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Disorders of Cardiac Function. Cardiac Pathology Outline. Blood Vessels Heart I Heart Failure Congenital Heart Disease Ischemic Heart Disease. Ischemic Heart Disease. Myocardial perfusion can ’ t meet demand

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cardiac pathology outline
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
    • Heart Failure
    • Congenital Heart Disease
    • Ischemic Heart Disease
ischemic heart disease
Ischemic Heart Disease
  • Myocardial perfusion can’t meet demand
  • Usually caused by decreased coronary artery blood flow (“coronary artery disease”)
  • Four syndromes:
    • angina pectoris
    • acute MI
    • chronic IHD
    • sudden cardiac death
angina pectoris
Angina Pectoris
  • Intermittent chest pain caused by transient, reversible ischemia
  • Typical (stable) angina
    • pain on exertion
    • fixed narrowing of coronary artery
  • Prinzmetal (variant) angina
    • pain at rest
    • coronary artery spasm of unknown etiology
  • Unstable (pre-infarction) angina
    • increasing pain with less exertion
    • plaque disruption and thrombosis
myocardial infarction
Myocardial Infarction
  • Necrosis of heart muscle caused by ischemia
  • 1.5 million people get MIs each year
  • Most due to acute coronary artery thrombosis
    • sudden plaque disruption
    • platelets adhere
    • coagulation cascade activated
    • thrombus occludes lumen within minutes
    • irreversible injury/cell death in 20-40 minutes
  • Prompt reperfusion can salvage myocardium
manifestations of st segment elevation acute myocardial infarction
Manifestations of ST-Segment Elevation Acute Myocardial Infarction
  • Abrupt onset
  • Severe and crushing pain, usually substernal, radiating to the left arm, neck, or jaw
  • Gastrointestinal complaints (nausea and vomiting)
  • Complaints of fatigue and weakness
  • Tachycardia, anxiety, restlessness, feelings of doom
  • Pale, cool, and moist skin
st segment
ST Segment
  • Abnormalities of the ST segment and the T wave represent abnormalities of ventricular repolarization.
factors determining the extent of an infarct
Factors Determining the Extent of an Infarct
  • Location and extent of occlusion
  • Amount of heart tissue supplied by the vessel
  • Duration of the occlusion
  • Metabolic needs of the affected tissue
  • Extent of collateral circulation
  • Heart rate, blood pressure, and cardiac rhythm
myocardial infarction1
Myocardial Infarction
  • Clinical features
    • Severe, crushing chest pain ± radiation
    • Not relieved by nitroglycerin, rest
    • Sweating, nausea, dyspnea
    • Sometimes no symptoms
  • Laboratory evaluation
    • Troponins increase within 2-4 hours, remain elevated for a week.
    • CK-MB increases within 2-4 hours, returns to normal within 72 hours.
myocardial infarction2
Myocardial Infarction
  • Complications
    • contractile dysfunction
    • arrhythmias
    • rupture
    • chronic progressive heart failure
  • Prognosis
    • depends on remaining function and perfusion
    • overall 1 year mortality: 30%
    • 3-4% mortality per year thereafter
cardiac pathology outline1
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
    • Heart Failure
    • Congenital Heart Disease
    • Ischemic Heart Disease
    • Hypertensive Heart Disease
hypertensive heart disease
Hypertensive Heart Disease
  • Can affect either L or R ventricle
  • Corpulmonale is RV enlargement due to pulmonary hypertension caused by primary lung disorders
  • Result: myocyte hypertrophy
  • Reasons for heart failure in hypertension are poorly understood
cardiac pathology outline2
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
cardiac pathology outline3
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
    • Heart Failure
    • Congenital Heart Disease
    • Ischemic Heart Disease
    • Hypertensive Heart Disease
cardiac pathology outline4
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
    • Valvular Heart Disease
    • Cardiomyopathies
    • Pericardial Disease
    • Tumors
cardiac pathology outline5
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
    • Valvular Heart Disease
valvular heart disease
Valvular Heart Disease
  • Stenosis and/or insufficiency
  • Stenosis: failure to open
  • Insufficiency: failure to close
  • Murmurs
  • Outcome depends on severity and speed of development
calcific aortic stenosis
Calcific Aortic Stenosis
  • Part of aging process
  • Can occur on normal or congenitally bicuspid valves
  • Results in increased LV pressure, LV hypertrophy, and relative ischemia
  • Angina, CHF, or fainting
mitral valve prolapse
Mitral Valve Prolapse
  • Common (5% of adults in US, F>M)
  • Ballooning of mitral leaflets
  • Myxoid/mucoid change within leaflet
  • Pathogenesis unknown
  • Most patients asymptomatic
rheumatic valvular disease
Rheumatic Valvular Disease
  • Rheumatic fever: systemic inflammatory disease occurring a few weeks after strep throat
  • Valves (esp. mitral) become scarred
  • Consequence: stenosis (± regurgitation)
rheumatic fever
Rheumatic Fever
  • Body makes antibody to strep bug that cross-reacts with antigens in heart and joints
  • 2-3 weeks after strep throat, patient gets:
    • migratory polyarthritis
    • pericardial friction rub, arrhythmias
  • Chronic disease can reappear decades later
    • mitral stenosis, left atrial enlargement, thrombi
    • increased risk of infective endocarditis
  • Long term prognosis variable
slide32

