Heart Pathology

Question 1

Arteriosclerosis

Answer 1

Hardening of arteries

Medial calcific sclerosis – Monckeberg

• calcification in media of artery
• elderly
• arteries of extremities
• does not obstruct blood flow – benign

Question 2

Arteriolosclerosis

Answer 2

Hyaline thickening of arterioles

Essential HTN and DM w/o hyperlipidemia

Question 3

Atherosclerosis

Answer 3

Fibrous plaques and atheromas of intima of arteries

Accumulation of fatty materials in walls of arteries

Causes:
HTN
high LDL, low HDL
DM
Smoking
FHx
Sedentary lifestyle

Question 4

Occlusion of RCA

Answer 4

-> arrhythmias

Question 5

Occlusion of LAD

Answer 5

Anterior wall MI

Question 6

Pathogenesis of atherosclerosis

Answer 6

1. Endothelial dysfunction -> increased vascular permeability, leukocyte adhesion, and thrombosis
2. Accumulation of lipoproteins – in vessel wall, mostly LDL
3. Monocyte adhesion to endothelium – migration of monocytes into intima, transform to macrophages and foam cells (full of lipid)
4. Factor release – activated platelets, macrophages, inflammatory mediators
5. Sm.m. proliferation – migration of sm.m. cells into intima (normally only in media)
   Lipid accumulation – extracellularly and w/in macrophages and sm.m. cells – if disrupted -> thrombi

Question 7

Abdominal aortic aneurysm

Answer 7

Caused by atherosclerotic plaque compressing underlying media
Nutrient and waste diffusion compromised
Media generates and necroses -> atertial wall weakness

Mean over 50, smokers

Pulsating mass in abdomen

Complications:

• rupture -> fatal hemorrhage
• embolism from atheroma
• obstruction of branch vessel
• impingement on adjacent structure (ureter)

Known AAA – U/S every 6 mo

Tx: surgical repair if over 5.5 cm or if rapidly enlarging (0.5 cm in 6 mo or 1 cm in year)

Question 8

Deadly causes of acute chest pain

Answer 8

“if you’re DUMPT you’re heartbroken”

aortic Dissection
Unstable angina
MI
Tension pneumo
PE

Question 9

Ischemic heart disease

Answer 9

Inadequate O2 supply relative to demand

MC: atherosclerosis

Question 10

Prinzmetal angina

Answer 10

Occurs at rest
Not assoc w/ exertion
d/t coronary artery spasm

younger

EKG change: ST segment elevation

Tx: dihydropyradine CCB (nifedipine)

Question 11

Angina (except treatment)

Answer 11

Retrosternal pain, pressure, radiates to neck, jaw, shoulder

SOB, diaphoresis
Women may only have fatigue

Narrowing of at least 75% coronary a.
-can’t accommodate by dilating anymore

CP d/t myocardial ischemia
Primary cause atherosclerosis
Worse overtime

Question 12

Stable vs unstable angina

Answer 12

Stable:
Predictable: with increased activity, resolves w/ rest
EKG change: ST depression or elevation

Unstable:
Increased frequency and increased severity
Unpredictable
Pain at rest

Question 13

Targets to improve angina

Answer 13

Goal: decrease myocardial O2 demand

Factors increasing O2 demand:
Preload
BP
Contractility
Ejection time
HR

Question 14

Statins

Answer 14

HMG-CoA inhibitors

Lovastatin
Pravastatin
Simvastatin
Atorvastatin
Rosuvastatin

Best effect on LDL/cholesterol

Inhibit denovo cholesterol production
-> increased cell surface LDL receptors, causing LDL to be internalized out of circulation, dropping plasma LDL levels

Increases HDL
Lowers TGs

AE:
Hepatotoxicity – check LFTs before prescribing and as sx present
Myalgias -> myositis -> rhabdomyolysis
-measure CDK

Question 15

Niacin

Answer 15

Increases HDL, lowers LDL

SE:
Flushing – 45%
-reduced w/ aspirin 30 min prior, remaining on drug and avoiding other causes (etOH, hot beverages)

Rash
Pruritis

Question 16

Fibrates

Answer 16

Gemifibrozil
Fenofibrate

Lower TGs – best effect on TG/VLDL

AE:
Myositis
Myalgias
Hepatotoxicity – elevated LFTs
Increased cholesterol gallstones

Dangerous to use w/ statin -> increased risk of myositis

Question 17

Omega 3 fatty acids

Answer 17

Fish oil – Salmon, halibut – cold water fish
Flax seed oil

Lower TG

No SE

Question 18

Bile Acid binding resins

Answer 18

Cholestyramine
Colestipol
Colesevelam

Prevent reabsorption of bile acids

Cause GI upset, decreased fat soluble vit absorption
-rarely cause cholesterol gallstones

