Diseases of cardiovascular system department of pathology huaxi hospital xu huan 2009 10
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DISEASES OF CARDIOVASCULAR SYSTEM Department of Pathology, Huaxi Hospital Xu Huan 2009.10. SYSTEMATIC PATHOLOGY CAUSES OF DISEASE PATHOGENESIS BASIC PATHOLOGIC CHANGES PATHOCLINICAL RELATIONS. HOW TO STUDY BETTER REVIEW THE NORMAL STRUCTURE AND FUNCTION OF THE ORGAN

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DISEASES OF CARDIOVASCULAR SYSTEM Department of Pathology, Huaxi Hospital Xu Huan 2009.10

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DISEASES OF CARDIOVASCULAR SYSTEMDepartment of Pathology, Huaxi HospitalXu Huan2009.10


SYSTEMATIC PATHOLOGYCAUSES OF DISEASE PATHOGENESISBASIC PATHOLOGIC CHANGES PATHOCLINICAL RELATIONS


HOW TO STUDY BETTER

REVIEW THENORMALSTRUCTURE ANDFUNCTIONOF THE ORGAN

REVIEW THE CONTENT OF THEGENERAL PATHOLOGY

NOTICE THECORRELATIONSHIPBETWEEN THE MORPHOLOGY AND THE FUNCTION


CARDIOVASCULAR SYSTEMTHE BLOOD VESSELSTHE HEART


VASCULAR DISEASES

Atherosclerosis (ATH)

Aneurysm

Hypertension

Vascular tumor


  • THE HEART DISEASES

  • Ischemic heart disease

  • Rheumatic heart disease

  • Infective heart disease

  • Virus myocarditis

  • Cardiomyopathy

  • Pericarditis


Incidence and Mortality

In the city

  • Brain vascular disease 93.7/106 17.7% 2

  • Heart disease 90.7/106 17.1% 3

    In the country

  • Brain vascular disease 105.5/106 2o.4% 2

  • Heart disease 71.8/106 13.9% 4

    Ministry of Health,China,2008


NORMAL VESSELS

artery

veinlymphatics


NORMAL ARTERY

Large(elastic) arteryMedium-sized(muscular)arterySmall artery and arteriole


Normal

Aorta


  • Elastic and muscular artery--------ATH

  • Small artery and arteriole---------- Hypertension


vein and its valves


Capillary

Arteriole

venule


Vascular abnormalities

  • Narrowing or obstructing the lumen

  • Dilation or rupture of the wall


Atherosclerosis


Arteriosclerosis “hardening of the arteries”

  • Atherosclerosis-------most common

  • Arteriolosclerosis-----hypertension and diabetes mellitus

  • Medial calcific sclerosis-----rare


DEFINITION

Atherosclerosis is a degenerative disease of large and medium-sized arteries characterized by lipid deposition and fibrosis


Affects the large and medium-sized arteries

It is a chronic inflammatory response of the arterial wall initiated by injury to the endothelium

Lesions comprise fatty streaks, fibrous plaque, atheromatous plaque and complicated lesions

Major cause of organ ischaemia


BASIC PATHOLOGIC CHANGES

fatty streaks

fibrous plaque

Atheromatous plaque (atheroma)


Fatty Streaks


Gross view

1. elongated Yellow streaks on the intima

2. Lesions tend to be much more prominent around the origins of major branches


Histological feature

1.Intimal thickening

2.Foamy cells

accumulation


Fatty streak


Fatty Streaks

The precursor lesion for atheromas?

The relationship is uncertain !


Fibrous Plaque


Gross view

1.Plaques along the vessel length

2.gray fibrous cap can be seen


Fibrous plaque


Histological feature

1.Fibrous cap

2.foamy cells, Smooth muscle cells and fibrous tissue

inflammatory cells can be seen

3.The structures of media are basically complete


Atheromatous Plaque


Gross view

1.Raised focal lesions with a soft, yellow grumous core of lipid and covered by a firm,gray fibrous cap.

2.Complications often can be seen


Atheromatous Plaque


Histological feature

1.A thick and hyalined fibrous cap.

2.Amorphous pink-staining core with blank fissure in it.

3.Granulation tissue, some foamy cell and lymphocytes can be seen by the border

4.The internal elastic lamina is destroyed and the media of the artery becomes thinner.


