ACCSAP Flashcards

Question

Major complications of LV non compaction?

Answer 1

The major complications of LVNC are HF, atrial and ventricular arrhythmias, sudden cardiac arrest, and thromboembolic events, including stroke

Answer 2

For diagnosis of LVNC using echocardiography, we use the Jenni criteria ## Footnote The presence of all four of the following echocardiographic criteria are required for diagnosis: * A thickened LV wall consisting of two layers: a thin compacted epicardial layer and a markedly thickened endocardial layer with numerous prominent trabeculations and deep recesses with a maximum ratio of noncompacted to compacted myocardium \>2:1 at end-systole in the parasternal short-axis view. * Color Doppler evidence of flow within the deep intertrabecular recesses. * Prominent trabecular meshwork in the LV apex or midventricular segments of the inferior and lateral wall. * Compacted wall thickness ≤8.1 mm. The criterion of maximal systolic compacta thickness of ≤8.1 mm was found to be very specific for myocardial thickening in LVNC compared to normal controls or patients with aortic stenosis

Answer 3

Parasternal-short-axis echocardiographic end-systolic view of the left ventricle. The ratio of noncompacted myocardium (spanned by the red line [top section]) to compacted myocardium (spanned by the yellow line [bottom section]) is 3:1. Thickened left ventricular wall with a ratio ≥2:1 of non-compacted to compacted myocardium at end-systole and prominent trabecular meshwork in the LV apex or midventicle (along with color Doppler evidence of flow within the deep intertrabecular recesses) are the criteria for left ventricular noncompaction proposed by Jenni et al.

Answer 4

CMR is generally used to aid in the diagnosis of LVNC when echocardiographic findings are inconclusive. In addition, since CMR provides morphologic information (including identification of fibrosis by late gadolinium enhancement (LGE) which may have prognostic implications) NOTE: Presence of LGE on CMR indicative of fibrosis is the strongest predictor of worse outcomes.

Answer 5

A maximum end-diastolic noncompacted to compacted myocardial thickness ratio of \>2.3 A trabeculated LV mass \>20 percent of global LV mass

Answer 6

**Exercise:** (limit in patients with systolic dysfunction, arrhythmia, syncope history) **Test family members for genetics** **Heart failure:** Treat per guidelines **Anticoagulation:** If indication present (atrial fibrillation, thrombus) anticoagulate. Also LVNC with LVEF \<40 percent and/or atrial fibrillation who do not otherwise have an indication for anticoagulation. **ICD:** Secondary prevention in those with sustained Vtach or SCD. Primary prevention in those with LVEF ≤35 percent and New York Heart Association (NYHA) class II to III HF

Answer 7

Coronary artery disease (MC) Infiltrative/restrictive cardiomyopathy Valvular heart disease Percardial constriction

Answer 8

We must assess for ACS/CAD. If patient has elevated troponin, EKG changes we should use TIMI score to guide whether patient needs invasive strategy (cath) vs ischemia guided approach (stress). Note: **Coronary artery disease is very common in patients with HFpEF and therefore both stable and ACS patients with preserved EF should get an ischemia evaluation.**

Answer 9

ECG is a valuable tool in patients with heart failure - Presence of Q waves can indicate underlying ischemia - Presence of SVT/Atrial fibrillation/Atrial flutter can indicate tachycardia induced myopathy - Low voltage QRS and pseudoinfarct pattern could indicate amyloidosis

Answer 10

Common in elderly black patients Hypotension, dizziness, autonomic symptoms Peripheral edema, volume overload, heart failure Carpel tunnel syndrome

Answer 11

Arthralgias Diabetes Hyperpigmentation Elevated LFTs, cirrhosis Cardiac: Restrictive or dilated cardiomyopathies. Low voltage QRS, atrial fibrillation

Answer 12

CMR is the test of choice! There are decreased myocardial signals on T2 weighted images Note: Endomyocardial biopsy is not used for diagnosis given accuracy of CMR for hemochromatosis.

