Severe and constant middle or left chest pain that may radiate to the neck and shoulders (particularly trapezius ridge). Increases on inspiration and is relieved by sitting up and leaning forward (postural) and auscultation reveals pericardial friction rub best heard with patient lying forward.
Drop in systolic BP > 10 mm on inspiration. Cardiac tamponade***. Disappearing radial pulse during inspiration
Cardiac tamponade is associated with pulsus paradoxus and
Cardiac tamponade happens when pericardial pressure >10 mmHg resulting in
Collapse of the atria, increase systemic venous pressure, reduced preload and eventually decreased CO -> cardiogenic shock
Cardiac tamponade findings
Beck triad (hypotension, distended JV, distant heart sounds), increased heart rate, pulsus paradoxus, low voltage QRS and electrical alternans
Aortic dissection, narrow it to
Longstanding HTN***, Marfan and EHD. Rarely syphilis.
How does syphilis cause thoracic aorta aneurysms
Vasa vasorum obliteration—particularly those in the thoracic aorta
Concentric vs Eccentric hypertrophy
Concentric from pressure overload/ increased afterload, adding sarcomeres in parallel vs. eccentric from volume overload, addition of sarcomeres in series, allowing venitruclar dilation while maintain normal sarcomere lengths. Concentric is capable of generating greater forces and higher pressures while increased while thickness maintains normal wall stress. Becomes stiff.
Concentric hypertrophy happens in
Aortic stenosis and longstanding systemic HTN
Single most important risk factor for aortic dissection/ intimal tears
HTN. Then cystic medial degeneration. Recall it can go towards or away from the heart.
Where does blood/ hematoma form
Between intimal flap and medial wall.
Single most important risk factor for aortic aneurysm? Others?
Atherosclerosis and based on that, then smoking, HTN, DM, and hypercholesterolemia.
Most common locations for atherosclerotic plaques (and thus aneurysms)
Large elastic vessels and large or medium sized muscular arteries; Abdominal aorta > Coronary artery > Popliteal artery > Internal carotid artery > Circle of Willis. Upper limb arteries, mesenteric and renal arteries all tend to be spared.
Acute onset heart failure in setting of recent viral infection...
Consider DCM from viral myocarditis. Direct viral injury and from autoimmune reaction to virally altered myocytes.
Viral myocarditis or bacterial (such as from diphtheria) usually result in what heart problem
DCM/ systolic dysfunction
Fatty streak composed of intimal lipid filled foam cells derived from
Macrophages and smooth muscle cells that have engulfed lipoproteins such as LDL; insudate into intima.
Aortic aneurysms are mostly caused by atherosclerosis, then medial degeneration (marfans) then last rare cause
Perivascular fibrosis/ dense periaortic fibrosis with inflammatory reaction, an unusual variant of AAA; the inflammatory reaction is rich in lymphocytes, plasma cells, macrophages and giant cells
DCM is a dx of exclusion once other etiologies of heart failure have been ruled out such as
High systolic pressure gradient between left ventricle and aorta?
Left ventricular outflow obstruction. Such as from aortic stenosis.
Acute onset mid-chest pleuritic that decreases on sitting up and leaning forward
Acute pericarditis. Fibrinous or serofibrinous are most common forms.
Acute pericarditis most often caused by
MI, rheumatic fever, uremia and sometimes viral infection leading to fibrinous exudate accumulating in pericardial space
Paradoxic increase in jugular venous pressure with inspiration; found most often in patients with chronic constrictive pericarditis, which takes months or years to develop. Because volume restricted right ventricule cannot accommodate inspiratory increase in venous return. Need to also consider restrictive cardiomyopathy, severe right HF, tricuspid stenosis, and rarely cardiac tamponade. NOT EXPECTED in a case of ACUTE pericarditis.
Constrictive pericarditis causes
Idiopathic or viral pericarditis; cardiac surgery or radiation therapy
Thick fibrous tissue in pericardial space; rigid itssue encases heart and restricts ventricular filling causing low CO and right sided HF
Diastolic dysfunction and or ventricular volume overload
Restrictive cardiomyopathy causes
amyloidosis, sarcoidosis, metastatic cancer or inborn metabolic errors
Pulsus paradoxus, systolic BP drop of 10 mm or more during inspiration, can be caused by
Cor pulmonale, constrictive chronic pericardial disease or cardiac tamponade.
constrictive pericarditis; brief high frequency precordial sound heard in early diastole (shortly after S2) (earlier than a S3 sound would be and also more sharp and accentuated)
Nmumber one cause of V Fib in people < 30
Systolic anterior motion of MV occurs in patients with
Hypertrophic cardiomyopathy and cau cause eccentric MR or worsen LV outflow tract obstruction
Fibrous intimtal thickening with endocardial plaques limited to the right heart
Carcinoid syndrome/ carc. Heart disease. May progress to pulmonic stenosis and or restrictive cardiomyopathy.