Cholesterol clefts


Cholesterol fissure


inflammation

calcification

neovascularization


Masson’s

trichrome

stain


elastic

fiber

stain


Eccentric thickening


Cross section of coronary artery


Mild,moderate and severe atherosclerosis


Mild,moderate and severe ATH


COMPLICATIONS

Rupture and ulceration

Hemorrhage

Thrombosis

Aneurysm

calcification


Rupture

and

ulceration


ulceration


haemorrhage


thrombosis


thrombosis


thrombosis


thrombosis


Ulceration

and

calcification


Atherosclerosis with calcification


aneurysm


Aneurysm

  • An aneurysm is a localized abnormal dilation of a blood vessel or the heart

  • ATH, syphilis, congenital defects, trauma …

  • ATH is the most common cause of aneurysm


Classification of Aneurysm

  • True Aneurysm

  • Pseudoaneurysm

  • Dissecting Aneurysm

    (Dissecting hematoma)


Aortic aneurysm

Usually below renal arteries and above the bifurcation of the aorta


dissection of the media


Aneurysm Of the circle of Willis


aneurysm and thrombosis


Risk factor of ATH


Hyperlipidemia

  • Major risk factor

  • CM, VLDL, IDL , LDL, HDL

  • “Good cholesterol”

  • Genetic defects in lipoprotein metabolism


Notice

  • 1﹢1≠2

  • Maybe no apparent risk factors


Pathogenesis of ATH

The response to injury hypothesis

chronic inflammatory response of the arterial wall initiated by injury to the endothelium


Clinicopathologic effects


angiogram

Of

Coronary

arteries


Myocardial infarct


Atrophy of kidney


ATHOf the circle of Willis


Cerebral infarct


gangrene


Summary of ATH

Affects the large and medium-sized arteries

Basic change consists fatty streaks, fibrous plaque, atheromatous plaque and complicated lesions

It is a chronic inflammatory response of the arterial wall initiated by injury to the endothelium

Major cause of organ ischaemia


HYPERTENSION

Functional definition

Hypertension is considered as sustained systolic pressure greater than 140 mmHg and/or diastolic pressure greater than 90 mmHg

25% of the general population

are hypertensive!!


  • Etiological classification

  • Primary(essential or idiopathic) hypertension 90%~95%

  • Secondary hypertension

  • Pathological classification

  • Benign hypertension 95%

  • Malignant hypertension


CAUSE AND PATHOGENESIS

Of

HYPERTENSION


Regulation of blood pressure

  • The blood pressure is determined by the interaction of multiple genetic,environmental and demographic factors

  • Hypertension occurs when the relationship between cardiac output and total peripheral resistance is altered


homeostasis


Causes of secondary

hypertension

renal diseases

endocrine factors

cardiovascular factors

neurological factors


Renal hypertension

  • Acute glomerulonephritis

  • Chronic renal diseases

  • Polycystic disease

  • Renal artery stenosis

  • Renal vasculitis

  • Renin-producing tumors


atherosclerosis


Chronic nephritis


Chronic pyelonephritis


GFR

Reabsorption

Macula densa

RENIN

BLOOD VOLUME

Juxtaglomerular

apparatus

Afferent arteriole


Renin-angiotensin system


Causes of Renal hypertension

Induced renin secretion lead to vasoconstriction and increased peripheral resistance

Increased sodium reabsorption and therefore increased blood volume


  • Causes of secondary hypertension

  • Endocrine courses

  • Hormones produced by hyperplasial endocrine cells or tumor cells caused episodic vasoconstriction and thus induce hypertension


Cushing syndrom

(adrenocortical hyperfunction)


  • Clinic features

  • Central obesity and

  • moon face

  • Plethora and acne

  • Menstrual irregularity

  • Hirsutism and hair

  • thinning

  • Hypertension

  • Diabetes

  • Osteoporosis

  • Muscle wasting and

  • weakness

  • Atrophy of skin and

  • dermis: paper thin skin

  • with bruising tendency,

  • purple stride


Phaeochromocytoma

(catecholamines )

Cortical adenoma


Causes of primary hypertension:

1. Genetic influences (multigenetic disorders)

Caused by different combinations of genetic variations that are individually of little consequence

2. Environmental influences

Heavy consumption of salt、stress、smoking、fat 、 physical inactivity……


Hypothesis for pathogenesis of primary hypertension


  • Cause of Primary hypertension is not so clear

  • Primary hypertension is a complex multi-factorial disorder .environmental factors affect the variables that control blood pressure in the genetically predisposed individual


Clinicopathological Features Of

Hypertension


New Classification

Systolic(mm Hg) diastolic (mm Hg)

  • Ideal <120 <80

  • Normal <130 <85

  • High normal 130-139 85-89

  • Stage 1 140-159 90-99

  • Stage 2 160-179 100-109

  • Stage 3 ≥180 ≥110

  • pure systolic ≥140 <90

    (WHO-ISH 1999)


