2008-心血管系統(tǒng)病理-湘雅本科課件

DiseasesofCardiovascularSystemDr.Zheng

changli

Atherosclerosis(AS)1.EtiologyandPathogenesisRiskfactors（1）Hyperlipemia:TC，TG，

LDL，VLDL，apoB，

Lp(a)HDL，apoA-I

（2）Hypertension

（3）Cigarettesmoking

（4）Elevatedbloodsugarlevels

（5）TheotherfactorsPathogenesis

（1）Theinjuryoftheendothelium

通透性增大，

Growthfactor:MPC-1,PDGF,TGF-beta（2）Theaccumulationoflipid

血脂增高，血管壁脂質(zhì)代謝障礙（3）Theinfiltrationofmacrophages

吞噬形成泡沫細胞，參與炎癥和免疫過程，促進平滑肌細胞遷移和增生（4）TheproliferationofSMC

增生，遷移，功能改變：吞噬，分泌合成（GF，ECM）2.Morphology

Predilectionforlargearteriesandmedium-sizedarteries

Basiclesion(1)Fattystreakaccumulatedlipid,foamcell黃色脂質(zhì)條紋(2)Fibrousplaque--Fibrouscap

肉眼:

鏡下:fibrouscaplipidzonebasalzone正常主動脈動脈粥樣硬化的纖維斑塊病變動脈管壁一側(cè)明顯增厚

(3)Atheromatousplaque(atheroma)

Fibrouscapcholesterolcrystalnecroticdebrisfoamcellcalcification

neovascularformation動脈分支開口處黃色隆起斑塊粥樣斑塊病變動脈內(nèi)膜下大量泡沫細胞堆積

斑塊底部塊纖維化

斑塊內(nèi)膽固醇積聚(4)ComplicatedLesions

★

Hemorrhageinplaque

★Ruptureoftheplaque

★Thrombosis

★Calcification

★Aneurysm:

definition,lesionclassification

(true,pseudo-,Dissecting)

粥樣硬化斑塊潰瘍形成腹主動脈髂動脈血栓形成腹主動脈血栓形成腎硬化髂動脈瘤

3.Atherosclerosisofmajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain★

Otherorgans正常主動脈動脈粥樣硬化的纖維斑塊病變

3.Atherosclerosisofthemajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain

★

Otherorgans

正常腦基底動脈環(huán)基底動脈環(huán)硬化基底動脈內(nèi)血栓形成基底動脈環(huán)硬化腦動脈硬化致腦萎縮

3.Atherosclerosisofthemajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain

★

Otherorgans新鮮足壞疽

足干性壞疽CoronaryHeartDisease(CHD)Definition

Cardiacdiseaseresultingfrominsufficientcoronarybloodflowsduetothenarrowingofthecoronaryarteries

causes①coronaryatherosclerosis

Distribution(location)

左冠狀動脈前降支，右主干或左旋支，后降支

featuresofthelesion

斑塊：新月形，偏心位狹窄程度分四級：正常心臟

右冠狀動脈左冠狀動脈冠狀動脈粥樣硬化左冠狀動脈右冠狀動脈冠狀動脈狹窄血栓形成正常冠狀動脈冠狀動脈粥樣硬化，管腔狹窄

冠狀動脈管壁增厚及鈣化，管腔明顯狹窄斑塊內(nèi)鈣化動脈管腔狹窄血栓形成冠狀動脈近端狹窄冠狀動脈遠端閉塞冠狀動脈硬化區(qū)冠狀動脈阻塞causes①

coronaryatherosclerosis②

spasmofthecoronaryarteris③

coronaryarteritisClassificationofCHD

1.

anginapectoris(AP)

episodiccardiacpainresultingfromtransientischemia

Precipitatingfactors

exertion，

emotion，

pain，

coldweather，

cigarettesmoking，

heavymeals

心絞痛病人ClassificationofAP

StableAPofexertionInstableAPofexertion(spontaneous)variantAP2.

