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Flashcards in Cardiovascular diseases 3 Deck (87):
1

What is endocarditis?

- Inflammation of the endocardium of the heart
- Prototypical lesion = “vegetation” on valves

2

What are the two main forms of endocarditis?

- Infective endocarditis
- Clinically important

- Non-infective endocarditis
- Nonbacterial thrombotic endocarditis (NBTE)
- Endocarditis of SLE (Libman-Sacks Disease)

3

What is infective endocarditis?

Colonization / invasion of heart valves or heart chamber endocardium by a microbe (bacteria and fungi)

4

What are the 'vegetations'?

- Mixture of thrombotic debris and organisms
- Destroy underlying cardiac tissues
- Aorta, aneurysmal sacs, blood vessels, prosthetic
valves can also be infected

5

What is acute infective endocarditis?

- Can occur with infection of a previously normal heart valve
- Caused by highly virulent organisms
- Necrotizing, ulcerative, destructive lesions
- Difficult to cure with antibiotics and usually require surgery
- Death frequent days to weeks despite treatment

6

What is subacute infective endocarditis?

- Organisms of lower virulence
- Insidious infections of deformed valves
- Less destructive
- Protracted “wax and wane” course of weeks to months
- Cured with antibiotics

7

What are the aetiologies of infective endocarditis?

- Cardiac/valvular abnormalities
- Rheumatic heart disease
- MV prolapse
- Valvular stenosis (calcification etc)
- Artificial (prosthetic) valves
- Unrepaired and repaired congenital defects
- Bicuspid AV

8

What sort of investigation should you perform if you discover Strep. bovis AND endocarditis in a patient?

Investigation for bowel cancer

9

How does an infection get to the heart?

- Any route of bacteria into the blood stream e.g.
- Dental abnormalities, IVDU, wounds, bowel cancer…..

10

What organisms are commonly associated with endocarditis?

Streptococcus viridans from the mouth
- Endocarditis in native but damaged / abnormal valves
- 50-60% cases

S. aureus from the skin
- 10% to 20% of cases overall esp. IVDU

Coagulase-negative staphylococci (e.g. S. epidermidis)
- Commonly infect prosthetic heart valves

11

What are the pertinent features of the vegetations of acute infective endocarditis?

- Friable, bulky, potentially destructive
- AV, MV, right heart (especially in IVDUs)
- Single, multiple and often more than one valve
- Can erode  myocardium  abscess (ring abscess).
- Emboli contain large numbers of virulent organisms
- Abscesses at the sites where emboli lodge
- Septic infarcts or mycotic aneurysms

Sub-acute IE – Less destruction

12

What are the clinical features of infective endocarditis?

Fever
- Most consistent sign
- Rapidly developing fever, chills, weakness
- Can be slight or absent, particularly in the elderly
Non-specific symptoms
- May be only presentation
- Loss of weight / flu-like syndrome.
Murmurs
- 90% of patients with left-sided IE
- New valvular defect or represent a pre-existing abnormality.

13

What are the complications of infective endocarditis?

- Immunologically mediated conditions e.g. glomerulonephritis

14

What are the pathological signs of infective endocarditis?

- Splinter / subungual hemorrhages

- Janeway lesions
- Erythematous or haemorrhagic non-tender lesions on the palms or soles

- Osler’s nodes
- Subcutaneous nodules in the pulp of the digits

- Roth spots
- Retinal haemorrhages in the eyes

15

What are Janeway lesions?

Janeway lesions are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis

16

What are Osler's nodes?

Painful, red, raised lesions found on the hands and feet

17

What are Roth spots?

Retinal hemorrhages with white or pale centers

18

What mnemonic is associated with infective endocarditis?

F – Fever
R – Roth spots
O – Osler’s nodes
M – Murmurs

J – Janeway Lesions
A – Anaemia
N – Nail (splinter) haemorrhage
E – Emboli (septic)

19

What is non-bacterial thrombotic endocarditis (NBTE)?

Occurs in debilitated patients (e.g. cancer or sepsis)
- AKA “marantic endocarditis”
Associated with a hypercoagulable state
- Hence DVT, PE and mucinous adenocarcinomas!
- Pro-coagulant effects of tumour-derived mucin or tissue factor

Part of trousseau syndrome of migratory thrombophlebitis

Endocardial trauma / indwelling catheter (e.g. central line)
- Predisposes

20

What are the features of vegetations in NBTE?

