1、Chapter 8：DISEASES OF CARDIOVASCULAR SYSTEMDepartment of Pathology TJMC, HUST Wang Guoping,Contents,Section 1 Atherosclerosis Section 2 Coronary AS and CHD Section 3 Hypertension Section 4 Aneurysm Section 5 Rheumatism Section 6 Infective endocarditis Section 7 Valvular Vitium of the heart Section 8
2、 Others,动脉粥样硬化 Atherosclerosis, AS 冠状动脉AS及冠心病 Coronary AS & CHD 高血压病 Hypertension 动脉瘤 Aneurysm风湿病 Rheumatism感染性心内膜炎 Infective Endocarditis 慢性心瓣膜病 Chronic valvular vitium 心肌病 Cardiomyopathy 心肌炎 Myocarditis、心包炎 Pericarditis 先天性心脏病 Congenital heart disease,ATHEROSCLEROSIS (AS),Arteriosclerosishardening
3、 of the arteries thickening and loss of elasticity of arterial wallsthree forms:AtherosclerosisMnckeberg medial calcific sclerosisArteriolosclerosis,ATHEROSCLEROSIS (AS),Characterized by： Intimal lesions called atheroma, or atheromatous or fibrofatty plaques.,Characterized by： 2. They protrude into
4、and obstruct vascular lumina, weaken the underlying media, and may undergo serious complications.,Characterized by： 3. AS affects elastic arteries (aorta, carotid, and iliac arteries) and large and medium-sized muscular arteries (coronary and popliteal arteries),ETIOLOGY & PATHOGENESIS,Risk Factors:
5、 hyperlipidemiahypertensioncigarette smokingdiabetes mellitushyperhomocystinemiaothers: age, sex and genetics,ETIOLOGY & PATHOGENESIS,2. Response to injury hypothesis:,Endothelial Dysfunction in Atherosclerosis.,Russell Ross, N Engl J Med 1999; 340(2):,Fatty-Streak Formation in Atherosclerosis.,Form
6、ation of an Advanced, Complicated Lesion of Atherosclerosis.,Unstable Fibrous Plaques in Atherosclerosis.,The Role of MCP-1 in Atherosclerosis,MCP-1 released by VSMCs, ECs and macrophages promotes the recruitment of monocytes and macrophages to the subendothelial cell layer. Deposition of lipids wit
7、hin these monocytes and macrophages then leads to development of atherosclerotic lesions.,EC,MORPHOLOGY (pathologic changes),1.脂纹 （fatty streak）2.纤维斑块 （fibrous plaque）3.粥样斑块 （atheromatous plaque）粥瘤 （atheroma）4.复合病变 （complicated lesions）,一、基本病变,脂纹(模式图),fatty streak,脂纹,fatty streak,SMCs migrate into i
8、ntima,proliferation、production of EM (collagen, elastic fibers, and proteoglycans),Fibrous Cap FC, SMC, LDL, MC, LC,Fibrous plaque,Fibrous cap Lipids, cell debris, cholesterol crystals, calcification、granulation tissue、LC,FC necrosis,Atheroma,complicated lesions,1. Hemorrhage into a plaque,complicat
9、ed lesions,2. Rupture, ulceration or erosion of atheroma,complicated lesions,3. Thrombosis,complicated lesions,4. Calcification,5.Aneurysm,二、主要动脉的病变,Aorta： Site: posterior wall of aorta ostia of major branches Severity：abdominal Athoracic Aascending A aneurysm: abdominal A,Coronary artery：,Carotid:
10、Internal carotid (at the beginning) Artery in brain：Basilar A, Middle cerebral A Circle of Willis Aneurysm: circle of Willis Atrophy, Softening of brain、 hemorrhages,Renal A： Hypertension、infarct、 AS contracted kidney,Artery of extremity： intermittent claudication dry gangrene of the legs,Mesenteric
11、 A ：Infarct,Coronary atherosclerosis & Coronary artery(heart) disease,一、Coronary atherosclerosis,1.2050 Y，men are more commonly, north as well。 2.The frequence：left anterior descendingright coronary arteryleft circumflex coronary artery 3.AS plaque 斑块多位于血管的心肌侧，crescentic,Here is a coronary artery wi
