Cvs 2

CARDIOVASCULAR
SYSTEM
Dr. Atifa Shuaib
Associate Professor of Pathology
Rawalpindi Medical College

CARDIOVASCULAR SYSTEM

Diseases of Blood vessels

Diseases of Heart

Diseases of blood vessels
Congenital anomalies
Arteriosclerosis
Hypertensive vascular disease
Aneurysms & Dissections
Vasculitis
Tumors


ARTERIOSCLEROSIS:

Atherosclerosis
Monckeberg medial calcific sclerosis
Arteriolosclerosis


Fatty streaks  Aortas of children

Risk factors  Atheroma in adults
↓↓
Ischaemic Heart Disease

ATHEROSCLEROSIS

RISK FACTORS:

Non Modifiable

Modifiable

NONMODIFIABLE:
Age:
advancing age
Sex:
males > females
postmenopausal risk equal
Genetics:
familial predisposition

MODIFIABLE:
Hyperlipidemia:
hypercholesterolemia
LDL (bad cholesterol)
HDL (good cholesterol)
↓ by exercise
↑ by obesity & smoking

Diet
↑ cholesterol  egg yolk, butter, animal fat
↓ cholesterol  omega 3 FA
Statins ↓ cholesterol

Hypertension:
>169/95 mm Hg 5 fold ↑ risk
Smoking:
200% ↑ death rate
Diabetes Mellitis:
twice ↑ risk MI
gangrene lower limbs (200% risk)

Others:
homocystinuria
inflammation
lipoprotein a (Lp a)
lack of exercise
stressful life
type A personality
obesity


Multiple risk factors  Multiplicative effect

participants had increases in HDL cholesterol
averaging about 2.5 mg/dL. This increase in
HDL cholesterol was only modest, but was
statistically significant. Furthermore, since
cardiac risk is thought to drop by two to three
percent for each 1 mg/dL increase in HDL, a
2.5 mg/dL rise in HDL amounts to a
substantial reduction in risk.

Exercise is involved in increasing the production and
action of several enzymes that function to enhance
the reverse cholesterol transport system (Durstine &
Haskell 1994). The precise mechanisms are unclear,
but evidence indicates that other factors including
diet, body fat, weight loss, and hormone and enzyme
activity interact with exercise to alter the rates of
synthesis, transport and clearance of cholesterol
from the blood (Durstine & Haskell 1994).

PATHOGENESIS:
“response to injury hypothesis”

A disease of intima

Chronic inflammation of arterial wall in
response to injury to endothelium


 Chronic endothelial injury  activation
 Accumulation of lpoproteins (LDL)
 Oxidation of LP
 Monocyte migration  macrophage
accumulation
 Foam cells


 Platelet adhesion
 Chemical mediator release
 Smooth muscle cells migration
 SMCs proliferation
 ECM deposition
 Lipid accumulation

1. Endothelial injury (repetitive):
endothelial dysfunction ? injury
repetetive non denuding
toxins, chemical mediators, infections
hemodynamic disturbance 
sites of ostia and bifurcation
posterior wall of abdominal aorta

2. Inflammation (chronic):
initiation - complications
endothelial cell adhesion molecules
VCAM-1
monocyte adhesion & migration
macrophage accumulation in intima
foam cell formation
IL-1, TNF
MCP-1

Macrophages
 toxic oxygen species  oxidation of lipids
 GF  smooth muscle cell proliferation

T lymphocytes  cellular & humoral

3. Lipids:
cholesterol & its esters in atheromas
Oxidized LDL in macrophages

genetic defects  hypercholesterolemia 
AS
MI at young age with ↑ cholesterol
DM, hypothyroidism  ↑ cholesterolAS
high cholesterol diet  AS
severity of AS  levels of cholesterol
↓ing cholesterol levels  risk of AS ↓

Mechanism :
1. Chronic hyperlipidemia  EC activation
2. Chronic hyperlipidemia  LP accumulate in
intima
3. Oxidized LDL  macrophages  foam
cells
 monocyte accumulation
 GF, cytokine release
 Ecs, SMCs cytotoxicity