Strep throat

Antibody

production

Antibody cross-reaction

with heart

vegetations

Aschoff body

pericarditis

slide34

Infective Endocarditis

  • Microbial invasion of heart valves, endocardium
  • Acute endocarditis
    • highly virulent bug attacks normal valve
    • half of patients dead within days to weeks
  • Subacuteendocarditis
    • low virulence bug colonizes abnormal valve
    • slow onset, long course, most recover
  • Symptoms: fever, flu-like symptoms
  • Complications: septicemia, arrhythmias, renal failure, systemic emboli
infective endocarditis
Invasion of the heart valves and endocardium by a microbial agent

Formation of bulky, friable vegetations and destruction of underlying cardiac tissues

Systemic manifestations

Streptocococci

Enterococci

Haemophilussp.

Actinobacillusactinomycetemcomitans

Cardiobacteriumhominis

Eikenellacorrodens

Kingellakingae

Gram-negative bacilli

Fungi

Infective Endocarditis
cardiac pathology outline6
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
    • Valvular Heart Disease
    • Cardiomyopathies
myocardial diseases
Myocardial Diseases
  • Myocarditis
    • Inflammation of the heart muscle and conduction system without evidence of myocardial infarction
  • Primary cardiomyopathies
    • Heart muscle diseases of unknown origin
  • Secondary cardiomyopathies
    • Conditions in which the cardiac abnormality results from another cardiovascular disease, such as myocardial infarction
cardiomyopathies
Cardiomyopathies
  • Diverse group of disorders in which there is intrinsic myocardial dysfunction
  • Lots of causes; some idiopathic
  • Three groups
    • dilated cardiomyopathy
    • hypertrophic cardiomyopathy
    • restrictive cardiomyopathy
dilated cardiomyopathy
Dilated Cardiomyopathy
  • Heart dilates, enlarges, and can’t contract well
  • Causes
    • viral
    • alcohol/toxin
    • genetic abnormalities
    • peripartum
  • Slowly progressing CHF
  • 70% of patients dead within 5 years
restrictive cardiomyopathy
Restrictive Cardiomyopathy
  • Heart wall is stiff; can’t fill during diastole
  • Cause: Idiopathic or secondary to systemic disease (amyloidosis, hemochromatosis, sarcoidosis)
  • Symptoms: shortness of breath, peripheral edema
  • Treatment: not often helpful
  • 70% of patients dead within 5 years
hypertrophic cardiomyopathy
Hypertrophic Cardiomyopathy
  • Massively hypertrophied L ventricle can’t fill
  • Cause: mutation in a sarcomereprotein gene
  • Symptoms: atrial fibrillation, CHF, arrhythmia, sudden death
  • Treatment: drugs to promote ventricular relaxation or surgical excision of part of septum
  • Prognosis: about 4% of patients die each year
treatment of cardiomyopathy
Treatment of Cardiomyopathy
  • Treatment depends on the type
    • Medication
    • Implanted pacemakers
    • Defribillators
    • Ventricular assist devices
    • Ablation
    • The goal of treatment is often symptom relief, and some patients may eventually require a heart transplant.
cardiac pathology outline7
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
    • Valvular Heart Disease
    • Cardiomyopathies
    • Pericardial Disease
pericardial disease
Pericardial Disease
  • Pericarditis
    • secondary (MI, radiation, pneumonia) or primary (infectious)
