1、病理生理心血管系统疾病病理生理心血管系统疾病Major Disorders of CVS Atherosclerosis Ischemic Heart Disease(IHD)Hypertension Rheumatic Heart Disease(RHD)Infective Endocarditis Valvular Heart Disease(VHD)2021/1/52Hypertension（HTN）高血压高血压 病病2021/1/53Hypertension，高血压病，高血压病2021/1/542021/1/55IntroductionA sustained diastolic pre
2、ssure 90 mmHg and/or a systolic pressure 140mmHg25%of general population,silent killer Chronic,end organ&vascular damageDisastrous late complicationsAtherosclerosis,IHD,Renal damage,Stroke2021/1/56Regulation of BPEndocrine Factors Renin,Angiotensin,ANP,ADH,AldosteroneNeural Factors Sympathetic&Paras
3、ympatheticBlood Volume Sodium,Mineralocorticoids Cardiac Factors Heart rate&Contractility2021/1/57Severity of HypertensionNormal 140 210 120Malignant Hypertension Rapid&Severe2021/1/58ClassificationPrimary or Essential HTN(95%)UnknownSecondary HTN(5-10%)Renal GN,Renin tumors Endocrine Cushing,Pheoch
4、romocytoma 2021/1/59Etiology 发病因素发病因素Genetic,familial Increased peripheral resistance stress,hormonal,neurallife style2021/1/510Benign HTN良性高血压病良性高血压病Accounts for 95%of the cases of HTNMild to moderate elevations in blood pressureAsymptomatic silent diseaseHyaline arteriolosclerosis2021/1/511Arterio
5、sclerosisAtherosclerosisLarge BVIntimaHyalineMnckeberg Medial SclerosisMedial BVAteriolosclerosisSmall BVFull ThicknessHyperplasticatheromaarteryarteriole细动脉硬化细动脉硬化动脉硬化动脉硬化动脉粥样硬化动脉粥样硬化动脉中层钙化动脉中层钙化2021/1/512Hyaline Arteriolosclerosis2021/1/513Hyaline Arteriolosclerosis2021/1/514Organ DamageHeart:conc
6、entric left ventricular hypertrophy eccentric left ventricular hypertrophy heart failureKidney:benign nephrosclerosisBrain:Intracerebral hemorrhage,infarction splinter hemorrhages&Lacunar infarctsEyes:hypertensive retinopathy2021/1/515心脏变化心脏变化2021/1/516Left ventricular Hypertrophy2021/1/517肾脏病变肾脏病变P
7、rimary Granular Atrophy of Kidney原发性颗粒固缩肾Arteriolar Nephrosclerosis细动脉性肾硬化2021/1/518脑病变脑病变脑水肿高血压脑病（Hypertensive encephalopathy）高血压危象（Hypertensive crisis）脑软化微梗死灶（Microinfarct）脑腔隙状梗死（Cerebral Lacunar Infarct）脑出血微小动脉瘤（Microaneurysm）2021/1/5192021/1/5202021/1/521Normal Retina vs Hypertensive Retinopathy
8、2021/1/522Malignant HTN恶性高血压病恶性高血压病Accounts for 5%of the cases of HTNMarkedly elevated pressures Artery necrosis with thrombosisRapidly progressive end organ damageRapidly developing renal failureHypertensive encephalopathyRetinal hemorrhages and exudates,papilledema2021/1/523Gross:kidney has petech
9、ial hemorrhages(flea-bitten appearance)Micro:Hyperplastic arteriolosclerosis-onion skin 增生性小动脉硬化 Necrotizing arteriolitis-fibrinoid necrosis of vessel walls 坏死性小动脉炎Morphology2021/1/524Rheumatism风风 湿湿 病病2021/1/525Acute Rheumatic Fever Rheumatic fever 风湿热风湿热Diffuse,inflammatory disease caused by a del
10、ayed immune response to infection by the group A-hemolytic streptococci(A组乙型溶血性链球菌).The joints,skin,nervous system,and heartIf left untreated,rheumatic fever causes rheumatic heart disease(风湿病).2021/1/526Rheumatic Heart DiseaseIn genetically susceptible individuals,the infection results in productio
11、n of antibodies that cross-react（交叉反应）with cardiac antigens.Initial attacks usually occur in late childhood(ages 5-15 years)and recurrent attacks can occur throughout adult life.2021/1/527PathogenesisDelayed immune response to infection with group A beta hemolytic streptococci（A组乙型溶血性链球菌）.After a la