4. Smooth muscle cells:
SMCs migration proliferation & ECM deposition
↓
Fatty streak  fibrofatty atheromatous plaque
PDGF, TGF-a, FGF
Foam cells
ECM (collagen) deposited
SMCs apoptosis

MORPHOLOGY:
Fatty streak:
children aortas
coronaries in adolescents
multiple, flat yellow dots
coalesce to streaks
lipid laden foam cells

Atheromatous plaque:
elastic & muscular arteries
lower abdominal aorta > thoracic aorta
ostia and branches
symptomatic AS disease
MI  heart attack
cerebral infarction  stroke
peripheral vascular  gangrene

aorta > coronaries > popliteal > internal
carotid > circle of willis
white – white yellow
variable size
eccentric lesions
obstruction of lumen

 Mild, Moderate, Severe AS

Components:
1. Cells:

SMCs
macrophages
T lymphocytes
other leukocytes

2. ECM:
collagen
elastic fibers
proteoglycans
3. lipids:
intracellular
extracellular

Plaque change:
enlargement
ulceration/erosion
rupture
thrombosis
embolism
haemorrhage
calcification
aneurysmal dilation

ARTEIOLOSCLEROSIS:
Small Bv, arterioles
Hyaline
homogenous pink hyaline thickening
narrowed lumen
elderly
Hypertension
Benign nephrosclerosis

microangiopathy of DM
Hyperplastic:
malignant HTN
onion skin
concentric, laminated thickening
SMCs & thickened BM
necrotizing arteriolitis

ANEURYSM:
Localized abnormal dilation of a blood vessel or
heart.
True aneurysm
all layers of Bv or heart
False aneurysm (pseudoaneurysm)
extravascular hematoma

Causes:
Atherosclerosis
Cystic medial degeneration
Trauma (A-V aneurysms)
Congenital defects (berry aneurysms)
Infections (mycotic)
Vasculitis

Types:
Saccular
Fusiform
Sites:
Abdominal aorta
common iliac A
Arch of aorta
descending thoracic aorta


Mycotic aneurysm:
septic embolus
direct extension
bacteraemia

ABDOMINAL AORTIC ANEURYSMS(AAA):
Atherosclerosis
> 50 yrs
> males
genetic susceptibility  ↓ connective tissue
strength
MMP  TIMP
HTN

Morphology:
B/W bifurcation & renal arteries
saccular/fusiform
variable size
thromboemboli
occlusion of ostia

Variants:
Inflammatory AAA
dense periaortic fibrosis
inflammatory cells (lymphos, plasma cells)
Mycotic AAA
AS AAA + bacteremia
Salmonella gastroentritis

Complications:
Rupture
Obstruction adjacent BV
Embolism
Compression adjacent structures
Abdominal mass

SYPHILITIC ANEURYSM:
Leutic
Obliterative endartritis
vasa vasorum
lymphocytes & plasma cells
syphilitic aortitis


weakening of media
tree barking
aortic valve insufficiency
cor bovinum (cow’s heart)

AORTIC DISSECTION
“Dissection of blood between & along laminar
planes of media”
1. HTN  40-60 yrs males

2. CT defects  young age

3. Iatrogenic

4. Pregnancy

Morphology:
intimal tear
10 cm from aortic valve
transverse / oblique
sharp edges
extension
 dissecting hematoma

rupture out  pericardial, pleural, peritoneal
double barreled aorta
cystic medial degeneration
 cystic medial necrosis
Classification:
Type A: Proximal
I
II
Type B: Distal

VASCULITIS:
Inflammation of vessel wall.
Infectious
direct invasion
immune mechanism
Immune mediated

PATHOGENETIC CLASSIFICATION:
Direct infection:
Bacterial, Rickettsial, Spirochetal, Fungal, Viral
Immunologic:
immune complex mediated
ANCA mediated
Direct antibody mediated
Cell mediated
Unknown

CLASSIFICATION ACCORDING TO SIZE:
Large vessel
Medium sized vessel
Small vessel

TYPES:
Granulomatous
granuloma formation
giant cells
Necrotizing
fibrinoid necrosis
fibrous thickening of wall

