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Flashcards in Pathology - cardiac Deck (53):
1

Right-to-left shunts in early cyanotic babies

5 T's
Truncus arteriosus (1 vessel)
Transposition (2 switched vessels)
Tricuspid atresia (3 = tri)
Tetralogy of Fallot (4 = tetra)
TAPVR (anomalous pulmonary venous return) (5 letters)

Generally caused by defects in aorticopulmonary septum (derived from neural crest)

2

Tetralogy of Fallot pathology

Caused by anterosuperior displacement of the infundibular septum

Four defects: pulmonary stenosis, RVH, overriding aorta, VSD

Pulm stenosis causes right-to-left shunting across VSD and RVH

Squatting increases systemic resistance, decr. R-to-L shunt, improves cyanosis

3

Late cyanosis in babies

VSD > ASD > PDA

4

ASD pathology

usually ostium secundum defects

distinct from PDA: pathology is missing tissue rather than unfused septa

5

End-stage effects of Eisenmenger syndrome

Late cyanosis, clubbing**, polycythemia

6

Associations with coarctation of the aorta

Bicuspid aortic valve, Turner syndrome (45 X)

aortic narrowing near insertion of ductus arteriosis (juxtaductal)

Look for delayed pulses in the lower extremities

7

Hypertension pathology

Primary (essential) - 90%, related to incr. CO or TPR

Secondary - 10%, related to renal/renovascular dz, primary hyper-aldosterone

8

Cause of hypertension in young woman

Fibromuscular dysplasia - string of beads in renal artery

9

Hypertensive nephropathy

Renal arterial hyalinosis

10

Evidence of end-organ damage in hypertensive emergency

Encephalopathy, stroke, retinal hemorrhages/exudates, papilledema, MI, HF, aortic dissection, kidney injury, MAHA, eclampsia

11

Hyperlipidemia signs

Xanthoma/xanthelesma - lipid-laden histiocytes in the skin

Tendinous xanthoma - seen particularly in Achilles

Corneal arcus - common in elderly

All appear in familial hypercholesterolemia

12

Arteriosclerosis

Arterial wall thickening and loss of elasticity

Includes arteriolosclerosis and medial calcific sclerosis

13

Arteriolosclerosis (two types)

Hyaline - thickening of vessel walls, seen in essential HTN/DM

Hyperplastic - proliferation of smooth muscle cells (onion skinning), seen in severe HTN

14

Medial calcific sclerosis

calcification of elastic lamina or arteries

Leads to vascular stiffening without obstruction

Intima not involved!

15

Atherosclerosis pathology progression

endothelial cell dysfunction --> macrophage/LDL accumulation --> foam cell formation --> fatty streaks --> smooth muscle migration (PDGF/FGF), ECM deposition --> fibrous plaque --> complex atheroma --> arterial occlusion or plaque rupture

Look for cholesterol crystals

16

Aortic aneurysm (abdominal vs. thoracic)

Localized pathologic dilatation of aorta

Abdominal: assoc. with atherosclerosis, older men

Thoracic: cystic medial degeneration, assoc. with bicuspid aortic valve, Marfan, tertiary syphillis (obliterative endarteritis)

17

Aortic dissection

intimal tear forming a false lumen

end results: rupture, pericardial tamponade, death

Type A: Ascending aorta, proximal, treat with surgery

Type B: involves descending aorta, treat with b-blockers then vasodilators

18

Coronary steal syndrome

phenomenon where administration of vasodilators (CCBs) dilates normal vessels and shunts blood to well-perfused areas, leading to decreased flow and ischemia in post-stenotic region

19

Pathologic evolution of MI

4-24 hrs

early coagulative necrosis, neuts appear, contraction bands with reperfusion

20

Pathologic evolution of MI

1-3 days

Extensive coagulative necrosis

Tissue surrounding infarct shows acute inflammation with neutrophils

Watch for pericarditis

21

Pathologic evolution of MI

3-14 days

Macrophages, then granulation tissue (thus, mac-mediated structural degradation)

Watch for free wall rupture (tampondade), pap muscle rupture (MR), septal rupture

LV pseudoaneurysm also appears

22

Pathologic evolution of MI

2 weeks - months

Contracted scar

Dressler syndrome: post-MI pericarditis (pleuritic chest pain, pericardial rub/effusion), autoimmune reaction to myocardial neo-antigens

True ventricular aneurysm (risk of mural thrombus)

23

MI diagnosis (ECG, markers)

ECG: gold standard in first 6 hours

troponin-I: rises after 4 hours, high for 7-10 days, more specific

CK-MB: rises after 6-12 hours (returns to normal in 48 hrs), found in myocardium, can be released from skeletal muscle, useful for reinfarction

24

Transmural vs. subendocardial infarcts

Transmural: incr. necrosis, affects entire wall, ST elevation

Subendocardial: less than 50% of wall affected, especially vulnerable to ischemia, ST depression

25

Dilated cardiomyopathy

Eccentric hypertrophy (cells added in series)

Alcohol, wet Beriberi, Coxsackie b, Cocaine use, Chagas, Doxorubicin tox

Look for S3, balloon appearance on CXR

Tx: Na restriction, ACEis, BBs, diuretics

26

Hypertrophic cardiomyopathy

Mostly familial (B-myosin heavy chain mutation)

Assoc. with Friedrich ataxia

Look for S4, mitral regurg (impaired valve closure)

