病理学课件：05 Cardiovascular Diseases

1、Chapter VI Diseases of Cardiovascular System 心血管系统疾病心血管系统疾病 Cardio vascular system Heart Blood vessels “Pump” More morbidity the constituents of the plaque include SMCs, ECMs, inflammatory cells, lipids, and necrotic debris. Natural history, morphologic features anterior two thirds of the interventr

2、icular septum Right coronary artery 30% 40% Posterior wall of the left ventricle; posterior one third of the interventricular septum Left circumflex coronary artery 15% 20% lateral wall of the left ventricle Rupture, fissuring, or ulceration rapid thrombosis Hemorrhage into the core of plaques Vasos

3、pasm Acute Plaque Change Acute coronary syndromes Palpitations；Pain；Exertional dyspnea（劳力性呼吸困难）； Diaphoresis（大汗）；Nausea（恶心）; Decreased exercise tolerance Plaque rupture Acute coronary thrombosis on a plaque with focal rupture, triggering fatal myocardial infarction Massive plaque rupture with thromb

4、us, triggering a fatal myocardial infarction Clinical Presentations 1. Angina pectoris 2. Myocardial infarction 3. Chronic coronary heart disease 4. Sudden coronary death Angina pectoris An intermittent chest pain caused by transient, reversible myocardial ischemia (1) Stable - A fixed atherosclerot

5、ic narrowing (usually 70%) - Occur in the setting of increased demands - Relieved by rest (reducing demand) or by administration of nitroglycerin (vasodilator) (2) Unstable - Results from a small fissure or rupture of atherosclerotic plaque triggering platelet aggregation, vasoconstriction, and form

6、ation of a mural thrombus - Occur progressively at less levels of exertion or even at rest (3) Variant - Caused by vasospasm - Occur at rest A crushing or squeezing substernal sensation, may radiate down the left arm Myocardial Infarction (MI，心肌梗死心肌梗死) Necrosis of heart muscle resulting from ischemi

7、a Most MIs are caused by acute coronary artery thrombosis Plaque disruption Platelet aggregation Hypercoagulable states; Malignancies particular adenocarcinoma; SLE, etc. Nonbacterial Thrombotic Endocarditis (NBTE) Microscopy: Single or multiple nodules, along the valve closure, 5mm Gross: Platelet,

8、 fibrin angina pectoris Aortic Regurgitation Cause: rheumatic heart disease, infective endocarditis ; syphilitic arteritis Hemodynamic and heart changes: Hypertrophy and dilation of the four chambers, especially the left ventricular Left and Right Heart Failure Edema and congestion of pulmonary Pulm

9、onary artery hypertension Clinical features: Diastolic murmur at the auscultation area of aortic valve angina pectoris; widened pulse pressure Boot-shaped Heart Myocarditis Definition A group of inflammatory processes primarily targeting the myocardium Cause: (1) Infections: Chlamydia, rickettsia, b

10、acteria, fungi, etc. (2) Immune-mediated reactions postviral; postbacteria; systemic lupus erythematosus; drug hypersensitivity (e.g. methyldopa, sulfonamides) , transplant rejection (3) Unknown: giant cell myocarditis Viral Myocarditis Cause Coxsackieviruses A and B and other enteroviruses (most co

11、mmon) Direct damage to myocardium Immune-mediated injury Morphology Gross: Heart is dilated. Myocardium is flabby and often mottled with pale and hemorrhagic areas. Microscopy: Edematous A diffuse lymphocytic infiltrate Myocyte degeneration and /or necrosis Clinical features Broad spectrum From an a

12、symptomatic state to severe congestive heart failure Self-limited, some may develop dilated cardiomyopathy Cardiomyopathies Heart diseases resulting from a primary abnormality in the myocardium “Heart muscle diseases” Dilated Hypertrophic Restrictive Dilated Cardiomyopathy Progressive cardiac hypert

13、rophy, dilation and contractile (systolic) dysfunction Cause A large number of different myocardial insults Genetic; alcohol; peripartum; myocarditis; hemochromatosis; chronic anemia; doxorubicin (adriamycin); sarcoidosis; idiopathic Morphology Gross Enlarged and flabby with weights often exceeding

14、900g Dilation and hypertrophy of all chambers Fragile mural thrombi there may be specific causes, or it may be idiopathic. The three categories are dilated (accounting for 90% of the cases), hypertrophic, and restrictive (least common). Dilated cardiomyopathy) results in systolic (contractile) dysfu