12、tent period of 1-3 weeks,antibody induced immunological damage occur to heart valves（心瓣膜）,joints（关节）,subcutaneous tissue（皮下组织）&basal ganglia（基底节）.2021/1/528病因与发病机制病因与发病机制与A组乙型溶血性链球菌没有直接关系；C抗原（糖蛋白）的抗体结缔组织；M抗原（蛋白）的抗体心肌、血管平滑肌；心肌抗体及N-乙酰氨基酸葡萄糖抗体。2021/1/5292021/1/5302021/1/531Pathologic changeEarly phase(
13、alterative and exudative phase)变质渗出期变质渗出期 1 to 4wProliferative phase(granulomatous phase)增生（肉芽肿）期增生（肉芽肿）期 2 to 3mFibrosis phase(healed phase)瘢痕（愈合）期瘢痕（愈合）期 2 to 3m2021/1/532增生（肉芽肿）期增生（肉芽肿）期 Around the fibrinoid necrotic foci the proliferation of histocytic cells,forming a granuloma.Each of these min
14、ute nodules of proliferation inflammaties is known as an Aschoff body（Aschoff 小体小体）.Pathologic change变质渗出期变质渗出期Fragmentation of collagen fibres,lymphocytic infiltration&fibrinoid deposition2021/1/533Karl Albert Ludwig Ashoff(1866-1942)2021/1/534Anitschkow细胞细胞2021/1/535ASCHOFF vs ANITSCHKOW2021/1/536
15、Acute rheumatic heart disease急性风湿性心脏病急性风湿性心脏病 Rheumatic endocarditis 风湿性心内膜炎 Involves mitral and aortic valves Fibrin vegetations along the lines of closure MacCallum plaques:left atrial endocardial thickening2021/1/537Rheumatic myocarditis 风湿性心肌炎 Aschoff body(fibrinoid necrosis surrounded by Anitsc
16、hkow cells),lymphocytes,and plasma cellsFibrinous pericarditis 风湿性心包炎 cor villosum 绒毛心2021/1/5382021/1/5392021/1/5402021/1/541Chronic rheumatic heart disease慢性风湿性心脏病慢性风湿性心脏病Mitral and aortic valvular fibrosis（二尖瓣和主动脉瓣纤维化）Valve thickening and calcification（瓣膜增厚和钙化）Fusion of the valve commissures（瓣膜连接
17、处融合）Chordae tendineae（腱索）are short,thickened,and fusedComplications Mitral stenosis and CHF（充血性心衰）Infectious endocarditis（感染性心内膜炎）2021/1/542Aortic valve showing active valvulitis.The valve is slightly thickened with small vegetations（赘生物赘生物）“verrucae（疣状疣状）Opened stenotic mitral valve showing thicken
18、ing distorted cusps,adherent commissures with calcification and thrombus deposition,&thickening,fusion and shortening of chordae tendinae 2021/1/543Rheumatic arthritis 风湿性关节风湿性关节炎炎Flitting migratory polyarthritis（游走性多关节炎）,involving major joints（大关节）Commonly involved joints-knee,ankle,elbow&wristArth
19、ritis do not progress to chronic disease(消退后，不遗留关节变形)2021/1/544Erythema annulare 环形红斑环形红斑Unique（单一的）,transient（一过性）,serpiginous（葡行的）-looking lesions of 1-2 inches in sizePale center with red irregular margin（淡红色环状红晕，中间肤色正常）More on trunks&limbs（多发生于躯干和四肢）Often associated with chronic carditis（心脏炎）202
20、1/1/5452021/1/546Painless（无痛的）,pea-sized（豌豆状的）,palpable（可触及的）nodulesMainly over extensor（伸肌）surfaces of joints,spine,&scalpAlways associated with severe carditisSubcutaneous nodules 皮下结皮下结节节2021/1/547Rheumatic arteritis 风湿性动脉风湿性动脉炎炎 大、中等动脉大、中等动脉 急性期急性期 粘液样变性、纤维素样坏死粘液样变性、纤维素样坏死 慢性期慢性期 瘢痕形成瘢痕形成2021/1/
21、548Chorea minor 小舞蹈症小舞蹈症Occur in 5-10%of casesMainly in girls of 5-12 yrs ageClinically manifest as-clumsiness（笨拙）,deterioration of handwriting（写字）,emotional lability（情绪不稳）or grimacing（抽动）of face2021/1/549Infective endocarditis 感染性心内膜炎感染性心内膜炎2021/1/550DefinitionAn infection associated with formation