Vascular pathology

  • Accelerate atherogenesis

  • Weaken the wall of large and medium artery

  • Hyaline arteriolosclerosis


  • Hyaline

  • arteriolo-sclerosis

  • Leakage of plasma components

  • ECM produced by SMC


Hyaline arteriolosclerosis


small artery

in hypertension


Hypertensive encephalopathy

Hypertensive crisis

Cerebral lacunar infarct

Cerebralhemorrhage


Cerebral lacunar infarct


Cerebralhemorrhage


CerebralInfract and hemorrhage

CT scan


granular nephrosclerosis


granular nephrosclerosis


Hypertensive heart disease

The presence of left ventricular hypertrophy in an individual with a history of hypertension and other cause of ventricular hypertrophy have been excluded


Hypertensive Heart Disease

Weight of the heart exceeds 450g


Concentric hypertrophy

Free wall thickness exceeds 2.0cm


Concentric hypertrophy


eccentric

hypertrophy


Malignant Hypertension

1.Dramatic elevation of blood pressure over a short period of time with a progressive renal disease.

2.Often discovered in young and middle age.

3.Diastolic blood pressure usually over 120mmHg.

4.Clinical course is short(months to 1-2years).


Basic pathologic changes

Artery: hyperplastic

arteriolosclerosis

necrotizing arteriolitis

Heart: hypertrophy of the left

ventricle and dilation

Kidney: haematuria and renal failure

Brain: severe headache,

cerebral hemorrhage

Eyes: retinal hemorrhage ,papilledema


hyperplastic arteriolo-sclerosis

Onion-skin like

Laminated thicken


Hyperplastic arteriolosclerosis


necrotizing arteriolitis


增生性小动脉硬化

hyaline arteriolosclerosis

Benign Hypertension

hyperplastic arteriolosclerosis

Malignant Hypertension

necrotizing arteriolitis

Malignant Hypertension

细动脉玻璃样变

坏死性细动脉炎

malignant

benign


Summary of hypertention

  • sustained systolic pressuregreater than 140 mmHg and/or diastolic pressure greater than 90 mmHg

  • Mainly affects the small arteries and arteriole

  • Basic changes consists hyaline Arteriolosclerosis, Hyperplastic arteriolosclerosis

  • Uncontrolled hypertension has serious effects on heart,kidney and brain


Vascular Tumours

  • Benign (haemangioma)

  • Borderline malignant (Kaposi sarcoma)

  • Malignant (angiosarcoma)


Cavernous hemangioma


Kaposi sarcoma


angiosarcoma


The heart

Ischemic heart disease

Rheumatic heart disease

Infective heart disease

Virus myocarditis

cardiomyopathy


Normal heart


Normal structure of heart


Normal tricuspid valve


Ventricle valve


Normal cardiac muscle


ISCHEMIC HEART DISEASE


DEFINITION

IHDrefers to a group of closely related syndromes by an imbalance between the myocardial oxygen demand and the blood supply.

The most common cause is narrowing of the lumen of the coronary arteries by atherosclerosis

(Coronary heart disease )


  • Narrowing of the lumen (75%,critical stenosis)

  • Acute plaque changes

  • Thrombosis

  • Coronary artery vasospasm

Pathogenesis


Narrowing of the lumen


Narrowing of the lumen


Acute plaque changes


Acute plaque changes


Thrombosis


thrombosis


Syndromes

1.angina pectoris

2.acute myocardial infarction

3.sudden cardiac death

4.chronic IHD


Angina Pectoris

Definition

Intermittent chest pain caused by transient,reversible myocardial ischemia


Type

Stable (typical)

Variant (prinzmetal)

Unstable (crescendo)

Angina Pectoris

  • More than one type of angina may be present in a given person


  • Stable(typical) Angina Pectoris

  • Episodic chest pain associated

  • with exertion or other form

  • of stress

  • Crushing substernal sensation,

  • radiate down the left arm

  • Relieved by rest or by

  • intake of nitroglycerin

  • A fixed atherosclerotic

  • narrowing(≧75%)


VariantAngina Pectoris

  • Occur at rest ,awaken from sleep

  • Response to the uptake of vasodilator

  • Coronary artery spasm


UnstableAngina Pectoris

  • Increased frequency of angina pectoris

  • More intense and often last longer than stable angina pectoris

  • Induced by acute plaque change with partial thrombosis,distal embolization and/or vasospasm

  • More serious,potentially irreversible myocardial ischemia


Myocardial Infarction

Definition

An area of myocardial necrosis caused by local ischemia.

Location

Determined by the site of the vascular occlusion and by the anatomy of the coronary circulation.


Branches of coronary artery


(15-20%)

(40-50%)

(30-40%)


Locations of MI


Transmural

Infarcts

Subendocardial

Infarcts


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