Week 8 Cardiovascular 3 Flashcards Preview

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Flashcards in Week 8 Cardiovascular 3 Deck (129)
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

Is infective endocarditis serious?

Clinically serious infection!!!
Colonization / invasion of heart valves or heart chamber endocardium by a microbe

4

What caues the vegetation of the valves in endocarditis?

Mixture of thrombotic debris and microorganisms
Invade and destroy underlying cardiac tissues

5

What is the cause of infective endocarditiis?

Most cases caused by bacterial infection
Fungi

6

How does acute infective endocarditis occur and what is the cause?

Can occur with infection of a previously normal healthy valve
Caused by highly virulent organisms



7

What is the consequence of acute infetive endocarditis?

Necrotizing, ulcerative, destructive lesions

8

What is the treatment of acute infective endocarditis

Difficult to cure with antibiotics and usually require surgery

Death frequent days to weeks despite aggressive treatment

9

What is more common acute or sub acute infective endocarditis?

Sub-acute

10

What is the cause and outcome of sub acute infective endocarditis?

Organisms of lower virulence
Insidious infections of deformed valves
Vague symptoms --> fever and maybe a murmur
Less destructive

11

What is the treatment of sub-acute infective endocarditis?

Protracted “wax and wane” course of weeks to months

Cured with antibiotics

12

What are the causes of infective endocarditis?

Mitral valave prolapse
Valvular stenosis (calcification etc)
Artificial (prosthetic) valves
Unrepaired and repaired congenital defects
Bicuspid AV

13

What disease use to be a major cause of infective endocarditis but not a problem as much any more?

Rheumatic heart disease

14

What are the different routes a bacteria can get into the blood stream and infected the heart?

Dental abnormalities, IVDU, wounds, bowel cancer

15

How does Streptococcus viridans affect the heart?

From the heart which cause damage/abnormal valves
50-60% cases

16

What bacteria on the skin can cause infection endocarditiis?

S.aureus--> 10% to 20% of cases overall esp in IVDU as they damage the skin

17

What bacteria commonly infects prosthetic heart valves?

Coagulase-negative staphylococci

18

What is appearance of vegetation in acute IE and what is effected?

Friable, bulky, potentially destructive
Often more than one valve --> AV,MV and the right heart (especially in IVDUS)

19

What effect does vegetation of acute IE have on the heart?

Can erode the myocardium and cause abscess

20

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  can be a new defect or a pre-existing condition
New valvular defect or represent a pre-existing abnormality.

21

What are the complications of Infective endocarditis?

Immunologically mediated conditions e.g. glomerulonephritis

22

What are the clinical manifestations 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

23

What type of patients will commonly have non-bacterial thrombotic endocarditis?

Occurs in debilitated patients (e.g. cancer or sepsis)

24

What is Non-bacterial thrombotic endocarditis (NBTE) assoicated with?

Assoicated with hypercoagulable state

Hence DVT, PE and mucinous adenocarcinomas!

Pro-coagulant effects of tumour-derived mucin or tissue factor

25

What predisposes people to NBTE?

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

26

What type of vegetation occurs 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

Systemic emboli

27

What is Rheumatic fever?

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

28

Why has Rheumatic fever become rare?

Rare because of improved diagnosis / treatment

29

What is a diagnostic presentation of RF in the heart?

If Aschoff bodies are found

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

30

What is the patholgical featrues of Rheumatic heart disease (RHD)

Vegetations called veruccae

Mitral valve changes are classical
Virtually ONLY cause of mitral stenosis

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”

31

What is the main cause of mitral stenosis?

Reumatic heart disease

32

What is the aetiology of RHD that presents Aschoff bodies?

Antibodies directed against the M proteins of Group A strep

Cd4 T cells specific for streptoccal peptides which react with self proteins in the heart

Produce cytokines that activate macrophages ( Aschoff bodies)

33

How is RHD diagnosed?

Diagnosis is made by the presence of:
One required criteria, two major criteria and zero minor criteria
Or
One required criteria, one major criteria, and two minor criteria

34

What is the cardiac complications of RHD?

Left atrium dilates

Right ventricular hypertrophy

35

What is pericarditis and the causes?

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

36

What are the two different forms of pericarditis?

