Patho SGD: Cardiovascular Module Case 1: A 58 year male came in the ER because of left arm pain with chest

heaviness for the past 8 hours. History revealed that he has been having increase in blood pressure for the past 20 years and on maintenance Amlodipine. He also noted occasional chest pains upon going flights of stairs in his apartment for the past month and noted to have chest pain even while at rest the day before. At the ER the resident doctor requested for ECG and CK-MB. The ECG showed s-t segment and q wave elevation. The CK-MB was also elevated. Patient died after 40 hours. 1. Salient Features: a. 58 y/o, male b. Left arm pain with chest heaviness for the past 8 hours c. Hypertensive for 20 years on maintenance Amlodipine d. Occasional chest pain upon going flights of stairs (stable angina) e. Chest pain at rest one day PTA (unstable angina) f. ECG: s-t segment and q wave elevation g. Cardiac marker: CK-MB elevation 2. Risk factors: a. 58 y/o i. Incidence of myocardial infarction may occur at any age, although increasing incidence is found with increasing age (45% occur with age < 65). b. Male i. Men are significantly at a greater risk than women c. Hypertension i. Any predispositions to atherosclerosis such as high blood pressure may also contribute to myocardial infarction Last question- What do you propose to do in this case if you were the attending physician at the ER? Give the rationale knowing the pathology. In an acute setting of myocardial infarction, initial therapy should be directed toward reperfusion and minimizing ischemia. Oxygen must be readily administered to increase arterial oxygen content to improve myocardial oxygenation. Other drugs routinely administered in this kind of setting are:

Nitrates to induce vasodilation and reverse vasospasm Aspirin and Heparin to prevent further thrombosis Morphine to reduce pain, anxiety and further oxygen demand B- adrenergic blockers also to diminish cardiac oxygen demand and decrease risk of arrhythmias. ACE inhibitors to limit ventricular dilation After the condition of the patient is stable, measures that may be taken for restoration of blood flow may include coronary angioplasty with or without stenting, and emergent CABG surgery.

Case 2 A 31 year old female complained of palpitations and increasing dyspnea for the past 6 years. On examination rales are auscultated in both lungs. She is afebrile. A chest radiograph shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta hemolytic streptococcal infection. Answers: Rheumatic Heart Disease is an acute, immunologically mediated, multisystem inflammatory disease that occurs a few weeks after an episode of group A hemolytic streptococcal pharyngitis; it can also rarely occur with streptococcal infections at other sites (e.g., skin). Acute rheumatic heart disease (RHD) is the cardiac manifestation of RF and is associated with inflammation of the valves, myocardium, or pericardium. Acute RF is a hypersensitivity reaction induced by host antibodies elicited by group A streptococci. However, many details of the pathogenesis remain uncertain despite years of investigation. It appears that the M proteins of certain streptococcal strains induce host antibodies that cross-react with glycoprotein antigens in the heart, joints, and other tissues. This explains the typical 2- to 3-week delay in symptom onset after the original infection, and the absence of streptococci in the lesions. The chronic sequelae result from progressive fibrosis due to healing of the acute inflammatory lesions. Diagnosis of Rheumatic Fever: Jones Criteria: According to revised Jones criteria, the diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection: elevated or rising antistreptolysin O titre or DNAase. Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.

Major Criteria Polyarthritis Carditis Erythema Marginatum Sydenhams Chorea Subcutaneous Nodules

Minor Criteria Fever of 38.238.9 C (101102 F) Arthralgia Raised erythrocyte sedimentation rate or C reactive protein Leukocytosis ECG showing prolonged PR interval Previous episode of rheumatic fever or inactive heart disease

Acute RF appears most often in children aged 5 to 15 years, but about 20% of first attacks occur in adults. Typically, the symptoms occur two to three weeks after an episode of streptococcal pharyngitis. Although cultures for streptococci are negative by the time clinical illness begins, antibodies to one or more streptococcal antigens (streptolysin O or DNAase) can be detected in most patients. The predominant clinical manifestations are arthritis and carditis; arthritis is far more common in adults. After an initial attack there is increased vulnerability to disease reactivation with subsequent pharyngeal infections. Carditis is likely to worsen with each recurrence, and damage is cumulative. Chronic rheumatic carditis usually does not cause clinical manifestations for years or even decades after the initial episode of RF. The signs and symptoms of valvular disease depend on which valve(s) are involved. As mentioned earlier, the mitral valve is the one most commonly involved and its stenosis is the most common manifestation. In addition to various cardiac murmurs, cardiac hypertrophy and dilation, and CHF, patients with chronic RHD often have arrhythmias (particularly atrial fibrillation in the setting of mitral stenosis), thromboembolic complications, and an increased risk of subsequent infective endocarditis. *Slide after the case* Gross Specimen of the opened heart left side exposed Small vegetations (verrucae) are visible along the line of closure of the mitral valve leaflet. Previous episodes of rheumatic valvulitis have caused fibrous thickening and fusion of the chordae tendineae

*Slide of the Microscopic slide Presence of Aschoff bodies. Fibrinoid degeneration surrounded by lymphocytes and Anitschkow cells (activated macrophage). Pathognomonic of RHF

What are the microscopic findings on the valve leaflet with the gross lesion? Identify and describe its composition. The histologic section of the heart valve indicates findings such as extensive fibrosis, dystrophic calcifications and necrosis. Stenosed valves are usually hard, unlike the normally pliable valves, due to calcifications and fibrin build-up. How do you manage the patient based on pathology? Based on the pathology of this patient, the rheumatic heart disease progressed to congestive heart failure. Management of CHF would be open heart surgery. Implantation of an artificial heart whuch would be the recommended surgical treatment option, albeit, as the last. Alternative surgeries include surgical left ventricular remodeling which aims to reduce to ventricular diameter thus, improving its shape and remove non-viable tissue at the same time. These procedures can be performed together with coronary artery bypass surgery or mitral valve repair.