    • atypical chest pain
    • dangers: tamponade, chronic fibrosis
  • Pericardial effusion
    • serous (CHF), serosanguinous (aortic dissection), chylous (lymphatic obstruction)
    • outcome depends on stretchiness of pericardial sac
    • slow = asymptomatic; sudden = catastrophic
cardiac pathology outline8
Cardiac Pathology Outline
  • Blood Vessels
  • Heart I
  • Heart II
    • Valvular Heart Disease
    • Cardiomyopathies
    • Pericardial Disease
    • Tumors
definition and functions of the pericardium
Definition and Functions of the Pericardium
  • Definition
    • A double-layered serous membrane surrounding the heart
  • Functions
    • Isolates the heart from other thoracic structures
    • Maintains its position in the thorax
    • Prevents it from overfilling
    • Contributes to coupling the distensibility between the two ventricles during diastole; they both fill equally
types of pericardial disorders
Types of Pericardial Disorders
  • Pericardial effusion
    • The accumulation of fluid in the pericardial cavity
  • Cardiac tamponade
    • Slow or rapid compression of the heart due to accumulation of fluid, pus, or blood in pericardial sac
pericarditis
Pericarditis
  • An acute inflammatory process of the pericardium
    • Can be acute, chronic, or constrictive
    • May be due to autoimmune disease, infection, Rheumatic fever
    • Difficulty breathing, swelling of legs and ankles, dry cough, fatigue, anxiety, chest pain
types of pericardial disorders cont
Types of Pericardial Disorders (cont.)
  • Constrictive pericarditis
    • A disorder caused by inflammation of the pericardium
    • Eventual thickening, scarring and contracture of the pericardium occurs causing it to be less elastic.
    • This prevents the pericardium from stretching and results in reduced filling of the chambers of the heart.
    • This reduces the amount of blood pumped by the heart and causes blood to back up behind the heart, resulting in symptoms of heart failure.
    • Constrictive pericarditis may be life threatening if untreated.
clinical manifestations
Clinical Manifestations
  • Acute pericarditis is based on clinical manifestations
    • ECG, chest radiography, and echocardiography
    • Friction rub
  • Chronic pericarditis
    • No pathogen identified
    • Autoimmune disorders
cardiac tumors
Cardiac Tumors
  • Most common: metastatic
    • heart is a rare site of metastasis
    • lung cancer, lymphoma most common
  • Primary tumors uncommon
    • most are benign
    • most common: myxoma
coronary circulation
Coronary Circulation
  • Left main coronary artery
  • Left anterior descending artery
  • Circumflex branch
  • Right coronary artery
  • Posterior descending artery
coronary heart disease
Coronary Heart Disease
  • Impaired coronary blood flow that may cause:
    • Angina
    • Myocardial infarction or heart attack
    • Cardiac arrhythmias
    • Conduction defects
    • Heart failure
    • Sudden death
    • http://www.youtube.com/watch?v=22bDs8teiZA
question
Question
  • Which of the following conditions will result in pathological changes arising from pulseless electrical activity?
  • A. Pericardial effusion
  • B. Cardiac tamponade
  • C. Pericarditis
slide65

