CVS Pathology

Question 1

Definition of hypertension and malignant hypertension

Answer 1

Hypertension: sustained SBP > 140mmHg / DBP > 90 mmHg
Malignant hypertension: rapid BP rise, sustained SBP > 200 mmHg / DBP > 120 mmHg

Question 2

How much % of hypertension is primary / essential?

Answer 2

95%

Question 3

Secondary hypertension causes (3+5+3)

Answer 3

Renal: RAS, renal parenchymal disease, chronic renal disease

Endocrine: Primary hyperaldosteronism, Cushing syndrome, Acromegaly, Hyper- / Hypo-thyroidism, Phaeochromocytoma

Neurologic: ↑ ICP, OSA, acute stress

Question 4

Risk factors for atherosclerosis (4+10)

Answer 4

Non-modifiable: male / post-menopausal female, elderly, familial hypercholesterolaemia, homocystinuria

Modifiable: hypercholesterolaemia, smoking, DM, HT, ↑ CRP, lipoprotein (a), physical inactivity, obesity, stress, infection

Question 5

3 stages of atherosclerosis

Answer 5

1. Fatty streaks
2. Atheromatous plaque
3. Complicated atheroma

Question 6

Which histological layer is fatty streak deposited within? What is the cell that can be found in fatty streak?

Answer 6

tunica intima
lipid-filled foamy macrophages

Question 7

2 parts of atheromatous plaque

Answer 7

fibrous cap + necrotic core

Question 8

Difference between unstable atheroma and stable atheroma histologically (4)

Answer 8

thinner fibrous cap, larger lipid core, fewer SMC, ↑ inflammation

Question 9

Pathogenesis of atherosclerosis

Answer 9

endotheilal injury + turbulent blood flow –> accumulation of lipoproteins –> monocytes and platelets adhere to endothelium –> monocytes migrate into intima –> differentiate into macrophages and foam cells

release cytokines and growth factors by platelets, macrophages, vascular wall cells –> SMC proliferate and migrate to intima

SMC, macrophages release cytokines –> produce ECM

Question 10

Complications of complicated atheroma (3) (explain)

Answer 10

Acute plaque change
a. rupture: exposed necrotic core –> thrombus formation
b. haemorrhage into plaque –> volume expansion

Atheroembolism
- ruptured plaques –> discharge debris into blood –> microemboli

Aneurysm

Question 11

In aneurysm, which layer of the blood vessel is weakened?

Answer 11

tunica media

Question 12

Pathogenesis of aneurysm (3)

Answer 12

1. inadequate / abnormal connective tissue synthesis
2. excessive connective tissue degradation
   (e.g. proteolytic enzymes by macrophages in atherosclerotic plaque)
3. loss of SMCs
   a. atherosclerosis –> ↑ diffusion distance –> ischaemia of inner media
   b. systemic hypertension –> luminal narrowing of vasa vasorum –> ischaemia of outer media

Question 13

Pathology of aneurysm

Answer 13

cystic medial degeneration

Question 14

Complications of AAA (4)

Answer 14

1. occlusion of vessel branching off the aorta –> ischaemia of organs
2. impingement on adjacent structures (e.g. ureter, vertebrae)
3. Thromboembolism
4. rupture –> fatal haemorrhage

Question 15

Relationship of diameter and annual rupture risk of AAA

Answer 15

<4cm: almost never
4~5cm: 1%
5~6cm: 10%
>6cm: 25%

Question 16

What is aortic dissection?

Answer 16

tear in tunica intima –> blood dissects into tunica media

Question 17

Which type of aortic dissection has a higher mortality? How much?

Answer 17

Type A
70%

Question 18

Immune-mediated vasculitis (2+4+3)

Answer 18

Giant cell arteritis
Takayasu arteritis

Polyarteritis nodosa
Kawasaki disease
Wegener’s granulomatosis
Churg-Strauss syndrome

Microscopic polyangiitis
Buerger disease
Behcet disease

Question 19

Which vasculitis involves granuloma formation? (4)

Answer 19

giant cell arteritis, Takayasu arteritis, Wegener’s granulomatosis, Churg-Strauss syndrome

Question 20

Which vasculitis is related to ANCA?

Answer 20

c-ANCA: Wegener’s granulomatosis
p-ANCA: Churg-Strauss syndrome, microscopic polyangiitis

Question 21

Which vasculitis is related to viral Ag IC deposition? (Which virus most common?)

Answer 21

Polyarteritis nodosa
HBV

Question 22

Which vasculitis is found in kids and is associated with coronary artery aneurysm?

