Cardiology - Pathology

eesohbel's version from 2015-08-03 00:43

Congenital heart disease

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22q11 syndromes (DiGeorge)Truncus arteriosus, tetralogy of Fallot
Down syndromeEndocardial cushion defects: ASD, VSD, and AV septal defect
Congenital rubellaSeptal defects, PDA, pulmonary artery stenosis
Turner syndromeCoarctation of aorta (preductal), bicuspid aortic valve
Marfan's syndromeMVP, Aortic insufficiency and dissection (late complication)
Infant of diabetic motherTransposition of great vessels
prenatal lithium exposureebstein anomaly
collateral circulation develops across arteries and leads to rib notchingcoarctation of the aorta

Too much McDonalds

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Hypertension defined as≥140/90 mmHg
90% is 1°, 10% is 2° to renal disease
Hypertension risk factors→ age, obesity, diabetes, smoking, genetics, black>white>Asian
Atheromasplaques in blood vessel walls
sign of hyperlipidemia
XanthomasPlaques or nodules composed of lipid-laden histiocytes in the skin, especially the eyelids (xanthelasma)
sign of hyperlipidemia
Tendinous xanthomaLipid deposit in tendon, esp. Achilles
sign of hyperlipidemia
MonchebergArteriosclerosis in radial or ulnar a.
Calcification in the media of the arteries - usually benign, nonobstructive - "pipestem" arteries
Arteriolosclerosis2 Types:
Hyaline - thickening of small arteries in essential hypertension or DM
Hyperplastic - "onion skinning" in malignant HTN
claudicationlipid filled intimal plaques
AtherosclerosisFibrous plaques and atheromas form in intima of elastic and med/lg muscular arteries
Atherosclerosis risk factors (modifiable & non-modifiable)Mod: smoking, HTN, hyperlipidemia, diabetes
Non-mod: men, post-menopausal women, positive family history
Pathogenesis of atherosclerosisEndothelial cell dysfn → macrophage and LDL accumulation → foam cell formation → fatty streaks → smooth muscle cell migration (involves PDGF and FGF), proliferation, and extracellular matrix deposition → fibrous plaque → complex atheromas
plaque stability reduced bymetalloproteinases
Atherosclosis - MC locationsAbdominal aorta > coronary artery > popliteal artery > carotid artery
Abdominal aortic aneurysm is likely to occur in what kind of patienthypertensive male smokers > 50 years of age with atherosclerosis
Thoracic aortic aneurysm is assoc. w? (3)Hypertension, cystic medial necrosis (Marfan's syndrome), 3° syphilis
Aortic dissection can result in...Pericardial tamponade, aortic rupture, death
CXR shows mediastinal wideningaortic dissection
presents with tearing chest pain radiating to the backaortic dissection
aortic dissection of ascending aortarequires surgery
aortic dissection of descending aortatreat with beta blockers then vasodilators
% obstruction required for angina75% - no necrosis
Stable angina cause and detection2° to atherosclerosis
Retrosternal chest pain with exertion, ST depression on ECG
Prinzmetal's variant of anginaOccurs at rest 2° to coronary artery spasm
ST elevation on ECG
Unstable/crescendo anginaThrombosis with incomplete coronary artery occlusion
Worsening chest pain at rest or with minimal exertion
ST depression on ECG
Coronary steal syndromeVasodilator ex adenosine → shunts blood to periphery, away from critical stenosis → aggravates ischemia
Myocardial infarction cause and ECGAcute, occlussive thrombosis d/t coronary a. atherosclerosis
ST depression → ST elevation
hibernating myocardiumreversible, caused by repetitive ischemia or persistent hypoperfusion
process that initiates formation of dissecting aortic aneurysmintimal tear
medial inflammationresults in arteritis
vaso vasorum obliterationthoracic artery aneurysms
triple A starts asintimal streak

MI over time

Question Answer
0-4hrs histominimal change
0-4hrs risk ofarrhythmias
4-12 hrs histoearly coagulation necrosis, edema, punctate hemorrhages, wavy fibers, cytoplasmic hypereosinophilia
4-24 hrs risk ofarrhythmias
12-24 hrs histocoagulation necrosis and marginal contraction band necrosis aka neutrophilic infiltration of the zone of dead myocardium
1-5 days histocoagulation necrosis and neutrophilic infiltrate and hyperemia (redness)
1-5 days risk ofpostinfarction fibrinous pericarditis
5-10 days histomacrophage phagocytosis of dead cells (acute inflammatory infiltrate recedes) and yellow tan softening grossly
5-14 days risk ofventricular aneurism, wall rupture, papillary muscle rupture
10-14 days histofibrovascular granulation tissue and neovascularization
2 weeks to 2 months histocollagen deposition/scar formation/decreased cellularity in the zone of infarced myocardium
>2weeks risk ofDressler syndrome (late onset pericarditis, autoimmune), ventricular aneurysm
MC cause of in-hospital death due to MIis LV failure/cardiogenic shock
major determinant of whether or not a plaque will cause ischemic MIrate at which it occludes the involved artery. slower the rate, the more opportunity for collaterals that would prevent myocardial necrosis.
myocardial stunningless severe, more acute form of ischemia. reversible loss of contractile function.
mycoardial hibernationmore chronic, but can be reversible


