Cardiology Flashcards
what is the main problem with atherosclerosis
plaque rupture - thrombus formation and partial/complete arterial blockage leading to heart attack
what is the best known risk factor for coronary artery disease
age
risk factors for atherosclerosis
age, tobacco smoking, high serum cholesterol, obesity, diabetes, hypertension, family history
where are atherosclerotic plaques most commonly distributed
peripheral and coronary arteries
what factors might govern the distribution of atherosclerotic plaque
- changes in flow/turbulence (bifurcations)
- wall thickness
- altered gene expression
what is found within an atherosclerotic plaque
- lipid
- Necrotic core
- Connective tissue
- Fibrous cap
what are the outcomes of an atherosclerotic plaque
it will either occlude the vessel lumen or it could rupture
what inflammatory cytokines can be found in plaques
IL-1, IL-6, IL-8, IFN-y, TGF-b, MCP-1 and C reactive protein
what are the steps in leukocyte recruitment and movement through the vessel wall
Capture
Rolling
Slow Rolling
Firm adhesion
Transmigration
what are the features of a fatty streak
- the earliest lesion of atherosclerosis
- Appear at a very early age (<10 years)
- consist of aggregations of foam cells and T lymphocytes within the intimal layer of the vessel
what are intermediate lesions
they progress from the fatty streak, containing foam cells, vascular smooth muscle cells, T lymphocytes, and platelet adhesion. They also contain isolates pools of extracellular lipid
what are the features of a fibrous cap (or advanced lesions)
- impedes blood flow
- prone to rupture
- covered by a dense fibrous cap made from
extracellular matrix proteins or collagen and elastin - contains a lipid core and necrotic debris
- may be calcified
what does a fibrous cap contain
smooth muscle cells
macrophages
foam cells
T lymphocytes
what causes a plaque rupture
if the balance is shifted and there are high inflammatory conditions, and increased enzyme activity, the cap becomes weak and the plaque can rupture
what is plaque erosion
this is where lesions tend to be small early lesions. A thickened fibrous cap may lead to collagen triggering thrombosis. A platelet-rich clot may cover the luminal surface and there is a small lipid core
what is a red thrombus
where there are red blood cells and fibrin present
what is a white thrombus
when there are platelets and fibrinogen present
what are the clinical characteristics that predispose someone to a plaque rupture
dyslipidemia
hypertension
diabetes Mellitus
chronic kidney disease
multi vessel disease
what can be done when someone gets a ruptured plaque
- stent implantation
- distal embolisation
what are clinical characteristics which predispose someone to plaque erosion
smoking
being female
being younger than 50
having anterior ischemia
how is coronary artery disease treated
PCI - percutaneous coronary intervention
stent
what are coronary stents made of
stainless steel
what action does aspirin
it irreversibly inhibits platelet cyclo-oxygenase
what is the action of clopidogrel or ticagrelor
it inhibits P2Y12 ADP receptors on platelets and therefore has antiplatelet action
what are statins used for
to lower cholesterol
what is the action of statins
it inhibits HMG CoA reductase and therefore reduces cholesterol synthesis
what is a PCSK9 inhibitor
it is a monoclonal antibody that inhibits PCSK9 protein in the liver and leads to improved clearance of cholesterol from the blood
what are the major cell types involved in atherosclerosis
epithelium, macrophages, smooth muscle cells and platelets
what are examples of acute coronary syndromes
Q wave MI
ST elevation MI
Non Q wave MI
Non ST elevation MI
unstable angina
Non ECG changes
what are the characteristics of an unstable angina
pain at rest
crescendo pattern
how would you diagnose an unstable angina
- history
- ECG
- troponin test - not normally risen in angina
what is the management for a myocardial infarction
300mg of aspirin immediately
- blood test
- ECG
- oxygen therapy
- pain relief
- Aspirin +/- platelet P2Y12 inhibitor
- Consider beta blockers
- Consider antiangial therapy
- Consider urgent angiography
what are other reasons someone may have acute coronary syndrome other than MI
stress-induced cardiomyopathy
vasospasm
drug abuse
dissection
what is troponin C a marker of
its a biological marker of myocardial damage and is used as a diagnostic tool for cardiac injury
what does aspirin do
it prevents platelet clotting
what is the side effect of using aspirin and P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) together
it increases the risk of bleeding
why are GP2b/3a blockers not used in clinical practice very often anymore
as they increase the risk of major bleeding
what medication is the most effective against angina
beta blockers
what is a major issue with using clopidogrel
it is a prodrug and it is unreliable as it can rapidly inactivate. therefore you can have different responses in different people and it is unpredictable
what factors can alter clopidogrel’s activity
- weight
- hight
- drug interactions
- genetic variations - CYP2C19 loss of function mutation
what is the process of Atherogenesis
There is damage to the endothelial cells which causes LDLs to move into the intima.