Question 19

Ezetimibe

Answer 19

Prevents cholesterol reabsorption at small intestine brushborder

SE: increased LFT, diarrhea

Question 20

Effects of Nitrates and Beta blockers on EDV (preload)

Answer 20

Nitrates: decrease – relaxes venous system

B-blockers: no effect

Question 21

Effects of Nitrates and Beta blockers on BP

Answer 21

Nitrates: decreases - preload

B-blockers: decreases - afterload

Question 22

Effects of Nitrates and Beta blockers on Contractility

Answer 22

Nitrates: indirectly slight increase

B-blockers: decreases

Net effect – no change

Question 23

Effects of Nitrates and Beta blockers on HR

Answer 23

Nitrates: increases

B-blockers: decreases (stronger)

Net effect - decreases

Question 24

Effects of Nitrates and Beta blockers on ejection time

Answer 24

Nitrates: decreases

B-blockers: increases

Net effect – no change

Question 25

Effects of Nitrates and Beta blockers on myocardial O2 demand or consumption

Answer 25

Nitrates: decreases - preload B-blockers: decreases – HR, contractility, afterload

Question 26

Hypertrophic obstructive Cardiomyopathy (aka hypertrophic cardiomyopathy, aka idiopathic hypertrophic subaortic stenosis)

Answer 26

MC sudden death in young healthy athletes Hereditary - 50% AD Disordered hypertrophy of LV - not parallel myocytes Enlarged ventricular septum obstructs aortic valve leaflets - blood can't get out Apical impulse enlarged and diffuse S4 heart sound - stiff ventricle Systolic murmur - louder w/ valsava -decreases preload --> worsening of LV outflow tract obstruction softer w/ squatting - increased afterload, less obstruction Volume depleted --> decreased preload --> death ``` Tx: b-blocker non-dihydropyridine CCB - verapamil --> prolonged diastole to increase ventricular filling Restrict physical exertion Avoid volume depletion ```

Question 27

Dilated cardiomyopathy

Answer 27

MC 90% heart dilates - myocytes in series instead of parallel Round, globular shape S3 herat sound apical impulse displaced laterally ``` Causes: chronic myocardial ischemia hemachromatosis anthracyclines - Doxorubicin, daunorubicin Chronic cocaine and etOH use (B1 def) Wet beriberi (b1 def) Chagas dz - Trypanosoma cruzi Mycarditis from Coxsackie B virus ```

Question 28

Restrictive cardiomyopathy

Answer 28

deposition in myocardium disrupts diastolic function "LEASH" Loffler syndrome - fibrosis, eosinophil infiltration (Ascaris lumbercoides) Endocardial fibroelastosis - congenital, thick fibroelastic tissue Amyloidosis Sarcoidosis - granulomas Hemochromatosis (MC w/ dilated CM) Also radiation tx --> fibrosis

Question 29

Myocarditis

Answer 29

generalized inflammation of the myocardium - not result from ischemia MC cause: Coxsackie B virus Histo: diffuse interstitial infiltrate of lymphocytes w/ myocyte necrosis

Question 30

Causes of Infectious endocarditis - bacterial

Answer 30

**BLOOD CX BEFORE ABX** 75%: S. aureus - 30% acutely ill -large vegetations on previously normal valves Viridans strep - 20-30% subacute illness - smaller vegetations on previously damaged valves - dental procedures Enterococci - 10% -some VRE Coagulase neg Staph (S. epidermidis) 5-10% -IV drug user S. bovis - assoc w/ colon CA

Question 31

Infectious endocarditis in IV drug user

Answer 31

Coagulase neg Staph (S. epidermidis) 5-10% -IV drug user More likely to have fungal endocarditis - Candida albicans

Question 32

Culture negative endocarditis causes

Answer 32

``` HACEK Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella ``` Now MC causes are intracellular organisms: Coxiella brunetti Bartonella spp. Brucella spp.

Question 33

Typical S/S of endocarditis

Answer 33

Fever, chills, weakness, anorexia New regurgitation murmur or HF - MV most common - left sided - Tricupsid MC in IV drug users --> septic pulmonary infarcts Splinter hemorrhages in fingernails Osler nodes - painful red nodules on finger and toe pads Janeway lesions - painless erythematous macules on palms and soles Roth spots - retinal hemorrhages w/ clear central area - rare

Question 34

Signs of embolism

Answer 34

Brain infarct -> focal neuro defects Renal infarct --> hematuria splenic infarct --> abdominal or shoulder pain

Question 35

Systemic immune reaction to endocarditis

Answer 35

glomerulonephritis | arthritis

Question 36

Complications of infective endocarditis

Answer 36

