病理學(xué)課件：05 Cardiovascular Diseases

1、Chapter VI Diseases of Cardiovascular System 心血管系統(tǒng)疾病心血管系統(tǒng)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（勞力性呼吸困難）； Diaphoresis（大汗）；Nausea（惡心）; 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歲，男性，死亡后歲，男性，死亡后1天行尸體解剖天行尸體解剖 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， 入院前數(shù)天有惡心感，突然意識(shí)喪失，大汗淋漓，小便失禁半小入院前數(shù)天有惡心感，突然意識(shí)喪失，大汗淋漓，小便失禁半小 時(shí)，時(shí)，EKG示示S-T段抬高，給予擴(kuò)血管、溶栓治療段抬高，給予擴(kuò)血管、溶栓治療 住院期間出現(xiàn)心源性休克，心動(dòng)過(guò)緩，完全性房室傳導(dǎo)阻滯，治住院期間出現(xiàn)心源性休克，心動(dòng)過(guò)緩，完全性房室傳導(dǎo)阻滯，治 療后血壓、心率、心律恢復(fù)正常療后血壓、心率、心律恢復(fù)正常 住院十天后出現(xiàn)腹脹、下肢浮腫，住院十天后出現(xiàn)腹脹、下肢浮腫，B超示左側(cè)胸水，后突然煩躁、超示左側(cè)胸水，

17、后突然煩躁、 大汗、氣促而死亡大汗、氣促而死亡 臨床診斷臨床診斷： 急性（下壁、前側(cè)壁、后壁）心肌梗塞、心源性暈厥、休克、心衰、應(yīng)激急性（下壁、前側(cè)壁、后壁）心肌梗塞、心源性暈厥、休克、心衰、應(yīng)激 性潰瘍、糖尿病性潰瘍、糖尿病 尸檢主要發(fā)現(xiàn)尸檢主要發(fā)現(xiàn)： 體表與體腔體表與體腔 指甲輕度紫紺，兩下肢輕度浮腫，肝劍下指甲輕度紫紺，兩下肢輕度浮腫，肝劍下4cm，兩，兩 胸腔淡黃色積液各胸腔淡黃色積液各60 ml，心臟膈面有少量纖維蛋白滲，心臟膈面有少量纖維蛋白滲 出，顱底動(dòng)脈硬化，腦萎縮出，顱底動(dòng)脈硬化，腦萎縮 內(nèi)內(nèi) 臟臟 1. 心臟心臟 520g 冠狀動(dòng)脈左前降支狹窄達(dá)冠狀動(dòng)脈左前降支狹窄達(dá)959

18、8， 右冠狀動(dòng)脈距起始右冠狀動(dòng)脈距起始7cm處見(jiàn)附壁血栓。室壁左厚處見(jiàn)附壁血栓。室壁左厚0.8 1.5cm，右厚，右厚0.6cm。左側(cè)、后壁與右后及后室間隔。左側(cè)、后壁與右后及后室間隔 見(jiàn)見(jiàn)9X8X9cm3梗死灶，此處心肌變薄、暗紅、灰梗死灶，此處心肌變薄、暗紅、灰 黃色壞死灶，并波及乳頭肌黃色壞死灶，并波及乳頭肌 2. 肝臟肝臟 1200g 切面紅黃相間切面紅黃相間 診斷：診斷： 一、冠狀動(dòng)脈粥樣硬化性心臟?。阂?、冠狀動(dòng)脈粥樣硬化性心臟?。?1.左前降支及右冠狀動(dòng)脈高度狹窄；左前降支及右冠狀動(dòng)脈高度狹窄； 2.右冠狀動(dòng)脈新鮮血栓形成，引起左側(cè)、后、右冠狀動(dòng)脈新鮮血栓形成，引起左側(cè)、后、 右后

19、、右后、 后間隔急性心肌梗死；后間隔急性心肌梗死； 3. 纖維素性心外膜炎；纖維素性心外膜炎； 二、高血壓病累及腎、心、脾等；二、高血壓病累及腎、心、脾等； 三、兩肺灶性炎癥伴纖維化，肺淤血、水腫及慢支。三、兩肺灶性炎癥伴纖維化，肺淤血、水腫及慢支。 死因：死因： 心律紊亂、左心衰竭心律紊亂、左心衰竭 病例分析2 （A5988) 死者男性，68歲。因“突發(fā)中上腹疼痛2小時(shí)余”于 2010年8月1日14時(shí)就診于急診，尿常規(guī)：RBC10-12/HP， B超顯示：膽囊膽固醇結(jié)晶，雙腎皮質(zhì)回聲稍強(qiáng)。臨床以 “腹痛待查：腎絞痛？腸絞痛？”收入院，并予以抗菌、 解痙治療。15點(diǎn)45分時(shí)，患者仍主訴“疼痛，惡心、嘔吐 加劇”，臨床仍予以抗菌、解痙治療；15點(diǎn)58分時(shí)，患者 突然出現(xiàn)意識(shí)喪失，血壓測(cè)不出