Due to the damage the endothelium secretes chemoattractants
leukocytes migrate and accumulate in the intima absorbing the LDLs and becoming foam cells
This forms a fatty streak
foam cells will rupture and release lipids
smooth muscle cells migrate from the media to the intima
a dense fibrous cap with a necrotic core is formed
this plaque can partially occlude the lumen and blood flow can be restricted.
this plaque can rupture ad a thrombus formed which can fully occlude the lumen
which cardiac arteries does atherogenesis affect most commonly
LAD, circumflex and RCA
what risk factors increase your chance of atheroma formation
age
smoking
obesity - high serum cholesterol
diabetes
hypertension
family history
male
put these in ascending order of severity
- stable angina, NSTEMI, STEMI, unstable angina
Stable angina> unstable angina > NSTEMI> STEMI
what are the main causes of cardiac myocyte damage
atheroma, valvular disease (stenosis) and anaemia
what is angina
Angina is the result of myocardial ischaemia, where blood supply < metabolic demand
what is stable angina
chest pain after cold/exercise and lasts about 1-5 minutes. it is relieved by rest or GTN spray
what is unstable angina/NSTEMI/STEMI
chest pain at rest and prolonged (longer than 20 minutes). there is no release at rest
what is seen on ECG during a STEMI
ST elevations
what does STEMI stand for
ST-elevation myocardial infarction
what is prinzmetal’s angina
it is caused by coronary artery spasms; occur at rest or at night
what are the symptoms of ischemic heart disease
chest pain - discomfort, heaviness
radiation - left arm, shoulder, jaw
NSFW - nausea, sweating, fatigue and weak breathing
what are atypical presentations of ischemic heart disease
no pain
low grade fever
pale, cool, clammy skin
hyper/hypotension
how do you diagnose ischemic heart disease
history taking and physical examination
- resting ECG
- exercise ECG
blood tests - HBA1C, full blood count, cholesterol profile
CT - coronary angiography
biological markers: troponin, myoglobulin, CK
what is heart contraction initiated by
depolarisation and changes intracellular calcium concentrations
what needs to occur for heart muscle relaxation to occur
removal of calcium - energy dependent
what are the two types of cardiac myocytes
- atrioventricular conduction system - slightly faster
- general cardiac myocytes
is blood flow through the myocardium from the aortic root diastolic or non-diastolic
diastolic
what is the normal systolic ejection fraction
about 60-65%
as venous return increases does cardiac/volume increase or decrease
it increases
what happens if you exceed the stretch capacity of the sarcomeres in the heart
then the cardiac contraction force diminishes
when can myocardial hypertrophy be an adaptive or physiological response
in athletes or in pregnancy
what is the myocardial hypertrophic response triggered by
angiotensin 2
ET-1
IGF-1
TGF - b
these activate mitogen-activated protein kinase
what happens in left sided cardiac failure
there is pulmonary congestion and then overload of the right side
what happens in right sided heart failure
there is venous hypertension and congestion
what is diastolic cardiac failure (HFpEF)
it is when the left ventricle of the heart becomes stiff and unable to fill properly
what happens in fetal embryogenesis of the heart
- the heart comprises a single chamber until week 5 of gestation
- it is then divided by intra-ventricular and intra-atrial septa from endocardial cushions
- the muscular intra-ventricular septum grows upward from the apex producing four chambers and allowing valves to develop
what does congenital heart disease result from
results from a faulty embryonic development
- misplaced structures or arrest of the progression of normal structure development
what percentage of live births can congenital heart disease complicate
may complicate up to 1% of live births
what are the four most common congenital heart defects
Ventricular septal defect -25-30%
Atrial septal defect - 10-15%
Patent ductus arteriosus - 10-20%
Fallots 4-10%
what single gene conditions are associated with an increased risk of congenital heart disease
- Trisomy 21
- Turners syndrome XO
- di-George syndrome
what infection in pregnancy is associated with an increased risk of congenital heart disease
rubella
What drugs in pregnancy increase the risk of congenital heart disease
thalidomide, alcohol, phenytoin, amphetamines, lithium, oestrogenic steroids
what classifications are used for congenital heart disease
- if cyanosis is present or absent
- whether it occurs from birth or whether it develops later
what types of congenital heart disease show an initial left to right shunt
Ventricular septal defect
atrial septal defect
patent ductus arteriosis
anonymous pulmonary venous drainage
hypoplastic left heart syndrome
what types of congenital heart disease show a right to left shunt
tetralogy of Fallot
tricuspid atresia
what types congenital heart disease show no shunt
complete transposition of great vessels
coarctation
pulmonary stenosis
aortic stenosis
coronary artery origin from pulmonary artery
Ebstein malformation
Endocardial fibroelastosis
what is patent foramen ovale
hole in the heart between the right and left atria that doesn’t close correctly after birth.
