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1、Chapter 8：DISEASES OF CARDIOVASCULAR SYSTEMDepartment of PathologyTJMC,HUSTWang Guoping,Contents,Section 1 AtherosclerosisSection 2 Coronary AS and CHDSection 3 HypertensionSection 4 Aneurysm Section 5 RheumatismSection 6 Infective endocarditisSection 7 Valvular Vitium of the heartSection 8 Others,动
2、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),Arteriosclerosis hardening of the arteries th
3、ickening and loss of elasticity of arterial walls three forms:Atherosclerosis Mnckeberg medial calcific sclerosis Arteriolosclerosis,ATHEROSCLEROSIS(AS),Characterized by：Intimal lesions called atheroma,or atheromatous or fibrofatty plaques.,Characterized by：2.They protrude into and obstruct vascular
4、 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:hyperlipidemia hypertension ciga
5、rette smoking diabetes mellitus hyperhomocystinemia others: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.,Formation of an Advanced,Complicated Le
6、sion 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 within these monocytes and macrophages th
7、en 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 intima,proliferation、production of EM(collage
8、n,elastic fibers,and proteoglycans),Fibrous CapFC,SMC,LDL,MC,LC,Fibrous plaque,Fibrous capLipids,cell debris,cholesterol crystals,calcification、granulation tissue、LC,FC necrosis,Atheroma,complicated lesions,1.Hemorrhage into a plaque,complicated lesions,2.Rupture,ulceration or erosion of atheroma,co
9、mplicated 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 branchesSeverity：abdominal Athoracic Aascending Aaneurysm:abdominal A,Coronary artery：,Carotid:Internal carotid(at the beginning)Artery in brain：Basilar A,Middle
10、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 A：Infarct,Coronary atherosclerosis&Coronary artery(heart)disease,一、Coronary
11、 atherosclerosis,1.2050 Y，men are more commonly,north as well。2.The frequence：left anterior descending right coronary artery left circumflex coronary artery 3.AS plaque 斑块多位于血管的心肌侧，crescentic,Here is a coronary artery with atherosclerotic plaques.There is hemorrhage into the plaque in the middle of
12、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（ischemic heart disease,IHD）冠状动脉粥样硬化性心脏病(coronary atherosclerotic heart disease),coronary
13、 atherosclerotic heart disease,（A）angina pectoris（B）myocardial infarction（C）myocardial fibrosis（D）sudden coronary death,（一）angina pectoris,Coronary A Oxygen demandnarrowing,Myocardial ischemia(transient),The chest pain is described as constricting,squeezing,choking,or knifelike.持续数分钟，可缓解,（二）myocardi
14、al infarction,Coronary A thrombosis Ischemia(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.Restricted to the inner one third of the ventricular wall,2.Necrosis:multifocal and small,3.diffuse steno
15、sing 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 transmural MI,involves the full or nearly full thickness of the ventricular walllocates in the distribut
16、ion of a single coronary arteryusually associated with total thrombotic occlusion induced by acute plaque changetransmural and large,Pathologic changes with MI：,1.6h 内 no changes on gross examination，micro few wavy fiber at margin of MI,3.第4天 contraction bands,2.6h 后 gross exam color micro coagulati
17、on 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 aneurysmMural thrombi：potential sources for systemic emboliRupture of infarctAcute pericarditis,Rupture of a necrotic papi
18、llary 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 caused 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 multifo
19、cal 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)Cause marked stenosing coronary AS with acute plaque disruption(3)Mechanism lethal arrhythmia,HYPERTENSION,是以体循环动脉血压持续高于
20、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,Etiology genetic predisposition others:environmental factors,2.Machanisms blood volume：total peripheral resistance：,Pathologic changes of benign hypertension(90%-95%of cases),Functiona
21、l disturbance,Vasculature injury,Organ injury,（1）Functional disturbance intermittent spasm of systemic arterioles accompanied with disturbance of high-grade neural function;fluctuation of blood pressure,（2）Vasculature injury Arteriolosclerosis Arterioles are the smallest branches of the arteries wit
22、h 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 plasma components across vascular endothelium Increasing ECM production by smooth muscle cells(SMCs)Apoptosis of SMCs Hyaline d
23、egeneration of the wall Loss of underlying structural detail Wall thickening and lumen narrowing,Renal arteriolosclerosis:homogenous,pink and hyaline deposition within the wall,Renal arteriolosclerosis,Muscular or smallarteriesFibroelastic hyperplasia:increased myofibroblastic tissue in the intima,d
