mc demands5. Collateral circulation6. Coronary artery spasm7. BP, HR, cardiac rhythm
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEMMorphology:
Left ventricle > right ventricle
Rim of subendocardium preserved
LAD 40 – 50% Ant wall left vent, apex, ant septum
RCA 30 – 40% Inf-post wall lt vent, post septum, post right vent
LCA 15 – 20% Lat wall left vent
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CARDIOVASCULAR SYSTEMTIME GROSS MICROSCOPIC
0 – ½ hr ----- myofibril relaxation, swelling of mitochondria
½ - 4 hr ----- Wavy fibers
4 – 12 h Occ dark mottling Coag necrosis, edema, hge
12-24 h Dark mottling Necrosis, pyknosis,myocyte eosinophilia, contraction bands, neutrophils
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CARDIOVASCULAR SYSTEM1 -3 days Mottling + yellow
centreLoss of nuclei & striations, PMNs ++
3 – 7 days Red border, yellow tan center
Disintegration, phagocytosis
7 – 10 days
Max yellow soft center, red borders
Phagocytosis ++, granulation tissue at margins
10-14 days
Red-gray depressed
Granulation tissue ++, collagen +
2 – 8 wks Grey white scar ↑ collagen, ↓ cellularity
> 2 month Complete scar Dense collagenous scar
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1 day MI showing contraction band
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1-2 days
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3-4 day
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1-2 wks
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Healing infarct
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Reperfusion injury/Myocardial stunning:
Restoration of coronary flow reperfusion
Ischemia variable effects on MC
Reperfusion salvage
damage O2 free radicals
haemorrhage
apoptosis
CARDIOVASCULAR SYSTEM
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Persistence of biochemical & functional changes
in reperfused MC stunned MC
CARDIAC ENZYMES:
CPK (MM, MB, BB)
AST
LDH
Troponins
CARDIOVASCULAR SYSTEM
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Complication of MI:1. Contractile dysfunction crdiogenic shock2. Arrhythmias3. MC rupture cardiac rupture syndrome4. Pericarditis5. Right ventricular infarction6. Extension7. Mural thrombosis8. Ventricular aneurysm9. Papillary muscle dysfunction10. Progressive late heart failure
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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BE GENTLE WITH THE EARTH
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RHEUMATIC FEVER & HEART DISEASE
“A multisystem inflammatory disease having an
acute onset with underlying immune
pathogenesis occurring few weeks after streptococcal pharyngitis.”
Acute Rheumatic carditis Rheumatic heart disease
CARDIOVASCULAR SYSTEM
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Children (5-15 yrs)
10 days – 6 weeks
Arthritis & carditis
Relapsing course
Chronic Rheumatic Carditis
CARDIOVASCULAR SYSTEM
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PATHOGENESIS:
Group A Streptococcal throat infection
↓
Antibodies M component streptococci
↓
Cross react glycoprotein antigens
Heart, joints, skin, brain
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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RF characterized by:
Migratory polyarthritis
Carditis
Subcutaneous nodules
Erythema marginatum
Sydenham chorea
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM
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MORPHOLOGY:Acute RF Focal inflammatory lesions Aschoff bodies
swollen eosinophilic collagenT lymphocytes, plasma cellsmacrophages Anitschkow cells
abundant cytoplasmcentral round/oval nucleuscentral slender chromatin caterpillar cellsAschoff giant cells
CARDIOVASCULAR SYSTEM
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Pancarditis
Bread & Butter Pericarditis
Myocarditis Perivascular Aschoff nodules
Verrucae/vegetations on valves
fibrinoid necrosis
MacCallum Plaques (left atrium)
CARDIOVASCULAR SYSTEM
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Chronic Rheumatic Heart Disease:Organization of acute inflammationLeaflet thickeningCommissural fusionThickened, short & fused cordae tendinaeProgressive fibrosisButtonhole deformityFish mouth appearance
