Diseases of the cardiovascular system

MaliqinDepartment of Pathology and PathophysiologySchool of Medicine, Zhejiang University

atherosclerosis(AS)

1. etiology and pathogenesisRisk factors Hyperlipemia:increased LDL, TG, VLDL, apoB,Lp(a) decreased HDL,apoA-I Hypertension Cigarette smoking Elevated blood sugar levels The other factors

pathogenesis

--Theory of inflammatory response to injury

The injury of the endotheliumThe accumulation of lipidThe infiltration of macrophagesThe proliferation of SMC

2.morphology

Predilection for large arteries and medium-sized arteries

Basic lesionFatty streak

Accumulated lipid, foam cellFibrous plaque-- Fibrous cap

黄色脂质条纹

2.morphology

Predilection for large arteries and medium-sized arteries

Basic lesionFatty streak

Accumulated lipid, foam cellFibrous plaque-- Fibrous cap

正常主动脉

动脉粥样硬化的纤维斑块病

变

动脉管壁一侧明显增厚

•Atheromatous plaque (atheroma)

Fibrous cap cholesterol crystal necnotic debris foam cell calcification neovascular formation

atheroma

complicated lesionsHemorrhage in plaqueRupture of the plaqueThrombosisCalcificationaneurysm: definition, lesion

classification (true , pseudo-, Dissecting )

Ulcer formation

3. Atherosclerosis of the important organs

• Aorta: abdominal aorta• Coronary arteries• Arteries of the brain• The other organs

正常主动脉

动脉粥样硬化的纤维斑块病

变

3. Atherosclerosis of the important organs

• Aorta: abdominal aorta• Coronary arteries• Arteries of the brain• The other organs

基底动脉内血栓形成

基底动脉环硬化

脑动脉硬化致脑萎缩

3. Atherosclerosis of the important organs

• Aorta: abdominal aorta• Coronary arteries• Arteries of the brain• The other organs

新

鲜

足

坏

疽

足干性坏疽

Coronary heart disease (C H D)

Definition

cardiac disease which result from insufficient coronary blood flows due to the narrowing of the coronary arteries

Causes• Coronary atherosclerosis Distribution(location) features of the lesion• Spasm of the coronary arteris• Coronary arteritis

正常心脏

右冠状动

脉

左冠状动脉

冠状动脉粥样硬化

左冠状动脉

右冠状动脉

冠状动脉狭窄

血栓形成

正常冠状动脉

冠状动脉粥样硬化，管腔狭窄

冠状动脉管壁增厚及钙化 ，管腔明显狭窄

斑块内钙化

动脉管腔狭窄血栓形成

冠状动脉近端狭窄

冠状动脉远端闭塞

冠状动脉硬化区

冠状动脉阻塞

Causes• Coronary atherosclerosis Distribution(location) features of the lesion• Spasm of the coronary arteris• Coronary arteritis

Classification1. angina pectoris (AP) a symptom complex consisting of severe paroxymal chest pain resulting from transient ischemia

Precipitating factors

Exertion, emotion, pain, cold weather, cigarette smoking, heavy meals

心绞痛病人

Classification• Stable (exerting ) AP• Instable (exerting) AP• (Spontaneous) variant AP

2. Myocardial infarction• Subendocardial MI Multiple small lesion• Transmural MI Distribution Morphology:shape, color, microscopic change Biochemical changes:

myocardial infarction

granulation tissue

Complications•Rupture of the heart•Ventricular aneurysm•Thrombosis•Acute pericarditis•Clinical complication

rupture of Infarct area

Pericardial

tamponade

hematocele in heart sac

vntricular aneurysm

3. Myocardial fibrosis

4. sudden coronary death

Hypertension Diagnostic criteria

sustained diastolic pressure above 90 mmHg

and/or sustained systolic pressure above 140mmHg

Classification• Primary(essential) hypertension • Secondary(symptomatic)

• Benign (chronic) hypertension• Malignant(accelerated)

Morphology(1) Benign hypertension• Stage of dysfunction• Stage of artery lesion arteriolosclerosis—the basic

lesion of hypertension

• Stage of organ dysfunction

Hypertensive heart disease Concentric hypertrophy Ecentric hypertrophyArteriolar nephrosclerosis (primary granulo-contracted kidney) Microscopic change Gross alteration

concentric hypertrophy

of left ventricle

decompensation distention of left ventricle

Hypertensive heart disease Concentric hypertrophy Ecentric hypertrophyArteriolar nephrosclerosis (primary granulo-contracted kidney) Microscopic change Gross alteration