12、th atherosclerotic plaques. There is hemorrhage into the plaque in the middle of this photograph. This is one of the complications of atherosclerosis. Such hemorrhage could acutely narrow the lumen,二、冠状动脉粥样硬化性心脏病 （coronary atherosclerotic heart disease）冠状动脉性心脏病 （coronary heart disease, CHD）缺血性心脏病 （i
13、schemic heart disease, IHD）冠状动脉粥样硬化性心脏病 (coronary atherosclerotic heart disease),coronary atherosclerotic heart disease,（A）angina pectoris （B）myocardial infarction （C）myocardial fibrosis （D）sudden coronary death,（一） angina pectoris,Coronary A Oxygen demand narrowing,Myocardial ischemia (transient),T
14、he chest pain is described as constricting, squeezing, choking, or knifelike. 持续数分钟，可缓解,（二） myocardial infarction,Coronary A thrombosisIschemia (permanent),necrosis,Severe and sustained precordial chest pain can not be relieved by rest or nitroglycerin completely.,Subendocardial MI (心内膜下心肌梗死),1. Res
15、tricted to the inner one third of the ventricular wall,2. Necrosis: multifocal and small,3. diffuse stenosing coronary atherosclerosis and reduction of coronary flow but neither plaque disruption nor superimposed thrombosis.,4. 狭窄 诱因，加重了冠状A供血不足，造成各冠状A支最末梢区域（心内膜下心肌）缺氧，侧枝循环不能建立，导致广泛的多灶性的心内膜下MI,透壁性心肌梗死
16、 transmural MI,involves the full or nearly full thickness of the ventricular wall locates in the distribution of a single coronary artery usually associated with total thrombotic occlusion induced by acute plaque change transmural and large,Pathologic changes with MI：,1. 6h 内 no changes on gross exa
17、mination，micro few wavy fiber at margin of MI,3. 第4天 contraction bands,2. 6h 后 gross exam colormicro coagulation necrosis,4. 第7天 granulation tissue；5. 第2-8 weeks，organization and dense scar tissue,Laboratory：,GOT、GPT、CPK、LDH,Important Complications：,Papillary muscle dysfunctionVentricular aneurysmMu
18、ral thrombi：potential sources for systemic emboliRupture of infarctAcute pericarditis,Rupture of a necrotic papillary muscle, resulting in the acute onset of severe mitral regurgitation,Mural thrombus,（三）心肌纤维化 myocardial fibrosis,long-term or repetitive and aggravated ischemic myocardial injury caus
19、ed by moderate to severe stenosing coronary AS,心肌纤维持续性、加重性缺血缺氧,Necrosis and proliferation 镜下：extensive and multifocal myocardial fibrosis, atrophy and hypertrophy,（四）冠状动脉性猝死sudden coronary death,(1) Definition unexpected death from cardiac causes early after or without the onset of symptoms. (2) Cau
20、semarked stenosing coronary AS with acute plaque disruption (3) Mechanismlethal arrhythmia,HYPERTENSION,是以体循环动脉血压持续高于正常水平 为主要表现的疾病,原发性高血压 primary hypertension 高血压病: 细小动脉硬化的基本病变的全身性疾病继发性高血压secondary hypertension,Etiology and Mechanisms,Etiologygenetic predispositionothers: environmental factors,2. Ma
21、chanismsblood volume：total peripheral resistance：,Pathologic changes of benign hypertension (90%-95% of cases),Functional disturbance,Vasculature injury,Organ injury,（1）Functional disturbanceintermittent spasm of systemic arterioles accompanied with disturbance of high-grade neural function; fluctua
22、tion of blood pressure,（2）Vasculature injuryArteriolosclerosisArterioles are the smallest branches of the arteries with only 1 or 2 smooth muscle cell layers in media, generally 20 to 100 m in diameter. eg. afferent arteriole of the glomerulus, retinal artery,splenic central artery.,Leakage of plasm