``` Embolic glomerulonephritis structural damage to valves valvular regurgitation or stenosis rupture chordae tendinae acute MR or TR Suppurative pericarditis ```

Question 37

Libman-sacks endocarditis

Answer 37

SLE causes LSE | sterile vegetations on BOTH sides of valve simultaneously

Question 38

Marantic endocarditis

Answer 38

Metastatic cancer cells platelet-fibrin aggregates in hypercoaguable states

Question 39

Cardiac tamponade

Answer 39

excessive fluid in space between myocardium and pericardium - blood, pericardial effusion - -> compresses heart, can't fill during diastole Causes decreased CO, equilibration of pressures in all chambers ``` Leads to: Hypotension increased venous pressure, JVD distant heart sounds increased HR Pulsus paradoxus ``` EKG: electrical alternans - alternating amplitude of QRS complexes - tall --> tiny --> tall (can't r/o tamponade if not present on EKG)

Question 40

Pulsus paradoxus

Answer 40

Exaggerated decrease in amplitude of SBP during inspiration - >10mmHg -decreased capacity of LV Normal up to 10 mmHg ``` Causes: Cardiac tamponade Asthma Croup OSA Severe COPD Rarely pericarditis ```

Question 41

Causes of fibrinous pericarditis

Answer 41

uremia RA Dressler syndrome

Question 42

Causes of serous pericarditis

Answer 42

noninfectious inflammatory dz lupus rheumatic fever

Question 43

Suppurative pericarditis

Answer 43

infection of pericardium

Question 44

Causes of hemorrhagic pericarditis

Answer 44

TB | melanoma - mets to heart

Question 45

Acute pericarditis

Answer 45

Pleuritic CP - sharp - worse w/ inspiration - better sitting up and leaning forward distant heart sounds friction rub diffuse ST elevation diffuse PR depression can either resolve w/o scarring or cause chronic constrictive pericarditis

Question 46

Chronic constructive pericarditis

Answer 46

Lupus Kussmaul sign - JVD w/ inspiration

Question 47

Diagnostic criteria for rheumatic fever

Answer 47

1. evidence of grp A strep infection - elevated ASO titer 2. 2 major criteria or 1 major and 2 minor criteria "Jones Criteria"

Question 48

Major criteria for Jones criteria

Answer 48

Joints - migratory polyartheritis Heart - pancarditis - peri/myo/endocarditis Nodules - subcutaneous, painless Erythema marginatum - serpiginous skin rash - ring like, comes and go Sydenham chorea - chorea of face, tongue, upper limb

Question 49

Minor criteria for Jones criteria

Answer 49

"PEACE" Prolonged PR interval Elevated temperature (fever) Arthralgia elevated Crp or Esr (counts as 1)

Question 50

Rheumatic heart disease

Answer 50

autoimmune d/t Grp A beta-hemolytic strep (S. pyogenes) --> type II HSR - Ab attack heart

Question 51

Scarlet fever

Answer 51

widespread sandpaper rash all over body toxin mediated active infection

Question 52

Post-strep glomerulonephritis

Answer 52

type III HSR - immune complexes hematuria, proteinuria, renal insufficiency 1-6 wks after

Question 53

Acute rheumatic fever

Answer 53

Type II HSR 2-4 weeks after pharyngitis

Question 54

Kussmaul's sign

Answer 54

JVD during inspiration d/t decreased capacity of RV caused by constrictive pericarditis >>tamponade

Question 55

Syphilitic heart disease

Answer 55

disrupt vasovasorum dilation of aorta and aortic valve ring Aortic regurg d/t dilation of aortic root Aortic stenosis Thoracic aortic aneurysm Calcification of aorta -tree bark appearance of inner surface of aorta

Question 56

Tuberous sclerosis tumor associations

Answer 56

Rhabdomyoma angiomyolipoma - renal tumor Astrocytoma

Question 57

Metastatic tumors to heart

Answer 57

MC overall type of cardiac tumors Melanoma lymphoma

Question 58

Myxoma

Answer 58

MC primary cardiac tumor in adults Left atrial myxoma - ball of tissue in atrium acts as ball valve - -> obstruction of mitral valve --> syncopal episodes can flip into LV during diastole --> early diastolic sound -"tumor plop"

Question 59

Rhabdomyoma

Answer 59

MC primary cardiac tumor in kids assoc w/ tuberous sclerosis