1、Diseases of the Cardiovascular System心血管系统疾病 (2),Major Disorders of CVS,Atherosclerosis Ischemic Heart Disease (IHD) Hypertension Rheumatic Heart Disease (RHD) Infective Endocarditis Valvular Heart Disease (VHD),Hypertension （HTN） 高血压,病,Hypertension，高血压病,Introduction,A sustained diastolic pressure 9
2、0 mmHg and/or a systolic pressure 140mmHg25% of general population, silent killer Chronic, end organ & vascular damageDisastrous late complicationsAtherosclerosis, IHD, Renal damage, Stroke,Regulation of BP,Endocrine Factors Renin, Angiotensin, ANP, ADH, AldosteroneNeural Factors Sympathetic & Paras
3、ympatheticBlood Volume Sodium, Mineralocorticoids Cardiac Factors Heart rate & Contractility,Severity of Hypertension,Normal 210 120Malignant Hypertension Rapid & Severe,Classification,Primary or Essential HTN (95%) UnknownSecondary HTN (5-10 %) Renal GN, Renin tumors Endocrine Cushing, Pheochromocy
4、toma,Etiology 发病因素,Genetic, familial Increased peripheral resistance stress, hormonal, neurallife style,Benign HTN良性高血压病,Accounts for 95% of the cases of HTNMild to moderate elevations in blood pressureAsymptomatic silent diseaseHyaline arteriolosclerosis,Arteriosclerosis,AtherosclerosisLarge BVInti
5、ma,Hyaline,Mnckeberg Medial SclerosisMedial BV,AteriolosclerosisSmall BVFull Thickness,Hyperplastic,atheroma,artery,arteriole,细动脉硬化,动脉硬化,动脉粥样硬化,动脉中层钙化,Hyaline Arteriolosclerosis,Hyaline Arteriolosclerosis,Organ Damage,Heart: concentric left ventricular hypertrophy eccentric left ventricular hypertro
6、phy heart failureKidney: benign nephrosclerosisBrain: Intracerebral hemorrhage , infarction splinter hemorrhages & Lacunar infarctsEyes: hypertensive retinopathy,心脏变化,Left ventricular Hypertrophy,肾脏病变,Primary Granular Atrophy of Kidney原发性颗粒固缩肾Arteriolar Nephrosclerosis细动脉性肾硬化,脑病变,脑水肿高血压脑病（Hypertensi
7、ve encephalopathy）高血压危象（Hypertensive crisis）脑软化微梗死灶（Microinfarct）脑腔隙状梗死（Cerebral Lacunar Infarct）脑出血微小动脉瘤（Microaneurysm）,Normal Retina vs Hypertensive Retinopathy,Malignant HTN恶性高血压病,Accounts for 5% of the cases of HTNMarkedly elevated pressures Artery necrosis with thrombosisRapidly progressive end
8、 organ damageRapidly developing renal failureHypertensive encephalopathyRetinal hemorrhages and exudates, papilledema,Gross: kidney has petechial hemorrhages (flea-bitten appearance)Micro: Hyperplastic arteriolosclerosis - onion skin 增生性小动脉硬化 Necrotizing arteriolitis - fibrinoid necrosis of vessel w
9、alls 坏死性小动脉炎,Morphology,Rheumatism风 湿 病,Acute Rheumatic Fever,Rheumatic fever 风湿热Diffuse, inflammatory disease caused by a delayed immune response to infection by the group A -hemolytic streptococci (A组乙型溶血性链球菌).The joints, skin, nervous system, and heartIf left untreated, rheumatic fever causes rhe
10、umatic heart disease(风湿病).,Rheumatic Heart Disease,In genetically susceptible individuals, the infection results in production of antibodies that cross-react （交叉反应）with cardiac antigens.Initial attacks usually occur in late childhood (ages 5-15 years) and recurrent attacks can occur throughout adult
11、 life.,Pathogenesis,Delayed immune response to infection with group A beta hemolytic streptococci（A组乙型溶血性链球菌）.After a latent period of 1-3 weeks, antibody induced immunological damage occur to heart valves（心瓣膜）, joints（关节）, subcutaneous tissue （皮下组织）& basal ganglia（基底节）.,病因与发病机制,与A组乙型溶血性链球菌没有直接关系；C抗
12、原（糖蛋白）的抗体结缔组织；M抗原（蛋白）的抗体心肌、血管平滑肌；心肌抗体及N-乙酰氨基酸葡萄糖抗体。,Pathologic change,Early phase (alterative and exudative phase) 变质渗出期 1 to 4wProliferative phase (granulomatous phase) 增生（肉芽肿）期 2 to 3mFibrosis phase (healed phase) 瘢痕（愈合）期 2 to 3m,增生（肉芽肿）期Around the fibrinoid necrotic foci the proliferation of hist
13、ocytic cells, forming a granuloma. Each of these minute nodules of proliferation inflammaties is known as an Aschoff body（Aschoff 小体）.Anitschkow cells,Pathologic change,变质渗出期Fragmentation of collagen fibres, lymphocytic infiltration & fibrinoid deposition,Karl Albert Ludwig Ashoff (1866-1942),Anitsc
14、hkow细胞,ASCHOFFvs ANITSCHKOW,Acute rheumatic heart disease急性风湿性心脏病,Rheumatic endocarditis 风湿性心内膜炎 Involves mitral and aortic valves Fibrin vegetations along the lines of closure MacCallum plaques: left atrial endocardial thickening,Rheumatic myocarditis 风湿性心肌炎 Aschoff body ( fibrinoid necrosis surrou