15、nction. Hypertrophic cardiomyopathy results in diastolic (relaxation) dysfunction. Restrictive cardiomyopathy results in a stiff, noncompliant myocardium. Questions The morphologic characteristics of myocardial infarction? The pathological characteristics of rheumatic heart disease? 病例分析病例分析(A.4937)

16、 83岁，男性，死亡后岁，男性，死亡后1天行尸体解剖天行尸体解剖 病史病史：24年前有年前有“急性心肌梗塞急性心肌梗塞”史，史， 入院前数天有恶心感，突然意识丧失，大汗淋漓，小便失禁半小入院前数天有恶心感，突然意识丧失，大汗淋漓，小便失禁半小 时，时，EKG示示S-T段抬高，给予扩血管、溶栓治疗段抬高，给予扩血管、溶栓治疗 住院期间出现心源性休克，心动过缓，完全性房室传导阻滞，治住院期间出现心源性休克，心动过缓，完全性房室传导阻滞，治 疗后血压、心率、心律恢复正常疗后血压、心率、心律恢复正常 住院十天后出现腹胀、下肢浮肿，住院十天后出现腹胀、下肢浮肿，B超示左侧胸水，后突然烦躁、超示左侧胸水，

17、后突然烦躁、 大汗、气促而死亡大汗、气促而死亡 临床诊断临床诊断： 急性（下壁、前侧壁、后壁）心肌梗塞、心源性晕厥、休克、心衰、应激急性（下壁、前侧壁、后壁）心肌梗塞、心源性晕厥、休克、心衰、应激 性溃疡、糖尿病性溃疡、糖尿病 尸检主要发现尸检主要发现： 体表与体腔体表与体腔 指甲轻度紫绀，两下肢轻度浮肿，肝剑下指甲轻度紫绀，两下肢轻度浮肿，肝剑下4cm，两，两 胸腔淡黄色积液各胸腔淡黄色积液各60 ml，心脏膈面有少量纤维蛋白渗，心脏膈面有少量纤维蛋白渗 出，颅底动脉硬化，脑萎缩出，颅底动脉硬化，脑萎缩 内内 脏脏 1. 心脏心脏 520g 冠状动脉左前降支狭窄达冠状动脉左前降支狭窄达959

18、8， 右冠状动脉距起始右冠状动脉距起始7cm处见附壁血栓。室壁左厚处见附壁血栓。室壁左厚0.8 1.5cm，右厚，右厚0.6cm。左侧、后壁与右后及后室间隔。左侧、后壁与右后及后室间隔 见见9X8X9cm3梗死灶，此处心肌变薄、暗红、灰梗死灶，此处心肌变薄、暗红、灰 黄色坏死灶，并波及乳头肌黄色坏死灶，并波及乳头肌 2. 肝脏肝脏 1200g 切面红黄相间切面红黄相间 诊断：诊断： 一、冠状动脉粥样硬化性心脏病：一、冠状动脉粥样硬化性心脏病： 1.左前降支及右冠状动脉高度狭窄；左前降支及右冠状动脉高度狭窄； 2.右冠状动脉新鲜血栓形成，引起左侧、后、右冠状动脉新鲜血栓形成，引起左侧、后、 右后

19、、右后、 后间隔急性心肌梗死；后间隔急性心肌梗死； 3. 纤维素性心外膜炎；纤维素性心外膜炎； 二、高血压病累及肾、心、脾等；二、高血压病累及肾、心、脾等； 三、两肺灶性炎症伴纤维化，肺淤血、水肿及慢支。三、两肺灶性炎症伴纤维化，肺淤血、水肿及慢支。 死因：死因： 心律紊乱、左心衰竭心律紊乱、左心衰竭 病例分析2 （A5988) 死者男性，68岁。因“突发中上腹疼痛2小时余”于 2010年8月1日14时就诊于急诊，尿常规：RBC10-12/HP， B超显示：胆囊胆固醇结晶，双肾皮质回声稍强。临床以 “腹痛待查：肾绞痛？肠绞痛？”收入院，并予以抗菌、 解痉治疗。15点45分时，患者仍主诉“疼痛，恶心、呕吐 加剧”，临床仍予以抗菌、解痉治疗；15点58分时，患者 突然出现意识丧失，血压测不出