can be found in the central septum (90%) or in the lower part of the septum primum.
what can a patent foramen ovale lead to
cardiac arrhythmias, pulmonary hypertension, right ventricular hypertrophy, and cardiac failure. Also has a risk of infective endocarditis
what is patent ductus arteriosus
where the ductus arteriosus persists beyond birth
what can a patent ductus arteriosus lead to
the left-to-right shunting eventually means the lung circulation is overloaded with pulmonary hypertension and right-sided cardiac failure subsequently
can a patent ductus arteriosus be closed
yes can be closed surgically, by catheters or my prostaglandin inhibitors (idomethacin)
what is tetralogy of Fallot
It has four main features
1. Pulmonary stenosis
2. Ventricular septal defect
3. Dextraposition/over-riding ventricular septal defect
4. Right ventricle hypertrophy
what is the characteristic shape of Tetralogy of Fallot on radiology and macroscopically
boot shaped
What happens due to a Tetralogy of Fallot
As a result of the pulmonary stenosis, right ventricle blood is shunted into the left heart producing cyanosis from birth. Surgical correction usually is performed during the first two years of life, as progressive cardiac debility and risk of cerebral thrombosis increases
What is complete transposition of the great arteries (TGA)
it involves the aorta coming off the right ventricle and the pulmonary trunk coming off the left ventricle.
does complete transposition of the great arteries have a male or female bias
male bias
is survival possible with complete transposition of the great vessels
only possible if there is communication between the circuits and virtually all have an atrial septal defect allowing for blood mixing
what is the treatment for complete transposition of the great vessels
arterial switch - less than 10% overall mortality
what is coarctation of the aorta
this is secondary to an excessive obliterating process that normally closes the ductus arteriosus, extending into the aortic wall. The net result is a narrowing of the aorta after the arch witch excessive blood flow diverted through the carotid and subclavian vessels into systemic vascular shunts to supply the rest of the body
What are the complications of coarctation of the aorta
- associated with berry aneurysms
- cardiac failure
- rupture of dissecting aneurysm
- infective endarteritis
- cerebral haemorrhage
- stenosis of the bicuspid aortic valve
what is the treatment for coarctation of the aorta
dilatation (stenting) of the stenosed segment
what is endocardial fibroelastosis
secondary -complication of congenital aortic stenosis and coarctation. Profound dense collagen and elastic tissues deposited on endocardial aspect of the left ventricle produces progressive stiffening of the heart and cardiac failure. Similar changes may affect the valves.
primary - may follow a familial pattern
what is Dextrocardia
the normal anatomy of the heart is versed with a rightward orientation
- often associated with severe cardiovascular abnormalities
what are the different types of angina
standard, prinzmetal/unstable, accelerated/Crescendo
what are risk factors for ischaemic heart disease
systemic hypertension
cigarette smoking
diabetes mellitus
elevated cholesterol
Sex
obesity
age
family history
sedentary life
what are some reasons for an imperfect blood supply to the heart
atherosclerosis
thrombosis
thromboemboli
artery spasm
collateral blood vessels
blood pressure/cardiac output/heart rate
arteritis
what conditions can limit coronary flow
Coronary arteritis
Dissecting aneurysm of aorta
Syphilitic aortitis, congenital abnormality of coronary artery origin
Myocardial bridge
what can occur upon reperfusion of ischaemic myocardium
reperfusion of completely infarcted tissue can produce significant haemorrhage. It can allow oxygen delivery and a further degree of injury as a result of generation of superoxide radicals
what are pathological complications of ischaemic damage of the heart
Arrhythmias (supraventricular and ventricular)
Left ventricular failure – cardiogenic shock.
