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ContentsSection 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动脉粥样硬化动脉粥样硬化 Atherosclerosis,AS冠状动脉冠状动脉ASAS及冠心病及冠心病 Coronary AS&CHD高血压病高血压病 Hypertension动脉瘤动脉瘤 Aneurysm风湿病风湿病 Rheumatism感染性心内膜炎感染性心内膜炎 Infective Endocarditis慢性心瓣膜病慢性心瓣膜病 Chronic valvular vitium心肌病心肌病 Cardiomyopathy心肌炎心肌炎 MyocarditisMyocarditis、心包炎心包炎 Pericarditis先天性心脏病先天性心脏病 Congenital heart diseaseATHEROSCLEROSIS (AS)Arteriosclerosis hardening of the arteries thickening and loss of elasticity of arterial walls three forms:Atherosclerosis Mnckeberg medial calcific sclerosis ArteriolosclerosisATHEROSCLEROSIS (AS)Characterized by：1.Intimal lesions called atheroma,or atheromatous or fibrofatty plaques.Characterized by：2.They protrude into 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&PATHOGENESIS1.Risk Factors:hyperlipidemia hypertension cigarette smoking diabetes mellitus hyperhomocystinemia others:age,sex and geneticsETIOLOGY&PATHOGENESIS2.Response to injury hypothesis:Russell Ross,N Engl J Med 1999;340(2):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 then leads to development of atherosclerotic lesions.ECMORPHOLOGY(pathologic changes)1 1.脂纹脂纹 （fatty streak）2.2.纤维斑块纤维斑块 （fibrous plaque）3.3.粥样斑块粥样斑块 （atheromatous plaque）粥瘤粥瘤 （atheroma）4.4.复合病变复合病变 （complicated lesions）一、一、基本病变基本病变fatty streakfatty streakSMCs migrate into intimaproliferation、production of EM(collagen,elastic fibers,and proteoglycans)Fibrous CapFC,SMC,LDL,MC,LCFibrous plaqueFibrous capLipids,cell debris,cholesterol crystals,calcification、granulation tissue、LCFC necrosisAtheroma1.Hemorrhage into a plaque 2.Rupture,ulceration or erosion of atheroma 3.Thrombosis 4.Calcification 5.Aneurysm 二、二、主要动脉的病变主要动脉的病变Coronary atherosclerosis&Coronary artery(heart)disease一、一、Coronary atherosclerosisCoronary atherosclerosis1.2050 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，斑块多位于血管的心肌侧，crescentic二、冠状动脉粥样硬化性心脏病二、冠状动脉粥样硬化性心脏病（coronary atherosclerotic heart disease）冠状动脉性心脏病冠状动脉性心脏病（coronary heart disease,CHD）缺血性心脏病缺血性心脏病（ischemic heart disease,IHD）冠状动脉粥样硬化性心脏病冠状动脉粥样硬化性心脏病(coronary atherosclerotic heart disease)coronary atherosclerotic heart disease（A A）angina pectoris（B B）myocardial infarction（C C）myocardial fibrosis（D D）sudden coronary death（一）（一）angina pectorisCoronary A Oxygen demandnarrowingMyocardial ischemia(transient)The chest pain is described as constricting,squeezing,choking,or knifelike.持续数分钟，可缓解持续数分钟，可缓解（二）（二）myocardial infarctionCoronary A thrombosis Ischemia(permanent)necrosisSevere and sustained precordial chest pain can not be relieved by rest or nitroglycerin completely.Subendocardial MI(心内膜下心肌梗死心内膜下心肌梗死)1.Restricted to the inner one third of the ventricular wall 2.Necrosis:multifocal and small 3.diffuse stenosing coronary atherosclerosis and reduction of coronary flow but neither plaque disruption nor superimposed thrombosis.4.狭窄狭窄 诱因诱因，加重了冠状，加重了冠状A供血不足，供血不足，造成各冠状造成各冠状A支最末梢区域（心内膜下心肌）支最末梢区域（心内膜下心肌）缺氧，侧枝循环不能建立，导致广泛的多灶缺氧，侧枝循环不能建立，导致广泛的多灶 性的心内膜下性的心内膜下MI透壁性心肌梗死透壁性心肌梗死 transmural MIlinvolves the full or nearly full thickness of the ventricular wallllocates in the distribution of a single coronary arterylusually associated with total thrombotic occlusion induced by acute plaque changeltransmural and largePathologic changes with MI：1.6h 内内 no changes on gross examination，micro few wavy fiber at margin of MI3.第第4天天 contraction bands2.6h 后后 gross exam color micro coagulation necrosis 4.第第7天天 granulation tissue；5.