Histopathology and cytologyHistopathology and cytology

((MLHC-201MLHC-201))

Faculty of allied medical Faculty of allied medical sciencessciences

PATHOLOGY OF THE PATHOLOGY OF THE CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

DISEASES OF THEDISEASES OF THE

HEARTHEART

SupervisionSupervision::

Prof.Dr. Noha RagabProf.Dr. Noha Ragab

By the end of this lecture, the student By the end of this lecture, the student will be able to know:will be able to know:

1-Definition, types and diagnosis of 1-Definition, types and diagnosis of rheumatic fever.rheumatic fever.

2-Type and causes of heart failure.2-Type and causes of heart failure.

Outcomes:

Normal Heart AnatomyNormal Heart Anatomy

Rheumatic Fever (RF)Rheumatic Fever (RF)

Definition:Definition: Rheumatic fever (RF) is an Rheumatic fever (RF) is an

autoimmune disease affecting the autoimmune disease affecting the heart and extra- cardiac sites (joints, heart and extra- cardiac sites (joints, brain, skin and others)brain, skin and others)

The incidence of RF has been The incidence of RF has been lowered in the developed countries lowered in the developed countries but is still high in poor communitiesbut is still high in poor communities

The disease affects children and The disease affects children and young adults (5-15years)young adults (5-15years)

The disease follows upper respiratory The disease follows upper respiratory infection (tonsillitis) with Group A infection (tonsillitis) with Group A Beta hemolytic streptococciBeta hemolytic streptococci

Theories of Pathogenesis:Theories of Pathogenesis:

Toxic products of streptococci Toxic products of streptococci Sensitized T-lymphocytes may lead to Sensitized T-lymphocytes may lead to

cardiac injury cardiac injury

JONES' CRITERIA FOR JONES' CRITERIA FOR DIAGNOSIS OF RF:DIAGNOSIS OF RF:

Major Major ManifestationsManifestations Carditis (friction rub, Carditis (friction rub,

murmur, cardiomegaly, murmur, cardiomegaly, Chronic Heart Failure Chronic Heart Failure (CHF) (CHF)

Arthritis (migratory Arthritis (migratory polyarthritis, swollen, polyarthritis, swollen, red, tender) red, tender)

Chorea Chorea Subcutaneous nodules Subcutaneous nodules Erythema marginatumErythema marginatum

Minor Minor ManifestationsManifestations Clinical Clinical

Fever Fever Arthralgia Arthralgia History of rheumatic History of rheumatic

fever or rheumatic fever or rheumatic heart disease heart disease

Laboratory Laboratory Acute phase reactants Acute phase reactants

(ESR, C-reactive (ESR, C-reactive protein, leukocytosis) protein, leukocytosis)

Prolonged P-R interval Prolonged P-R interval on ECGon ECG

PATHOLOGY OF RHEUMATIC FEVERPATHOLOGY OF RHEUMATIC FEVER Cardiac Disease (Rheumatic heart Cardiac Disease (Rheumatic heart

disease)disease) Extra-Cardiac DiseaseExtra-Cardiac Disease

RHEUMATIC HEART RHEUMATIC HEART DISEASEDISEASE

Rheumatic heart disease: all the Rheumatic heart disease: all the heart layers are affected heart layers are affected (pancarditis)(pancarditis)

1.1. Rheumatic myocarditisRheumatic myocarditis

2.2. Rheumatic pericarditisRheumatic pericarditis

3.3. Rheumatic endocarditisRheumatic endocarditis

11 - -Rheumatic myocarditisRheumatic myocarditis::

Acute phaseAcute phase:: it is characterized by the development of it is characterized by the development of pathognomonic lesions called pathognomonic lesions called AschoffAschoff’’s Bodiess Bodies within within the myocardium.the myocardium.

Gross featuresGross features:: Aschoff bodies are multiple tiny nodules (1-2 mm in Aschoff bodies are multiple tiny nodules (1-2 mm in

diameter)diameter)

Microscopic features:Microscopic features: Aschoff body is a lesion composed of:Aschoff body is a lesion composed of:

Fibrinoid necrosis ( destroyed fragmented collagen)Fibrinoid necrosis ( destroyed fragmented collagen) Surrounded by lymphocytes and histiocytes &Surrounded by lymphocytes and histiocytes & Aschoff cells (large mononuclear or multinuclear Aschoff cells (large mononuclear or multinuclear

macrophages)macrophages)

Aschoff’s bodyAschoff’s body

Blood vessel fibrinoid degeneration

Aschoff cells

Chronic phaseChronic phase:: Over years or decades the Aschoff Over years or decades the Aschoff

bodies undergo fibrous scarringbodies undergo fibrous scarring

22 - -Rheumatic PericarditisRheumatic Pericarditis : :

Acute phaseAcute phase: Aschoff bodies are formed : Aschoff bodies are formed accompanied by serofibrinous accompanied by serofibrinous inflammation.inflammation.