15、nded by Anitschkow cells), lymphocytes, and plasma cellsFibrinous pericarditis 风湿性心包炎 cor villosum 绒毛心,Chronic rheumatic heart disease慢性风湿性心脏病,Mitral and aortic valvular fibrosis（二尖瓣和主动脉瓣纤维化） Valve thickening and calcification（瓣膜增厚和钙化） Fusion of the valve commissures（瓣膜连接处融合） Chordae tendineae （腱索）
16、are short, thickened, and fusedComplications Mitral stenosis and CHF（充血性心衰） Infectious endocarditis（感染性心内膜炎）,Aortic valve showing active valvulitis. The valve is slightly thickened with small vegetations（赘生物） “verrucae（疣状）,Opened stenotic mitral valve showing thickening distorted cusps, adherent com
17、missures with calcification and thrombus deposition, & thickening, fusion and shortening of chordae tendinae,Rheumatic arthritis 风湿性关节炎,Flitting migratory polyarthritis（游走性多关节炎）, involving major joints（大关节）Commonly involved joints-knee, ankle, elbow & wristArthritis do not progress to chronic diseas
18、e (消退后，不遗留关节变形),Erythema annulare 环形红斑,Unique（单一的）, transient（一过性）, serpiginous（葡行的）-looking lesions of 1-2 inches in sizePale center with red irregular margin（淡红色环状红晕，中间肤色正常）More on trunks & limbs （多发生于躯干和四肢）Often associated with chronic carditis （心脏炎）,Painless（无痛的）, pea-sized（豌豆状的）, palpable（可触及的）
19、 nodulesMainly over extensor（伸肌） surfaces of joints, spine, & scalpAlways associated with severe carditis,Subcutaneous nodules 皮下结节,Rheumatic arteritis 风湿性动脉炎,大、中等动脉 急性期 粘液样变性、纤维素样坏死 慢性期 瘢痕形成,Chorea minor 小舞蹈症,Occur in 5-10% of casesMainly in girls of 5-12 yrs ageClinically manifest as-clumsiness（笨拙
20、）, deterioration of handwriting （写字）, emotional lability （情绪不稳） or grimacing（抽动） of face,Infective endocarditis 感染性心内膜炎,Definition,An infection associated with formation of an adherent, bulky mass of thrombotic debris and organisms, termed vegetations （赘生物）on the endocardial surface, usually on a va
21、lve.,AgentsBacteria, viruses, fungi, and parasitesPathogenesis“Prepared” endocardiumBlood-borne microorganism adherenceProliferation of the microorganism,Pathogenesis,Endothelial damage,Platelet-fibrin thrombi,Microorganism adherence,Vegetation,Variable in sizeAmorphous mass of fibrin & plateletsAbu
22、ndant organismsFew inflammatory cells,Acute Infective Endocarditis,High virulence organism: Staphylococcus aureusCan colonize a normal valveProduces large destructive vegetationsPrognosis: poor; mortality =50%,Subacute Infective Endocarditis,Low virulence organism: Streptococcus group viridans Usual
23、ly colonize a previously damaged valvePresentation over weeks to monthsRarely leads to metastatic infection,Fever, chills, weight loss, and cardiac murmurSystemic emboli （全身栓塞）Roth spots (retinal emboli)Osler nodes （Osler结节）Janeway lesions Renal insufficiency,Clinical presentation,Valvular vitium of
24、 the heart 心 瓣 膜 病,Internal view of the heart,Mitral Valve Anatomy,Valvular vitium of the heart result from a healed or chronic valvulitis （瓣膜炎） or, occasionally, are congenital malformations （先天畸形）. The results of inflammation in the valves are seen as thickening（增厚）, adhesions（粘连）, retraction（缩回）,
25、 and shortening （变短） of the leaflets. There may be a narrowing of the valve opening (stenosis，狭窄), or closure of the valve may be insufficient so that leakage (regurgitation，反流) occur through it.,Introduction,Valvular insufficiency and stenosis may be produced by the same deformity. Valve deformitie
26、s are common on the left side of the heart (aortic and mitral，主动脉瓣和二尖瓣) but are uncommon on the right side (tricuspid and pulmonary).,Introduction,Valvular Dysfunction,Valvular Dysfunction,MITRAL STENOSIS 二尖瓣狭窄,predominant cause - Rheumatic fever Less frequently, congenital in etiologyleft atrium fa
27、ilure lung congestion right heart failure systemic congestionX ray: pear like heart （梨形心）,Mitral Insufficiency 二尖瓣关闭不全,predominant cause - Rheumatic feverCombined with mitral stenosisleft heart failure lung congestion right heart failure systemic congestionX ray: ball like heart （球形心）,Aortic stenosi
28、s 主动脉瓣狭窄,Rheumatic AS, degenerative (senile) calcific AS ,atherosclerotic aortic valvular stenosis Angina pectoris, pulse pressure left atrium failure lung congestion right heart failure systemic congestionX ray: boot like heart（靴型心）,Aortic insufficiency 主动脉瓣关闭不全,Rheumatic fever , Syphilis, Systemic hypertension, Infective endocarditis left atrium failure lung congestion right heart failure systemic congestionPulse pressure , water-hammer pulse（水冲脉）, pistol shot sound（枪击音）,Summary,Hypertension Rheumatic Heart Disease Infective Endocarditis Valvular Heart Disease,Thanks,