TUMORS OF BLOOD VESSELS:
Vascular malformations
Hamartomas
Reactive vascular proliferations
Bacillary angiomatosis
Benign tumors:
Blood/lymphatic filled channels
Transudate
Endothelial lining without atypia

Malignant tumors :
More solid & cellular
Atypia ++
Mitotic figures
No well formed vascular channels

Benign:
Hemangioma
capillary
cavernous
pyogenic granuloma
Lymphangioma
simple
cavernous

Glomus tumor
Vascular ectasias
nevus flamus
spider telangiectasia
hereditary haemorrhagic telangiectasia
reactive vascular proliferations
bacillary angiomatosis

Intermediate grade tumors:
Kaposi sarcoma
Hemangioendothelioma
Malignant neoplasms:
Angiosarcoma
Hemangiopericytoma

HEMANGIOMA:
localized
superficial
head & neck
internal
angiomatosis
7% of benign childhood tumors

Capillary hemangioma:
Gross:
skin, sub-cutaneous tissue, mucus membranes
liver, spleen, kidneys
variable size
bright red – blue
elevated
intact epithelium

Histologically:
lobulated
unencapsulated
closely packed
thin walled capillaries
flat endothelium
scanty stroma
thrombosed lumen

Strawberry hemangioma
newborns
grows and regresses

Cavernous hemangioma:
less common
larger
less well circumscribed
deep structures
locally destructive

Gross:
red-blue
spongy
1-2 cm
Histologically:
sharply defined
not encapsulated
large cavernous vascular spaces

blood filled
scanty stroma
intravascular thrombosis
dystrophic calcification

IOVCARDASCULAR SYSTEM
GLOMUS TUMOR:
Benign
Painful
Glomus body
Distal part of digits
Small, elevated, round
Red-blue firm nodules
Branching vascular channels
Aggregates/nests of glomus cells around BV

KAPOSI’S SARCOMA:
1. Chronic/Classic/European
Kaposi in 1872
older men
not associated with HIV
homosexual men
multiple red – purple skin plaques/nodules
arms & legs

gradual spread
asymptomatic & localized
visceral involvement 10%
2. Lymphadenopathic/African/Endemic:
Bantu children of SA
lymphadenopathy
aggressive

3. Transplant associated/immunosuppression
associated:
months-years post transplant
aggressive
lymph node, mucosa, viscera
internal involvement  fatal

4. AIDS associated:
1/3rd AIDS patients
wide dissemination
Morphology:
3 stages:
 Patch

pink-red-purple
single/multiple macules

distal lower extremities
dilated, irregular angulated BV
endothelial cell lined
lymphocytes, plasma cells, macrophages
 Plaques
larger, violaceous
raised
dermal dilated vascular channels

plump spindle cell lining
perivascular aggregates of spindle cells
red cells
hemosiderin laden macrophages
lymphocytes, plasma cells
pink hyaline globules in spindle cells
mitotic figures

 Nodules
neoplastic
sheets of plump spindle cells
proliferate in dermis, sub-cutaneous tissue
slit like spaces & small Bv
hemosiderin , macrophages
mitotic figures
LN + viscera

Pathogenesis:
HHV-8/KSHV  latent infection
immunosuppression  ↓ apoptosis
endothelial cells (p53)
 ↑ cell proliferation

DISEASES OF HEART:
Mechanisms of Cardiac dysfunction:
1. Pump failure

2. Outflow obstruction

3. Regurgitant flow

4. Conduction defects

5. Disruption of circulation


Genetics  environment

HEART FAILURE (Congestive heart failure):
Forward failure (↓ CO) or
Backward failure (venous damming) or
Both
Myocardial hypertrophy:
permanent cells
no hyperplasia
hypertrophy

CARDIAC HYPERTROPHY:
Pressure overload hypertrophy
concentric hypertrophy
HTN, aortic stenosis
thickened left vent wall  ↓ chamber
sarcomere deposition parallel
cross sectional area of myocyte ↑ not length

Volume overload hypertrophy:
ventricular dilation
wall thickness  chamber diameter
sarcomere deposition parallel & vertical
↑ thickness & length

“ Structure of hypertrophied heart is not normal.
It is a tight balance between adaptation and
deleterious alterations ( ↓ capillary-to-
myocyte ratio, ↑ fibrous tissue & synthesis of
abnormal proteins). Thus sustained cardiac
hypertrophy evolves into cardiac failure.”

