What are the common causes of myocardial dysfunction?
Ischemic heart disease
valvular heart disease
What are the three major categories of cardiomyopathy?
Dilated (90% of all cases)
What measure is used to define a cardiomyopathy [in the presence of what]?
An ejection fraction less than 40% in the presence of increased left ventricular dimensions.
What is the most common form of non-ischemic cardiomyopathy?
Dilated cardiomyopathy is characterized by enlargement and dilation of which chambers?
What is the most common cause of non-ischemic dilated cardiomyopathy in the U.S.?
What is the most commonly identified specific cause of dilated cardiomyopathy?
Which form of cardiomyopathy is characterized by abnormal diastolic filling? (in 1/3 of cases, intermittent ventricular outflow obstruction)
What causes hypertrophic cardiomyopathy?
It is an inherited autosomal dominant trait attributed to mutations in one of a number of genes that encode for one of the sarcomere proteins.
What are the three anatomical changes found in a hypertrophic cardiomyopathy heart?
Myocardial hypertrophy without ventricular dilation
Often only one ventricle is hypertrophic
Disproportionate septum as compared to the free wall of the ventricle
What are the two most common causes of restrictive cardiomyopathy?
In restrictive cardiomyopathy, what results in impaired ventricular wall motion with abnormal ventricular wall contraction and relaxation?
The myocardium is usually infiltrated with abnormal tissue
What is hemochromatosis and what can it lead to in terms of the myocardium?
It is excessive deposition of iron leading to enlargement and failure of the heart. It is a form of restrictive cardiomyopathy
What is characterized by amorphous deposits of pale pink material between myocardial fibers?
Restrictive cardiomyopathy due to amyloidosis
What term generally refers to inflammation on the valve leaflets? (although the endocardial lining of the atrium and ventricles may also be involved)
Where does the process of endocarditis tend to begin?
The lines of closure, where the pressure is greatest
What are the vegetations of infectious endocarditis collections of?
Infected thrombotic debris deposited on and around the affected valve
In infectious endocarditis, what valves are most commonly infected?
Left-sided, equal frequency b/w mitral and aortic valves
What are some of the risks of infectious endocarditis?
Destruction of underlying valves and tissue
Prosthetic valves and pacemakers can also become infected
Vegetations can embolize
Bacteria, fungi, chlamydia, and Rickettsiae can all cause endocarditis. Which is by far most common?
What organism is the most common cause of community acquired endocarditis? Second?
1st: Staphylococcus aureus (30-50%)
2nd: Alpha-hemolytic Strep (S. viridans)(10-35%)
What are some portals of entry for organisms that may cause endocarditis?
Poor dental health, dental procedures, pharyngeal infection GU infection Skin infections Pulmonary infections IV drug use
What factors make a case of endocarditis acute?
Highly virulent organism, leading to death within days to weeks in ~50% of cases even with treatment
Acute endocarditis most often has a dramatic onset with what rapidly developing symptoms?
Fever (MC), chills, weakness, and fatigue. New murmurs may be heard.
It is common in endocarditis for the vegetations to embolize. What visible places can they end up at and what are they called?
Skin - petechiae, in the mouth or under the tongue.
Finger nail beds - splinter hemorrhages.
Retina - Roth’s spots
What are Roth’s spots cause by and what is a DDX for them?
Immune complex mediated vasculitis.
Leukemia, diabetes, pernicious anemia, ischemic events, and HIV.
What are some of the risk factors for endocarditis?
Rheumatic heart disease Artificial valves Immunocompromised IV drug users Alcoholics Indwelling catheters Vascular grafts
With endocarditis of NATIVE valves, what organism is most common?
Strep. viridens (alpha hemolytic strep)
What are the associated endocarditis organisms for the following risk factors:
- Prosthetic valves
- IV drug abusers
- Cystoscopy/prostatectomy/indwelling catheters
- Staph epidermitis
- Staph aureus
- Anaerobes and oral cavity bugs
- Gram- such as E. coli
5-20% of blood cultures for endocarditis are negative. What are some of the potential reasons?
Organism not in the blood stream at the time of draw
Limitations of culture process
May be inflammatory rather than infectious
A hypercoagulable state
What is Libman-Sacks endocarditis?
Systemic lupus endocarditis (collagen vascular disease) causing inflammatory vegetations
What term is used to refer to endocarditis that results from an underlying hypercoagulable state also known as Trousseau’s syndrome and what kind of syndrome is it?
Marantic endocarditis, a paraneoplastic syndrome associated with malignancies
What is the most common infectious agent of myocarditis? 2nd?
1st: Coxsackie virus (type B)
2nd: Cytomegalic virus
Which valve is most commonly diseased? Least?