- Small (1 to 5mm) sterile thrombi on valve leaflets
- Singly or multiple on line of closure of leaflets or cusps
- Not invasive / no inflammatory reaction  minimal local effect
- Systemic emboli
- Infarcts in the brain, heart etc.

21

What is rheumatic fever?

Acute, immunologically mediated, multi-system inflammatory disease following group A streptococcal pharyngitis

22

What are Aschoff bodies?

- Distinctive cardiac lesions
- Foci of T-cells, plasma cells and macrophages
- Can be found in all three cardiac layers (pancarditis)

23

What are the vegetations called in rheumatic fever?

Veruccae

24

What mitral valve changes are seen in rheumatic fever?

- Virtually ONLY cause of mitral stenosis
- Leaflet thickening
- Virtually always involved in chronic disease
- MV only in most cases cases
- Aortic valve in 25% of cases
- Tricuspid valve / pulmonary valves - uncommon

- Fibrous bridging of valvular commissures & calcification
- “FISH MOUTH” or “buttonhole” stenoses 

25

What is the aetiology of rheumatic fever?

- Antibodies directed against the M proteins of streptococci
- Cross-react with self antigens in the heart

- CD4+ T cells specific for streptococcal peptides
- React with self proteins in the heart
- Produce cytokines that activate macrophages (e.g. Aschoff bodies)

26

What are the possible causes of pericarditis?

- Inflammation of the pericardial sac can be caused by…..

- Infections
- Viruses (Coxsackie B), bacteria, TB, fungi, parasites

- Immunologically mediated processes
- Rheumatic fever, SLE, scleroderma, post-cardiotomy
- Late post-MI = Dressler’s, drug hypersensitivity

- Miscellaneous conditions
- Post-MI (early), uraemia, cardiac surgery, neoplasia
- Trauma, radiation

27

What are the features of acute pericarditis?

- Serous
- Serofibrinous / fibrinous
- Purulent / suppurative
- Haemorrhagic
- Caseous

28

What are the features of chronic pericarditis?

- Adhesive
- Adhesive mediastinopericarditis
- Constrictive pericarditis

29

What is serous pericarditis?

Inflammation causes serous fluid accumulation in pericardium.

30

What is usually the cause of serous pericarditis?

- Caused by non-infectious aetiologies (generally)
- Inflammation in adjacent structures can cause pericardial reaction
- Rarely by viral pericarditis (Coxsackie B / echovirus)

- Immunologically mediated processes
- Rheumatic fever, SLE, scleroderma

- Miscellaneous conditions
- Uraemia, neoplasia, radiation

31

What is Dressler's syndrome?

Secondary pericarditis - AKA – Post-MI syndrome

Clinical triad of…..

1. Fever
2. Pleuritic chest pain
3. Pericardial effusion

32

What is the cause of Dressler's syndrome?

Autoimmune reaction to antigens released following myocardial infarction

NOT acute pericarditis

33

What is the cause of purulant/suppurative pericarditis?

Infections

34

What are the features of purulent/suppurative pericarditis?

- Red, granular, exudate i.e. pus (can be upto 500mls!)
- Inflammation can extend causing mediastino-pericarditis

35

What is the outcome of purulant/suppurative endocarditis?

Complete resolution is rare
- Scarring
- Restrictive pericarditis

36

What is haemmorhagic pericarditis?

Blood mixed with serous (watery) or suppurative (pus) effusion

37

What are the common causes of haemorrhagic pericarditis?

- Neoplasia (malignant cells in effusion)
- Infections (in TB/fungal preicarditis is caseous)
- Following cardiac surgery -> cardiac tamponade

38

What are the different forms of chronic pericarditis?

- Adhesive
- Adhesive mediastinopericarditis
- Constrictive

39

What are the features of adhesive pericarditis?

Fibrosis / stringy adhesions obliterates pericardial cavity

40

What are the features of adhesive mediastinopericarditis?

- Follows pericarditis caused by infections, surgery or radiation
- Obliterated pericardial cavity with adherence to surrounding structures
- Causes cardiac hypertrophy / cardiac dilation

41

What are the features of constrictive pericarditis?

- Heart encased in fibrous scar – limits cardiac function
- Treated by surgery to remove ‘shell’ around heart

42

What are the broad clinical features of pericarditis?

