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Chapter8:DISEASESOFCARDIOVASCULARSYSTEMDepartmentofPathologyTJMC,HUSTWangGuoping08心血管系統(tǒng)疾病ContentsSection1AtherosclerosisSection2CoronaryASandCHDSection3HypertensionSection4AneurysmSection5RheumatismSection6InfectiveendocarditisSection7ValvularVitiumoftheheartSection8Others08心血管系統(tǒng)疾病動(dòng)脈粥樣硬化Atherosclerosis,AS冠狀動(dòng)脈AS及冠心病CoronaryAS&CHD高血壓病Hypertension動(dòng)脈瘤Aneurysm風(fēng)濕病Rheumatism感染性心內(nèi)膜炎InfectiveEndocarditis慢性心瓣膜病Chronicvalvularvitium心肌病Cardiomyopathy心肌炎Myocarditis、心包炎Pericarditis先天性心臟病
Congenitalheartdisease08心血管系統(tǒng)疾病ATHEROSCLEROSIS
(AS)Arteriosclerosishardeningofthearteriesthickeningandlossofelasticityofarterialwalls
threeforms:
AtherosclerosisM?nckebergmedialcalcificsclerosisArteriolosclerosis08心血管系統(tǒng)疾病ATHEROSCLEROSIS
(AS)
Characterizedby:Intimallesionscalledatheroma,oratheromatousorfibrofattyplaques.08心血管系統(tǒng)疾病
Characterizedby:2.Theyprotrudeintoandobstructvascularlumina,weakentheunderlyingmedia,andmayundergoseriouscomplications.08心血管系統(tǒng)疾病
Characterizedby:3.ASaffects
elasticarteries(aorta,carotid,andiliacarteries)andlargeandmedium-sizedmusculararteries(coronaryandpoplitealarteries)08心血管系統(tǒng)疾病ETIOLOGY&PATHOGENESISRiskFactors:
hyperlipidemia
hypertension
cigarettesmoking
diabetesmellitus
hyperhomocystinemia
others:age,sexandgenetics08心血管系統(tǒng)疾病ETIOLOGY&PATHOGENESIS2.Responsetoinjuryhypothesis:
08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病EndothelialDysfunctioninAtherosclerosis.RussellRoss,NEnglJMed1999;340(2):08心血管系統(tǒng)疾病Fatty-StreakFormationinAtherosclerosis.08心血管系統(tǒng)疾病FormationofanAdvanced,ComplicatedLesionofAtherosclerosis.08心血管系統(tǒng)疾病
UnstableFibrousPlaquesinAtherosclerosis.08心血管系統(tǒng)疾病TheRoleofMCP-1inAtherosclerosisMCP-1releasedbyVSMCs,ECsandmacrophagespromotestherecruitmentofmonocytesandmacrophagestothesubendothelialcelllayer.Depositionoflipidswithinthesemonocytesandmacrophagesthenleadstodevelopmentofatheroscleroticlesions.EC08心血管系統(tǒng)疾病MORPHOLOGY(pathologicchanges)
1.脂紋(fattystreak)
2.纖維斑塊(fibrousplaque)
3.粥樣斑塊(atheromatousplaque)
粥瘤(atheroma)
4.復(fù)合病變(complicatedlesions)一、基本病變08心血管系統(tǒng)疾病脂紋(模式圖)fattystreak08心血管系統(tǒng)疾病脂紋fattystreak08心血管系統(tǒng)疾病SMCsmigrateintointimaproliferation、productionofEM(collagen,elasticfibers,andproteoglycans)FibrousCapFC,SMC,LDL,MC,LCFibrous
plaqueFibrouscapLipids,celldebris,cholesterolcrystals,calcification、granulationtissue、LCFCnecrosisAtheroma08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病complicatedlesions1.
Hemorrhageintoaplaque
08心血管系統(tǒng)疾病complicatedlesions2.
Rupture,ulcerationorerosionofatheroma08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病complicatedlesions3.
Thrombosis
08心血管系統(tǒng)疾病complicatedlesions4.
