5.6 DCM

Question 1

a) List any three presenting clinical features of dilated
cardiomyopathy (DCM).

Answer 1

● Palpitations (tachycardia).

● Breathlessness (dyspnoea).

● Fatigue.

● Pedal oedema.

● Ascites.

● TIA/stroke (emboli from LV thrombus).

Question 2

b) What are the pharmacological and non-pharmacological management options for a patient with DCM?

Answer 2

● ACE inhibitors.

● Loop diuretics.

● Beta-blockers.

● Spironolactone.

● Anticoagulants (LV thrombus).

● Biventricular (resynchronisation) pacing.*

● Left ventricle assist devices.*

● Heart transplantation.*

Question 3

c) List the predictors of poor outcome in patients with DCM undergoing surgery.

Answer 3

● Left ventricular ejection fraction <20%.*

● Elevated left ventricular end-diastolic pressure.*

● Left ventricle hypokinesia.*

● Non-sustained ventricular tachycardia.*

Question 4

d) What are the haemodynamic goals when anaesthetising
patients with DCM?

Answer 4

● Avoid tachycardia.

● Minimise cardiodepressant negative ionotropic

(myocardial depression)
effects of anaesthetic agents.

● Maintain preload.

● Prevent an increase in afterload
(facilitates LV offloading).

Question 5

e) What measures would you take to achieve these
haemodynamic goals during anaesthesia?

Answer 5

arterial line -

goal directed fluid therapy -
co monitoring / toe

vasopressors to maintain svr

cardiac stable induction with higher dose of fentanyl / opiod and titrated propofol doses

quickly rx arryhthmia

avoid pain and stress response - regional tech whwere possible

● Opioids have minimal myocardial depressant effects.

● Etomidate causes the least haemodynamic changes.

● Ketamine should be avoided
(causes undesirable tachycardia and a rise in SVR).

● Careful titration of anaesthesia.

● Avoid sudden hypotension for
maintaining organ perfusion.

● Invasive monitoring and guided fluid therapy.

● Maintain systemic vascular resistance
with vasopressors.

● Maintain cardiac output
(with inodilators such as
phosphodiesterase inhibitors).

● Treat arrhythmias.

● Regional anaesthesia offers
minimal haemodynamic changes.

● Central neuraxial blockade would increase forward cardiac output (by reducing afterload),
but hypotension should be avoided.