Answer 13

Iron chelation therapy Phlebotomy

Answer 14

ACE-I inhibit kinase which breaks down bradykinin. Therefore, low kinase leads to higher levels of bradykinin and cough. ARBs do not inhibit kinase and therefore, bradykinin levels decrease. ACE-I also increase the levels of substance P

Answer 15

Sacubitril is a neprilysin inhibitor. Neprilysin degrades naturitic peptides and so BNP levels increase with Sacubitril use.

Answer 16

Entresto is first line therapy for patient with HFrEF and symptoms. For patients who cannot take Entresto, we use ACEI as second line therapy.

Answer 17

Young patient Hypotension, cool and pale skin Bibasalar crackles, pulmonary and peripheral edema ST elevations, elevated troponin, low voltage QRS due to edema in myocardium Reduced EF

Answer 18

Conditions associated with fulminant myocarditis include lymphocytic myocarditis (autoimmune, toxic, or infectious), giant cell myocarditis, acute necrotizing eosinophilic myocarditis, immune checkpoint inhibitor myocarditis, and, more rarely, cardiac sarcoidosis.

Answer 19

Endomyocardial biopsy (EMB) is recommended if there is: ## Footnote New onset of unexplained heart failure (HF) of \<2 weeks' duration associated with hemodynamic compromise; Unexplained new-onset HF between 2 weeks' and 3 months' duration that is associated with a dilated left ventricle and new bradyarrhythmia, new ventricular arrhythmias, or a failure to respond to standard care within 1-2 weeks of diagnosis; and HF that is rapidly progressing when there is a high suspicion that the cause can only be confirmed by histology. Note: EMB is important to rule out giant cell and eosinophillic myocarditis both of which can respond to immunosuppression

Answer 20

The differential diagnosis of acute HF in young people includes cardiac sarcoidosis, myocarditis (due to giant cell, eosinophilic, or lymphocytic myocarditis), coronary artery disease (possibly with a spontaneous coronary artery dissection), peripartum cardiomyopathy, and takotsubo cardiomyopathy.

Answer 21

The end-systolic pressure–volume relationship (ESPVR) describes the maximum possible tension (pressure) than can be generated for any given end-diastolic volume (EDV). Contractility is described by the slope of this line.

Answer 22

Cardiovascular adverse events with ICIs may range from myocarditis and resultant heart failure to potentially serious arrhythmias. Although myocarditis may be completely reversible, mortality is up to 50% in fulminant cases. Symptoms range from dyspnea to cardiogenic shock. Troponin and B-type natriuretic peptide may be elevated. ECG may show conduction abnormalities and echocardiography may show reduced LVEF. Endomyocardial biopsy reveals interstitial inflammation with lymphocytes

Answer 23

African american race Gestation hypertension Advanced maternal age Multiparity Preclampsia

Answer 24

Fatigue Dyspnea Hypoxemia Pulmonary edema, rales Wheezing

Answer 25

Usually diagnosed in the last month of pregnancy up to 5 months after pregnancy LVEF \< 45% without focal wall motion abnormalities Note: Biventricular decreased systolic function is also common

Answer 26

Shortness of breath, other symptoms of heart failure MC early echocardiographic finding is diastolic dysfunction Arrhythmias such as PACs

Answer 27

Best test is endomyocardial biopsy Note: Coronay allograft vasculopathy usually occurs after 1 year

Answer 28

RT has been shown to improve ventricular contractile function, reverse ventricular remodeling, improve LVEF, and reduce secondary mitral regurgitation. It can also improve blood pressure, allowing titration of neurohormonal antagonists that may have additional benefits.

