2008-心血管系统病理-湘雅本科课件

DiseasesofCardiovascularSystemDr.Zheng

changli

Atherosclerosis(AS)1.EtiologyandPathogenesisRiskfactors（1）Hyperlipemia:TC，TG，

LDL，VLDL，apoB，

Lp(a)HDL，apoA-I

（2）Hypertension

（3）Cigarettesmoking

（4）Elevatedbloodsugarlevels

（5）TheotherfactorsPathogenesis

（1）Theinjuryoftheendothelium

通透性增大，

Growthfactor:MPC-1,PDGF,TGF-beta（2）Theaccumulationoflipid

血脂增高，血管壁脂质代谢障碍（3）Theinfiltrationofmacrophages

吞噬形成泡沫细胞，参与炎症和免疫过程，促进平滑肌细胞迁移和增生（4）TheproliferationofSMC

增生，迁移，功能改变：吞噬，分泌合成（GF，ECM）2.Morphology

Predilectionforlargearteriesandmedium-sizedarteries

Basiclesion(1)Fattystreakaccumulatedlipid,foamcell黄色脂质条纹(2)Fibrousplaque--Fibrouscap

肉眼:

镜下:fibrouscaplipidzonebasalzone正常主动脉动脉粥样硬化的纤维斑块病变动脉管壁一侧明显增厚

(3)Atheromatousplaque(atheroma)

Fibrouscapcholesterolcrystalnecroticdebrisfoamcellcalcification

neovascularformation动脉分支开口处黄色隆起斑块粥样斑块病变动脉内膜下大量泡沫细胞堆积

斑块底部块纤维化

斑块内胆固醇积聚(4)ComplicatedLesions

★

Hemorrhageinplaque

★Ruptureoftheplaque

★Thrombosis

★Calcification

★Aneurysm:

definition,lesionclassification

(true,pseudo-,Dissecting)

粥样硬化斑块溃疡形成腹主动脉髂动脉血栓形成腹主动脉血栓形成肾硬化髂动脉瘤

3.Atherosclerosisofmajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain★

Otherorgans正常主动脉动脉粥样硬化的纤维斑块病变

3.Atherosclerosisofthemajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain

★

Otherorgans

正常脑基底动脉环基底动脉环硬化基底动脉内血栓形成基底动脉环硬化脑动脉硬化致脑萎缩

3.Atherosclerosisofthemajororgans

★

Aorta:abdominalaorta

★

Coronaryarteries

★

Arteriesofthebrain

★

Otherorgans新鲜足坏疽

足干性坏疽CoronaryHeartDisease(CHD)Definition

Cardiacdiseaseresultingfrominsufficientcoronarybloodflowsduetothenarrowingofthecoronaryarteries

causes①coronaryatherosclerosis

Distribution(location)

左冠状动脉前降支，右主干或左旋支，后降支

featuresofthelesion

斑块：新月形，偏心位狭窄程度分四级：正常心脏

右冠状动脉左冠状动脉冠状动脉粥样硬化左冠状动脉右冠状动脉冠状动脉狭窄血栓形成正常冠状动脉冠状动脉粥样硬化，管腔狭窄

冠状动脉管壁增厚及钙化，管腔明显狭窄斑块内钙化动脉管腔狭窄血栓形成冠状动脉近端狭窄冠状动脉远端闭塞冠状动脉硬化区冠状动脉阻塞causes①

coronaryatherosclerosis②

spasmofthecoronaryarteris③

coronaryarteritisClassificationofCHD

1.

anginapectoris(AP)

episodiccardiacpainresultingfromtransientischemia

Precipitatingfactors

exertion，

emotion，

pain，

coldweather，

cigarettesmoking，

heavymeals

心绞痛病人ClassificationofAP

StableAPofexertionInstableAPofexertion(spontaneous)variantAP2.

Myocardialinfarction(MI)

subendocardialMI

Multiplesmalllesion

transmuralMI

（1）Distribution

（2）Morphology:shape：

color:6h苍白，8-9h土黄色，1-2周红色，

3周后灰白

microscopicchange

（3）Biochemicalchanges:新鲜心肌梗死心肌梗死灶肉芽组织左心室大片坏死ComplicationsofMIRuptureoftheheartVentricularaneurysmThrombosisAcutepericarditisClinicalcomplication

心律失常—最常见的并发症心衰，心源性休克梗死区破裂口心包填塞心包内积血左心室慢性室壁瘤3.myocardialfibrosis4.suddencoronarydeath

Hypertension

诊断标准Diagnosticcriteria

sustaineddiastolicpressure≥90mmHg(12.0kPa)and/orsustainedsystolicpressure≥140mmHg(18.4kPa)

分类ClassificationPrimary(essential)hypertensionSecondary(symptomatic)•Specialhypertension(妊娠高血压，高血压危象)

Benign(chronic)hypertensionMalignant(accelerated)病变Morphology（一）良性高血压Benignhypertension1.机能紊乱期Stageofdysfunction2.动脉病变期Stageofarterylesionbasiclesion：

arteriolosclerosis3.内脏病变期Stageoforgandysfunction

高血压心脏病

HypertensiveHeartDisease

（1）病变

向心性肥大Concentrichypertrophy

离心性肥大

Eccentrichypertrophy（2）临床病理联系左心室向心性肥大左心室失代偿性扩张

细动脉性肾硬化

ArteriolarNephrosclerosis

(primarygranulo-contractedkidney)

（1）镜下:(Microscopicchange)

肾血管，肾小球，肾小管，肾间质

（2）大体:(Grossalteration)