Molecular & cellular changes that initially
mediate enhanced function later contributes to
heart failure.

Physiologic hypertrophy.
Pathologic hypertrophy.

Left sided heart failure:
Causes:
IHD
HTN
Aortic, mitral valvular disease
non ischemic MC disease

Morphology:
Evidence of cause
enlarged size
↑ left vent wall thickness
secondary effects on atria

Extracardiac effects:
1. Pulmonary congestion & edema

heavy, wet lungs
interstitial transudate  Kerly’s B lines
widening of alveolar septa
edema in alveolar spaces
heart failure cells

dyspnea
orthopnea
paroxysmal nocturnal dyspnea
2. Kidneys
↓ renal perfusion
pre renal azotemia

3. Brain
hypoxic encephalopathy
Right sided heart failure:
Causes
left sided heart failure
chronic severe pulmonary HTN
(cor pulmonale)

Morphology
engorgement of systemic & portal venous
systems
1. Liver & portal system:
congestive hepatomegaly
centrilobular necrosis
cardiac sclerosis / cardiac cirrhosis
congestive splenomegaly

2. Kidneys:
severely affected
pronounced azotemia
3. Brain:
venous congestion & hypoxia
4. Pleural & pericardial space:
effusions
5. Subcutaneous tissues:
edema (pedal)
anasarca

Heart disease:
Congenital heart disease
Ischemic heart disease
Hypertensive heart disease
Valvular heart disease
Myocardial disease

ISCHEMIC HEART DISEASE (IHD):

↓ oxygen supply
↓ nutrient supply
↓ removal of waste

90% coronary atherosclerosis  CAD

4 clinical manifestations of IHD:
1. Myocardial Infarction

2. Angina Pectoris

3. Chronic IHD

4. Sudden cardiac death

Acute Coronary Syndromes (1, 2, 4)

Leading cause of death

50% reduction in IHD related mortality in USA
Prevention
Early diagnosis (advanced facilities)
Therapeutic intervention (effective, safer)

PATHOGENESIS:

Demand  supply
↑↑  ↓↓
↓
ISCHEMIA

AS  obstruction  fixed / stable obstruction
 plaque change ↓
↓ ↓
ISCHEMIA

75% obstruction  symptomatic on ↑ demand
90% obstruction  symptomatic at rest

Role of acute plaque change:
Rupture/ulceration
Erosion/fissuring  thrombosis
Haemorrhage
Intrinsic influences
structure & composition of plaque
extrinsic influences
blood pressure, Plt reactivity

Structure of plaque
Vulnerable plaque
↑ foam cells
↑ extracellular lipids
thin fibrous caps
few SMCs
inflammatory cell clusters
Junction of fibrous cap & adjacent endothelium


Collagen deposition  degradation
metalloproteinases by macrophages

Adrenergic stimulation  systemic HTN & plt
reactivity  stress on plaques
Early morning
Emotional stress

Role of inflammation:
All stages of AS
Macrophages & T lymphocytes
IL-1, IL-6, TNF, INF g
Metalloproteinses  weaken plaque
Inflammation destabilizes plaque

Role of coronary thrombus:
Partial / total  acute coronary syndromes
Mural branch thrombus  embolize
 Microinfarcts
Role of vasoconstriction:
Potentiate plaque change

ANGINA PECTORIS:

“A symptom complex of IHD cahracaterized by
recurrent attacks of substernal/precordial
chest discomfort caused by transient MC
ischemia that falls short of inducing
infarction.”