Answer

  • Pericardial effusion
  • B. Cardiac tamponade: Cardiac tamponade is the result of restricted movement of the muscle and will inhibit ventricular contraction. The conduction is intact, but there will be little or no SV.
  • Pericarditis
the evaluation of coronary blood flow and myocardial perfusion
The Evaluation of Coronary Blood Flow and Myocardial Perfusion
  • ECG
    • Changes in pattern or orientation of wave forms
  • Echocardiogram
    • M-mode, two-dimensional, Doppler, and esophageal
  • Exercise stress testing
    • Motorized treadmill and bicycle ergometer
  • Nuclear cardiovascular imaging methods
    • Myocardial perfusion imaging, infarct imaging, radionuclide angiocardiography, and positron emission tomography
classification of coronary heart disease
Classification of Coronary Heart Disease
  • Chronic ischemic heart disease
    • Chronic stable angina
    • Silent myocardial ischemia
    • Variant or vasospastic angina
acute coronary syndromes acs
Acute coronary syndromes (ACS)
  • Represent the spectrum of ischemic coronary disease
  • Ranges from unstable angina through myocardial infarction
  • Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer
  • Pain elsewhere in the body, such as the left upper arm or jaw (referred pain
  • Nausea
  • Vomiting
  • Shortness of breath (dyspnea
  • Sudden, heavy sweating (diaphoresis)
types of angina
Types of Angina
  • Chronic stable angina
    • Associated with a fixed coronary obstruction that produces a disparity between coronary blood flow and metabolic demands of the myocardium
  • Stable angina
    • The initial manifestation of ischemic heart disease in approximately half of people with CHD
populations affected by silent myocardial ischemia
Populations Affected by Silent Myocardial Ischemia
  • Persons who are asymptomatic without other evidence of CHD
  • Persons who have had a myocardial infarct and continue to have episodes of silent ischemia
  • Persons with angina who also have episodes of silent ischemia
non pharmacologic treatment of angina
Non-pharmacologic Treatment of Angina
  • Smoking cessation in persons who smoke
  • Stress reduction
  • Regular exercise program
  • Limiting dietary intake of cholesterol and saturated fats
  • Weight reduction if obesity is present
  • Avoidance of cold or other stresses that produce vasoconstriction
anti platelet and anticoagulant therapy
Anti-platelet and Anticoagulant Therapy
  • Aspirin
    • The preferred anti-platelet agent for preventing platelet aggregation in persons with CHD
    • Inhibits synthesis of prostaglandin and thromboxaneA2
anti platelet and anticoagulant therapy cont
Anti-platelet and Anticoagulant Therapy (cont.)
  • Platelet receptor antagonists
    • Target a single step in the aggregation process
    • Block the receptor involved in the final common pathway for platelet adhesion, activation, and aggregation
    • Treat acute coronary syndrome
determinants of acs acute coronary syndrome status
Determinants of ACS (Acute Coronary Syndrome) Status
  • Persons with an ACS are routinely classified as low risk or high risk for infarction based on
    • Presenting characteristics
    • ECG variables
    • Serum cardiac markers
    • Timing of presentation
causes of unstable angina
Causes of Unstable Angina
  • Atherosclerotic plaque disruption
  • Platelet aggregation
  • Secondary hemostasis
characteristics of pain associated with unstable angina
Characteristics of Pain Associated With Unstable Angina
  • The pain has a more persistent and severecourse and is characterized by at least one of threefeatures:
  • It occurs at rest (or with minimal exertion) usually lasting more than 20 minutes (if not interrupted by nitroglycerin).
  • It is severe and described as frank pain and of new onset.
  • It occurs with a pattern that is more severe, prolonged, or frequent than previously experienced.
basis for diagnosis of unstable angina
Basis for Diagnosis of Unstable Angina
  • Pain severity and presenting symptoms
  • Hemodynamic stability
  • ECG findings
  • Serum cardiac markers
involvement of heart muscle in an infarct
Involvement of Heart Muscle in an Infarct
  • Transmural infarcts
    • Involves the full thickness of the ventricular wall
    • Occur when there is obstruction of a single artery
    • Associated with atherosclerosis involving major coronary artery
subendocardial infarcts
Subendocardial infarcts
  • Involves the inner one third to one half of the ventricular wall
  • Occur more frequently in the presence of severely narrowed but still patent arteries
medical management following infarct
Medical Management Following Infarct
  • Thrombolytic therapy
    • The use of drugs to break up or dissolve blood clots, which are the main cause of both heart attacks and stroke.
  • Revascularization interventions
    • Coronary artery bypass grafting (CABG)
    • Percutaneous coronary intervention (PCI)
    • Atherectomy
  • Cardiac rehabilitation programs
question1
Question
  • Which type of angina is brought about by exercise or stress?
  • A. Stable
  • B. Unstable
slide84