Chronic phaseChronic phase: Fibrosis and adhesions : Fibrosis and adhesions may occur between the visceral and the may occur between the visceral and the parietal layers of the pericardiumparietal layers of the pericardium

33 - -Rheumatic EndocarditisRheumatic Endocarditis::

It affects both mural and valvular It affects both mural and valvular endocardiumendocardium

1.1. Mural EndocardiumMural Endocardium: : i- i- Acute phaseAcute phase: Aschoff bodies develop in : Aschoff bodies develop in

the endocardiumthe endocardium ii- ii- Chronic phaseChronic phase: healing results in a : healing results in a

white patch white patch

Valvular EndocardiumValvular Endocardium

Vegetations (thrombi) develop at the Vegetations (thrombi) develop at the lines of contact of the cusps causing lines of contact of the cusps causing friction of the swollen cusps.friction of the swollen cusps.

Rheumatic Mitral ValveRheumatic Mitral Valve

Small vegetations are formed at injured parts

CHRONIC RHEUMATIC CHRONIC RHEUMATIC VALVULAR DISEASEVALVULAR DISEASE

Mitral & Aortic Valves PathologyMitral & Aortic Valves Pathology:: Thickening of valve leaflet, especially Thickening of valve leaflet, especially

along the lines of closure along the lines of closure Fusion of commissures Fusion of commissures Result is mitral or aortic stenosis, Result is mitral or aortic stenosis,

insufficiency, or bothinsufficiency, or both

Rheumatic Mitral StenosisRheumatic Mitral Stenosis

Thick valve leaflet

Fusion of commisures

EXTRACARDIAC LESIONS OF RHEUMATIC FEVEREXTRACARDIAC LESIONS OF RHEUMATIC FEVER

JointsJoints:: Rheumatic arthritis affect the large joints in a Rheumatic arthritis affect the large joints in a fleeting way i.e joint inflammation is followed by joint fleeting way i.e joint inflammation is followed by joint resolution, then another joint become inflamed followed by resolution, then another joint become inflamed followed by resolution and so on. The affected joint is painful, tender, resolution and so on. The affected joint is painful, tender, hot & swollen. Microscopically: it shows congestion, hot & swollen. Microscopically: it shows congestion, oedema, lymphocytes, plasma cells and macrophages.oedema, lymphocytes, plasma cells and macrophages.

BrainBrain:: Rheumatic chorea (rapid involuntary purposeless Rheumatic chorea (rapid involuntary purposeless movements); it is due to inflammation of the basal ganglia. movements); it is due to inflammation of the basal ganglia. The condition is reversibleThe condition is reversible

SkinSkin:: Rheumatic subcutaneous nodules occur over bony Rheumatic subcutaneous nodules occur over bony prominences and their structure is similar to the Aschoff prominences and their structure is similar to the Aschoff bodies.bodies.

Rheumatic arteritisRheumatic arteritis: affecting the coronaries, renal, : affecting the coronaries, renal, mesenteric and cerebral arteriesmesenteric and cerebral arteries

Pleurisy and peritonitisPleurisy and peritonitis: serofibrinous type: serofibrinous type

PERICARDIAL DISEASESPERICARDIAL DISEASES

I. PERICARDITISI. PERICARDITIS

Inflammation of the pericardiumInflammation of the pericardium CausesCauses

Myocardial Infarction (MI), Myocardial Infarction (MI), Staphylococcus, tumor, TB, uremia Staphylococcus, tumor, TB, uremia

II. II. PERICARDIAL EFFUSIONPERICARDIAL EFFUSION Serous fluid in pericardial sacSerous fluid in pericardial sac Usual cause: Chronic Heart Failure Usual cause: Chronic Heart Failure

III. HEMOPERICARDIUMIII. HEMOPERICARDIUM Myocardial rupture from MIMyocardial rupture from MI TraumaTrauma Bleeding from infection, tumor, etc.Bleeding from infection, tumor, etc. Haemorrhage from aortaHaemorrhage from aorta

Hemopericardium

IHDIHD-Ischaemic Heart -Ischaemic Heart DiseaseDisease::

Coronary Coronary ArteriesArteries

•Left Coronary A.•L.A.Descending•Left Circumflex

•Right Coronary A.