Generally reflects >40% muscle damage
Extension of infarction, rupture of the myocardium (into pericardial space, between chambers, across papillary muscle insertion)
what is an aneurysm
it is a dilation of part of the myocardia wall, usually associated with fibrosis and atrophy of myocytes
what is pericarditis (dressler syndrome)
this is a delayed pericarditic reaction following infarction (2-10 weeks)
what is the WHO classification of hypertension
> 140/90mm Hg
what is hypertensive heart disease
it reflects cardiac enlargement due to hypertension and in the absence of other causes
there is compensatory hypertrophy of the heart with increased myocyte size. Eventually, the hypertrophy will no longer be able to compensate and oxygen delivery will start to fail
what is the most common reason for angina
ischemic heart disease
what are exacerbating factors of angina
supply - anaemia, hypoxia, polycythemia, hypothermia, hypovolaemia, hypervolaemia
demand - hypertension, tachyarrhythmia, hypertrophic cardiomyopathy, hyperthyroidism (should be treated)
what environmental factors can bring on angina
exercise
cold weather
heavy meals
emotional stress
what is ohms law in biology
pressure = flow X resistance
P=QR
what is poiseuilles law in biology
P = 8uLQ / pi r^4
essentially coronary flow falls off with the 4th power of the radius
what is microvascular angina
small blood vessels are affected, main coronary vessels mostly normal
what is the treatment for angina
lifestyle - stop smoking, weight, exercise, diet
advice for emergency
medication - GTN spray, aspirin and beta blocker
revascularisation
what is the gold standard non-invasive test for angina (IHD) diagnosis
a perfusion MRI
what is the gold standard (but invasive) test for angina (IHD) diagnosis
coronary angiography
what are beta blockers affect on the heart
bradycardia
reduce contractility
decrease cardiac output
what are contra-indications of beta blockers
in severe asthma will block beta receptors in the lungs and can cause bronchoconstriction
How do nitrates work
dilates veins, reducing the venous return and therefore preload. Can also dilate arterioles, reducing blood pressure and afterload
what are side effects of nitrates
headache due to venous dilation
what are side effects of beta blockers
tiredness
bradycardia
erectile dysfunction
cold hands and feet
what are the effects of calcium channel blockers
decreased contraction therefore work the heart has to do and its oxygen demand
decrease heart rate
cause arterial dilation, decreasing BP and afterload
what are side effects of calcium channel blockers
flushing
postural hypertension
swollen ankles
what is a major side effect of aspirin therapy
gastric ulceration
why would you give an ACE inhibitor to someone with IHD
inhibits the production of angiotensin 2 and therefore prevents vasoconstriction and increases sodium and water excretion. This will reduce blood pressure
when is bypass surgery used in cardiac disease
when there is multivessel disease
how is bypass surgery performed
there is internal mammary graft from the chest, to the right coronary artery past the blockage. Can use veins from your leg (long saphenous vein), if other coronary arteried have blockages as well
what are the pros and cons of Percutaneous Coronary Intervention (stent)
pros - less invasive, convenient, repeatable, acceptable
cons - risk stent thrombosis, risk restenosis, cant deal with complex disease, dual antiplatelet therapy
what are the pros and cons of coronary artery bypass graft
pros - prognosis is better, deals with complex disease
cons - invasive, risk of stroke/bleeding, can’t do if frail, one time treatment, long length of stay, long recovery time
what is acute pericarditis
it is an inflammatory pericardial syndrome
what is Cor pulmonale
it is right ventricular hypertrophy and dilation due to pulmonary hypertension
what can cause Cor pulmonale
- embolisation of material into the pulmonary circuit
- chronic bronchitis and emphysema
- pulmonary fibrosis
- cystic fibrosis
- recurrent emboli
- primary pulmonary hypertension
- peripheral pulmonary stenosis
- IV drug use
- high altitude
- abnormal movement of the thoracic cage
what are features of right sided heart failure
venous overload, peripheral oedema, and progressive hepatic congestion
what bacteria causes acute rheumatic fever
Group A b-haemolytic streptococcus infection
what remains a major factor with regard to heart disease in developing countries
acute rheumatic fever
why can acute rheumatic fever cause cardiac dysfunction
development of immunity against streptococcal pharyngitis produces antibodies that cross-react with cardiac myocytes and valvular glycoproteins. This produces localised inflammation and subsequent scarring
what are the clinical features of acute Rheumatic fever
Carditis (cardiomegaly, murmurs, pericarditis and cardiac failure)
Polyarthritis
chorea - sudden, uncontrolled jerky movement
erythema - redness of skin/mucus membranes
marginatum - rash
subcutaneous nodules
What are minor criteria for acute rheumatic fever diagnosis
previous history of rheumatic fever, arthralgia, raised CRP, ESR, and white cell count. Antibodies against group A strep antigens, anti-streptolysin O, anti-DNAsa B and anti-hyaluronidase
how long does it take for symptoms of acute rheumatic fever to diminish
3-6 months
what other disorders can affect cardiac valves
SLE, Rheumatoid arthritis, ankylosing and other connective tissue disorders
How can progressive cardiac dysfunction occur due to acute rheumatic fever
Chronically scarring and deformity produces contracture of the valve and chordae tendinae. These may subsequently calcify and distort blood flow allowing localised thrombosis. They also provide ideal settling sites for bacteria within the blood stream, and the development of infective endocarditis.