Answer 22

Kawasaki disease

Question 23

Which vasculitis is also called pulseless disease and is commonly found in aorta?

Answer 23

Takayasu arteritis

Question 24

Which vasculitis is related to asthma?

Answer 24

Churg-Strauss syndrome

Question 25

Which vasculitis is associated with young smokers and peripheral vascular disease?

Answer 25

Buerger disease

Question 26

Which vasculitis is associated with orogenital ulcers?

Answer 26

Behcet's disease

Question 27

Which vasculitis is commonly found on temporal artery and ophthalmic artery?

Answer 27

Giant cell arteritis

Question 28

Which vasculitis is almost always spared from pulmonary circulation?

Answer 28

Polyarteritis nodosa

Question 29

Morphology change in myocardial infarction

Answer 29

Gross: pallor --> mottling --> yellow centre with hyperaemic border --> grey fibrous scar LM: coagulative necrosis, oedema, wavy fibres --> hypereosionophilic myocytes --> loss of nuclei & striations, neutrophil infiltrate, microscopic haemorrhage --> infiltration of lymphocytes, fibroblasts, macrophages --> organising granulatous tissue —> fibrosis

Question 30

What is Dressler syndrome?

Answer 30

postmyocardial infarction pericarditis

Question 31

Complications of MI (8)

Answer 31

Arrhythmia --> SCD CHF Ventricular aneurysm Pericarditis Mural thrombosis MR Left-to-right shunt Cardiac tamponade

Question 32

Pathogenesis of reperfusion injury (2)

Answer 32

- reoxygenation --> ROS --> sarcolemmal injury --> ↑ Ca2+ --> myocyte hypercontration --> cell death - ↑ WBCs --> capillary occlusions

Question 33

Diagnosis of systemic hypertensive heart disease

Answer 33

LVH + evidence of HT in other organs

Question 34

MC cardiomyopathy

Answer 34

dilated cardiomyopathy

Question 35

Aetiology of dilated cardiomyopathy (5)

Answer 35

- genetics / idiopathic - previous myocarditis - pregnancy - haemochromatosis (secondary) - toxin (alcohol, cocaine, catecholamines...)

Question 36

MC cause of death in young athletes (What is the aetiology?)

Answer 36

hypertrophic cardiomyopathy (genetic mutation)

Question 37

What is Loeffler endomyocarditis? (Treatment)

Answer 37

restrictive cardiomyopathy caused by parasitic infection, mostly found in Africa Treatment: TKI

Question 38

MC cause of restrictive cardiomyopathy

Answer 38

amyloidosis

Question 39

What is the cardiomyopathy caused by defected desmosomal proteins?

Answer 39

Arrhythmogenic RV cardiomyopathy

Question 40

Causes of aortic regurgitation

Answer 40

organic: - IE - degeneration - chronic RHD - subacute IE functional: - aortic dissection - aortic root dilatation

Question 41

Causes of aortic root dilatation

Answer 41

aortitis (syphilis, Takayasu arteritis, ankylosing spondylitis, psoriasis...) Marfan's syndrome hypertension, atherosclerosis

Question 42

Causes of aortic stenosis

Answer 42

[<60y] Chronic RHD, congenital [60~75y] Bicuspid aortic valve [>75y] Degenerative calcification

Question 43

Causes of mitral regurgitation

Answer 43

Organic: - IE - MVP - chronic RHD - subacute IE Functional: - MI, trauma - LV dilatation (e.g. myocarditis, DCM)

Question 44

Causes of mitral stenosis

Answer 44

chronic RHD congenital stenosis

Question 45

Causes of tricuspid regurgitation

Answer 45

- pulmonary HT - L. ventricular disease - IE - chronic RHD - complication of pacemaker insertion - carcinoid syndrome

Question 46

Diagnosis of acute rheumatic fever

Answer 46

Jones' criteria - migratory polyarthritis - pancarditis - subcutaneous nodules - erythema mariginatum - chorea (2 out of 5)

Question 47

Diagnosis of infective endocarditis

Answer 47

Duke criteria (BE TIMER) (2 or 1+3 or 0+5) Major: - blood culture (typical organisms from 2 separate blood cultures) - echocardiogram findings Minor: - temperature (fever) - immunologic phenomena - microbiological evidence - embolic phenomena - risk factor (predisposing conditions)

Question 48

Usual precursor of non-bacterial thrombotic endocarditis

Answer 48

hypercoagulable state

Question 49

What is the Libman-Sacks endocarditis?

Answer 49

endocarditis in SLE

Question 50

Aetiology of pericarditis (4)

Answer 50

Infection, post-MI, uraemia, drugs