Calcification
5.Aneurysm
08心血管系統(tǒng)疾病二、主要?jiǎng)用}的病變Aorta:
Site:posteriorwallofaorta
ostiaofmajorbranches
Severity:abdominalA-thoracicA-ascendingA
aneurysm:abdominalA08心血管系統(tǒng)疾病Coronaryartery:Carotid:Internalcarotid(atthebeginning)
Arteryinbrain:BasilarA,MiddlecerebralA
CircleofWillis
Aneurysm:circleofWillis
Atrophy,Softeningofbrain、
hemorrhages08心血管系統(tǒng)疾病RenalA:
Hypertension、infarct、
AScontractedkidneyArteryofextremity:intermittentclaudication
drygangreneofthelegsMesentericA:Infarct08心血管系統(tǒng)疾病Coronaryatherosclerosis&Coronaryartery(heart)disease一、Coronaryatherosclerosis08心血管系統(tǒng)疾病1.20-50Y,menaremorecommonly,northaswell。2.Thefrequence:leftanteriordescending
rightcoronaryartery
leftcircumflexcoronaryartery
3.ASplaque斑塊多位于血管的心肌側(cè),crescentic08心血管系統(tǒng)疾病Hereisacoronaryarterywithatheroscleroticplaques.There
ishemorrhageintotheplaqueinthemiddleofthisphotograph.Thisisoneofthecomplicationsofatherosclerosis.Suchhemorrhagecouldacutelynarrowthelumen08心血管系統(tǒng)疾病二、冠狀動(dòng)脈粥樣硬化性心臟?。╟oronaryatheroscleroticheartdisease)
冠狀動(dòng)脈性心臟?。╟oronaryheartdisease,CHD)
缺血性心臟?。╥schemicheartdisease,IHD)
冠狀動(dòng)脈粥樣硬化性心臟病(coronaryatheroscleroticheartdisease)08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病coronaryatheroscleroticheartdisease(A)anginapectoris(B)myocardialinfarction(C)myocardialfibrosis(D)suddencoronarydeath08心血管系統(tǒng)疾病(一)anginapectorisCoronaryAOxygendemandnarrowingMyocardialischemia(transient)Thechestpainisdescribedasconstricting,squeezing,choking,orknifelike.持續(xù)數(shù)分鐘,可緩解08心血管系統(tǒng)疾病(二)myocardialinfarctionCoronaryAthrombosisIschemia(permanent)necrosisSevereandsustainedprecordialchestpaincannotberelievedbyrestornitroglycerincompletely.08心血管系統(tǒng)疾病SubendocardialMI(心內(nèi)膜下心肌梗死)1.
Restrictedtotheinneronethirdoftheventricularwall
2.Necrosis:multifocalandsmall
3.diffusestenosingcoronaryatherosclerosisandreductionofcoronaryflowbutneitherplaquedisruptionnorsuperimposedthrombosis.08心血管系統(tǒng)疾病4.狹窄+誘因,加重了冠狀A(yù)供血不足,
造成各冠狀A(yù)支最末梢區(qū)域(心內(nèi)膜下心?。?/p>
缺氧,側(cè)枝循環(huán)不能建立,導(dǎo)致廣泛的多灶
性的心內(nèi)膜下MI08心血管系統(tǒng)疾病透壁性心肌梗死
transmuralMIinvolvesthefullornearlyfullthicknessoftheventricularwalllocatesinthedistributionofasinglecoronaryarteryusuallyassociatedwithtotalthromboticocclusioninducedbyacuteplaquechangetransmuralandlarge08心血管系統(tǒng)疾病PathologicchangeswithMI:1.6h內(nèi)nochangesongrossexamination,
microfewwavyfiberatmarginofMI3.第4天contractionbands2.6h后grossexamcolor
microcoagulationnecrosis
4.第7天granulationtissue;5.第2-8weeks,organizationanddensescartissue08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病Laboratory:GOT、GPT、CPK、LDH08心血管系統(tǒng)疾病ImportantComplications:PapillarymuscledysfunctionVentricularaneurysmMuralthrombi:potentialsourcesforsystemicemboliRuptureofinfarctAcutepericarditis08心血管系統(tǒng)疾病Ruptureofanecroticpapillarymuscle,
resultingintheacuteonsetofseveremitralregurgitation08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病Muralthrombus08心血管系統(tǒng)疾病08心血管系統(tǒng)疾?。ㄈ┬募±w維化
myocardialfibrosislong-termorrepetitiveandaggravatedischemicmyocardialinjurycausedbymoderatetoseverestenosingcoronaryAS心肌纖維持續(xù)性、加重性缺血缺氧Necrosisandproliferation鏡下:extensiveandmultifocalmyocardialfibrosis,atrophyandhypertrophy,08心血管系統(tǒng)疾?。ㄋ模┕跔顒?dòng)脈性猝死
suddencoronarydeath(1)Definitionunexpecteddeathfromcardiaccausesearlyafterorwithouttheonsetofsymptoms.(2)CausemarkedstenosingcoronaryASwithacuteplaquedisruption(3)Mechanismlethalarrhythmia08心血管系統(tǒng)疾病HYPERTENSION是以體循環(huán)動(dòng)脈血壓持續(xù)高于正常水平為主要表現(xiàn)的疾病血壓水平的定義和分類(WHO/ISH)分類收縮壓(mmHg)舒張壓(mmHg)理想血壓﹤120﹤80正常血壓﹤130﹤85正常高值130~13985~89一級(jí)高血壓(輕度)140~15990~99二級(jí)高血壓(中度)160~179100~109三級(jí)高血壓(重度)≥180≥11008心血管系統(tǒng)疾病原發(fā)性高血壓primaryhypertension高血壓病:細(xì)小動(dòng)脈硬化的基本病變的