23、a components across vascular endothelium Increasing ECM production by smooth muscle cells (SMCs) Apoptosis of SMCsHyaline degeneration of the wallLoss of underlying structural detailWall thickening and lumen narrowing,Renal arteriolosclerosis: homogenous, pink and hyaline deposition within the wall,
24、Renal arteriolosclerosis,Muscular or smallarteries Fibroelastic hyperplasia:increased myofibroblastic tissue in the intima, destruction of internal elastic membrane;medial SMCs proliferation and hypertrophy withreduplication of the elastic laminawall thickening and lumen narrowinglarge or elastic ar
25、teries,（3）Organ injury,Heart (hypertensive heart disease)concentric hypertrophyeccentric hypertrophy,Concentric hypertrophy,Morphology of the kidney,Gross appearanceprimary granulo-contracted kidney:symmetrically contracted; decreased in size and weight; hardened;fine, leathery granularity of the su
26、rface;on section, cortical narrowing,Histologic examination:,Hyaline arteriolosclerosis, Fibroelastic hyperplasiaFoci of tubular atrophy and interstitial fibrosis, Glomerular hyalinization and periglomerular fibrosis； Hypertrophy of the remaining compensated nephrons,Morphology of the brain,cerebral
27、 edemahypertensive encephalopathyhypertensive crisiscerebral softeningmicroinfarct (lacunar infarct)cerebral hemorrhagelarge fatalmicroaneurysmslit hemorrhages,Blood supply of the brain,Cerebral hemorrhage rupturing into the lateral ventricles,Morphology of the retina,Increased in the arteriolar lig
28、ht reflex Arteriolar-venular crossing defects (arteriovenous nicking) Retinal hemorrhages, exudates and papilledema.,Accelerated Hypertension,Gross inspection:“flea-bitten” appearancesmall, pinpoint petechial hemorrhages on the cortical surface,Histologic alterations:,Fibrinoid necrosis of arteriole
29、s (necrotizing arteriolitis)Eosinophilic granular change in the wall,动脉瘤 Aneurysm,动脉瘤：心、血管壁局限性异常扩张或连 通于血管腔的血囊肿。由于常见 于动脉血管，因而称动脉瘤。,RHEUMATISM,An immunologically mediated disease, related to an episode of group A (-hemolytic) streptococcal pharyngitis.Multisystem inflammatory disease, heart and joints
30、 are favored sites.Rheumatic fever, acute rheumatic carditis Repetitive attacks lead to chronic valvular deformitiesThe pathologic feature is Aschoff bodies.,Mechnism：Cross React：Ag-Ab链球菌C抗原-CT的糖蛋白链球菌M抗原-平滑肌,(1) alteration and exudationserous, fibrinous exudate, and leukocytes infiltration, mucoid d
31、egeneration and fibrinoid necrosis.outcomes: complete resolution, fibrosis, granulomas.,ESSENTIAL MORPHOLOGY,(2) Proliferation or granulomasHallmark: Aschoff bodiesfibrinoid necrosis, Anitschkow cellsAschoff giant cellslymphocytes plasma cells,Aschoff body,Aschoff bodies,(3) FibrosisAschoff bodies s
32、pindle scar,Morphology of major organs,Rheumatic heart diseaseRheumatic arthritis,Rheumatic endocarditissites: mitral and aortic valvesFibrinoid necrosisVegetations: small, warty, along the line of closure,Precipitation of fibrinOrganization, fibrosisthickening, shortening, commissural fusion of lea
