Exam 2 Review

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Exam 2 Review Kristine Krafts, M.D. October 20,
2008
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(No Transcript)
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What is atherosclerosis?

• Disease of arterial intima
• Plaques (lipid core, fibrous cap)
• Obstruct vessel, weaken wall, lead to
  atheroembolism
• Responsible for half of all deaths in US

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What are the major risk factors for
atherosclerosis?

• Age (older)
• Gender (male)
• Family history
• Genetic abnormalities
• Hyperlipidemia
• Hypertension
• Smoking
• Diabetes

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What are the complications of atherosclerosis?

• Stenosis
• Thrombosis/embolism
• Aneurysm
• Calcification (brittle)

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What is ischemic heart disease?

• Excess O2 demand/inadequate supply
• 4 clinical diseases
• Angina
• MI
• Sudden death
• Congestive heart failure

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What are the causes of ischemic heart disease?

• Atherosclerosis (most cases)
• Increased O2 demand (exercise, pregnancy)
• Decreased O2 transport (anemia, lung disease)

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What is a myocardial infarction (MI)?

• Death of myocytes due to lack of blood

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What, in general terms, happens in the heart
tissue in the first 24 hours after an MI? What
happens after that?

• First 24 hours coagulative necrosis, hemorrhage,
  neutrophils come in.
• Then neutrophils die off, granulation tissue
  starts. Scar forms at about the end of the first
  month.

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What are some complications of MI?

• Nothing.
• Arrhythmia and sudden death
• Heart failure
• Heart wall thrombus or embolism
• Heart aneurysm
• Heart rupture

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What are the 4 kinds of idiopathic cardiomyopathy?

• Dilated
• Hypertrophic
• Restrictive
• Arrythmogenic right ventricular
  dysplasia/cardiomyopathy

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What are some features of dilated cardiomyopathy?

• Commonest form
• Big, dilated heart that contracts poorly
• Young people, short course
• Death from CHF, embolism, arrhythmia

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What are some features of
hypertrophic cardiomyopathy?

• Huge, hypertrophied left ventricle
• Half are hereditary
• Myocyte disarray
• Death is sudden, from obstruction or arrhythmia

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What are some features of restrictive
cardiomyopathy?

• Ventricles stiff, dont fill well
• Lots of causes amyloidosis, sarcoidosis,
  hemochromatosis, fibrosis

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Amyloidosis

• Amyloid an insoluble protein with a particular
  structure
• Looks pink on H E, shows apple-green color with
  congo red stain
• Amyloidosis the deposition of amyloid in
  different organs
• Many diseases have some amyloid deposition
  (myeloma, Alzheimers, Mad cow disease, medullary
  thyroid carcinoma)

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Amyloid H E (left) and congo red (right)
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Sarcoidosis

• Immune disease characterized by non-caseating
  granulomas
• Young adults
• Lungs, lymph nodes
• Variable clinical course

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Sarcoidosis Non-caseating granulomas
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Hemochromatosis

• Hereditary defect ? iron overload
• MgtF, 50s
• Cirrhosis, diabetes, heart problems
• Phlebotomy, iron chelators, diet

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What are some features of arrhythmogenic right
ventricular dysplasia/ cardiomyopathy?

• Sudden death in young people
• Thin right ventricular wall (replaced by fat)
• Arrhythmias from poor conduction in thin wall

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What are some features of myocarditis?

• Inflammation of myocardium
• Often viral
• Fatigue, palpitations, sudden death
• Most resolve

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What are the common heart tumors?

• Most heart tumors are metastases from somewhere
  else
• Primary heart tumors are rare myxoma is the most
  common of these

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What sorts of things can happen in the
pericardium?

• Effusion (non-inflammatory fluid)
• Hemopericardium (blood)
• Acute fibrinous pericarditis (fibrin and
  inflammation)
• Constrictive pericarditis (dense fibrosis from a
  healed infection)

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What happens in left heart failure?

• Blood backs up in lungs
• Get pulmonary edema

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What happens in right heart failure?

• Blood backs up in rest of body
• Get increased jugular venous pressure, congested
  liver, ascites, peripheral edema.

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What are 4 diseases causing hardening of the
arteries (arteriosclerosis)?