Acute pericarditis (inflammed)

Chronic pericarditis ( stuck down)

37

What are the different types of acute pericarditis? (5)

Serous
Serofibrinous / fibrinous
Purulent / suppurative
Haemorrhagic
Caseous

38

What are the different type of chronic pericarditis? (3)

Adhesive mediastinopericarditis
Constrictive pericarditis

39

What disease is libman-sacks endocarditis assoicated with?

Associated with Systemic Lupus Erythematosis (SLE)

40

What are the common symptoms and signs of Libman sacks endocarditis?

Usually asymptomatic (other than features of SLE)

Rarely cardiac failure or systemic emboli

41

What valves are affected in Libman-Sacks endocarditis and what type of vegetation occurs?

Mitral and tricuspid (AV) valves affected

Small (1–4 mm) sterile pink warty vegetations being either single or multiple.

Often occur on AV valves (often under-surfaces), on the chordae, vavular endocardium or mural endocardium of atria or ventricles.


42

What is pericarditis?

What is the term for inflammation in all 3 layers in the heart?

43

What is vegetation in RHD called?

Veruccae

44

What is the criteries used for diagnosing RHD?

Jones criteria

45

What virus is commonly associated with infections of the heart?

Coxsackie B virus

46

What is the consequence of the inflammation caused by serious pericarditis?

Causes clear serious fluid accumulation

47

What is the common cause of serous pericarditis?

Caused by non-infectious aetiologie

48

What are less common causes of aetiologies of serious pericarditis?

Inflammation in adjacent structures can cause pericardial reaction

Rarely by viral pericarditis (Coxsackie B / echovirus)

49

What are the immunological mediated process that cause serous pericarditis?

Rheumatic fever, SLE, scleroderma

50

What are the Miscellaneous conditions that cause serous pericarditis?

Uraemia, neoplasia, radiation

51

What occurs in fibrinous pericarditis?

Serous fluid and / or fibrinous exudate in pericardial

52

What are the common causes of fibrinous pericarditis? (8)

Acute MI, Dressler's syndrome
Uraemia, radation, rheumatic fever, SLE, trauma and surgery

53

What are the features of fibrinous pericarditis (without fluid)

Dry, granular, roughened surface
More intense inflammatory response  sero-fibrinous

54

What is Dresslers syndrome?

Secondary pericarditis - AKA post MI syndrome Clinical triad of: 1) Fever 2) Pleuritic chest pain - worse on inspiration 3) Pericardial effusion

55

What is the aetiology of Dresslers syndrome?

Autoimmune reaction to antigens released following an MI - it is not the same as acute pericarditis as there is a delay of weeks

56

What is the cause of purulent/suppurative pericarditis?

infection

57

What are the features of purulent/suppurative pericarditis?

Red, granular, exudate i.e. pus (can be upto 500mls!)

58

Where can the inflammation of purulent/suppurative pericarditis extend into?

Extend into the mediastinum causing mediastino-pericarditis

59

What is the usual outcome of purulent/suppurative pericarditis?

complete resolution is rare

Organisation by scarring --> restrictive pericarditis – serious

60

What is Haemorrhagic pericarditis?

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

61

What are the common causes of haemorrhagic pericarditis?

Trauma to the chest
Neoplasia (malignant cells in effusion)
Infections (inc TB)
Following cardiac surgery

62

Why can cardiac surgery cause haemorrhagic pericarditis?

cardiac tamponade

compression of the heart by an accumulation of fluid in the pericardial sac.

63

What are the two causes of caseous pericarditis?

TB or fungal

64

Give 3 examples of chronic pericarditis?

Adhesive pericarditis

Adhesive mediastinopericarditis

Constrictive pericarditis

65

What is adhesive pericarditis?

Fibrosis / stringy adhesions obliterates pericardial cavity

66

What is the cause of adhesive mediastinopericarditis?

Follows pericarditis caused by infections, surgery or radiation

67

What occurs in adhesive mediastinopericarditis and what does it cause?

Obliterated pericardial cavity with adherence to surrounding structures

Causes cardiac hypertrophy / cardiac dilation

68

What is the pathology of constrictive pericarditis?

Heart encased in fibrous scar due to inflammation – limits cardiac function

69

What is the treatment of constrictive pericarditis?

Treated by surgery to remove ‘shell’ around heart

70

What are the clinical features of pericarditis?