Question Answer
MC cardiomyopathyDilated (congestive) cardiomyopathy
Causes of dilated cardiomyopathyABCCCD
Alcohol (chronic)
Beriberi (wet)
Coxsacki B virus
Cocaine (chronic)
Chagas' disease
Doxorubicin toxicity
peripartum cardiomyopathy
Findings of dilated cardiomyopathyS3, dilated heart on US, balloon appearance on CXR
Eccentric hypertrophy - sarcomeres added in series
Systolic dysfunction
Tx of dilated cardiomyopathyNa restriction, ACE inhibitors, diuretics, digoxin, heart transplant
Hypertrophic cardiomyopathy (differences from dilated cardiom.)Diastolic dysfn
Asymmetric concentric hypertrophy - sarcomeres added in parallel
Systolic murmur & sycopal episodes
Cause of sudden death in young athletes
Causes of hypertrophic cardiomyopathy60-70% are AD B-myosin heavy chain mutation
associated with Friedreich's ataxia
Findings of hypertrophic cardiomyopathynormal-sized heart
apical impulses
systolic murmur
Tx of hypertrophic cardiomyopathyB-blocker or non-dihydropyridine calcium channel blocker (verapamil)
Causes of restrictive/obliterative cardiomyopathySarcoidosis, amyloidosis, postradiation fibrosis, endocardial fibroelastosis (thick fibroelastic tissue in endocardium of young children)
Loffler's syndrome - endomyocardial fibrosis with a prominent eosinophilic infiltrate
hemochromatosis - dilated cardiomyopathy can also occur
Restrictive/obliterative cardiom. - systolic or diastolic dysfn?Diastolic
Cause of right heart failureusually left heart failure
isolated: cor pulmonale
CHF drugs that reduce mortalityACEi's, B-blockers, angiotensin receptor antagonists, spironolactone
Hydralazine with nitrates improves mortality and symptoms in select pts.
Signs of left heart failurePulm. edema, paroxysmal nocturnal dyspnea, orthopnea
Hemosiderin-laden macrophages in the lungs ("heart failure" cells)
Signs of right heart failureHepatomegaly (nutmeg liver), peripheral edema, jugular venous distention
cardiomyopathy that has an S3 with systolic dysfunctiondilated cardiomyopathy
cardiomyopathy that has an S4 with diastolic dysfunctionhypertrophic cardiomyopathy and restrictive cardiomyopathy
eccentric dilation of ventricledue to increased volume (AR, MR, MI, dilated cardiomyopathy)
concentric dilation of ventricledue to increased pressure (AS and hypertension)
cardiac hypertrophy characterized byincreased rate of myosin mRNA synthesis


Question Answer
CO in sepsisincreases!
SVR in sepsisdecreases whole body vasodilate
CO in cardiogenic shockdecreases. hl
CO in hypovolemic shockdecrease because there is not enough blood
increased JVDcardiogenic shock. Heart not working well
warm bounding pulsesdistributive shock
IV fluids contraindicated incardiogenic shock

General cardiac path (part 1)