what is infective endocarditis
Infective endocarditis, also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel
what are characteristic microorganisms of infective endocarditis
strep. Viridans and Staph. Aures
Fungal and atypical bacteria are also recognised
what occurs in infective endocarditis
infection produces a rapidly increasing cardiac valve distortion and disruption, with an acute cardiac dysfunction
what are symptoms of infective endocarditis
sudden cardiac failure
septic problems
generation of infected thromboemboli
damage to kidneys
fever
anorexia
fatigue
splenomegaly
clubbing
neurological dysfunction
what is the mortality rate of infective endocarditis
30-40% mortality rate
what is the most common cause of infective endocarditis in children
congenital heart disease
what are the most common cause of infective endocarditis in adults
rheumatic valvular heart
mitral valve prolapse
intravenous drug abuse
prosthetic valves
diabetes
elderly
pregnancy
what is non bacterial thrombotic endocarditis/marantic endocarditis
- sterile thrombotic matter deposits on valves with variable degrees of valve dysfunction
- degenerative valve disease
what is calcific aortic stenosis
it is when there are nodular calcific deposits in the cusps with progressive distortion of valves.
what can nodular calcific stenosis lead to
obstruction of left ventricle outflow, leading to pressure overload and cardiac hypertrophy. There can be a risk of sudden cardiac death and MI
what type of valve accelerates development of calcific aortic stenosis
bicuspid aortic valves
what is mitral valve disease
when there is an issue with the mitral valve and can lead to regurgitation due to a lack of closure
what is one of the main causes of mitral valve stenosis
One of the main causes of mitral valve stenosis is rheumatic heart disease. This is where an infection causes the heart to become inflamed
what is mitral valve prolapse
it is the degeneration of the mitral valve such that the inner fibrosa becomes loose and fragment, with fragments of mucopolysaccharide material
what can occur in mitral valve prolapse
it can cause the valve cusp to bow upwards and may not close which can produce incompetence regurgitation.
what diseases are mitral valve prolapse associated with
underlying connective tissue disorders, Marfan’s syndrome and myotonic dystrophy
can mitral valve prolapse lead to sudden cardiac death
Yes
what is myocarditis
inflammation of the myocardium
usually associated with muscle cell necrosis and degeneration
what is the most common type of myocarditis
viral myocarditis
- viral toxicity with associated cell mediated cell damage
what is the most common type of myocarditis
viral myocarditis
- viral toxicity with associated cell mediated cell damagewhat are the causes of myocarditis
what is the most common type of myocarditis
viral myocarditis
- viral toxicity with associated cell mediated cell damagewhat are the causes of myocarditis
what are the causes of myocarditis
viruses - coxsacke, adeno, echo, influenza
Rickettsia
bacteria - Diptheria, staphylococcal, streptococci, borrelia, leptospira
fungi and protozoa parasites - toxoplasmosis and cryptococcus
metazoa - echinococcus
what are non infectious causes of myocarditis
hypersensitivity/immune-related diseases - rheumatic fever, SLE, scleroderma, drug reaction, RA
radiation
Miscellaneous - sarcoid and uraemia
what is myocarditis often associated with
a preceding upper respiratory tract infection
what is giant cell myocarditis
A very rare highly aggressive form of cardiac disease with areas of muscle cell death due to macrophage giant cells. Often fatal.
Early treatment is transplantation but disease can often recur.
what metabolic diseases are associated with myocarditis
Hyperthyroidism, hypothyroidism
Thiamin deficiency (vitamin B1/thiamin)
Particularly association with poor diet
what is cardiomyopathy
primary cardiac disease with contractile dysfunction and atypical morphology
what are the different forms of cardiomyopathy
dilated cardiomyopathy
hypertrophic cardiomyopathy
arrhythmogenic right ventricular cardiomyopathy
secondary
rare forms
what is dilated cardiomyopathy
Dilated cardiomyopathy is a type of heart muscle disease that causes the ventricles to thin and stretch, growing larger. It typically starts in the left ventricle.
is there a genetic component to dilated cardiomyopathy
yes - 1/3 familial inheritance but could be more. It is mostly autosomal dominant inheritance.