CARDIOVASCULAR SYSTEM
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Mitral stenosis:
99% cases due to RHD
RHD 65% - 70 % alone
with aortic valve 25%
Atrial dilation mural thrombosis
Pulmonary vascular changes
CARDIOVASCULAR SYSTEM
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INFECTIVE ENDOCARDITIS:Severe infection of endocardium and heart
valvesVegetations (thrombotic debris &
microorganisms)Clinical classification:
AcuteSubacute
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEM ACUTE IE SUBACUTE IE
Healthy valves Diseased/prosthesis
Highly virulent organisms Low virulence
Acute & severe Insidious
50% mortality Recovery common
Destructive necrotizing Less destructive
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PATHOGENESIS:Valvular diseases (RHD, prolapse, degenerative
calcific stenosis)Immune compromised statesAetiology:
Strep viridans (50-60%) defective valvesStaph Aureus (10-20%) healthy.defective
I/V drug abusers
CARDIOVASCULAR SYSTEM
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HACEK group
Staph epidermidis prosthetic valve IE
gram –ive bacilli
fungi
culture negative
CARDIOVASCULAR SYSTEM
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MORPHOLOGY:
Bulky, Friable, Destructive vegetations
Single/multiple
Fibrin & inflammatory cells
Aortic & mitral valves
Ring abscess
CARDIOVASCULAR SYSTEM
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Fungal Endocarditis
larger vegetations
Systemic emboli Septic infarcts
SIE granulation tissue at base
LIBMAN-SACKS ENDOCARDITIS:
Endocarditis of SLE
CARDIOVASCULAR SYSTEM
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Dukes Diagnostic Criteria for IE:Pathologic:
+ culturesvegetation histologyintracardiac abscess
Clinical:Major:
+ blood cultureEchocardiographic findings, valvular defects
CARDIOVASCULAR SYSTEM
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Minor:
predisposing heart lesion
vascular lesions
immunologic phenomena
cultures
echocardiographic
CARDIOVASCULAR SYSTEM
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CARDIOMYOPATHIES:
Intrinsic disease of myocardium:
Myocarditis
Immunologic
Systemic metabolic
Muscular dystrophies
Genetic abnormalities
CARDIOVASCULAR SYSTEM
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Heart disease resulting from a primary
abnormality in the myocardium Cardiomyopathy
Dilated cardiomyopathy (DCM) Hypertrophic cardiomyopathy (HCM) Restrictive cardiomyopathy (RCM)
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEMDCM HCM RCM
Commonest 90% Least common
Systolic dysfunction
Diastolic dysfunction
Diastolic dysfunction
Dilated heart obstructive CM Compliance ↓
Hypertrophied Hypertrophy ++ Normal
Hypocontracting hypercontracting Normal
Heavy, large, flabby
Banana-like cavity left vent
-----
Thin walls Thick septum++ ----------
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CARDIOVASCULAR SYSTEM
Dilated No dilation -----
Thrombosis Mural palque ------
Hypertrophied cells/attenuated
Hypertrophy ++
Myofiberdisarray
------
fibrosis Fibrosis Patchy/diffuse fibrosis +
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Causes:
Idiopathic
Genetic abnormalities in MC metabolism
Myocarditis
Alcohol
Pregnancy associated
Genetic influences
CARDIOVASCULAR SYSTEM
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DCM HCMGenetic(30-40%) 100% genetic
↓ Non genetic ↓↓ ↓ ↓
Force generation ↓ force generation ↓ DCM phenotype HCM phenotype
↓ ↓heart failure, sudden death, atrial fib, stroke
CARDIOVASCULAR SYSTEM
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MYOCARDITIS:Infections:
Viruses (coxsackie, ECHO, influenza, HIV)ChlamydiaRickettsiaeBacteriaFungiProtozoaHelminths
CARDIOVASCULAR SYSTEM
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Immune mediatedpost viralpost streptococcal (RF)SLEDrugsTransplant rejection
Unknownsarcoidosisgiant cell myeloma
CARDIOVASCULAR SYSTEM
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Morphology:
Hypertrophy, dilated, flabby
Diffuse/patchy
Mottled
Mural thrombi
Interstitial inflammatory infiltrate (mononuclear)
