The Heart Dr Mo Mazhari
Overview
Heart failure
Types of heart disease
Answers to the MCQs
Pump Failure = Heart Failure
Cardiac output rate does not match requirements
Congestive Cardiac Failure 50% mortality in <5years
What Causes Heart Failure?
Left-Sided
IHD Hypertension Valvular disease Myocardial disease
• Primary/Intrinsic Myocardial Disease – Amyloid – Cardiomyopathies – Myocarditis
• Right-Sided – Left sided HF – Cor Pulmonale – Myocardial disease
Left Sided Heart Failure
Why does this cause problems?
Reduced peripheral flow
Increased pulmonary pressure
A 56 year old man has increasing shortness of breath and is found to have isolated LVH. A CXR shows pulmonary oedema. What is the likely underlying pathology? A. B. C. D. E.
Bronchial chronic inflammation, mucus hypersecretion and alveolar septal destruction Calcified and narrowed aortic valve Pulmonary fibrosis with asbestos bodies Hypertension Myocardial necrosis with coronary artery thrombosis
Answer
D. Hypertension
LVF - Lungs
LVH - Heart
A 70 year old woman develops congestive cardiac failure over a few years. She has bilateral pitting oedema. At PM she is found to have RV hypertrophy and dilatation. The pulmonary trunk contains atherosclerosis. What is the likely underlying pathology? A. B. C. D. E.
Myocardial necrosis with coronary artery thrombosis A large thrombosis occluding the pulmonary artery Bronchial chronic inflammation, mucus hypersecretion and alveolar septal destruction Myocyte disarray Fatty replacement and fibrosis of the right ventricle
Answer C. Bronchial chronic inflammation, mucus hypersecretion and alveolar septal destruction
Right Sided Heart Failure
Why does this cause problems?
Increased preload: engorgement of systemic and portal circulation
Right Sided Heart Failure
Causes
Left sided heart failure
Chronic pulmonary hypertension- cor pulmonale
RVF - Heart
RVF - Liver
RVF - Liver
Types of Heart Disease
Ischaemic heart disease Hypertensive heart disease Valvular heart disease Non-ischaemic primary myocardial disease Congenital heart disease
Ischaemic Heart Disease
Perfusion < demand
Coronary artery atheroma
What increases demand
Hypertrophy, lowered BP, hypoxaemia
IHD
4 manifestations:
MI
Angina pectoris
Chronic IHD/Heart failure
Sudden death
Pathogenesis of IHD
Atheroma
Atherosclerotic plaques develop slowly over decades but may acutely cause symptoms due to: Thrombosis Development of critical stenosis
Aneurysm and rupture Embolisation
Plaque rupture
What Happens When A Plaque Ruptures?
Pro-thrombotic Platelet/fibrin aggregation Thrombosis Complete luminal occlusion Partial luminal occlusion Embolisation
Any Other Causes of Reduced Perfusion?
Vasoconstriction Spasm Drugs Myocardial bridging
Myocardial Infarction Transmural
Full thickness necrosis Pattern usually associated with coronary artery distribution Coronary artery thrombosis
Subendocardial
Inner 1/3 of myocardium Diffuse stenosis of coronary arteries Hypovolaemia Hypotension
Myocardial Perfusion
LAD 50%
RCA 40%
LCCA 10%
Myocardial Infarction- Macro • • • • • • • •
<4h normal 4-24h dark mottling 1-3 day mottling with yellow infarct centre 3-7 day hyperaemic border; central softening 7-10 day depressed red tan margin 10-14 day red-grey infarct border 2-8 wks grey scar >2month scarring complete
Myocardial Infarction- Micro • <4h normal • 4-24h Coagulative necrosis, oedema, contraction bands • 1-3 day CN, neutrophils • 3-7 day Disintergration of myocytes, dying neuts • 7-10 day Phagocytosis • 10-14 day Well formed granulation tissue, vessels • 2-8 wks collagen deposition • >2month collagenous scar
A 60 year old man develops sudden onset retrosternal chest pain that radiates to the neck. Emergency CAA shows thrombosis of the LCA main stem. What is the most likely complication to occur in the next 1hr? A. B. C. D. E.
Ventricular tachycardia Myocardial rupture Pericarditis Ventricular aneurysm CVA
Answer A. Ventricular tachycardia
Complications of MI
arrhythmias, VF (75-95%) & sudden death ischaemic pain LVF (60%) & shock (10-15%) pericarditis (Dressler’s syndrome) mural thrombus & emboli, dvt & pe (15-40%) myocardial rupture - tamponade, vsd, papillary muscle (1-5%) ventricular aneurysm
MI Prognosis
Mortality 1st year = 30% 50% of these prehospital death Depends on amount of heart damage and success of re-perfusion
A 60 year old man develops worsening shortness of breath and occasional LOC. He has pleural effusions, LVH and marked aortic stenosis. What best accounts for these findings? A. B. C. D. E.