Tx: BBs, CCBs (verapimil), ICD if high-risk

Path: myofibrillar disarray and fibrosis

can be obstructive

27

Restrictive/infiltrative cardiomyopathy

Sarcoid/amyloid, postradiation fibrosis, hemochromatosis

Loffler syndrome (endomyocardial fibrosis with a prominent eosinophilic infiltrate)

Leads to diastolic dysfunction

28

Systolic vs. diastolic dysfunction

systolic: reduced EF, incr. EDV, decr. contractility

diastolic: preserved EF, normal EDV, decr. compliance

29

Decreased mortality in HF

ACEis/ARBs

BBs

Spironolactone

30

Hemosiderin-laden macrophages in the lungs

Sign of pulmonary edema

31

Four types of shock

Hypovolemic (decr. preload)
Cardiogenic (decr. CO)
Obstructive (decr. CO)
Distributive (decr. SVR)

32

Bacterial endocarditis findings

Fever
Roth spots (white spots on retina)
Osler nodes (finger/toe pads),
Mitral valve/murmur

Janeway lesions (red lesions on palms/soles)
Anemia
Nail splinter hemorrhages
Emboli

33

acute endocarditis etiology

S. aureus (high virulence)

Rapid onset, large vegetations on normal valves

34

chronic endocarditis etiology

viridans streptococci


Smaller vegetations on damaged valves

Dental procedure sequela

35

tricuspid valve endocarditis

S. aureus, Pseudomonas, Candida

36

culture negative endocarditis

Coxiella, Bartonella, HACEK (h. flu, actinobacillus, cardiobacterium, eikenella, kingella)

37

Rheumatic fever

Consequence of pharyngeal infection with GABHS, type II hypersensitivity (Abs to M protein cross-react)

Early: MVR, progresses to MS

Joints (migratory polyarthritis)
Heart sign
Nodules
Erythema marginatum
Sydenham chorea

Tx: penicillin

38

Acute pericarditis

Sharp pain, aggravated by inspiration

Causes: coxsackie, idiopathic, autoimmune (Dressler, SLE, RA), radiation therapy

39

Tamponade findings

Equilibration of diastolic pressure in all four chambers

Beck triad: hypotension, distended neck veins, distant heart sounds

low-voltage QRS and electrical alternans

40

Cardiac tumors

Myxomas - ball valve obstruction in left atrium, early diastolic tumor plop sound

Rhabdomyomas - Most frequent primary tumor in children (assoc. with tuberous sclerosis)

41

Kussmaul sign

- increase in JVP with inspiration (normally there's a decrease)

Impaired filling of RV with inspiration due to constrictive pericarditis, restrictive cardiomyopathies, right atrial/ventricular tumors

42

Vascular tumors assoc. with elderly

Angiosarcoma - rare, malignancy, if hepatic then assoc. with vinyl chloride/arsenic, very aggressive

Cherry hemangioma - benign, capillary, does not regress

43

Vascular tumors assoc. with AIDS

Bacillary angiomatosis - capillary skin papules, caused by Bartonella henselae, neutrophilic infiltrate

Kaposi sarcoma - endothelial malignancy, assoc. with HHV-8, HIV, lymphocytic infiltrate

44

Vascular tumors assoc. with pregnancy or childhood

Pyogenic granuloma - pregnancy, can ulcerate and bleed

Strawberry hemangioma - grows rapidly, regresses spontaneously by 5-8 yo

45

Raynaud phenomenon

decr. blood flow to skin due to arteriolar vasospasm in response to cold/stress

syndrome occurs when 2ry to SLE, CREST, mixed connective tissue dz

Tx: CCBs

46

Large-vessel vasculitis

Temporal arteritis - elderly females, can lead to blindness due to ophthalmic artery occlusion, assoc. w/ polymyalgia rheumatica

Takayasu arteritis - aortic arch syndrome, weak UE pulses, granulomatous thickening of aortic arch

47

Medium-vessel vasculitis

Polyarteritis nodosa - young adults, Hep B, const. sx, renal/visceral vessels (microaneurysms), immune complex mediated, tx: cyclophosphamide

Kawasaki dz - CRASH and burn (conjunctiva, rash, adenopathy, strawberry tongue, hand-foot changes, fever, can develop coronary artery aneurysms

Beurger dz - heavy smokers under 40, male, intermittent claudication, loss of digits, often seen w/ Raynaud, tx = quit smoking!

48

ANCA assoc vasculitidies

GPA (c-ANCA, anti PR3) - nasal septum perforation, chronic sinusitis, hemoptysis, hematuria, red cell casts, large pulmonary nodules on CXR

Microscopic polyangiitis (p-ANCA, anti MPO) - necrotizing vasculitis involving lungs, kidneys, skin. No nasal involvement.

EGPA (p-ANCA, anti MPO) - asthma, sinusitis, peripheral neuropathy, look for eosinophilia

49

Henoch-Schonlein Purpura

Follows URI, triad: skin (palpable purpura), arthralgias, GI (ab pain)

secondary to IgA complex deposition, assoc with IgA nephropathy

50

Familial chylomicronemia syndrome

Type 1
defect in lipoprotein lipase and ApoC-II

risk of pancreatitis

51

Familial hypercholesterolemia

Type 2a
defect in LDL receptor, ApoB-100
(lack of uptake by liver --> incr. LDL serum)
premature coronary artery disease

52

Familial dysbetalipoproteinemia

Type 3
ApoE defect

premature coronary artery disease

53

Familial hypertriglyceridemia

Type 4
ApoA-V defect