what mutations are linked with dilated cardiomyopathy
dystrophin
troponin T
beta myosin heavy chain
actin
lamin A/C
desmin
what is clinical presentation of dilated cardiomyopathy
Shortness of breath, thromboemboli, cardiac failure, dysrhythmias and ultimately death
what are causes of secondary dilated cardiomyopathy
alcohol
cobalt toxicity
catecholamines
Micro-infarction
Anthracyclines - dose dependent toxicity
cocaine
pregnancy
what is hypertrophic cardiomyopathy
the heart muscle cells enlarge and the walls of the heart chambers thicken. The heart chambers are reduced in size so they cannot hold much blood, and the walls cannot relax properly and may stiffen. Also, the flow of blood through the heart may be obstructed.
what mutations are linked to hypertrophic cardiomyopathy
beta myosin
myosin binding protein c
troponin C
titin
what mutations found in hypertrophic cardiomyopathy are linked to clinical features
beta myosin - cardiac hypertrophic and dysrhythmias
troponin T - risk of sudden death
what changes occur in hypertrophic cardiomyopathy
asymmetric hypertrophy with distortion
increased fibrosis
ventricular outflow distortion
myocyte disarray
variation in small artery structure
at investigations are done for hypertrophic cardiomyopathy
echocardiology and other imaging modalities together with investigation of genetics and family history
what is arrhythmogenic right ventricular cardiomyopathy
a degenerative condition with progressive dilatation of right ventricle, with fibrosis, lymphoid infiltrate and fatty tissue replacement
what is restrictive cardiomyopathy
this is a group of diseases in which poor dilation of the heart restricts the ability of the heart to take on blood and pass it to the rest of the body.
what causes restrictive cardiomyopathy
amyloid - cardiac or amyloidosis AL/AA
deposits in the heart and stiffens it
what does restrictive cardiomyopathy show on an ECG
a low voltage ECG
what is endomyocardial disease
Endomyocardial fibrosis (EMF) is a disease of rural poverty that is characterized by fibrosis of the apical endocardium of the right ventricle (RV), left ventricle (LV), or both.
clinical signs of endomyocardial disease
high grade eosinophilia
rash
progressive endocarditis
cardiac failure
what is glycogen storage disease
Glycogen storage disease (GSD) is a rare condition that changes the way the body uses and stores glycogen, a form of sugar. It is passed down from parents to children (inherited). For most GSDs, each parent must pass on one abnormal copy of the same gene. Most parents do not show any signs of GSD.
type 2, 3 and 4
what is hurler syndrome
Mucopolysaccharosis-glycosaminoglycans deposition in cells
what is hemochromotosis
multiorgan dysfunction with excess iron deposition in multiple tissues.
what is a sarcoidosis
A chronic granulomatous disease with numerous granulomas of non-caseating giant cell type. May involve the heart producing widespread areas of fibrosis and compensatory hypertrophy. It can produce a restrictive disorder. If it involves the conduction system then this may be the prime pathology of the patients with the risk of sudden death.
what is cardiac myxoma
cardiac tumour (75%) with bias towards the atria.
proliferation of myxoid cells with endothelial vascular channels and usually produces obstructive symptoms
what is rhabdomyoma
paediatric tumour with similarity to fetal cardiac cells
probably a hamartoma
what is a cardiac sarcoma
Cardiac sarcoma is a rare type of primary malignant (cancerous) tumor that occurs in the heart
These are rare and can show differentiation towards vascular, fibrous and muscle phenotypes. Almost invariably fatal.
what is the definition of haemopericardium
direct bleeding from the vascular wall through the ventricular wall fallowing a MI
what is the definition of haemopericardium
direct bleeding from the vascular wall through the ventricular wall fallowing a MI
what is cardiac tamponade
it is compression of the heart leading to acute cardiac failure following bleeding into the pericardial space direct bleeding from the vascular wall through the ventricular wall fallowing a MI
what is a cardiac tamponade
compression of the heart leading to acute cardiac failure following bleeding into the pericardial space
what is acute pericarditis
Acute pericarditis is an inflammatory process involving the pericardium that results in a clinical syndrome characterized by chest pain, pericardial friction rub, changes in the electrocardiogram (ECG) and occasionally, a pericardial effusion.2 Generally, the diagnosis requires 2 of these 3 features.
what are the signs and symptoms of acute pericarditis
Acute pericarditis typically presents with acute onset severe, sharp retrosternal chest pain, often radiating to the neck, shoulders, or back. Positional changes are characteristic with worsening of the pain in the supine position and with inspiration; and improvement with sitting upright and leaning forward.