33、flets and tendinous cord,Rheumatic myocarditis,Perivascular Aschoff body,Rheumatic pericarditis,Serous exudate pericardial effusionFibrinous exudate cor villosum constrictive pericarditis,Rheumatic arthritis,Serous inflammation Complete resolution Large joints: migratory Local signs: arthralgia Self
34、-limited, no chronic deformity,Rheumatic arteritis,Often involves small arteries, Fibrinoid necrosis Mononuclear infiltrationAschoff bodiesFibrosisLumen narrowing,CNS changes,Rheumatic arteritis, Subcortical encephalitisMinor chorea / Sydenham chorea (a neurologic disorder with involuntary purposele
35、ss, rapid movements),感染性心内膜炎 Infective endocarditis,病原微生物直接侵袭心内膜特别是心瓣膜而引起的心内膜炎,急性感染性心内膜炎,亚急性感染性心内膜炎,急性感染性心内膜炎,病原：致病力强的化脓菌：金黄色葡萄球菌、溶血性链球菌、肺炎球菌,心瓣膜：发生在原来无病变的正常心内膜主要累及二尖瓣、主动脉瓣,临床上：起病急，发展快，病程短，死亡率高,亚急性感染性心内膜炎,病原：致病力较小病原微生物：草绿色链球菌，肠球菌，真菌等。,心瓣膜：发生在原来有病变的心内膜主要累及二尖瓣、主动脉瓣菜花状或息肉状疣状赘生物：纤维素、血小板、NC、坏死物细菌团 血管：动脉栓
36、塞和血管炎； 肾： 微栓塞致灶性肾小球肾炎。,临床上：病程长，数月或1年,CARDIOMYOPATHY,Heart disease resulting from a primary abnormality in the myocardium, of unknown cause .Three clinical, functional, and pathologic patterns,1. Dilated (congestive) cardiomyopathyprogressive cardiac hypertrophy, dilation, and contractile (systolic)
37、dysfunction.,Heart: heavy, large, and flabby, with dilation of all chambers and the wall thinning, mural thrombi, functional mitral or tricuspid regurgitation.,Histologic changes: nonspecific, hypertrophied muscle cells with enlarged nuclei, attenuated or streched, interstitial and endocardial fibro
38、sis.,2. Hypertrophic cardiomyopathy,Myocardial hypertrophy, abnormal diastolic filling, and intermittent left ventricular outflow obstruction. Morphology: Heart: heavy, muscular, and hypercontracting, massive myocardial hypertrophy without ventricular dilation (asymmetric septal hypertrophy), endoca
39、rdial thickening or mural plaque formation.,Hypertrophic cardiomyopathy,Hypertrophic cardiomyopathy （disarray of fibers),Hypertrophic cardiomyopathy,Histologic changes: extensive myocyte hypertrophy; haphazard disarray of the bundles of myocytes, individual myocytes, and contractile elements in sarc
40、omeres within cells; interstitial fibrosis.,3. Restrictive cardiomyopathy,A primary decrease in ventricular compliance, resulting in impaired ventricular filling during diastole; the contractile function of the left ventricle is usually unaffected. Morphology: Heart: normal or slightly enlarged vent
41、ricles, without ventricular cavity dilation, firm myocardium, biatrial dilation. Histologic changes: patchy or diffuse interstitial fibrosis.,Microscopically, the heart in cardiomyopathy demonstrates hypertrophy of myocardial fibers (which also have prominent dark nuclei) along with interstitial fib
42、rosis.,慢性心瓣膜病,先天性心脏病,1.动脉粥样硬化的病理特征及其并发症。2.以血管病变为基础，阐明高血压病时肾脏的病变特点及其形成过程。3.何谓Aschoff body？它的基本成分是什么？4.个型心肌梗死的病理特征及其临床病理联系。5.试述亚急性感染性心内膜炎与风湿性心内膜炎的异同点？,教学复习题,常见的英文专业词汇,动脉粥样硬化（atherosclerosis）， 动脉硬化（arteriosclerosis）， 损伤应答学说（response to injury）， 脂纹（fatty streak）， 纤维斑块（fibrous plaque）， 粥样斑块（atheroma）， 动脉
43、瘤（aneurysm）， 冠心病（coronary heart disease）， 心绞痛（angina pectoris）， 心肌梗死（myocardial infarction）， 高血压（hypertention）， 风湿病（rheumatism）， 阿少夫小体（Aschoff body）， 感染性心内膜炎（infective endocarditis）,参考书籍,1.陈杰,李甘地.病理学.第2版.北京:人民卫生出版社，20102.Vinay Kumar, Abul Abbas, Nelson Fausto,et al. Robbins and Cotran Pathologic Basis of Disease.8th ed. Saunders Elsevier, 20083.李玉林. 病理学.第7版.北京:人民卫生出版社，2007,