TYPES:

Stable / typical
Unstable / crescendo
Prinzmetal / variant

STABLE ANGINA:
Chronic stenosing atherosclerosis  ↓ coronary
perfusion
↑ demand  MC ischemia
Triggered by exercise, stress
Relieved by rest, nitroglycerine

UNSTABLE ANGINA:
Progressively ↑ing frequency
At rest
Prolonged duration
Disruption of stable atheroma  thrombosis
Embolization, vasospasm

PRINZMETAL ANGINA:
Uncommon
Episodic
At rest
Coronary vasospasm
Responds to vasodilators

MYOCARDIAL INFARCTION:
“Heart attack”
Death of cardiac muscle due to ischemia.

Transmural infarction
Subendocardial infarction

TRANSMURAL SUBENDOCARDIAL

Full thickness of MC Inner 1/3rd or half

AS  plaque change  As  plaque change 
thrombosis thrombosis  recanalized
Hypotension / shock on
chronic stenosing AS
Limited to area of supply Can extend beyond

Incidence & risk factors:
Any age
Risk factors of AS
Pathogenesis:
Coronary artery occlusion
Acute plaque change  thrombosis  VC 
↑ size of thrombus  complete occlusion

10% MI not associated with AS plaque change.
 Vasospasm

 Emboli (paradoxical emboli)

 Unexplained (vasculitis, Hg defects, amyloid)

Myocardial response:

Biochemical
Functional
Morphological

FEATURE TIME

ATP depletion Seconds

Loss of contractility < 2 min

ATP reduced to 50% 10 min
10% 40 min
Irreversible cell injury 20 – 40 min

Microvascular injury > 1 hr

Early identification
Reperfusion

30 min reversible injury
MC ischemia  subendocardial zone
Wavefront progression  transmural
Necrosis within 6 hrs
Grossly visible after 12 hrs

Factors influencing MI:
1. Site, size, rate of development of AS
2. Size of vascular bed
3. Duration
4. Mc demands
5. Collateral circulation
6. Coronary artery spasm
7. BP, HR, cardiac rhythm

Morphology:
Left ventricle > right
ventricle
Rim of subendocardium
preserved
LAD 40 – 50% Ant wall left vent, apex, ant septum

RCA 30 – 40% Inf-post wall lt vent, post septum,
post right vent
LCA 15 – 20% Lat wall left vent

TIME GROSS MICROSCOPIC

0 – ½ hr ----- myofibril relaxation, swelling
of mitochondria
½ - 4 hr ----- Wavy fibers

4 – 12 h Occ dark mottling Coag necrosis, edema, hge

12-24 h Dark mottling Necrosis, pyknosis,myocyte
eosinophilia, contraction
bands, neutrophils

1 -3 days Mottling + yellow Loss of nuclei & striations,
centre PMNs ++
3 – 7 days Red border, Disintegration, phagocytosis
yellow tan center
7 – 10 Max yellow soft Phagocytosis ++, granulation
days center, red borders tissue at margins
10-14 Red-gray Granulation tissue ++,
days depressed collagen +
2 – 8 wks Grey white scar ↑ collagen, ↓ cellularity

> 2 month Complete scar Dense collagenous scar

1 day MI showing contraction band

Reperfusion injury/Myocardial stunning:
Restoration of coronary flow  reperfusion
Ischemia  variable effects on MC
Reperfusion  salvage
 damage  O2 free radicals
 haemorrhage
 apoptosis

Persistence of biochemical & functional changes
in reperfused MC  stunned MC
CARDIAC ENZYMES:
CPK (MM, MB, BB)
AST
LDH
Troponins

Complication of MI:
1. Contractile dysfunction  crdiogenic shock
2. Arrhythmias
3. MC rupture  cardiac rupture syndrome
4. Pericarditis
5. Right ventricular infarction
6. Extension
7. Mural thrombosis
8. Ventricular aneurysm
9. Papillary muscle dysfunction
10. Progressive late heart failure

RHEUMATIC FEVER & HEART DISEASE
“A multisystem inflammatory disease having an
acute onset with underlying immune
pathogenesis occurring few weeks after
streptococcal pharyngitis.”
Acute Rheumatic carditis  Rheumatic heart
disease

Children (5-15 yrs)
10 days – 6 weeks
Arthritis & carditis
Relapsing course
Chronic Rheumatic Carditis