Severity of carcinoid syndrome determined by
Serotonin levels and urinary excretion of its metabolite 5-hydroxyindoleacetic acid. Also will see niacin deficiency.
Carcinoid syndrome symptoms
Skin flushing, abdominal cramping, n/v, diarrhea
Carcinoid tumors produce serotonin and...
Bradykinin, kallilkrein, histamine, prostaglandins and or tachykinins
Why does carcinoid syndrome only affect right heart
Serotonin, along with bradykinin, is generally inactivated by pulmonary vascular endothelial monoamine oxidase
Recall, carcinoid syndrome is most common malignancy in what system
Most plentiful catecholamine in urine
VMA; indicator of catecholamine level in blood
Cancer mets to heart usually go to
Pericardium or myocardium
Ankylosing spondylitis is associated with
Uveitis, apical pulmonary fibrosis, peripheral enthesopathies and aortic insufficiency
Aging associated with increased or decreased left ventricle size
Localized amyloidosis confined to cardiac atria/ isolated atrial amyloidosis is due to
Deposition of abnormally folded B-pleated hsheet confirmation atrial NATRIURETIC PEPTIDE-derived proteins. Incidence increases with age reaching >90% in the ninth decade. Senile cardiac amyloidosis** increases risk of AFib.
Persistent lymphedema, such as after radical mastectomy and or radiation, predisposes to
Lymphangiosarcoma, malignant neoplasm of endothelial lining of lymphatic channels. Occurs approximately 10 years following radical mastectomy.
Bacillary angiomatosis vs Kaposi Sarcoma, benign?
B, not K
Bacillary angiomatosis vs Kaposi Sarcoma, AIDS?
Bacillary angiomatosis vs Kaposi Sarcoma, infiltrate made of
B- neutrophils and K-lymphocytes
Bacillary angiomatosis vs Kaposi Sarcoma, cause
B- bartonella henselae vs K- HHV8/ HIV
Hemangiomas, Strawberry vs Cherry vs Pyogenic, who
Hemangiomas, Strawberry vs Cherry vs Pyogenic, prognosis
Strawberry – grows with child but then usually regresses by 5-8 years; Cherry – does not regress; Pyogenic – can ulcerate and bleed
Liver hemangiosarcoma a/w
Arsenic (pesticides), thorotrast (radioactive), and PVC
Pyogenic hemangiomas consist of
Hypertrophic granulation tissue; polypoid form of capillary hemangioma; grow rapidly
Port-wine stains/ nevus flammeus consists of what
Malformed dilated blood vessels in superficial dermis; dark red or purple typically involving face or limbs
Kaposi sarcoma consists of
Spindle shaped cells from smooth muscle and vascular endothelial lineage
Cardiac atrial myxoma
most common primary cardiac neoplasm; 80% time in LA
Cardiac atrial myxoma composition
Scattered cells within mucopolysac stroma, abnormal blood vessels and hemorrhaging; produce a large amount of VEGF (which constributes to angiogenesis, hemorrhaging and friability seen in these tumors) and IL-6 (leading to constitutional symptoms). Often pedunculated and may become very large.
Cardiac atrial myxoma pathology
Valvular obstruction (position dependent), hemorrhage, embolus and constitutional symptoms from IL-6
VASCULITIS and HYPERTENSION
Granulomatous inflammation of media?
GCA (older men >50; tends to be temporal arteries) and Takayasu arteritis (aortic arch; women <40)
Segmental fibrinoid necrosis of small vessels; similar to PAN
Segmental transmural necrotizing inflammation of medium to small sized arteries; necrotic tissue and deposits of immune complexes and plasma proteins with smudy eosinophilic deposit + fibrinoid necrosis
Thrombosing vasc of medium and small arteries principly tibial and radial** arteries; usually seen in chronic smokers and people <35
Rheumatoid arteritis , hypersensitivity vascultiis that affects...
Arterioles and arteries of any size; produces visceral infarctions after longstanding RArthritis; similar to PAN and MPA
Monckeberg’s medial calcific sclerosis do or do not narrow vessel lumen
do NOT; asymptomatic; seen in adults > 50
Hyaline arteriosclerosis a/w high or low levels of HTN
Transmural inflammation of arterial wall with fibrinoid necrosis
PAN** (young adults, Hep B, typically renal and visceral; immune complex mediated; string of pearls; fever, weight loss, malaise, headache, neurological dysfunction...)
Hyperplatic arteriolosclerosis results from
Diastolic pressures >120-130/ severe HTN; presents as onion-like concentric thickening of walls of arterioles as result of laminated smooth muscle cells and reduplicated basement membranes;
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