Question Answer
Sxs/signs of bacterial endocarditisFROM JANE
Fever (MC)
Roth's spots - round white spots on retina surrounded by hemorrhage
Osler's nodes - tender raised lesions on finger or toe pads
New murmur
Janeway lesions - small, painless erythematous lesions on palm or sole
Nail-bed hemorrhage
Acute endocarditisStaph aureus (high virulence)
Large vegetations on previously normal valves
Rapid onset
Subacute endocarditisViridans strep (low virulence
Smaller vegetations on congenitally abnormal or disease valves
Sequela of dental procedures
culture - endocoxiella, bartonella, brucella, HACEK
Endocarditis 2° to diseasemalignancy
hypercoaculable state
lupus (marantic/thrombotic endocarditis)
S. bovis - colon cancer
S. epidermidis - prosthetic valves
Complications of endocarditischordae rupture, glomerulonephritis, suppurative pericarditis, emboli
IV drug abuse endocarditisStaph a., Pseudomonas, Candida
Rheumatic fever pathogenesisUntreated pharyngeal infection with strep pyogenes → antibodies eventually form to antigens that mimic heart tissue antigens (M protein) → heart valve destruction
Type II hypersensitivity
Rheumatic fever most commonly affected valvesMitral>aortic>>tricuspid (high pressure valves affected most)
Rheumatic fever associationsEarly - mitral valve regurgitation
Later - mitral stenosis
Aschoff bodies - granuloma with giant cells
Anitschkow's cells - activated histiocytes
Elevated ASO titers
Rheumatic fever FEVERSSFever
Erythema marginatum
Valvular damage (vegetation and fibrosis)
Red-hot joints (migratory polyarthritis)
Subcutaneous nodules
St. Vitus' dance (Sydenham's chorea)
ECG changes include widespread ST segment elevationacute pericarditis
hypotension, distended, neck vains, distant heart soundscardiac tamponade
ECG shows electrical alternanscardiac tamponade
pulsus parodoxusincrease of systolic BP by more more than 10 during inspiration. The inspiratory drop is exacerbated. Usually seen in cardiac tamponade, asthma, obstructive sleep apnea and pericarditis
Kussmaul signincrease in JVP on inspiration instead of a normal decrease. seen in constrictive pericarditis, restrictive cardiomyopathy


Question Answer
Fibrous intimtal thickening with endocardial plaques limited to the right heartCarcinoid syndrome/ carc. Heart disease. May progress to pulmonic stenosis and or restrictive cardiomyopathy.
Severity of carcinoid syndrome determined bySerotonin levels and urinary excretion of its metabolite 5-hydroxyindoleacetic acid. Also will see niacin deficiency.
Carcinoid syndrome symptomsSkin 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 heartSerotonin, along with bradykinin, is generally inactivated by pulmonary vascular endothelial monoamine oxidase
Recall, carcinoid syndrome is most common malignancy in what systemSmall intestine
Most plentiful catecholamine in urineVMA; indicator of catecholamine level in blood
Cancer mets to heart usually go toPericardium or myocardium
Ankylosing spondylitis is associated withUveitis, apical pulmonary fibrosis, peripheral enthesopathies and aortic insufficiency
Aging associated with increased or decreased left ventricle sizeDecreased.
Localized amyloidosis confined to cardiac atria/ isolated atrial amyloidosis is due toDeposition 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.


Question Answer
Persistent lymphedema, such as after radical mastectomy and or radiation, predisposes toLymphangiosarcoma, 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?Both
Bacillary angiomatosis vs Kaposi Sarcoma, infiltrate made ofB- neutrophils and K-lymphocytes
Bacillary angiomatosis vs Kaposi Sarcoma, causeB- bartonella henselae vs K- HHV8/ HIV
Hemangiomas, Strawberry vs Cherry vs Pyogenic, whoStrawberry – infants/ children; Cherry – elderly, Pyogenic – pregnancy or trauma
Hemangiomas, Strawberry vs Cherry vs Pyogenic, prognosisStrawberry – grows with child but then usually regresses by 5-8 years; Cherry – does not regress; Pyogenic – can ulcerate and bleed
Liver hemangiosarcoma a/wArsenic (pesticides), thorotrast (radioactive), and PVC
Pyogenic hemangiomas consist ofHypertrophic granulation tissue; polypoid form of capillary hemangioma; grow rapidly
Port-wine stains/ nevus flammeus consists of whatMalformed dilated blood vessels in superficial dermis; dark red or purple typically involving face or limbs
Kaposi sarcoma consists ofSpindle shaped cells from smooth muscle and vascular endothelial lineage
Cardiac atrial myxomamost common primary cardiac neoplasm; 80% time in LA
Cardiac atrial myxoma compositionScattered 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 pathologyValvular obstruction (position dependent), hemorrhage, embolus an

Changes in vasculature

Question Answer
onion skinning of renal arteriolesmalignant hypertension
granulomatous inflammation of mediagiant cell arteritis
myxomatous changes in media of large arteriescystic medial degeneration whcih predisposes to aortic dissections


Question Answer
unilateral headache, jaw claudicationtemporal arteritis
associated with PMRtemporal arteritis
PANtransmural inflammation of arterial wall with fibrinoid necrosis
Hep B associationPAN
pulseless diseaseTakayasu
conjunctival injection, desquamating rash, adenopathy, strawberry tongue, hand foot changes, feverKawasaki disease
worst outcome of Kawasaki diseasecoronary artery aneurysms
gangrene of digitsBuerger disease
GPAURI, glomerulonephritis
pauci immune glomerulonephritisMPA
palpable purpura on buttocks/legs w IgA nephropathyHSP
P-ANCAMPA and Churg Strauss
segmental thrombosing vasculitisBuerger's disease
lower extremity vascular insufficiency and a heavy smokerBuerger's disease

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