Classically, a scratchy, grating, high-pitched friction rub is heard. This is felt to be caused by fibrinous deposits in the inflamed pericardial space.
where is the pericardial friction rub best heard
It is best heard during inspiration at the left lower sternal border, with the patient leaning forward. The rub may disappear with the development of an effusion and impending cardiac tamponade.
what are the features of elastic arteries
have two elastic laminae along with
tunica interna
tunica media
tunica adventitia
they also contain vasa vasorum
how does clot lysis occur
plasminogen is converted into plasmin. This then acts on fibrin to produce fibrin degradation products, and remove the fibrin cap on the clot.
what are complicated plaques
when there is calcification, mural thrombus or a vulnerable plaque
what are complications of plaque rupture
acute occlusion due to thrombus
chronic narrowing of vessel lumen with healing of the local thrombus
aneurysm change
embolism of thrombus +/- plaque lipid content
what is essential hypertension
Essential (primary) hypertension occurs when you have abnormally high blood pressure that’s not the result of a medical condition. This form of high blood pressure is often due to obesity, family history and an unhealthy diet. The condition is reversible with medications and lifestyle changes
what is the relationship between resistance and lumen size
resistance = 1/r^4
what are acquired causes of hypertension
chronic vascular disease - diabetes, primary elevation of aldosterone, cushings syndrome, pheochromocytoma, hyperthyroidism, coarctation or the aorta and rennin secreting tumours
what is arteriosclerosis
deposition of basement membrane like material and accumulation of plasma proteins within the vessel wall
in what conditions can arteriosclerosis be accelerated
diabetes and hypertension
what blood pressure indicates malignant or accelerated hypertension
> 160/110 mmHg
what is malignant or accelerated hypertension
Malignant/Accelerated hypertension is defined as a recent significant increase over baseline BP that is associated with target organ damage.
often seen in fundoscopic examination and is a medical emergency
what is raynaud’s phenomenon
Intermittent bilateral ischaemia of digits/extremities precipitated by motional cold temperature. Accelerated in cases of scleroderma and SLE. May produce distal atrophy and ulceration.
what is fibromuscular dysplasia
Abnormal architecture for the arteries producing variable lumen narrowing and distal poverty of circulation.
Particular importance in the renal arteries which produce renal vascular insufficiency and progressive hypertension due to renin-angiotensin stimulation.
what is vasculitis
an inflammatory and variably necrotic process centered on the blood vessels that can involve arteries veins and capillaries
how does vasculitis occur
it has an immune background of one of the following
- there is deposition of immune complexes
- there is direct attack on vessels by antibodies
- cell mediated immunity
viral infection
what viral antigens have been found in human vasculitis cases
HSV, CMV, parvovirus
what is polyarteritis nodosa
patchy necrotising arteries, affecting small and medium arteries. It is associated with neutrophils, lymphocytes, plasma cells and macrophages
what can polyarteritis nodosa lead to
can thrombose and cause a distal infarction, or heal with subsequent aneurysms. can cause widespread damage to the kidneys, cerebrocirculation and cardiac tissue. Can be rapidly fatal without treatment
what is hypersensitivity angiitis
it is a disease that involves deposition of immune complexesis causing inflammation of small blood vessels (usually post-capillary venules in the dermis), characterized by palpable purpura.
- can also be a feature of vascular disease
what is a diagnostic marker of hypersensitivity angiitis
palpable purpura
what drugs can cause hypersensitivity angiitis
aspirin
penicillin
phenytoin (Dilantin, an antiseizure medication)
allopurinol (used for gout)
what infections can cause hypersensitivity angiitis
streptococci
staphylococci
viral hepatitis
TB
bacterial endocarditis
what is Churg -Strauss syndrome
Churg-Strauss syndrome is a disorder marked by blood vessel inflammation. This inflammation can restrict blood flow to organs and tissues, sometimes permanently damaging them. This condition is also known as eosinophilic granulomatosis with polyangiitis (EGPA).
what organs can Churg -Strauss syndrome affect
lungs, spleen, kidney, heart, liver, CAN
what drug can be used to improve Churg-Strauss syndrome
steroids
what are features of Churg - Strauss syndrome
granulomatous inflammation with intense eosinophilic infiltrates
what is giant cell arteritis
an inflammation of the lining of your arteries. Most often, it affects the arteries in your head, especially those in your temples
what is the commonest type of vasculitis
giant cell vasculitis
what are risk factors for giant cell arteritis
Age. Giant cell arteritis affects adults only, and rarely those under 50
Sex. Women are about two times more likely to develop the condition than men are
Race and geographic region
Polymyalgia rheumatica
Family history.