- Sharp central chest pain…characteristics?
- Exacerbated by : movement, respiration, laying flat
- Relieved : sitting forwards
- Radiating : shoulders / neck
- Differentials : angina, pleurisy

- Pericardial friction rub
- Loudest with diaphragm, left sternal edge

- Fever, leucocytosis, lymphocytosis, pericardial effusion

- Complications – pericardial effusion / cardiac tamponade

43

What is cardiomyopathy?

Literally 'heart muscle disease'?

44

What are the four types of cardiomyopathy?

- Dilated
- Hypertrophic
- Restrictive
- Arrythmogenic right venticular
cardiomyopathy

45

What are the pathological features of dilated cardiomyopathy?

- Progressive dilation -> contractile (systolic) dysfunction
- Heart enlarged, heavy, flabby (dilation of chambers)
- Myocyte hypertrophy with fibrosis

46

What are the causes of dilated cardiomyopathy?

Genetic
- 20 – 50% cases
- Autosomal dominant (mainly)
- Cytoskeletal proteins gene mutation

Alcohol and other toxins
- 10-20%
- chemotherapy

Others
- SLE
- scleroderma
- thiamine def
- acromegaly
- thyrotoxicosis
- diabetes

47

What are the clinical features of dilated cardiomyopathy?

Any age but commonly 20 – 50

Slow progressive signs / symptoms of
- CCF
- SoB
- fatigue
- poor exertional capacity

48

What is the 5 year survival for dilated cardiomyopathy?

~ 25% (like the ejection fraction!)

Death due to
- CCF
- arrhythmia / embolism (intra-cardiac thrombus)

49

What is the treatment for dilated cardiomyopathy?

Cardiac transplantation

Long-term ventricular assist (can induce regression)

50

What is hypertrophic cardiomyopathy?

Defined by myocardial hypertrophy

Poorly compliant (stiff) left ventricular myocardium

Diastolic dysfunction with preserved systolic function

Intermittent ventricular outflow obstruction (1/3 cases)

Thick-walled, heavy, and hyper-contracting
Main cause of unexplained LVH

(in the absence of any obvious cause)

51

What is the aetiology of hypertrophic cardiomyopathy?

100% genetic
- Mutations sarcomeric proteins
- Can be sporadic

52

What are the clinical features of hypertrophic cardiomyopathy?

↓Stroke volume
- Impaired diastolic filling - reduced chamber size / compliance of hypertrophied left ventricle

Obstruction to the left ventricular outflow
- 25% of patients

Exertional dyspnoea due to above

Systolic ejection murmur
- Ventricular outflow obstruction
- Anterior mitral leaflet moves toward the ventricular septum during systole.

53

What are the complications of hypertrophic cardiomyopathy?

Atrial fibrillation

Mural thrombus formation -> embolization / stroke

Cardiac failure

Ventricular arrhythmias

Sudden death, especially in some affected families
- Most common causes of sudden death in athletes

54

What is the treatment of hypertropic cardiomyopathy?

Decrease heart rate and contractility - β-adrenergic blockers.

Reduction of the mass of the septum, which relieves the outflow tract obstruction

55

What is restrictive cardiomyopathy?

Primary decrease in ventricular compliance
- Impaired ventricular filling during diastole

Idiopathic or secondary (infiltration)
- fibrosis
- amyloidosis
- sarcoidosis
- metastatic tumors
- deposition of
metabolites (inborn errors of metabolism)

56

What is the morphology of restrictive cardiomyopathy?

- Ventricles normal size / slightly enlarged chambers normal

- Myocardium is firm and noncompliant

57

What is arrythmogenic right ventricular cardiomyopathy?

AKA arrhythmogenic R.V. dysplasia

Genetic disease (A.D.), ~1 in 5000

RV dilation / myocardial thinning

Fibrofatty replacement of RV

Disorder of cell-cell desmosomes

Exercise -> cells detach and die

Silent, syncope, chest pain, palpitations

Sudden cardiac death – young / exercise

58

What are the most common causes of infective endocarditis?

Coxsackie A&B viruses
- most common cause in West

Chagas disease (Trypanosoma cruzi) protozoa
- important non-viral cause (endemic in South America)
- 10% die acutely

59

What are the broad clinical features of infective endocarditis?

