Flashcards in Cardiovascular diseases 2 Deck (57):
What is the pathogenesis behind left-sided (congestive) heart failure?
Hypertension = pressure overload
Valvular disease = pressure/volume overload
MI = regional dysfunction with volume overload
All can lead to increase cardiac work = increased wall stress = cell stretch = hypertrophy and/or dilatation
What are the cellular pathological features of heart failure?
Increase heart size and mass
Increased protein synthesis
Induction of immediate-early genes
Induction of foetal gene programme
What are the characteristics of cardiac dysfunction?
Heart failure (systolic/diastolic)
What is the impact of low output left heart failure on the kidneys?
Salt and fluid retention
- renin-aldosterone activation
- natriuretic peptides
What is the impact of low output left heart failure on the brain?
Brain: Irritability, decreased attention, stupor -> coma
What are the general signs and symptoms of left-sided heart failure?
PND (Paroxysmal Nocturnal Dyspnea)
Blood tinged sputum
Elevated pulmonary “WEDGE” pressure (PCWP) (nl = 2-15 mm Hg)
What is the main cause of the signs/symptoms of left-sided heart failure?
Pulmonary congestion and oedema
What is the aetiology of right-sided heart failure?
Left-sided heart failure
What is cor pumonale?
Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
What are the signs and symptoms of left heart failure?
Liver and spleen
- passive congestion (nutmeg liver)
- congestive splenomegaly
- pleural and pericardial effusions
- Pitting oedema
Distention of jugular veins
Elevation of peripheral venous pressure
What might you find in the autopsy of a person with congestive cardiac failure?
Hypertrophy of myocardial fibers, BOXCAR nuclei
What are the two basic types of valvular heart disease
Opening problems: Stenosis
Closing problems: Regurgitation or Incompetence or “insufficiency”
Aortic and mitral stenosis account for what percentage of valvular heart defects?
What is the aetiology of aortic stenosis?
Calcification of a deformed valve
- “Senile” calcific AS
- Rheum, Heart Dis.
What is the aetiology of mitral stenosis?
Rheumatic heart disease
What is the precursor to rhematic heart disease?
Follows a group A strep infection, a few weeks later.
What is pancarditis?
What are the features of acute rheumatic heart disease?
Vegetations on chordae tendinae at leaflet junction
What are the features of chronic rheumatic heart disease?
Thick, short chordae tendinae
What are the pertinent features of aortic stenosis?
2X gradient pressure
LVH (but no hypertension), ischemia
Cardiac decompensation, angina, CHF
50% die in 5 years if angina present
50% die in 2 years if CHF present
What is mitral annular calcification?
Calcification of the mitral “skeleton”
Usually NO dysfunction
Regurgitation usually, but Stenosis possible
More common in males
What are the pathological valve regurgitations?
What are the aetiologies of aortic regurgitation?
- Rheumatoid Arthritis
What are the aetiologies of mitral valve regurgitation?
Mitral valve prolapse
Papillary muscles, chordae tendinae
Calcification of mitral ring (annulus)
What are the features of mitral valve prolapse?
MYXOMATOUS degeneration (pathological weakening) of the mitral valve
Associated with connective tissue disorders
3% incidence, F>>M
Easily seen on echocardiogram
What are the clinical features of mitral valve prolapse?
- Usually asymptomatic
- Mid-systolic “click”
- Holosystolic murmur if regurg. present
- Occasional chest pain, dyspnea
- 97% NO untoward effects
- 3% Infective endocarditis, mitral insufficiency, arrythmias, sudden death
What is the aetiology of congenital heart defects?
Faulty embryogenesis (week 3-8)
May not be evident till adulthood
What is the incidence of congenital heart defects?
1% of births
What percentage of congenital heart defects are seen with genetic abnormalities?
Which of the aneuploidies are involved in congenital heart disease?
Trisomies 21, 13, 15, 18, XO
What environmental factors might contribute to the development of congenital heart disease?
What are the three types of congenital heart disease?
L -> R shunts: all “D’s” in their names (VSD, ASD, PDA, AVSD)
- NO cyanosis
- Pulmonary hypertension
- significant pulmonary hypertension is irreversible
R -> L shunts: all “T’s” in their names
- cyanosi (i.e., “blue” babies)
- venous emboli become systemic “paradoxical”
OBSTRUCTIONS: aorta or pulmonary artery
Are left to right shunts cyanotic or non-cyanotic?
What is the most feared consequence of left to right shunts?
Irreversible pulmonary hypertension
What are different kinds of atrial septal defects?
- Defective fossa ovalis
- Next to AV valves, mitral cleft
SINUS VENOSUS (5%):
- Next to SVC with anomalous pulmonary veins draining to SVC or RA
Does not include PFO
Usually asymptomatic until adulthood
What are the most common congenital heart disease defects?
Ventricular septal defects (VSDs)
What percentage of ventricular septal defects are isolated?
What condition are ventricular septal defects often associated with?
Tetralogy of Fallot
What percentage of VSDs involve the membranous septum?
What can happen if the muscular septum is involved in VSDs?
Can have multiple holes (Swiss cheese septum)
What often happens with small VSDs?
They close spontaneously
What often happens with large VSDs?
Often progress to pulmonary hypertension
What percentage of patent ductus arteriosus (PDA) are isolated?
What other conditions are associated with PDA?
Coarctation of aorta
Pulmonary or aortic stenosis
What is the pathology of an atrioventricular septal defect?
Associated with defective, inadequate AV valves
Can be partial, or complete (all 4 chambers freely communicate)
More than 1/3rd with complete AVSD have Down syndrome
Which of the congenital heart defects cause a right to left shunt?
Tetralogy of Fallot
Transposition of great arteries
Total anomalous pulmonary venous connection
- ALL THE Ts
What are the features of Tetralogy of Fallot?
1) VSD, large
2) OBSTRUCTION to RV outflow
3) Aorta OVERRIDES the VSD
4) Right Valve Hypertrophy
What does survival in Tetraology of Fallot depend on?
On severity of subpulmonic stenosis - the greater the onstruction the greater the right to left shunt
What is transposition of the great arteries?
- Abnormal formation of truncal and aortopulmonary septa
- needs a shunt for survival, obviously
- PDA or PFO (65%), “unstable” shunt
- VSD (35%), “stable” shunt
- RV>LV in thickness
- Fatal in first few months without shunt
- Surgical “switching”
What is truncus arteriosis?
Developmental failure of separation of truncus arteriosus - connection between aorta and pulmonary artery
Produces systemic cyanosis as
well as increased pulmonary blood flow
What is tricuspid atresia?
Lack of development of the tricuspid valve.
Needs shunt, ASD, VSD ord PDA
Very high mortality
What is a Total Anomalous Pulmonary Venous Connection (TAPVC)?
Pulmonary veins do not go into LA, but into L. innominate v. or coronary sinus
Needs a PFO or a VSD
What are the obstructive CHDs?
- COARCTATION of aorta
- Pulmonary stenosis/atresia
- Aortic stenosis/atresia
What chromosomal abnormality is frequently associated with coarctation of the aorta?
XO - Turner Syndrome
Which form of coarctation of the aorta is serious?
Infantile form - with PDA
What are the clinical features of pulmonic stenosis/atresia?
- If 100% atretic, hypoplastic RV with ASD
- Clinical severity ~ stenosis severity