颗粒性固缩肾高血压固缩肾

高血压脑HypertensivebrainhypertensiveencephalopathyHemorrhageofbrainSofteningofbrain

视网膜病变Lesionsofretina侧脑室出血呈银丝状眼底细动脉

(2)恶性高血压Malignanthypertension

基本病变Basiclesion:

坏死性细动脉炎necroticarteriolitis

增生性小动脉硬化proliferatingarteriosclerosis

主要受损器官Themajorinjuredorgans:

kidneyandbrainEtiologyandPathogenesis1.Riskfactors（1）Geneticfactors

肾素—血管紧张素编码基因（多态性、点突变）激素样物质—抑制Na/K-ATP酶的活性（2）Dietaryfactors:

Na+的摄入量，肥胖，饮酒（3）Socialfactors，psychologicalstress（4）otherfactors

体力活动，神经内分泌2.PathogenesisVariantfactors—increasedVolume，

orIncreasedvasoconstriction（1）retentionofSodiumandwater（2）Vasoconstriction（神经、体液调节）（3）Thickeningofthearterywall

RheumatismEtiologyandPathogenesisInfectionwithgroupAbetahemolyticstreptococcusImmuneinjury

主要抗原:M蛋白，C多糖

Basiclesions(threestages)(1)Alterativeandexudativephase

mucoiddegeneration

fibrinoidnecrosis(2)Proliferativephase(granulomatousphase)

Aschoffbody

fibrinoidnecrosis

Aschoffcell:awl-eyecell,caterpillarcell

Aschoffgiantcellotherinflammatorycells

风湿细胞的特点

(1)来源巨噬细胞，CD68，LYSOZYME+

（2）细胞浆偏硷性（3）核染色质向中间聚集风湿性肉芽肿纤维素样坏死风湿细胞风湿性肉芽肿中风湿细胞

(3)FibrosisphaseorhealedphaseRheumaticheartdiseaseRheumaticendocarditis(verrucous

endocarditis)Distribution:

mitralvalve50%

mitralandaorticvalve50%Lesion:rheumaticlesion

verrucosvegetationsequla:valvulardisease,McCallumpatch疣状风湿性心内膜炎

Rheumaticmyocarditis

Adults:localstromal

myocarditis

Children:diffusestromal

myocarditis

风湿性心肌炎风湿性肉芽肿形成风湿性肉芽肿纤维素样坏死风湿细胞Rheumaticpericarditis

drypericarditiswetpericarditisClinicalcourse:

心音遥远，心界扩大，

X线--烧瓶状，心包摩擦音风湿性心外膜炎-绒毛心Rheumaticarthritis

70%，大关节，游走性，可复性，主为浆液性炎症Rheumaticlesionoftheskin

Erythema

annulareSubcutaneousnodulesRheumaticarteritis

动脉受累，黏液变，纤维素样坏死，偶见风湿小体RheumaticencephalopathyRheumaticarteritisofthebrainRheumaticencephalitisChoreaminor(小舞蹈病)

ChronicValvular

VitiumoftheHeart

（Valvulardisease，VD）

概念：心脏瓣膜器质性病变，引起瓣膜狭窄、关闭不全，导致心功能不全

类型：stenosis，insufficiency，并存，联合

病因：风湿性心内膜炎，亚细

Mitral

Stenosis1.thevalvularchanges

隔膜型，增厚型，漏斗型2.haemodynamicsandcardiacchanges3.clinicalcorelation

心尖区舒张期隆隆样杂音梨形心，二尖瓣面容二尖瓣狭窄——左房淤血——左房代偿性扩张肥大——肺淤血——肺动脉高压——右心室肥大——右房、大循环淤血

风湿性心瓣膜病左房扩张左房扩张瓣膜硬化左室萎缩二尖瓣膜及腱索增厚变硬二尖瓣狭窄左心房扩张

Mitralinsufficiency

1.

thevalvularchanges2.thecardiacchanges3.theclinicalcourse

收缩期吹风样杂音

X线：球形心脏

AorticstenosisX线：靴形心

Aorticinsufficiency

脉压差增大：水冲脉，血管枪击音，毛细血管波动主动脉瓣关闭不全SubacuteInfectiveEndocarditisEtiologyandpathogenesisStreptococcusviridans（草绿色链球菌）局部感染灶，医源性感染常常发生在有损伤的瓣膜发病机制：直接损伤—化脓性免疫损伤

MorphologyvegetationsVegetations(comparedwithrheumaticvalvulitis)

Large，yellowlocatedhaphazardly，

locatedatthemarginofthevalvecontainingcausativeorganismfriable亚急性细菌性心内膜炎赘生物瓣膜病变ComplicationSepticemiaEmbolismImmuneinjury

Myocarditis1.Etiology2.Morphology

ViralmyocarditisBacterialmyocarditisIsolatedmyocarditis3.ClinicalcourseTheinterstitiallymphocyticinfiltrationischaracteristicforaviralmyocarditis.

PrimarycardiomyopathyAnydysfunctionofthemyocardiumnotattributabletoCHD，valvulardisease，hypertensionorpulmonaryheartdisease.

Dilatedcardiomyopathy

Hypertrophy(M>350gF>300g)DilatationofthefourcavitiesHeartfailurethecardiomyopathydemonstrateshypertrophyofmyocardialfibersalongwithinterstitialfibrosis.Hereisalarge,dilatedleftventricletypicalofadilated,orcongestive,cardiomyopathy.Hypertrophic

cardiomyopathyHypertrophyofthemyocardiumAsymmetrichypertrophyoftheventricularseptumObstructionoftheoutflowtractThereismarkedleftventricularhypertrophy,withasymmetricbulgingofaverylargeinterventricularseptumintotheleftventricularchamber.Thisishypertrophic

cardiomyopathy.Restrictivecardiomyopathyprogressi