What happens to vessels during giant cell arteritis
blood vessel is often thickened
there is granulomatous inflammation involving the full thickness of the wall - macrophages, lymphocytes, plasma cells, neutrophils involved.
variable necrosis
giant cells congregate in internal elastic lamina
thrombosis may occur
what can giant cell arteritis lead to
tends to be self-limiting but it can lead to blindness if it affects the ocular artery
what is Wegener’s granulomatosis
this is vasculitis of the respiratory tract and the kidney
what can Wegener’s granulomatosis cause in the lungs
bilateral pneumonitis with nodular infiltrates that can undergo cavitation mimics TB. Chronic sinusitis and ulcers of the nasal tissues are also common
what can Wegener’s granulomatosis cause in the kidney
focal necrotizing glomerulonephritis which progresses to crescentic glomerulonephritis
what are common symptoms of Wegener’s granulomatosis
pneumonitis
sinusitis
haematuria
proteinuria
skin rash
joint pains
neurological changes
what gender bias does Wegener’s granulomatosis have
male bias
what is Buerger disease
this is an inflammatory disease of medium and small arteries affecting the distal limbs
what does Buergers disease have a strong association risk with
tobacco smoking
what is the pathophysiology of Beurger disease
there is cell-mediated hypersensitivity to collagen type 2 and 3 with impaired endothelium - can have thrombotic and micro-abscess change
this can cause distal ischaemic symptoms and necrosis
stopping what can lead to remission of beurgers disease
stopping smoking
what is kawasaki disease
it is mucocutaneous lymph node syndrome - generation of antigens that bind to MHCII receptors
what arteries does Kawasaki syndrome principally effect
the coronary arteries
what pathogens is Kawasaki disease associated with
parvovirus B19
Coronovirus
staphylococci
streptococci
chlamydia infection
what is an aneurysm
dilated areas of vasculature suggesting either congenital or acquired weakness of the wall of the vessels
what are aneurysms described as
fusiform
saccular
dissecting
arterio-venous
what is an abdominal aortic aneurysm
it is when there is over 50% dilation of the aortic diameter
are the majority of abdominal aortic aneurysms found
below the renal arteries
what is the major problem with abdominal aortic aneurysms
aneurysm rupture - those greater than 5-6 cm at increased risk
what are different treatment options for abdominal aortic aneurysms
waiting for rupture - higher mortality risk
prophylactic replacement with Dacron graft
endoluminal prosthesis - stent with prosthetic cover
what is a berry aneurysm
vascular dilation found in the cerebral circulation
what is a berry aneurism a consequence of
longstanding hypertension and/or focal area of weakness within the artery
where in the cerebrum are berry aneurysms commonly found
circle of Willis leading to a subarachnoid haemorrhage
what is a dissecting aneurysm
a tear occurs in the inner layer of the body’s main artery (aorta). Blood rushes through the tear, causing the inner and middle layers of the aorta to split (dissect)
where do the majority of dissecting aneurysms occur
just above the aortic ring
what disorders can predispose someone to getting a dissecting aneurysm
Marfans syndrome and other connective tissue disorders
what is syphilitic aortitis
an inflammatory disease affecting the vasa vasorum in the late stages of syphilis
what is the pathophysiology of syphilitic aortitis
Syphilitic aortitis begins as inflammation of the outermost layer of the blood vessel, including the blood vessels that supply the aorta itself with blood, the vasa vasorum
As it worsens, the vasa vasorum undergo hyperplastic thickening of their walls thereby restricting blood flow and causing ischemia of the outer two-thirds of the aortic wall.
Starved for oxygen and nutrients, elastic fibers become patchy and smooth muscle cells die. If the disease progresses, syphilitic aortitis leads to an aortic aneurysm
what are varicose veins
an enlarged and torturous vein, principally affecting the superficial leg veins
what are risk factors for varicose veins
age
female
hereditary
posture
obesity
wht causes varicose veins
progressive incompetence of valves with back pressure on venous circuit. This can cause thinning and dilation of the vascular wall with patchy calcification
what is lymphatic vessel obstruction
Lymphatic obstruction is a blockage of the lymph vessels that drain fluid from tissues throughout the body and allow immune cells to travel where they are needed. Lymphatic obstruction may cause lymphedema, which means swelling due to a blockage of the lymph passages.
what can cause lymphatic vessel obstruction
Infections with parasites, such as filariasis
Injury
Radiation therapy
Skin infections, such as cellulitis (more common in obese people)
Surgery
Tumors