Smoking Diabetes Marfan’s Hypertension Bicuspid aortic valve
Answer E. Bicuspid aortic valve
Valvular Heart Disease
Stenosis- failure to open Regurgitation- failure to close properly Both
Aortic Valve
Stenosis Senile calicific stenosis (70+) Postinflammatory scarring Calcification of congenitally deformed valve(50+)
Regurgitation Postinflammatory scarring Infective endocarditis Degenerative aortic dilation Marphan’s
Mitral Valve
Stenosis- postinflammatory scarring
Regurgitation: Leaflet abnormalities
Tensor apparatus
Postinflammatory scarring, myxomatous degn Rupture/fibrosis of papillary muscle/chordae tendinae
Ventricle abnormality- mitral valve annulus
A 44 year old man with rheumatic aortic stenosis undergoes valve replacement with a bioprosthesis. After 10 years, he develops exercise intolerance. What complication is likely to have occurred? A. B. C. D. E.
Haemolysis Thromboembolism Ishaemic heart disease Stenosis Paravalvular leak
Answer D. Stenosis
A 16 year old girl is admitted to hospital 2 weeks after a sore throat. She has AF and develops pulmonary oedema and acute renal failure. Which is the most likely underlying pathology? A. B. C. D. E.
Tamponade Acute myocardial infarction Hypertrophic cardiomyopathy Amyloidosis Acute rheumatic myocarditis
Answer E. Acute rheumatic myocarditis
Rheumatic Heart Disease
Group A strep pharyngitis Constellation of features including polyarthritis, carditis Aschoff bodies & Anitschkow cells Valve leaflet thickening & fibrosis, mitral valve almost always involved
Rheumatic Fever – Clinical Features
Migratory polyarthritis Carditis Subcutaneous nodules Erythema marginatum Sydenham chorea
Jones Criteria
A 25 year old intravenous drug user is found dead at home. External examination finds splinter haemorrhages. At PM, the aortic valve bears a friable vegetation. Which finding is likely to provide the cause of the disease? A. B. C. D. E.
Positive ANCA Raised Troponin T Positive blood culture for Staph aureus High double stranded-DNA antibody titre Raised antistreptolysin O level
Answer C. Positive blood culture for Staph aureus
Infective Endocarditis
Vegetations – destroy cardiac tissue Most bacterial – Strep Viridans, oral Acute/subacute 50% mortality
IE – Clinical Features
Fever Weight loss Renal failure Murmurs Microemboli
Diagnosis – Duke Criteria
A 44 year old man develops reduced exercise tolerance over 2 years. He has abdominal distention and a fluid wave. An echo shows an EF of 30%. Chronic use of which drug produces these findings? A. B. C. D. E.
Paracetamol Ethanol Nicotine Methotrexate Beta blockers
Answer
B Ethanol
Cardiomyopathies
Dilated – impaired contractility
Hypertrophic – impaired compliance
Idiopathic, alcohol, myocarditis (Cox A), anaemia, haemochromatosis, pregnancy Genetic, Friedreich ataxia, storage diseases
Restrictive – impairment of compliance
Idiopathic, amyloid, radiation
Hypertrophic Cardiomyopathy
Disproportionate thickening of septum Myocyte disarray Sudden death in adults
A 15 year old boy collapses whilst playing rugby. Despite CPR, he cannot be revived. He was otherwise fit and healthy. Which of the following is the pathologist most likely to find at autopsy? A. B. C. D. E.
Haphazardly arranged hypertrophied septal myocytes Myocardial haemosiderin deposition Myocardial fibrosis Myocardial hypertrophy with deposition of amorphous pinkish material Aortic vegetations
Answer A. Haphazardly arranged hypertrophied septal myocytes
Arrhythmogenic Right Ventricular Cardiomyopathy
Right sided heart failure VT Sudden death in adults Dilated right ventricle & fat/fibrosis Chromosome 14 mutation
A 50 year old man reports collapse with LOC on 6 occasions over the past 6 months. Following the last LOC, he developed left sided weakness. Doppler examination of the carotid arteries are normal. What is most likely present? A. B. C. D. E.
Carotid artery atherosclerosis Coronary artery thrombosis Tricuspid valve stenosis Atrial myxoma DVT
Answer D. Atrial myxoma
Cardiac Tumours
Myxoma 200 tumours/1 million autopsies 75% females Death due to embolisation
Thanks