全身性疾病繼發(fā)性高血壓secondaryhypertension08心血管系統(tǒng)疾病EtiologyandMechanismsEtiology
geneticpredisposition
others:environmentalfactors2.Machanisms
bloodvolume:
totalperipheralresistance:08心血管系統(tǒng)疾病Pathologicchangesofbenignhypertension(90%-95%ofcases)FunctionaldisturbanceVasculatureinjuryOrganinjury08心血管系統(tǒng)疾?。?)Functionaldisturbanceintermittentspasmofsystemicarteriolesaccompaniedwithdisturbanceofhigh-gradeneuralfunction;fluctuationofbloodpressure08心血管系統(tǒng)疾?。?)VasculatureinjuryArteriolosclerosisArteriolesarethesmallestbranchesofthearterieswithonly1or2smoothmusclecelllayersinmedia,generally20to100
mindiameter.eg.afferentarterioleoftheglomerulus,retinalartery,spleniccentralartery.08心血管系統(tǒng)疾病LeakageofplasmacomponentsacrossvascularendotheliumIncreasingECMproductionbysmoothmusclecells(SMCs)ApoptosisofSMCs
HyalinedegenerationofthewallLossofunderlyingstructuraldetailWallthickeningandlumennarrowing08心血管系統(tǒng)疾病Renalarteriolosclerosis:
homogenous,pinkandhyalinedepositionwithinthewall08心血管系統(tǒng)疾病Renalarteriolosclerosis08心血管系統(tǒng)疾病MuscularorsmallarteriesFibroelastichyperplasia:increasedmyofibroblastictissueintheintima,destructionofinternalelasticmembrane;medialSMCsproliferationandhypertrophywithreduplicationoftheelasticlaminawallthickeningandlumennarrowinglargeorelasticarteries08心血管系統(tǒng)疾?。?)OrganinjuryHeart(hypertensiveheartdisease)concentrichypertrophyeccentrichypertrophy08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病Concentrichypertrophy
08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病MorphologyofthekidneyGrossappearanceprimarygranulo-contractedkidney:symmetricallycontracted;decreasedinsizeandweight;hardened;fine,leatherygranularityofthesurface;onsection,corticalnarrowing08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病Histologicexamination:Hyalinearteriolosclerosis,FibroelastichyperplasiaFocioftubularatrophyandinterstitialfibrosis,Glomerularhyalinizationandperiglomerularfibrosis;Hypertrophyoftheremainingcompensatednephrons08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病Morphologyofthebrain①cerebraledemahypertensiveencephalopathyhypertensivecrisis②cerebralsofteningmicroinfarct(lacunarinfarct)③cerebralhemorrhagelargefatalmicroaneurysmslithemorrhages08心血管系統(tǒng)疾病Bloodsupplyofthebrain08心血管系統(tǒng)疾病Cerebralhemorrhagerupturingintothelateralventricles08心血管系統(tǒng)疾病MorphologyoftheretinaIncreasedinthearteriolarlightreflexArteriolar-venularcrossingdefects(arteriovenousnicking)Retinalhemorrhages,exudatesandpapilledema.08心血管系統(tǒng)疾病AcceleratedHypertensionGrossinspection:“flea-bitten”appearancesmall,pinpointpetechialhemorrhagesonthecorticalsurface08心血管系統(tǒng)疾病Histologicalterations:Fibrinoidnecrosisofarterioles(necrotizingarteriolitis)Eosinophilicgranularchangeinthewall08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病動(dòng)脈瘤
Aneurysm動(dòng)脈瘤:心、血管壁局限性異常擴(kuò)張或連通于血管腔的血囊腫。由于常見(jiàn)于動(dòng)脈血管,因而稱動(dòng)脈瘤。動(dòng)脈瘤:
1.真性動(dòng)脈瘤trueaneurysm
2.假性動(dòng)脈瘤falseaneurysm
3.夾層動(dòng)脈瘤dissectinganeurysm(血液進(jìn)入動(dòng)脈中膜)08心血管系統(tǒng)疾病RHEUMATISMAnimmunologicallymediateddisease,relatedtoanepisodeofgroupA(β-hemolytic)streptococcalpharyngitis.Multisysteminflammatorydisease,heartandjointsarefavoredsites.Rheumaticfever,acuterheumaticcarditisRepetitiveattacksleadtochronicvalvulardeformitiesThepathologicfeatureisAschoffbodies.08心血管系統(tǒng)疾病Mechnism:
CrossReact:Ag-Ab
鏈球菌C抗原---CT的糖蛋白
鏈球菌M抗原---平滑肌08心血管系統(tǒng)疾病(1)alterationandexudationserous,fibrinousexudate,andleukocytesinfiltration,mucoiddegenerationandfibrinoidnecrosis.