Answer

  • A. Stable: Stable angina does not present as a problem until there is an increase in workload.
  • Unstable
manifestations of rheumatic fever
Manifestations of Rheumatic Fever
  • Acute stage
    • History of an initiating streptococcal infection
    • Involves mesenchymal connective tissue of the heart, blood vessels, joints, and subcutaneous tissues
  • Recurrent phase
    • Extension of the cardiac effects of the disease
  • Chronic phase
    • Permanent deformity of the heart valves
fetal blood flow
Fetal Blood Flow
  • Parallel rather than in series
  • Right ventricle delivering most of its output to the placenta for oxygen uptake
  • Left ventricle pumping blood to the heart, brain, and primarily upper body
  • Umbilical vein and two umbilical arteries
  • Foramen ovale
    • Allows blood to enter the left atrium from the right atriumDuctusarteriosus
    • A shunt connecting the pulmonary artery to the aortic arch
cyanosis and shunting
Cyanosis and Shunting
  • Defects that increase resistance to aortic outflow increase left-to-right shunting.
  • Defects that obstruct pulmonary outflow increase right-to-left shunting.
  • Crying, defecating, or stress of feeding may increase pulmonary vascular resistance and cause an increase in right-to-left shunting.
  • Resulting cyanosis
factors affecting postnatal pulmonary vascular development
Factors Affecting Postnatal Pulmonary Vascular Development
  • Prematurity
  • Alveolar hypoxia
  • Lung disease
  • Congenital heart defects
types of congenital heart defects
Types of Congenital Heart Defects
  • Patent ductusarteriosus
  • Atrial septal defects
  • Ventricular septal defects
  • Endocardial cushion defects
  • Pulmonary stenosis
  • Tetralogy of Fallot
  • Transposition of the great vessels
  • Coarctation of the aorta
  • Kawasaki disease
question2
Question
  • Which of the following might result in the development of a cardiomyopathy?
  • A. Valvularstenosis
  • B. Valvularregurgitation
  • C. MI
  • D. Ischemia
  • E. All the above
slide94

Answer

  • A. Valvularstenosis
  • B. Valvularregurgitation
  • C. MI
  • D. Ischemia
  • E. All the above: Any of these conditions can contribute to the development of a cardiomyopathy.
kawasaki disease
Kawasaki Disease
  • Vasculitisin the small vessels; progresses to involve some of the larger arteries
  • Immunologic in origin
    • Acute phase: fever, conjunctivitis, rash, involvement of the oral mucosa, redness and swelling of the hands and feet, and enlarged cervical lymph nodes
    • Subacute phase: defervescence and desquamation
    • Convalescent phase: complete resolution of symptoms until all signs of inflammation have disappeared after about 8 weeks
signs and symptoms of childhood congenital heart disease
Signs and Symptoms of Childhood Congenital Heart Disease
  • Symptoms associated with altered heart action
  • Heart failure
  • Pulmonary vascular disorders
  • Difficulty in supplying the peripheral tissues with oxygen and other nutrients
ad