Asymptomatic

Heart failure, arrhythmias and sudden death

Non-specific symptoms - fatigue, dyspnea, palpitations, precordial discomfort, and fever

Can mimic acute MI

DCM can develop

60

What are the other viral causes of infective endocarditis?

ECHO

Influenza

HIV

CMV

61

What are the bacterial causes of infective endocarditis?

C.diptheriae

N.meningococcus

Borrelia (Lyme)

Chlamydiae

Rickettsiae

62

What are the fungal causes of infective endocarditis?

Candida

Histoplasma

(Immunosuppressed)

63

What are the protozoan causes of infective endocarditis?

Trypanosoma cruzi (Chagas disease)

64

What are the helminths that can cause infective endocarditis?

Trichonosis

65

What are the immune-mediated causes of myocarditis?

Post-viral

Post-Strep (grp A) - rheumatic fever

SLE

Drugs
- methyldopa
- sulfonamides

Transplant rejection

66

What are the other causes of myocarditis?

Sarcoidosis

Giant cell myocarditis

67

What is vasculitis?

Inflammation of the vessel walls

68

How is vasculitis classified?

Chapel Hill Classification

By size first

Small vessel then split to ANCA/non-ANCA

69

What is the most common form of vasculitis?

Giant cell arteritis
- elderly individuals in the west

70

What is the pathology of giant cell arteritis?

Chronic granulomatous inflammation

Large to medium-sized arteries

Esp. in the head (e.g. temporal arteries
- AKA temporal arteritis)

Also vertebral and ophthalmic arteries

Ophthalmic arterial involvement
- Permanent blindness
- Giant-cell arteritis is a medical emergency requiring prompt recognition and treatment – early recognition is VITAL!

Also occurs in other vessels the aorta (giant-cell aortitis).

71

What is the morphology of giant cell arteritis?

Intimal thickening
- reduces the lumenal diameter

Med. granulomatous inflammation
- elastic lamina fragmentation

Multinucleated giant cells
- 75% of adequately biopsied

72

How is giant cell arteritis diagnosed?

biopsy and histologic
- Segmental disease
- Hence 2- to 3-cm length of artery

73

What is the treatment of giant cell arteritis?

- Corticosteroids is generally effective
- anti-TNF therapy in refractory cases

74

What is an aneurysm?

Localised, permanent, abnormal dilatations of a blood vessel

75

How can aneurysms be classified?

Shape

Aetiology
- Atherosclerotic
- Dissecting
- Berry
- Microaneurysms
- Syphilitic
- Mycotic
- False

76

What are atherosclerotic aneurysms?

Most common, often in the elderly

Commonly - AAA secondary to atherosclerosis

77

How are atherosclerotic aneurysms detected?

USS

78

What are the complications of atherosclerotic aneurysms?

Rupture causing retroperitoneal haemorrhage

Embolisation causing limb ischaemia

79

What is a dissecting aneurysm?

Tear in the wall

Blood tracks between intimal and medial layers

80

What are the classical features of a dissecting aneurysm?

Tearing pain in chest radiating to upper left shoulder

81

What are the pathological features of dissecting aneurysms?

Usually thoracic aorta secondary to systemic hypertension

Progressive vascular occlusion and haemopericardium

↑↑ Mortality without treatment (aim to reduce arterial pressure / surgery)

82

What are berry aneurysms?

Small, saccular lesions that develop in the Circle of Willis

Develop at sites of medial weakness at arterial bifurcations

Commonly found in young hypertensive patients

Rupture causes
subarachnoid haemorrhage (SAH)

83

What are Charcot-Bouchard aneurysms?

Occur in intracerebral capillaries in hypertensive disease

Causes intracerebral haemorrhage (i.e. stroke)

84

What are microaneurysms?

Retinal microaneurysms can develop in diabetes causing diabetic retinopathy

85

What are mycotic aneurysms?

Rare

Weakening of arterial wall secondary to bacterial / fungal infection

Organisms enter media from the vasa vasorum

SBE is the most common underlying infection

Often in the cerebral arteries

Infection of AAAs  risk rupture

86

What is a false aneurysm?

Blood filled space around a vessel, usually following traumatic rupture or perforating injury

The adventitial fibrous tissue contains the haematoma

Commonly seen following femoral artery puncture during angiography / angioplasty

87

What are the 6 Ps of acute ischaemia?

Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing Cold

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