LCx

LAD

Ischaemic Heart DiseaseIschaemic Heart Disease

Common Health problem.Common Health problem. High Mortality & Morbidity. High Mortality & Morbidity. Etiology – common Atherosclerosis Etiology – common Atherosclerosis Two major types Angina & MI.Two major types Angina & MI. Risk factors – Risk factors –

HypertensionHypertension HypercholesterolemiaHypercholesterolemia DiabetesDiabetes Smoking, Life style, Diet, Genetic.Smoking, Life style, Diet, Genetic.

Patterns of Coronary Heart Patterns of Coronary Heart Disease:Disease:

Angina PectorisAngina Pectoris Acute Myocardial InfarctionAcute Myocardial Infarction Sudden cardiac deathSudden cardiac death

PathogenesisPathogenesis::

Obstruction to blood flow.Obstruction to blood flow. Atheroma, Thrombosis, Embolism Atheroma, Thrombosis, Embolism

Diminished coronary blood flow.Diminished coronary blood flow. Ischemia leads to Angina PectorisIschemia leads to Angina Pectoris Infarction leads to Coagulative Infarction leads to Coagulative

NecrosisNecrosis InflammationInflammation Granulation tissueGranulation tissue Fibrous scarring.Fibrous scarring.

Myocardial Infarction-MI

““Death of heart tissue due to lack of Death of heart tissue due to lack of blood supply”blood supply”

Atherosclerosis is the common cause.Atherosclerosis is the common cause. Coagulative necrosis – intact tissue Coagulative necrosis – intact tissue

shape.shape. Characterized by Severe chest pain, Characterized by Severe chest pain,

breathlessness & sweatingbreathlessness & sweating Complications: Shock, Death or Cardiac Complications: Shock, Death or Cardiac

failure.failure.

Normal MyocardiumNormal Myocardium::

MI 18-24 hr MI 18-24 hr loss of nucleus, loss of nucleus, coagulative necrosiscoagulative necrosis..

Laboratory DiagnosisLaboratory Diagnosis

LDHLDH Creatinine Kinase- IsoenzymesCreatinine Kinase- Isoenzymes TroponinsTroponins

ManagementManagement:: Aims at preventing Aims at preventing

complications.complications.

1.1. Rest & sedationRest & sedation

2.2. Supportive measuresSupportive measures

3.3. Thrombolytic agents - Thrombolytic agents - StreptokinaseStreptokinase

HEART FAILUREHEART FAILURE

Definition:Definition: Failure of the ventricles to pump Failure of the ventricles to pump

enough blood to meet the body enough blood to meet the body needsneeds

Types of heart failure:Types of heart failure: Acute heart failureAcute heart failure Chronic heart failureChronic heart failure

ACUTE HEART FAILUREACUTE HEART FAILURE

Eitiology:Eitiology: Acute myocardial infarction or Acute myocardial infarction or

myocarditismyocarditis Massive pulmonary embolismMassive pulmonary embolism hemopericardium hemopericardium heart compression heart compression

Complications:Complications: Acute congestion and edemaAcute congestion and edema

CHRONIC HEART FAILURECHRONIC HEART FAILURE

Pathogenesis:Pathogenesis:

I-Stage of compensation:I-Stage of compensation:The heart maintains adequate cardiac output The heart maintains adequate cardiac output

by:by:1-slight dilatation 1-slight dilatation stretch of myocardial fibers stretch of myocardial fibers

stronger contraction stronger contraction2-compensatory hypertrophy 2-compensatory hypertrophy stronger stronger

contractioncontraction3-increased heart rate3-increased heart rate

II- Stage of decompensation:II- Stage of decompensation:

Marked dilatation of the affected chamber Marked dilatation of the affected chamber & cardiac fatigue& cardiac fatigue

dilatation dilatation overstretching of muscle overstretching of muscle fibers fibers weak contraction of heart weak contraction of heart

CAUSES OF CHRONIC HEART FAILURECAUSES OF CHRONIC HEART FAILURE::

hypertensionhypertension coronary diseasecoronary disease valve diseases as aortic stenosis, aortic valve diseases as aortic stenosis, aortic

incompetence or mitral incompetenceincompetence or mitral incompetence congenital heart diseases as ASD &VSDcongenital heart diseases as ASD &VSD

Complete:1-Rheumatic fever (RF) is ………………………..2-Complications of myocardial infarction are……………3-Rheumatic arteritis affecting ………………4-Risk factors for Ischaemic Heart Disease are……….5- Stages of compensation in CHRONIC HEART FAILURE are……………….

QuestionsQuestions

AssignmentsMyocardial infarction احمد محمد احمد

الوكيل عبد محمد اسراءاحمد حسن اسماء

Heart failure الوهاب عبد محمد اسماءعاطف الزهيري

الكردي عرابي امال