Hypertensive brain•Edema of brain, hypertensive

encephalopathy,

hypertensive crisis•Hemorrhage of brain•Softening of brain

Lesions of retina

Arteriole of eyeground

(2) Malignant hypertension Basic lesion: necrotic arteriolitis proliferating arteriosclerosis The major injured organs: kidney and brain

Etiology and pathogenesis

Causes• Genetic factors• Environmental factors Dietary factors: Na+, K+,Ca2+

Social factors

psychological stress

other factors

PathogenesisVariant factors—increased Volum, or Increased vasoconstriction• retention of Sodium and water• Vasoconstriction• Thickening of the artery wall

Cardiomyopathy Classification: The common lesion:Primary cardiomyopathy Any dysfunction of the myocardiumnot attribulable to CHD,valvular disease, hypertension or pulmonary heart disease .

Dilated cardiomyopathy Hypertrophy(M>350g F>300g) Dilatation of the four cavities Heart failure

Microscopically, the heart in cardiomyopathy demonstrates hypertrophy of myocardial fibers (which also have prominent dark nuclei) along with interstitial fibrosis.

Here is a large, dilated left ventricle typical of a dilated, or congestive, cardiomyopathy. Many of these have no known etiology (so-called "idiopathic dilated cardiomyopathy") while others may be associated with chronic alcoholism. The heart is very enlarged and flabby.

Hypertrophic cardiomyopathy

•Hypertrophy of the myocardium•Asymetric hypertrophy of the ventricular septum•Obstruction of the outflow tract

There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber. This is hypertrophic cardiomyopathy.

Restrictive cardiomyopathy progressive fibrosis of the endocardium and subendocardial myocadium

This section of myocardium demonstrates amorphous deposits of pale pink material between myocardial fibers. This is characteristic for amyloid. Amyloidosis is a cause for "infiltrative" or "restrictive" cardiomyopathy. It is a nightmare for anesthesiologists when intractable arrhythmias occur during surgery on such patients.

KeShan diseaseEtiology•Virus infection Coxsackie B•Lack of SelenniumMorphologyDilatation of the left and right ventricle

RheumatismEtiology and pathogenesis•Infection with group A beta

hemolytic streptococci•Immune injury

Basic lesion(three stages)• Alterative and exudative phase Mucoid degeneration fibrinoid necrosis• Proliferative phase (granulomatous phase)

Aschoff body (consist of) Fibrinoid necrosis Aschoff cell:awl-eye cell, caterpillar cell Aschoff giant cell Other inflammatory cells• Fibrosis phase

Aschoff body (consist of) Fibrinoid necrosis Aschoff cell:awl-eye cell, caterpillar cell Aschoff giant cell Other inflammatory cells• Fibrosis phase

Rheumatic heart diseaseRheumatic endocarditis(verrucous endocarditis)Distribution: mitral valve 50% mitral and aortic valve 50%Lesion: vegetationssequla: valvular disease, MacCallum’s plaque

疣状风湿性心内膜炎

Rheumatic myocarditis Adults: local stromal myocarditis Children:diffuse stromal myocarditis Rheumatic pericarditis dry pericarditis wet pericarditis Clinical course

rheumatic myocarditis

rheumatic granulomas

Aschoff cell

Rheumatic myoicarditis Adults: local stromal myocarditis Children:diffuse stromal myocarditis Rheumatic pericarditis dry pericarditis wet pericarditis Clinical course

Rheumatic arthritis Large joints, reversibleRheumatic lesion of the skin Erythema annullare Subcutaneous nodulesRheumatic arteritis

Rheumatic encephalopathyRheumatic arteritis of the brainRheumatic encephalitisChorea minor

Chronic valvular vitium of the heart stenosis, insufficiencyMitral stenosis The valvular changes The cardiac changes The clinical course

风湿性心瓣膜病 左房扩张

左房扩张

瓣膜硬化

左室萎缩

二尖瓣膜及腱索增厚

变硬

二尖瓣狭窄

左心房扩张

主动脉瓣关闭不全

Mitral insufficiency The valvular changes The cardiac changes The clinical courseAortic stenosis and insufficiency

Subacute infective endocarditis(SBE)EtiologyStreptococci. Morphologyvegetations

Vegetations(compared with rheumatic valvitis) Large, yellow, located haphazardly, located at the margin of the valve containing causative organism friable

亚急性细菌性心内膜炎

赘生物

瓣膜病变

Complication•Septicemia•Embolism•Immune injury

MyocarditisEtiologyMorphologyViral myocarditisBacterial myocarditisIsolated myocarditisClinical course

The interstitial lymphocytic infiltrates shown here are characteristic for a viral myocarditis, which is probably the most common type of myocarditis.

Thank you!