outcomes:completeresolution,fibrosis,granulomas.ESSENTIALMORPHOLOGY08心血管系統(tǒng)疾病(2)ProliferationorgranulomasHallmark:
Aschoffbodies
fibrinoidnecrosis,AnitschkowcellsAschoffgiantcellslymphocytesplasmacells08心血管系統(tǒng)疾病Aschoffbody08心血管系統(tǒng)疾病Aschoffbodies08心血管系統(tǒng)疾病(3)FibrosisAschoffbodiesspindlescar08心血管系統(tǒng)疾病MorphologyofmajororgansRheumaticheartdiseaseRheumaticarthritis08心血管系統(tǒng)疾病Rheumaticendocarditissites:mitralandaorticvalvesFibrinoidnecrosisVegetations:small,warty,alongthelineofclosure08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病PrecipitationoffibrinOrganization,fibrosisthickening,shortening,commissuralfusionofleafletsandtendinouscord08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病RheumaticmyocarditisPerivascularAschoffbody08心血管系統(tǒng)疾病RheumaticpericarditisSerousexudatepericardialeffusionFibrinousexudatecorvillosumconstrictivepericarditis08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病RheumaticarthritisSerousinflammationCompleteresolutionLargejoints:migratoryLocalsigns:arthralgiaSelf-limited,nochronicdeformity08心血管系統(tǒng)疾病RheumaticarteritisOfteninvolvessmallarteries,FibrinoidnecrosisMononuclearinfiltrationAschoffbodiesFibrosisLumennarrowing08心血管系統(tǒng)疾病CNSchangesRheumaticarteritis,SubcorticalencephalitisMinorchorea/Sydenhamchorea(aneurologicdisorderwithinvoluntarypurposeless,rapidmovements)08心血管系統(tǒng)疾病感染性心內(nèi)膜炎
Infectiveendocarditis病原微生物直接侵襲心內(nèi)膜特別是心瓣膜而引起的心內(nèi)膜炎急性感染性心內(nèi)膜炎亞急性感染性心內(nèi)膜炎08心血管系統(tǒng)疾病急性感染性心內(nèi)膜炎病原:致病力強(qiáng)的化膿菌:金黃色葡萄球菌、溶血性鏈球菌、肺炎球菌心瓣膜:發(fā)生在原來(lái)無(wú)病變的正常心內(nèi)膜主要累及二尖瓣、主動(dòng)脈瓣臨床上:起病急,發(fā)展快,病程短,死亡率高08心血管系統(tǒng)疾病亞急性感染性心內(nèi)膜炎病原:致病力較小病原微生物:草綠色鏈球菌,腸球菌,真菌等。心瓣膜:發(fā)生在原來(lái)有病變的心內(nèi)膜主要累及二尖瓣、主動(dòng)脈瓣菜花狀或息肉狀疣狀贅生物:纖維素、血小板、NC、壞死物細(xì)菌團(tuán)血管:動(dòng)脈栓塞和血管炎;腎:微栓塞致灶性腎小球腎炎。臨床上:病程長(zhǎng),數(shù)月或1年08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病08心血管系統(tǒng)疾病CARDIOMYOPATHYHeartdiseaseresultingfromaprimaryabnormalityinthemyocardium,ofunknowncause.Threeclinical,functional,andpathologicpatterns08心血管系統(tǒng)疾病1.Dilated(congestive)cardiomyopathyprogressivecardiachypertrophy,dilation,andcontractile(systolic)dysfunction.08心血管系統(tǒng)疾病Heart:heavy,large,andflabby,withdilationofallchambersandthewallthinning,muralthrombi,functionalmitralortricuspidregurgitation.08心血管系統(tǒng)疾病Histologicchanges:nonspecific,hypertrophiedmusclecellswithenlargednuclei,attenuatedorstreched,interstitialandendocardialfibrosis.08心血管系統(tǒng)疾病2.HypertrophiccardiomyopathyMyocardialhypertrophy,abnormaldiastolicfilling,andintermittentleftventricularoutflowobstruction.Morphology:Heart:heavy,muscular,andhypercontracting,massivemyocardialhypertrophywithoutventriculardilation(asymmetricseptalhypertrophy),endocardialthickeningormuralplaqueformation.08心血管系統(tǒng)疾病Hypertrophiccardiomyopathy08心血管系統(tǒng)疾病Hypertrophiccardiomyopathy(disarrayoffiber
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