Focal necrosis
CARDIOVASCULAR SYSTEM
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Hypersensitivty MC perivascular lymphocytes
Macrophages, eosinophils
Giant cell myocarditis giant cells, lympho, eos
plasma cells, macrophages
CARDIOVASCULAR SYSTEM
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PERICARDITIS:
Acute
Serous
Fibrinous
Purulent
Haemorrhagic
Caseous
CARDIOVASCULAR SYSTEM
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Chronic:Adhesive mediatinopericarditisConstrictive pericarditis
CAUSES:Infectious (viruses, bacteria, TB, fungi)Immunologic (RF, SLE, scleroderma, post MI,(dresslers syndrome) drugsMiscellaneous (MI, uremia, cardiac surgery, neoplasia,
trauma, radiation)
CARDIOVASCULAR SYSTEM
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TUMORS OF HEART:Primary (rare)Secondary/metastatic (5% dying patients)Benign:
MyxomaFibromaLipomaPapillary fibroelastomaRhabdomyomas
Malignant:Angiosarcoma & other SAs
CARDIOVASCULAR SYSTEM
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MYXOMA:Commonest primary tumor90% in atria Atrial MyxomaLeft : right = 4 : 1SingleNear fossa ovalis<1 – 10 cmSessile / pedunculated wrecking ball effect embolize
CARDIOVASCULAR SYSTEM
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Hard – soft gelatinous
Stellate cells (lepidic cells)
Endothelial cells
SMCs
Undifferentiated cells
Mucopolysaccharide ground substance ++
Endothelial covering
CARDIOVASCULAR SYSTEM
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HYPERTENSIVE HEART DISEASE (HHD)
An adaptive response
Systemic HTN left HHD
Pulmonary HTN right HHD
Systemic HHD:
1. Left ventricular hypertrophy
2. Evidence of HTN
CARDIOVASCULAR SYSTEM
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Pressure overload = afterload concentricHypertrophy↑ weightDefective diastolic fillingLeft atrial dilation↑ transverse diameter of myocyteVariation in cell sizeInterstitial fibrosis
CARDIOVASCULAR SYSTEM
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Pulmonary HHD:
COR PULMONALE
Right vent hypertrophy & dilation
Acute/chronic
Massive pulmonary embolism acute PHHD
Prolonged pulmonary overload chronic PHHD
CARDIOVASCULAR SYSTEM
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Acute:
Ventricle dilated ++
NO HYPERTROPHY
Ovoid shaped vent cavity
Chronic:
hypertrophy
CARDIOVASCULAR SYSTEM
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CONGENITAL HEART DISEASE:Ventricular septal defectsAtrial septal defectsPulmonary stenosisPatent ductus arteriosisCoarctation of aortaAV septal defectsTransposition of great arteriesTruncus arteriosisTricuspid atresia
CARDIOVASCULAR SYSTEM
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TETROLOGY OF FALLOT:
1. VSD
2. Sub-pulmonary stenosis
3. Overriding aorta over pulmonary stenosis
4. Right ventricular hypertrophy
CARDIOVASCULAR SYSTEM
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HYPERTENSIVE VASCULAR DISEASE:
HTN carries potential risk of
cardiac hypertrophy heart failure
coronary artery disease IHD
CVA
Genetic
Environmental factors
CARDIOVASCULAR SYSTEM
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CAUSES:Essential HTNSecondary HTN:
RenalAGNCRDpolycystic diseaserenal artery stenosisrenal vasculitisRenin producing tumors
CARDIOVASCULAR SYSTEM
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Endocrine:Adrenocortical hyperfunctionexogenous hoemonespheochromocytomaacromegalyhypothyroidismhyperthyroidismpregnancy induced
CARDIOVASCULAR SYSTEM
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Cardiovascular:
coarctation aorta
polyartritis nodosa
↑ intravascular volume
↑ CO
rigidity of aorta
CARDIOVASCULAR SYSTEM
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Neurologic:
psychogenic
↑ intracranial pressure
sleep apnea
acute stress
CARDIOVASCULAR SYSTEM
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PATHOGENESIS:
BP = CO x PR
CARDIOVASCULAR SYSTEM
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CARDIOVASCULAR SYSTEMThe mediocre teacher tells.The good teacher explains.
The superior teacher demonstrates.The great teacher inspires.
(William Arthur Ward)