第第2-8 weeks，organization and dense scar tissueLaboratory：GOT、GPT、CPK、LDHImportant Complications：Papillary muscle dysfunctionVentricular aneurysmMural thrombi：potential sources for systemic emboliRupture of infarctAcute pericarditis（三）（三）心肌纤维化心肌纤维化 myocardial fibrosislong-term or repetitive and aggravated ischemic myocardial injury caused by moderate to severe stenosing coronary AS心肌纤维持续性、加重性缺血缺氧心肌纤维持续性、加重性缺血缺氧Necrosis and proliferation镜下：镜下：extensive and multifocal myocardial fibrosis,atrophy and hypertrophy,（四）（四）冠状动脉性猝死冠状动脉性猝死 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 arrhythmiaHYPERTENSION是以体循环动脉血压持续高于正常水平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为主要表现的疾病血压水平的定义和分类（WHO/ISH）分 类收缩压（mmHg）舒张压（mmHg）理想血压12080正常血压13085正常高值1301398589一级高血压（轻度）1401599099二级高血压（中度）160179100109三级高血压（重度）180110原发性高血压原发性高血压 primary hypertension高血压病高血压病:细小动脉硬化的基本病变的细小动脉硬化的基本病变的 全身性疾病全身性疾病继发性高血压继发性高血压secondary hypertensionEtiology and Mechanisms1.Etiology genetic predisposition others:environmental factors2.Machanisms blood volume：total peripheral resistance：Functional disturbanceVasculature injuryOrgan 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 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 plasma components across vascular endothelium Increasing ECM production by smooth muscle cells(SMCs)Apoptosis of SMCs Hyaline degeneration of the wall Loss of underlying structural detail Wall thickening and lumen narrowingMuscular or smallarteriesFibroelastic hyperplasia:increased myofibroblastic tissue in the intima,destruction of internal elastic membrane;medial SMCs proliferation and hypertrophy with reduplication of the elastic lamina wall thickening and lumen narrowinglarge or elastic arteriesHeart(hypertensive heart disease)concentric hypertrophy eccentric hypertrophyGross appearance primary granulo-contracted kidney:symmetrically contracted;decreased in size and weight;hardened;fine,leathery granularity of the surface;on section,cortical narrowingHyaline arteriolosclerosis,Fibroelastic hyperplasiaFoci of tubular atrophy and interstitial fibrosis,Glomerular hyalinization and periglomerular fibrosis；Hypertrophy of the remaining compensated nephronscerebral edema hypertensive encephalopathy hypertensive crisiscerebral softening microinfarct(lacunar infarct)cerebral hemorrhage large fatal microaneurysm slit hemorrhagesIncreased in the arteriolar light reflexArteriolar-venular crossing defects(arteriovenous nicking)Retinal hemorrhages,exudates and papilledema.Gross inspection:“flea-bitten”appearancesmall,pinpoint petechial hemorrhages on the cortical surface Fibrinoid necrosis of arterioles(necrotizing arteriolitis)Eosinophilic granular change in the wall动脉瘤动脉瘤 Aneurysm动脉瘤动脉瘤：心、血管壁局限性异常扩张或连心、血管壁局限性异常扩张或连 通于血管腔的血囊肿。由于常见通于血管腔的血囊肿。由于常见 于动脉血管，因而称动脉瘤。于动脉血管，因而称动脉瘤。动脉瘤动脉瘤：1.真性动脉瘤真性动脉瘤 true aneurysm 2.假性动脉瘤假性动脉瘤 false aneurysm 3.夹层动脉瘤夹层动脉瘤 dissecting aneurysm (血液进入动脉中膜血液进入动脉中膜)RHEUMATISMAn immunologically mediated disease,related to an episode of group A(-hemolytic)streptococcal pharyngitis.Multisystem inflammatory disease,heart and jointsare favored sites.Rheumatic fever,acute rheumatic carditisRepetitive attacks lead to chronic valvular deformitiesThe pathologic feature is Aschoff bodies.Mechnism：Cross React：Ag-Ab 链球菌链球菌C抗原抗原-CT的糖蛋白的糖蛋白 链球菌链球菌M抗原抗原-平滑肌平滑肌(1)alteration and exudation serous,fibrinous exudate,and leukocytes infiltration,mucoid degeneration and fibrinoid necrosis.outcomes:complete resolution,fibrosis,granulomas.