MC - Aortic
Least - Pulmonary
What term describes the failure of a valve to open completely, thereby impeding forward flow?
What term describes the result of failure of a valve to close completely, thereby allowing reversed flow?
What are the two most common valve diseases?
Aortic stenosis and mitral regurgitation or insufficiency
Acquired aortic stenosis is usually the consequence of what?
Calcification owing to progressive and advanced age-associated wear and tear
Where do degenerative calcific deposits develop in mitral valve insufficiency?
Fibrous ring (annulus) behind the leaflets
In this valvular abnormality, one or both leaflets are “floppy” and prolapse or balloon back into the atrium during systole. (Fish face)
Mitral valve prolapse
Mitral valve prolapse effects what population the most?
Women, aged 20 to 40
What pathological term used to describe a disease of the mitral valve, is one of the most common forms of valvular heart disease?
What does myxomatous degeneration mean?
A pathological weakening of connective tissue (most often used in the context of mitral valve prolapse)
How is mitral valve prolapse usually discovered in a patient?
Incidentally because it is usually asymptomatic. A mid-systolic click is present
What are the potential complications of mitral valve prolapse?
Stroke or other infarct
What is an acute, immunologically mediated, multisystem inflammatory disease that usually occurs within a period of a few weeks following an episode of strep throat?
Rheumatic fever (RF)
Fill in the blank: While a century ago rheumatic heart disease was a leading cause of ____(1) in the U.S. for individuals ___ to ___(2) years of age, the incidence has markedly decreased. The vast majority of those with RHD in the U.S. contracted the disease 40-50 years ago.
- 5 - 20
It has not decreased in developing parts of the world.
Rheumatic fever develops following pharyngitis with what organism?
Group A beta hemolytic streptococcus (strep. pyogenes)
What antibody titer is elevated in group a strep pharyngitis?
Antistreptolysin O (ASO). O induces persistently high antibody titers that provide a useful marker of infection
0.3 to 3% of untreated cases of group A strep pharyngitis leads to rheumatic fever. Post streptococcal acute rheumatic fever is likely due to what?
An autoimmune responce caused by anti-streptococcal M protein antibodies which cross-react with cardiac myosin
What are nodules found in the hearts of individuals with RF that result from inflammation in the heart muscle and are characteristic of RHF?
Aschoff bodies - granulomatous structures consisting of fibrinous material, lymphocytes, occasional plasma cells and macrophages which often surround necrotic centers
Aschoff bodies may fuse to form multinucleated giants cells. Others may become what? [named so because of the appearance of their chromatin]
Anitschkow cells or caterpillar cells
RF manifest in form of focal inflammatory involvement of the interstitial tissue in all 3 layers of the heart. What is the pathognomonic feature of pan-carditis?
The presence of Aschoff bodies
What is the most common non-cardiac sxs of acute RF?
What is a dermatological condition associated with RF?
Erythema marginatum (annulare). [trunk and proximal limbs]
The most common cause of pericarditis.
Which form of pericarditis is usually non-infectious, has minimal fluid in the pericardium and less inflammatory response, and is associated with acute uremia and autoimmune conditions like RA and SLE? [often has complete resolution]
Which form of pericarditis is associated with post-MI or dressler’s syn., post-cardiac surgery, trauma, has chronic uremia, AI conditions like RA and SLE, pericardial fluid is a mixture of fibrinous exudate in serous fluid, and a pericardial friction rub may be audible? [Bread and butter]
Which form of pericarditis is associated with TB, tumor, bacterial infection, trauma, and has pericardial fluid containing blood mixed with fibrin and possible exudates such as pus?
Which form of pericarditis is associate with adjacent infections, septic embolization, septicemia and iatrogenic causes after procedures involving the heart, the pericardial fluid is exudative containing pus and fibrin, and resolution often involves scarring with potential for constrictive pericarditis?
What is the most common heart tumor and how severe is it?
Atrial myxoma, benign
Atrial myxomas are masses most often attached where and what effect do they have?
The wall of the left atrium (but can arise on a valve or in a ventricle). They produce a “ball valve” effect by intermittently occluding the valve orifice.
What is the most common primary pediatric tumor of the heart?
What neoplasm has the greatest propensity to metastasize to the heart?
What malignancy is most often seen in the heart?
Carcinoma of the lung
Perhaps the most important cardiac related consequence of RHD is the potential development of chronic valvular deformities, particularly what?
Fusion of the valve apparatus resulting in stenosis or a combination of stenosis and insufficiency develops how long after an episode of acute RF? [recurrent episodes may cause progressive damage to the valves]
2 to 10 years