Myocardialinfarction(MI)

subendocardialMI

Multiplesmalllesion

transmuralMI

（1）Distribution

（2）Morphology:shape：

color:6h蒼白，8-9h土黃色，1-2周紅色，

3周后灰白

microscopicchange

（3）Biochemicalchanges:新鮮心肌梗死心肌梗死灶肉芽組織左心室大片壞死ComplicationsofMIRuptureoftheheartVentricularaneurysmThrombosisAcutepericarditisClinicalcomplication

心律失?！畛Ｒ姷牟l(fā)癥心衰，心源性休克梗死區(qū)破裂口心包填塞心包內(nèi)積血左心室慢性室壁瘤3.myocardialfibrosis4.suddencoronarydeath

Hypertension

診斷標(biāo)準Diagnosticcriteria

sustaineddiastolicpressure≥90mmHg(12.0kPa)and/orsustainedsystolicpressure≥140mmHg(18.4kPa)

分類ClassificationPrimary(essential)hypertensionSecondary(symptomatic)?Specialhypertension(妊娠高血壓，高血壓危象)

Benign(chronic)hypertensionMalignant(accelerated)病變Morphology（一）良性高血壓Benignhypertension1.機能紊亂期Stageofdysfunction2.動脈病變期Stageofarterylesionbasiclesion：

arteriolosclerosis3.內(nèi)臟病變期Stageoforgandysfunction

高血壓心臟病

HypertensiveHeartDisease

（1）病變

向心性肥大Concentrichypertrophy

離心性肥大

Eccentrichypertrophy（2）臨床病理聯(lián)系左心室向心性肥大左心室失代償性擴張

細動脈性腎硬化

ArteriolarNephrosclerosis

(primarygranulo-contractedkidney)

（1）鏡下:(Microscopicchange)

腎血管，腎小球，腎小管，腎間質(zhì)

（2）大體:(Grossalteration)

顆粒性固縮腎高血壓固縮腎

高血壓腦HypertensivebrainhypertensiveencephalopathyHemorrhageofbrainSofteningofbrain

視網(wǎng)膜病變Lesionsofretina側(cè)腦室出血呈銀絲狀眼底細動脈

(2)惡性高血壓Malignanthypertension

基本病變Basiclesion:

壞死性細動脈炎necroticarteriolitis

增生性小動脈硬化proliferatingarteriosclerosis

主要受損器官Themajorinjuredorgans:

kidneyandbrainEtiologyandPathogenesis1.Riskfactors（1）Geneticfactors

腎素—血管緊張素編碼基因（多態(tài)性、點突變）激素樣物質(zhì)—抑制Na/K-ATP酶的活性（2）Dietaryfactors:

Na+的攝入量，肥胖，飲酒（3）Socialfactors，psychologicalstress（4）otherfactors

體力活動，神經(jīng)內(nèi)分泌2.PathogenesisVariantfactors—increasedVolume，

orIncreasedvasoconstriction（1）retentionofSodiumandwater（2）Vasoconstriction（神經(jīng)、體液調(diào)節(jié)）（3）Thickeningofthearterywall

RheumatismEtiologyandPathogenesisInfectionwithgroupAbetahemolyticstreptococcusImmuneinjury

主要抗原:M蛋白，C多糖

Basiclesions(threestages)(1)Alterativeandexudativephase

mucoiddegeneration

fibrinoidnecrosis(2)Proliferativephase(granulomatousphase)

Aschoffbody

fibrinoidnecrosis

Aschoffcell:awl-eyecell,caterpillarcell

Aschoffgiantcellotherinflammatorycells

風(fēng)濕細胞的特點

(1)來源巨噬細胞，CD68，LYSOZYME+

（2）細胞漿偏鹼性（3）核染色質(zhì)向中間聚集風(fēng)濕性肉芽腫纖維素樣壞死風(fēng)濕細胞風(fēng)濕性肉芽腫中風(fēng)濕細胞

(3)FibrosisphaseorhealedphaseRheumaticheartdiseaseRheumaticendocarditis(verrucous

endocarditis)Distribution:

mitralvalve50%

mitralandaorticvalve50%Lesion:rheumaticlesion

verrucosvegetationsequla:valvulardisease,McCallumpatch疣狀風(fēng)濕性心內(nèi)膜炎

Rheumaticmyocarditis

Adults:localstromal

myocarditis

Children:diffusestromal

myocarditis

風(fēng)濕性心肌炎風(fēng)濕性肉芽腫形成風(fēng)濕性肉芽腫纖維素樣壞死風(fēng)濕細胞Rheumaticpericarditis

drypericarditiswetpericarditisClinicalcourse:

心音遙遠，心界擴大，

X線--燒瓶狀，心包摩擦音風(fēng)濕性心外膜炎-絨毛心Rheumaticarthritis

70%，大關(guān)節(jié)，游走性，可復(fù)性，主為漿液性炎癥Rheumaticlesionoftheskin

Erythema

annulareSubcutaneousnodulesRheumaticarteritis

動脈受累，黏液變，纖維素樣壞死，偶見風(fēng)濕小體RheumaticencephalopathyRheumaticarteritisofthebrainRheumaticencephalitisChoreaminor(小舞蹈病)

ChronicValvular

VitiumoftheHeart

（Valvulardisease，VD）

概念：心臟瓣膜器質(zhì)性病變，引起瓣膜狹窄、關(guān)閉不全，導(dǎo)致心功能不全

類型：stenosis，insufficiency，并存，聯(lián)合

病因：風(fēng)濕性心內(nèi)膜炎，亞細

Mitral

Stenosis1.thevalvularchanges

隔膜型，增厚型，漏斗型2.haemodynamicsandcardiacchanges3.clinicalcorelation

心尖區(qū)舒張期隆隆樣雜音梨形心，二尖瓣面容二尖瓣狹窄——左房淤血——左房代償性擴張肥大——肺淤血——肺動脈高壓——右心室肥大——右房、大循環(huán)淤血

風(fēng)濕性心瓣膜病左房擴張左房擴張瓣膜硬化左室萎縮二尖瓣膜及腱索增厚變硬二尖瓣狹窄左心房擴張

Mitralinsufficiency

1.

thevalvularchanges2.thecardiacchanges3.theclinicalcourse

收縮期吹風(fēng)樣雜音

X線：球形心臟

AorticstenosisX線：靴形心

Aorticinsufficiency

脈壓差增大：水沖脈，血管槍擊音，毛細血管波動主動脈瓣關(guān)閉不全SubacuteInfectiveEndocarditisEtiologyandpathogenesisStreptococcusviridans（草綠色鏈球菌）局部感染灶，醫(yī)源性感染常常發(fā)生在有損傷的瓣膜發(fā)病機制：直接損傷—化膿性免疫損傷

MorphologyvegetationsVegetations(comparedwithrheumaticvalvulitis)

Large，yellowlocatedhaphazardly，

locatedatthemarginofthevalvecontainingcausativeorganismfriable亞急性細菌性心內(nèi)膜炎贅生物瓣膜病變ComplicationSepticemiaEmbolismImmuneinjury

Myocarditis1.Etiology2.Morphology

ViralmyocarditisBacterialmyocarditisIsolatedmyocarditis3.ClinicalcourseTheinterstitiallymphocyticinfiltrationischaracteristicforaviralmyocarditis.

PrimarycardiomyopathyAnydysfunctionofthemyocardiumnotattributabletoCHD，valvulardisease，hypertensionorpulmonaryheartdisease.

Dilatedcardiomyopathy

Hypertrophy(M>350gF>300g)DilatationofthefourcavitiesHeartfailurethecardiomyopathydemonstrateshypertrophyofmyocardialfibersalongwithinterstitialfibrosis.Hereisalarge,dilatedleftventricletypicalofadilated,orcongestive,cardiomyopathy.Hypertrophic

cardiomyopathyHypertrophyofthemyocardiumAsymmetrichypertrophyoftheventricularseptumObstructionoftheoutflowtractThereismarkedleftventricularhypertrophy,withasymmetricbulgingofaverylargeinterventricularseptumintotheleftventricularchamber.Thisishypertrophic

cardiomyopathy.Restrictivecardiomyopathyprogressi