PATHOGENESIS:
Group A Streptococcal throat infection
↓
Antibodies M component streptococci
↓
Cross react glycoprotein antigens
Heart, joints, skin, brain

RF characterized by:
Migratory polyarthritis
Carditis
Subcutaneous nodules
Erythema marginatum
Sydenham chorea

MORPHOLOGY:
Acute RF  Focal inflammatory lesions 
Aschoff bodies
swollen eosinophilic collagen
T lymphocytes, plasma cells
macrophages  Anitschkow cells
abundant cytoplasm
central round/oval nucleus
central slender chromatin  caterpillar cells
Aschoff giant cells

Pancarditis
Bread & Butter Pericarditis
Myocarditis  Perivascular Aschoff nodules
Verrucae/vegetations on valves
fibrinoid necrosis
MacCallum Plaques (left atrium)

Chronic Rheumatic Heart Disease:
Organization of acute inflammation
Leaflet thickening
Commissural fusion
Thickened, short & fused cordae tendinae
Progressive fibrosis
Buttonhole deformity
Fish mouth appearance

Mitral stenosis:
99% cases due to RHD
RHD  65% - 70 % alone
with aortic valve 25%
Atrial dilation  mural thrombosis
Pulmonary vascular changes

INFECTIVE ENDOCARDITIS:
Severe infection of endocardium and heart
valves
Vegetations (thrombotic debris &
microorganisms)
Clinical classification:
Acute
Subacute

ACUTE IE SUBACUTE IE

Healthy valves Diseased/prosthesis

Highly virulent organisms Low virulence

Acute & severe Insidious

50% mortality Recovery common

Destructive necrotizing Less destructive

PATHOGENESIS:
Valvular diseases (RHD, prolapse, degenerative
calcific stenosis)
Immune compromised states
Aetiology:
Strep viridans (50-60%)  defective valves
Staph Aureus (10-20%)  healthy.defective
I/V drug abusers

HACEK group
Staph epidermidis  prosthetic valve IE
gram –ive bacilli
fungi
culture negative

MORPHOLOGY:
Bulky, Friable, Destructive vegetations
Single/multiple
Fibrin & inflammatory cells
Aortic & mitral valves
Ring abscess

Fungal Endocarditis
larger vegetations
Systemic emboli  Septic infarcts
SIE  granulation tissue at base
LIBMAN-SACKS ENDOCARDITIS:
Endocarditis of SLE

Dukes Diagnostic Criteria for IE:
Pathologic:
+ cultures
vegetation histology
intracardiac abscess
Clinical:
Major:
+ blood culture
Echocardiographic findings, valvular defects

Minor:
predisposing heart lesion
vascular lesions
immunologic phenomena
cultures
echocardiographic

CARDIOMYOPATHIES:
Intrinsic disease of myocardium:
Myocarditis
Immunologic
Systemic metabolic
Muscular dystrophies
Genetic abnormalities

Heart disease resulting from a primary
abnormality in the myocardium 
Cardiomyopathy

 Dilated cardiomyopathy (DCM)
 Hypertrophic cardiomyopathy (HCM)
 Restrictive cardiomyopathy (RCM)

DCM HCM RCM
Commonest 90% Least common
Systolic Diastolic Diastolic
dysfunction dysfunction dysfunction
Dilated heart obstructive CM Compliance ↓
Hypertrophied Hypertrophy ++ Normal
Hypocontracting hypercontracting Normal
Heavy, large, Banana-like -----
flabby cavity left vent
Thin walls Thick septum++ ----------


Dilated No dilation -----
Thrombosis Mural palque ------
Hypertrophied Hypertrophy ++ ------
cells/attenuated Myofiberdisarray
fibrosis Fibrosis Patchy/diffuse
fibrosis +

Causes:
Idiopathic
Genetic abnormalities in MC metabolism
Myocarditis
Alcohol
Pregnancy associated
Genetic influences

DCM HCM
Genetic(30-40%) 100% genetic
↓ Non genetic ↓
↓ ↓ ↓
Force generation ↓ force generation ↓
DCM phenotype HCM phenotype
↓ ↓
heart failure, sudden death, atrial fib, stroke