24、estruction of internal elastic membrane;medial SMCs proliferation and hypertrophy with reduplication of the elastic lamina wall thickening and lumen narrowinglarge or elastic arteries,（3）Organ injury,Heart(hypertensive heart disease)concentric hypertrophy eccentric hypertrophy,Concentric hypertrophy
25、,Morphology of the kidney,Gross appearance primary granulo-contracted kidney:symmetrically contracted;decreased in size and weight;hardened;fine,leathery granularity of the surface;on section,cortical narrowing,Histologic examination:,Hyaline arteriolosclerosis,Fibroelastic hyperplasiaFoci of tubula
26、r atrophy and interstitial fibrosis,Glomerular hyalinization and periglomerular fibrosis；Hypertrophy of the remaining compensated nephrons,Morphology of the brain,cerebral edema hypertensive encephalopathy hypertensive crisiscerebral softening microinfarct(lacunar infarct)cerebral hemorrhage large f
27、atal microaneurysm slit hemorrhages,Blood supply of the brain,Cerebral hemorrhage rupturing into the lateral ventricles,Morphology of the retina,Increased in the arteriolar light reflexArteriolar-venular crossing defects(arteriovenous nicking)Retinal hemorrhages,exudates and papilledema.,Accelerated
28、 Hypertension,Gross inspection:“flea-bitten”appearancesmall,pinpoint petechial hemorrhages on the cortical surface,Histologic alterations:,Fibrinoid necrosis of arterioles(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。,动
29、脉瘤：1.真性动脉瘤 true aneurysm 2.假性动脉瘤 false aneurysm 3.夹层动脉瘤 dissecting aneurysm(血液进入动脉中膜),RHEUMATISM,An immunologically mediated disease,related to an episode of group A(-hemolytic)streptococcal pharyngitis.Multisystem inflammatory disease,heart and jointsare favored sites.Rheumatic fever,acute rheumati
30、c carditisRepetitive 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 exudation serous,fibrinous exudate,and leukocytes infiltration,mucoid degeneration and fibrinoid necrosis.outcomes:complete
31、 resolution,fibrosis,granulomas.,ESSENTIAL MORPHOLOGY,(2)Proliferation or granulomas Hallmark:Aschoff bodies fibrinoid necrosis,Anitschkow cells Aschoff giant cells lymphocytes plasma cells,Aschoff body,Aschoff bodies,(3)Fibrosis Aschoff bodies spindle scar,Morphology of major organs,Rheumatic heart
32、 disease Rheumatic arthritis,Rheumatic endocarditis sites:mitral and aortic valves Fibrinoid necrosis Vegetations:small,warty,along the line of closure,Precipitation of fibrinOrganization,fibrosisthickening,shortening,commissural fusion of leaflets and tendinous cord,Rheumatic myocarditis,Perivascul
33、arAschoff body,Rheumatic pericarditis,Serous exudate pericardial effusionFibrinous exudate cor villosum constrictive pericarditis,Rheumatic arthritis,Serous inflammationComplete resolutionLarge joints:migratoryLocal signs:arthralgiaSelf-limited,no chronic deformity,Rheumatic arteritis,Often involves
34、 small arteries,Fibrinoid necrosisMononuclear infiltrationAschoff bodiesFibrosisLumen narrowing,CNS changes,Rheumatic arteritis,Subcortical encephalitisMinor chorea/Sydenham chorea(a neurologic disorder with involuntary purposeless,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
35、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 resul
36、ting from a primary abnormality in the myocardium,of unknown cause.Three clinical,functional,and pathologic patterns,1.Dilated(congestive)cardiomyopathy progressive cardiac hypertrophy,dilation,and contractile(systolic)dysfunction.,Heart:heavy,large,and flabby,with dilation of all chambers and the w
37、all thinning,mural thrombi,functional mitral or tricuspid regurgitation.,Histologic changes:nonspecific,hypertrophied muscle cells with enlarged nuclei,attenuated or streched,interstitial and endocardial fibrosis.,2.Hypertrophic cardiomyopathy,Myocardial hypertrophy,abnormal diastolic filling,and in
38、termittent left ventricular outflow obstruction.Morphology:Heart:heavy,muscular,and hypercontracting,massive myocardial hypertrophy without ventricular dilation(asymmetric septal hypertrophy),endocardial thickening or mural plaque formation.,Hypertrophic cardiomyopathy,Hypertrophic cardiomyopathy（di
39、sarray of fibers),Hypertrophic cardiomyopathy,Histologic changes:extensive myocyte hypertrophy;haphazard disarray of the bundles of myocytes,individual myocytes,and contractile elements in sarcomeres within cells;interstitial fibrosis.,3.Restrictive cardiomyopathy,A primary decrease in ventricular c
40、ompliance,resulting in impaired ventricular filling during diastole;the contractile function of the left ventricle is usually unaffected.Morphology:Heart:normal or slightly enlarged ventricles,without ventricular cavity dilation,firm myocardium,biatrial dilation.Histologic changes:patchy or diffuse
41、interstitial fibrosis.,Microscopically,the heart in cardiomyopathy demonstrates hypertrophy of myocardial fibers(which also have prominent dark nuclei)along with interstitial fibrosis.,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
42、。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,
