Circulatory Pathology Workshop

• Define ischaemia.

  Deficient supply of blood to a body part
• Define thrombosis.

  Formation or presence of a blood clot within a blood vessel
• Define embolism.

  Sudden obstruction of a blood vessel by an abnormal circulating particle
• Define infarction.

  Injury or death of tissue resulting from inadequate blood supply
• Define shock.

  A state of profound depression of the vital processes associated with reduced blood volume & pressure
• Define congestion.

  An excessive accumulation especially of blood or mucus
• Define oedema.

  An abnormal infiltration and excess accumulation of serous fluid in connective tissue or in a serous cavity
• Define haemorrhage.

  Heavy discharge of blood from the blood vessels
• 72M, heaviness in chest when walking, comes on when walking & wears off after a couple mins of rest. What is the differential diagnosis?

  Acute coronary syndrome (MI, angina)

  Pericarditis

  Myocarditis

  GERD

  Costochondritis

  Pneumona
• What are the pathophysiological steps in atherosclerosis?

  Endothelial injury

  Migration of leukocytes

  Smooth muscle cell migration & proliferation

  Macrophages & smooth muscles engulf lipids

  Maturation of plaque (smooth muscle proliferation, collagen & ECM deposition)

  Atheromatous plaque
• What is shown in the image?

  Coronary artery with atherosclerosis

  
• What is shown microscopically in atherosclerosis?

  Left image

  • intimal thickening

  Right image

  • atheromatous plaque

  
• What investigations need to be done for MI?

  FBC

  Cardiac markers

  Echocardiogram

  ECG
• What does creatinine kinase-MB check for?

  Reinfarction (as troponin I stays in the blood for a while so cannot tell if another infarction has occurred)

  
• What does this ECG show?

  ST elevation in V1 - V6

  
• What are the differential diagnosis of ST elevation?

  Use acronym ELEVATIONS

  Electrolyte (hyperkalaemia)

  Left bundle branch block

  Early repolarization

  Ventricular hypertrophy

  Aneurysmal, left ventricular

  Thrombotic occlusion (MI)

  Inflammation (pericarditis)

  Osborn (hypothermia)

  Neurogenic

  Sudden death (Brugada)
• What is shown in the image?

  Coronary thrombosis

  
• What is seen microscopically in coronary artery thrombosis?

  Right image - Lines of Zahn

  
• What are the 3 most common coronary arteries that are blocked in MI?

  Left anterior descending (40-50%)

  Right coronary (30-40%)

  Left circumflex (15-20%)
• How does the histopathology change after an MI?

  1 day after infarct (A) -> coagulative necrosis & wavy fibres

  3-4 days after (B) -> oedema & scattered neutrophil

  7-10 days after (C) -> removal of necrotic myocytes by phagocytosis

  (D) -> granulation tissue & abundant capillaries

  6 weeks after (E) -> healed MI necrotic tissue replaced by dense collagen

  
• What are the types of infarcts?

  Full thickness (transmural) -> involves entire thickness of ventricular wall

  Subendocardial (laminar) -> occupy the inner subendocardial half of the myocardium

  
• What are the different types of shock?

  Cardiogenic

  Hypovolaemic

  Obstructive

  Septic

  Analphylactic
• What is the pathophysiology of cardiogenic shock?

  CO falls -> right atrial pressure rises -> baroreceptor & other responses activated by a fall in BP & cardiac damage -> sympathetic NS activation -> vasoconstriction, increased venous return & stimulation of heart -> reduced renal blood flow -> stimulates RAAS (fluid retention) -> danger of reduced BP causing poor myocardial perfusion (esp. through diseased coronary circulation) & cycle of further myocardial damage
• What is bronchiectasis?

  Bronchiectasis is a chronic lung condition characterized by the widening and inflammation of the bronchial tubes.
• What are the different types of sputum? What are the characteristics of them?

  Purulent - thick, yellow/green sputum

  Mucoid - clear, grey/white

  Serous - clear, frothy, can be pink

  Blood - blood
• What is purulent sputum indicative of?

  Infectious - pneumonia, bronchiectasis & abscess
• WHat is mucoid sputum associated with?

  COPD & asthma
• What is serous sputum indicative of?

  Pulmonary oedema
• What is blood in sputum indicative of?

  Malignancy

  Pulmonary oedema

  Clotting disorders

  Infection
• What is shown in the image?

  Pulmonary oedema

  
• What is shown in the image?

  Nutmeg liver -> mottled appearance due to hepatic venous congestion

  
• What is shown in the image?

  PE - saddle embolism

  
• What is shown microscopically in pulmonary embolism?

  Left image - lines of Zahn

  Right image - partial recanalisation of blocked artery

  
• What is shown in the image?

  Cerebral haemorrhage

  
• What is shown in the image?

  Cerebral infarction

  
• Give 6 complications of MI.

  Arrhythmias

  Congestive heart failure

  Cardiogenic shock

  Rupture

  Pericarditis

  Post myocardial infarction syndrome (Dressler syndrome)
• What is shown microscopically in pulmonary oedema?

  Alveoli filled with oedema

  Congested capillaries

  Hemosiderin-laden macrophages (right image) - contain brown cytoplasmic hemosiderin granules from the breakdown of RBCs

  
• What is the pathophysiology of pulmonary oedema?

  Can result from either the elevation of pulmonary hydrostatic pressure OR the increased capillary permeability

  
• What is shown in the image?

  European society for cardiology treatment algorithm for HF with reduced ejection fraction

  
• What is shown in the image?

  ESC algorithm for HF with mid-range EF