MYOCARDITIS:
Infections:
Viruses (coxsackie, ECHO, influenza, HIV)
Chlamydia
Rickettsiae
Bacteria
Fungi
Protozoa
Helminths

Immune mediated
post viral
post streptococcal (RF)
SLE
Drugs
Transplant rejection
Unknown
sarcoidosis
giant cell myeloma

Morphology:
Hypertrophy, dilated, flabby
Diffuse/patchy
Mottled
Mural thrombi
Interstitial inflammatory infiltrate (mononuclear)
Focal necrosis

Hypersensitivty MC perivascular lymphocytes
Macrophages, eosinophils
Giant cell myocarditis giant cells, lympho, eos
plasma cells, macrophages

PERICARDITIS:
Acute
Serous
Fibrinous
Purulent
Haemorrhagic
Caseous

Chronic:
Adhesive mediatinopericarditis
Constrictive pericarditis
CAUSES:
Infectious (viruses, bacteria, TB, fungi)
Immunologic (RF, SLE, scleroderma, post MI,
(dresslers syndrome) drugs
Miscellaneous (MI, uremia, cardiac surgery, neoplasia,
trauma, radiation)

TUMORS OF HEART:
Primary (rare)
Secondary/metastatic (5% dying patients)
Benign:
Myxoma
Fibroma
Lipoma
Papillary fibroelastoma
Rhabdomyomas
Malignant:
Angiosarcoma & other SAs

MYXOMA:
Commonest primary tumor
90% in atria  Atrial Myxoma
Left : right = 4 : 1
Single
Near fossa ovalis
<1 – 10 cm
Sessile / pedunculated  wrecking ball effect
 embolize

Hard – soft gelatinous
Stellate cells (lepidic cells)
Endothelial cells
SMCs
Undifferentiated cells
Mucopolysaccharide ground substance ++
Endothelial covering

HYPERTENSIVE HEART DISEASE (HHD)
An adaptive response
Systemic HTN  left HHD
Pulmonary HTN  right HHD
Systemic HHD:
1. Left ventricular hypertrophy

2. Evidence of HTN

Pressure overload = afterload  concentric
Hypertrophy
↑ weight
Defective diastolic filling
Left atrial dilation
↑ transverse diameter of myocyte
Variation in cell size
Interstitial fibrosis

Pulmonary HHD:
COR PULMONALE
Right vent hypertrophy & dilation
Acute/chronic
Massive pulmonary embolism  acute PHHD
Prolonged pulmonary overload  chronic
PHHD

Acute:
Ventricle dilated ++
NO HYPERTROPHY
Ovoid shaped vent cavity
Chronic:
hypertrophy

CONGENITAL HEART DISEASE:
Ventricular septal defects
Atrial septal defects
Pulmonary stenosis
Patent ductus arteriosis
Coarctation of aorta
AV septal defects
Transposition of great arteries
Truncus arteriosis
Tricuspid atresia

TETROLOGY OF FALLOT:
1. VSD

2. Sub-pulmonary stenosis

3. Overriding aorta over pulmonary stenosis

4. Right ventricular hypertrophy

HYPERTENSIVE VASCULAR DISEASE:
HTN carries potential risk of
cardiac hypertrophy  heart failure
coronary artery disease  IHD
CVA
Genetic
Environmental factors

CAUSES:
Essential HTN
Secondary HTN:
Renal
AGN
CRD
polycystic disease
renal artery stenosis
renal vasculitis
Renin producing tumors

Endocrine:
Adrenocortical hyperfunction
exogenous hoemones
pheochromocytoma
acromegaly
hypothyroidism
hyperthyroidism
pregnancy induced

Cardiovascular:
coarctation aorta
polyartritis nodosa
↑ intravascular volume
↑ CO
rigidity of aorta

Neurologic:
psychogenic
↑ intracranial pressure
sleep apnea
acute stress

PATHOGENESIS:
BP = CO x PR

The mediocre teacher tells.
The good teacher explains.
The superior teacher demonstrates. SYSTEM
CARDIOVASCULAR
The great teacher inspires.
(William Arthur Ward)

Cvs 2

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