(2)Proliferation or granulomas Hallmark:Aschoff bodies fibrinoid necrosis,Anitschkow cells Aschoff giant cells lymphocytes plasma cells(3)Fibrosis Aschoff bodies spindle scar Rheumatic heart disease Rheumatic arthritisRheumatic endocarditis sites:mitral and aortic valves Fibrinoid necrosis Vegetations:small,warty,along the line of closurePrecipitation of fibrinOrganization,fibrosisthickening,shortening,commissural fusion of leaflets and tendinous cordPerivascularAschoff bodySerous exudate pericardial effusionFibrinous exudate cor villosum constrictive pericarditisSerous inflammationComplete resolutionLarge joints:migratoryLocal signs:arthralgiaSelf-limited,no chronic deformityOften involves small arteries,Fibrinoid necrosisMononuclear infiltrationAschoff bodiesFibrosisLumen narrowingRheumatic arteritis,Subcortical encephalitisMinor chorea/Sydenham chorea(a neurologic disorder with involuntary purposeless,rapid movements)感染性心内膜炎感染性心内膜炎 Infective endocarditis病原微生物直接侵袭心内膜特别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是心瓣膜而引起的心内膜炎急性感染性心内膜炎急性感染性心内膜炎亚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急性感染性心内膜炎病原病原：致病力强的化脓菌：致病力强的化脓菌：金金黄色黄色葡葡萄球萄球菌、溶血性链球菌、肺炎球菌菌、溶血性链球菌、肺炎球菌心瓣膜心瓣膜：发生在原来无病变的正常心内膜：发生在原来无病变的正常心内膜 主要累及二尖瓣、主主要累及二尖瓣、主动脉动脉瓣瓣临床上临床上：起病急，发展快，病程短，死亡率高：起病急，发展快，病程短，死亡率高亚急性感染性心内膜炎亚急性感染性心内膜炎病原病原：致病力较小病原微生物：致病力较小病原微生物：草绿色链球菌，肠球菌，真菌等。草绿色链球菌，肠球菌，真菌等。心瓣膜心瓣膜：发生在原来有病变的心内膜：发生在原来有病变的心内膜 主要累及二尖瓣、主主要累及二尖瓣、主动脉动脉瓣瓣 菜花状或息肉状疣状赘生物：菜花状或息肉状疣状赘生物：纤维素、血小板、纤维素、血小板、NC、坏死物坏死物 细菌团细菌团血管：动脉栓塞和血管炎；血管：动脉栓塞和血管炎；肾：肾：微栓塞致灶性肾小球肾炎。微栓塞致灶性肾小球肾炎。临床上临床上：病程长，数月或：病程长，数月或1年年Heart disease resulting from a primary abnormality in the myocardium,of unknown cause.Three clinical,functional,and pathologic patterns1.Dilated(congestive)cardiomyopathy progressive cardiac hypertrophy,dilation,and contractile(systolic)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 fibrosis.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),endocardial thickening or mural plaque formation.Histologic changes:extensive myocyte hypertrophy;haphazard disarray of the bundles of myocytes,individual myocytes,and contractile elements in sarcomeres within cells;interstitial fibrosis.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 ventricles,without ventricular cavity dilation,firm myocardium,biatrial dilation.Histologic changes:patchy or diffuse interstitial fibrosis.慢性心瓣膜病慢性心瓣膜病先天性心脏病先天性心脏病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？教学复习题教学复习题常见的英文专业词汇常见的英文专业词汇动脉粥样硬化（动脉粥样硬化（atherosclerosisatherosclerosis），），动脉硬化（动脉硬化（arteriosclerosisarteriosclerosis），），损伤应答学说（损伤应答学说（response to injuryresponse to injury），），脂纹（脂纹（fatty streakfatty streak），），纤维斑块（纤维斑块（fibrous plaquefibrous plaque），），粥样斑块（粥样斑块（atheromaatheroma），），动脉瘤（动脉瘤（aneurysmaneurysm），），冠心病（冠心病（coronary heart diseasecoronary heart disease），），心绞痛（心绞痛（angina pectorisangina pectoris），），心肌梗死（心肌梗死（myocardial infarctionmyocardial infarction），），高血压（高血压（hypertentionhypertention），），风湿病（风湿病（rheumatismrheumatism），），阿少夫小体（阿少夫小体（Aschoff bodyAschoff body），），感染性心内膜炎（感染性心内膜炎（infective endocarditisinfective endocarditis）参考书籍参考书籍1 1.陈杰陈杰,李甘地李甘地.病理学病理学.第第2 2版版.北京北京:人民卫生出版人民卫生出版社，社，202010102.Vinay Kumar,Abul Abbas,Nelson Fausto,et 2.Vinay Kumar,Abul Abbas,Nelson Fausto,et al.Robbins and Cotran Pathologic Basis of al.Robbins and Cotran Pathologic Basis of Disease.8Disease.8thth ed.Saunders Elsevier,2008 ed.Saunders Elsevier,20083.3.李玉林李玉林.病理学病理学.第第7 7版版.北京北京:人民卫生出版社，人民卫生出版社，2002007 7
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