心血管系統(tǒng)疾病課件

Chapter8：DISEASESOFCARDIOVASCULARSYSTEMDepartmentofPathologyTJMC,HUSTWangGuoping08心血管系統(tǒng)疾病ContentsSection1AtherosclerosisSection2CoronaryASandCHDSection3HypertensionSection4AneurysmSection5RheumatismSection6InfectiveendocarditisSection7ValvularVitiumoftheheartSection8Others08心血管系統(tǒng)疾病動脈粥樣硬化Atherosclerosis,AS冠狀動脈AS及冠心病CoronaryAS&CHD高血壓病Hypertension動脈瘤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、主要動脈的病變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、冠狀動脈粥樣硬化性心臟?。╟oronaryatheroscleroticheartdisease）

冠狀動脈性心臟病（coronaryheartdisease,CHD）

缺血性心臟?。╥schemicheartdisease,IHD）

冠狀動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?。ǘ﹎yocardialinfarctionCoronaryAthrombosisIschemia(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┕跔顒用}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130~13985~89一級高血壓（輕度）140~15990~99二級高血壓（中度）160~179100~109三級高血壓（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)疾病（1）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)疾病（3）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)疾病動脈瘤

Aneurysm動脈瘤：心、血管壁局限性異常擴(kuò)張或連通于血管腔的血囊腫。由于常見于動脈血管，因而稱動脈瘤。動脈瘤：

1.真性動脈瘤trueaneurysm

2.假性動脈瘤falseaneurysm

3.夾層動脈瘤dissectinganeurysm(血液進(jìn)入動脈中膜)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)生在原來無病變的正常心內(nèi)膜主要累及二尖瓣、主動脈瓣臨床上：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)生在原來有病變的心內(nèi)膜主要累及二尖瓣、主動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，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