• Atherosclerosis (most important)
• Senile arteriosclerosis
• Monckeberg sclerosis
• Hypertensive arteriolosclerosis

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What is senile arteriosclerosis?

• Changes happen as a result of aging
• Distention, tortuousity of big elastic arteries
• Intimal thickening of muscular arteries
• Fibrosis, loss of medial muscle

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What is Monckeberg sclerosis?

• Disease of elderly
• Thickening, calcification of media
• No intimal changes

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What are the two types of hypertensive
arteriosclerosis?

• Hyaline form (hyaline material in vessel) seen
  in benign hypertension
• Hyperplastic form (concentric fibrosis, fibrinoid
  necrosis of vessel) seen in malignant
  hypertension

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What is an aneurysm, and what causes it?

• Localized, abnormal dilation of part of a vessel
  (usually an artery)
• Caused by wall weakening, or excessive blood flow
  force, or both

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What are true and false aneurysms?

• True still has a bit of vessel wall in it
• False no vessel wall left just a pulsating
  hematoma covering a hole in the artery

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What is a fusiform aneurysm?

• Whole circumference of the artery is dilated
• Usually abdominal aorta
• Commonest aneurysm in elderly
• Caused by atherosclerosis

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What is a saccular aneurysm what causes it,
and what is one example?

• Only a part of the circumference of the artery is
  dilated
• Caused by medionecrosis, hypertension, arteritis
• Example berry aneurysm in brain

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What are some complications of these aneurysms?

• Pressure on adjacent structures
• Rupture
• Thrombosis
• Embolism

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What is a dissecting aortic aneurysm, and what
causes it?

• The aortic wall tears a little, and blood pours
  into the wall, tunneling up or down or both.
• Causes medionecrosis, hypertension, trauma

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What are some complications of dissecting aortic
aneurysms?

• External rupture, possibly into pericardial space
• Occlusion of aortic branches
• Dissection down aortic branches

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What are the two kinds of cardiac aneurysms?

• True (aneurysm in area of healed MI doesnt
  rupture)
• False (ruptured heart wall with pericardium
  covering the hole very likely to rupture)

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What is the most common congenital heart
abnormality?

• Ventricular septal defect

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What happens in ventricular septal defect?

• Get flow from left into right ventricle
• so increased pulmonary flow
• Half close spontaneously in first year

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What is tetralogy of Fallot?

• Most common form of cyanotic heart disease
• Four components
• VSD
• Pulmonary stenosis
• Overriding aorta
• RV hypertrophy
• So get a right to left shunt, with decreased
  pulmonary flow, and cyanosis

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Normal
Tetralogy of Fallot
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What is valve stenosis? Insufficiency?

• Stenosis valve doesnt open fully (get
  obstruction to blood flow)
• Insufficiency valve doesnt close fully (get
  backward flow)

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What are some features of aortic valve stenosis?

• An degenerative, calcific change in the aorta
  that occurs in older people
• Big calcific masses in aortic valve obstruct
  blood flow to body
• May result in sudden death

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What are some features of mitral valve prolapse?

• Common
• Most cases age 20-40
• Usually asymptomatic
• But predisposes to infective endocarditis, mitral
  insufficiency, arrhythmia, sudden death

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What causes infective endocarditis?

• Usually occurs on an abnormal valve
• Most of the time, bacterial (strep or staph)
• Less commonly fungal or viral organisms

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What are the risk factors for infective
endocarditis?

• Pre-existing abnormal valve (for whatever reason)
• Prosthetic valve
• Dental procedures
• Surgery
• IV drug use

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What is the clinical course of infective
endocarditis?

• Subacute bacterial endocarditis low-virulence
  organism course is prolonged (untreated patients
  die after 6th week)
• Acute bacterial endocarditis virulent organism
  (untreated patients die within 6 weeks) patient
  appears acutely ill
• 5y survival in both is 50-90.

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Dermal Abscess - Staphylococcus aureus
Splinter hemorrhages in bacterial endocarditis
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What is rheumatic heart disease?

• An acute, recurrent inflammatory disease
  occurring 10-20 days after group A strep
  infection
• Antibodies to strep cross-react with heart
• All layers of the heart can be involved
  endocardium, myocardium, pericardium
• Most important consequence is valvular disease
  (especially mitral valve). Get vegetations and
  chronic inflammation, leading to mitral stenosis