Sharp central chest pain --> pleuritic

Pericardial friction rub

Fever, leucocytosis, lymphocytosis, pericardial effusion

71

When is pericardial friction rub the loudest?

Loudest with diaphragm, left sternal edge

72

How is pleuritic pain, Exacerbated, relieved, radiated and differentiated?

Exacerbated by: movement, repiration, lying flat

Relieved: sitting forwards

Radiating: shoulders/neck

Differentials: angina, pleurisy

73

What is the complications of pericarditis?

pericardial effusion / cardiac tamponade

74

What type of disease is cardiomyopathy and what are the 4 main types?

Heart muscle disease

Four main types are:
Dilated
Hypertrophic
Restrictive
Arrythmogenic right venticular
cardiomyopathy

75

What is the pathology of dilated cardioyopathy?

Progressive dilation --> contractile dysfunction

Heart enlarged, heavy, flabby (dilation of chambers)

Myocyte hypertrophy with fibrosis

76

What is the cause of dialted cardiomyopathy?

Genetic (20 – 50% cases)
Autosomal dominant (mainly)

Cytoskeletal proteins gene mutation
Alcohol (10-20%) and other toxins
E.g. chemotherapy

Others
SLE, scleroderma, thiamine def., acromegaly, thyrotoxicosis, diabetes….

77

What is the clinical presentation of dilated cardiomyopathy?

Any age but commonly 20 – 50

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

78

Dilated cardiomyopathy has a common survival rate of 5 years what is the death due to?

Death due to Congested Cardiac Failure, arrhythmia / embolism

79

What is the treatment for cardiomyopathy?

Cardiac transplantation
Long-term ventricular assist

80

What is the pathology of hypertropic cardiomyopathy?

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

81

How would you define hypertropic cardiomyopathy?

Defined as myocardial hypertrophy with absence of an obvious cause such as hypertension.

82

What is the main cause of unexplained left ventricular hypertrophy?

Hypertrophic cardiomyopathy

83

What is the cause of hypertrophic cardiomyopathy?

100% genetic
Mutations sarcomeric proteins
Can be sporadic

84

What are the clincal features of hypertrophic cardiomyopathy?

Decrease in stroke volume --> Impaired diastolic filling - reduced chamber size / compliance of hypertrophied left ventricle

Obstruction to the left ventricular outflow

Exertional dyspnoea

Systolic ejection murmur due to:

Ventricular outflow obstruction

Anterior mitral leaflet moves toward the ventricular septum during systole.

85

What is the complications of hypertorophic cardiomyopathy?

Atrial fibrillation
Mural thrombus formation embolization / stroke
Cardiac failure
Ventricular arrhythmias
Sudden death, especially in some affected families

86

What is the treatment for hypertrophic cardiomyopathy?

Decrease heart rate and contractility - β-adrenergic blockers.
Reduction of the mass of the septum, which relieves the outflow tract obstruction

87

What is the common cause of sudden death in atheletes?

Hypertrophic cardiomyopathy

88

What is the morphology of restrictive cardiomyopathy?

Ventricles normal size / slightly enlarged
chambers normal

Myocardium is firm and noncompliant --> it has been infiltrated so cannot enlarge

89

What are secondary causes of restrictive cardiomyopathy?

fibrosis, amyloidosis, sarcoidosis,
metastatic tumors or deposition of
metabolites

90

What is the primary cause of restrictive cardiomyopathy?

Decrease in ventricular compliance

Impaired ventricular filling during diastole

91

What type of genetic disease is Arrythmogenic right ventricular cardiomyopathy?

Autosomal dominant disease

92

What is another name for Arrythmogenic right ventricular cardiomyopathy?

Arrhythmogenic R.V. dysplasia

93

What is the morpholy of arrhythmogenic R.V. cardiomyopathy?

RV dilation / myocardial thinning  get fat in the wall as there is a defect in cell adhesion
Fibrofatty replacement of RV
Disorder of cell-cell desmosomes
Exercise --> cells detach and die

94

What is the signs and symptoms of Arrythmogenic right ventricular cardiomyopathy?

Silent, syncope, chest pain, palpitations

Sudden cardiac death – young / exercise

95

What are the infectious causes of myocarditis?

Coxsackie A&B viruses most common cause in West

Chagas disease (Trypanosoma cruzi) protozoa

96

What are the clinical features of myocarditis?