22、 of an adherent,bulky mass of thrombotic debris and organisms,termed vegetations（赘生物）on the endocardial surface,usually on a valve.2021/1/551AgentsBacteria,viruses,fungi,and parasitesPathogenesis“Prepared”endocardiumBlood-borne microorganism adherenceProliferation of the microorganism2021/1/552Patho
23、genesisEndothelial damagePlatelet-fibrin thrombi Microorganism adherence2021/1/553VegetationVariable in sizeAmorphous mass of fibrin&plateletsAbundant organismsFew inflammatory cells2021/1/554Acute Infective EndocarditisHigh virulence organism:Staphylococcus aureusCan colonize a normal valveProduces
24、 large destructive vegetationsPrognosis:poor;mortality=50%2021/1/5552021/1/5562021/1/5572021/1/5582021/1/559Subacute Infective EndocarditisLow virulence organism:Streptococcus group viridans Usually colonize a previously damaged valvePresentation over weeks to monthsRarely leads to metastatic infect
25、ion2021/1/5602021/1/561亚急性细菌性心内膜炎急性细菌性心内膜炎细菌毒力弱强原瓣膜已有病变多正常赘生物干燥、松脆细菌少、少量或无坏死较大、松软细菌多、瓣膜坏死重结局多愈合瓣膜破坏、可多穿孔细菌入血败血症脓毒败血症栓塞非感染性梗死多发性栓塞性小脓肿2021/1/562Fever,chills,weight loss,and cardiac murmurSystemic emboli（全身栓塞）Roth spots(retinal emboli)Osler nodes（Osler结节）Janeway lesions Renal insufficiencyClinical pre
26、sentation2021/1/563Valvular vitium of the hear心心 瓣瓣 膜膜 病病2021/1/564Internal view of the heart2021/1/5652021/1/566Mitral Valve Anatomy2021/1/567 Valvular vitium of the heart result from a healed or chronic valvulitis（瓣膜炎瓣膜炎）or,occasionally,are congenital malformations（先天畸形先天畸形）.The results of inflamm
27、ation in the valves are seen as thickening（增厚增厚）,adhesions（粘连粘连）,retraction（缩回缩回）,and shortening（变短变短）of the leaflets.There may be a narrowing of the valve opening(stenosis，狭狭窄窄),or closure of the valve may be insufficient so that leakage(regurgitation，反流反流)occur through it.Introduction2021/1/568Val
28、vular insufficiency and stenosis may be produced by the same deformity.Valve deformities are common on the left side of the heart(aortic and mitral，主动脉瓣和二尖瓣)but are uncommon on the right side(tricuspid and pulmonary).Introduction2021/1/569Valvular Dysfunction2021/1/570Valvular Dysfunction2021/1/571N
29、oImage2021/1/572MITRAL STENOSIS 二尖瓣狭二尖瓣狭窄窄predominant cause-Rheumatic fever Less frequently,congenital in etiologyleft atrium failure lung congestion right heart failure systemic congestionX ray:pear like heart（梨形心）2021/1/573Mitral Insufficiency 二尖瓣关闭不全二尖瓣关闭不全predominant cause-Rheumatic feverCombine
30、d with mitral stenosisleft heart failure lung congestion right heart failure systemic congestionX ray:ball like heart（球形心）2021/1/574Aortic stenosis 主动脉瓣狭窄主动脉瓣狭窄Rheumatic AS,degenerative(senile)calcific AS,atherosclerotic aortic valvular stenosis Angina pectoris,pulse pressure left atrium failure lun
31、g congestion right heart failure systemic congestionX ray:boot like heart（靴型心）2021/1/575Aortic insufficiency 主动脉瓣关闭不全主动脉瓣关闭不全Rheumatic fever,Syphilis,Systemic hypertension,Infective endocarditis left atrium failure lung congestion right heart failure systemic congestionPulse pressure,water-hammer pulse（水冲脉）,pistol shot sound（枪击音）2021/1/576SummaryHypertension Rheumatic Heart Disease Infective Endocarditis Valvular Heart Disease2021/1/577NoImage2021/1/578