Asymptomatic
Heart failure, arrhythmias and sudden death

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

Can mimic acute MI

DCM can develop

97

What are the immune mediated causes of myocarditis?

Post-viral

Post steptococcal (RF)

SLE

Drugs

Transplant rejection

98

What is Vascuilitis

Inflammation of the vessel walls

Any organ and any vessel size

99

What is the clinical features of vasculitis

Clinical features depend on vascular bed

100

What is the most common form vasculitis?

Giant cell arteritis

seen in elderly individuals in west

101

What is the pathology of Giant cell arteritis?

Chronic granulomatous inflammation
Large to medium-sized arteries

102

What arteries are commonly effected by giant cell arteritis?

Large and medium sized arteries in the head (e.g. temporal arteries – AKA temporal arteritis)
Also vertebral and ophthalmic arteries

Vessels of the aorta

103

What is the consequence if there is ophthalmic arterial involvement in Giant cell arteritis?

Ophthalmic arterial involvement is a medical emergency.

Permanent blindness

Giant-cell arteritis is a medical emergency requiring prompt recognition and treatment – early recognition is VITAL!

104

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

105

What are the clinical features of Giant cell arteritis?

Rare

106

How do you diagnose giant cell arteritis?

biopsy and histologic
Segmental disease

Hence 2- to 3-cm length of artery

107

What is the treatment for Giant cell arteritis?

Corticosteroids is generally effective -->prednisolone

Also anti-TNF therapy in refractory cases

108

What is a aneurysm?

Localised, permanent, abnormal dilatations of a blood vessel

109

What are the two ways aneurystms can be classified?

Shape
Aetiology

110

What are the different caues of a aneurysm?

Atherosclerotic
Dissecting
Berry
Microaneurysms
Syphilitic
Mycotic
False

111

What is risk factor for rupture of atherosclerotic aneurysms?

Nil 6cm

Risk of surgery is big --> so only do it when the risk of rupture is more than surgery

112

What is a common sight of atherosclerotic aneurysm?

Abdominal aortic aneurysm

113

How is atherosclerotic aneurysm detected and treated?

Detected by ultrasound scan
Can be repaired endovascularly

114

What are the complications of atherosclerotic aneurysms?

Rupture causing retroperitoneal haemorrhage

Embolisation causing limb ischaemia.

115

What is dissecting aneurysm?

Tear in the wall
Blood tracks between intimal and medial layers

116

What is the classical symptoms of dissecting aneursysm?

Tearing pain in chest radiating to upper left shoulder

117

Where does dissecting aneurysm commonly effect?

Usually thoracic aorta secondary to systemic hypertension

Progressive vascular occlusion and haemopericardium which is the chambers filling up with blood

118

What is a berry Aneurysm and where does it occur?

Small, saccular lesions that develop in the Circle of Willis

Develop at sites of medial weakness at arterial bifurcations or anastomoses

Commonly found in young hypertensive patients

119

What is the consequence of rupture of Berry Aneurysms?

Rupture causes subarachnoid haemorrhage (SAH)

Thunder clap headache

120

Give a example of microaneurysm?

Charcot-Bouchard aneurysms

121

Where does Charcot-Bouchard aneurysms occur?

It ocurs in the intracerebral capillaries in hypertensive disease.

122

What can Charcot-Bouchard aneurysms cause?

Causes intracerebral haemorrhage (i.e. stroke)

Retinal microaneurysms can develop in diabetes causing diabetic retinopathy

123

What is syphilitic aneurysms?

Syphilitic aneurysm is associated with tertiary state of syphilis infection which causes ascending (thoracic) aorta aneurysms.

124

What is mycotic aneurysms?

Rare
Weakening of arterial wall secondary to bacterial / fungal infection
Often in the cerebral arteries

125

What causes mycotic aneurysms?

Organisms enter media from the vasa vasorum
Subacute bacterial endocarditis is the most common underlying infection

126

What is false aneurysm?

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

The adventitial fibrous tissue contains the haematoma

127

When do you see false aneurysms? What is the treatment?

Commonly seen following femoral artery puncture during angiography / angioplasty

Resolves few days or week

128

What are the 3 main causes of acute arterial occlusion?

Embolus

Thrombosis

Trauma

129

What are the 6ps when investgiating acute ischaemia?

Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing Cold