Answer 29

Cardiac resynchronization therapy (CRT) is indicated for patients who have an LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration of ≥150 msec, and New York Heart Association (NYHA) class II or III symptoms or ambulatory class IV symptoms on guideline-directed medical therapy

Answer 30

Type I CRCD is well studied and understood. It is most commonly associated with anthracyclines (i.e., doxorubicin) and generally results in myocyte destruction and clinical heart failure. This is at least in part a result of iron-based oxygen free radicals that pose an oxidative stress on the cardiac myocytes, ultimately leading to myocyte necrosis. Type II dysfunction, as seen with trastuzumab (monoclonal antibody against the human epidermal growth factor receptor 2 molecule), is often associated with loss of myocardial contractility but is less likely to be associated with myocyte death. As a result, it is much more likely to be reversible when compared with type I CRCD. Trastuzumab-related cardiac dysfunction has been shown to respond to drug cessation and usual medical therapies for heart failure with reduced ejection fraction (HFrEF; i.e., angiotensin-converting enzyme inhibitors, beta-blockers) in contrast to type I CRCD, which tends to be permanent

Answer 31

Multiple studies have shown that mortality is similar for both types

Answer 32

Coronary angiography should be considered in the evaluation of new onset heart failure to rule of ischemic etiology. This is especially true in older patients (low concern for myocarditis) who have risk factors for CAD. Patients with risk factors and high pre-test probability should undergo coronary angiography. (Stress testing is appropriate for those without risk factors and not high pre-test probability)

Answer 33

Normal BNP values (≤100 pg/mL) may be seen in a large percentage of patients with heart failure with preserved ejection fraction (HFpEF). Thus, a normal BNP cannot be used to rule out heart failure (HF) in patients with normal LVEF. Note: In a single-center cohort study of patients with HFpEF confirmed by elevated pulmonary capillary wedge pressure on right heart catheterization, about 30% of symptomatic outpatients had normal BNP despite high prevalence of HF symptoms and signs, including exertional dyspnea, orthopnea, elevated jugular venous pressure, and lower extremity edema.

Answer 34

Female sex Young age Obesity

Answer 35

The M-mode tracing of the mitral valve shows fluttering of the anterior leaflet of the mitral valve due to the turbulent jet of aortic insufficiency (the echocardiographic correlate of the Austin-Flint murmur). Preclosure of the mitral valve is another sign of rapidly rising left ventricular end-diastolic pressure, and the echocardiographic M-mode may show that the mitral valve is closed prior to onset of the QRS.

Answer 36

The treatment of acute aortic regurgitation is surgical replacement of the valve. Hemodynamic support with extracorporeal membrane oxygenation and percutaneous left ventricular assist devices may be required, but immediate surgery is the best option.

Answer 37

Intra-aortic balloon pump is contraindicated in aortic regurgitation because it inflates in diastole and worsens the regurgitation.

Answer 38

IABP is a balloon inflated and deflated with helium. It is introduced via femoral approach and sits in the proximal descending arota (1-2 mm below the left subclavian and above the renal arteries) Once placed we require heparin anticoagulation

Answer 39

Balloon inflates during diastole \> Increased diastolic pressure and retrograde flow \> Since coronary arteries perfuse in diastole this increases coronary perfusion and also systemic BP Balloon deflates during isovolumeric contraction \> As the balloon deflates before the opening of the aortic valve, it creates a suction force which then decreased afterload and less pressure during isovolumetric contraction to open the aortic valve \> decreased afterload and workload of the heart \> increased cardiac output

Answer 40

Aortic regurgitation Aortic dissection/aneursym Severe PAD Sepsis Coagulopathy & contraindication to anticoagulation

Answer 41

1. Failure to come off bypass/wean off bypass 2. Cardiogenic shock from severe acute MR/VSD awaiting surgery 3. High risk PCI 4. Cardiogenic shock/acute systolic heart failure

Answer 42

The degree of obstruction in oHCM, and therefore the intensity of the murmur, is dependent on preload. When preload is decreased (as with Valsalva maneuver), there is less volume flowing through the narrowed outflow tract, and therefore more obstruction, leading to an increase in murmur intensity.

Answer 43

Hypotension \> cool/clammy/pale Pulmonary congestion \> hypoxia, SOB No or faint murmur due to equalization of LA and LV pressures

Answer 44

EF is usually = SV/EDV x 100 SV = EDV - ESV (ESV decreased due to retrograde flow and EDV increases due to more blood moving in from higher preload, so both cause increased SV) In acute severe MR, there is increased preload and therefore, increased SV which causes high EF and hyperdynamic precordium However, LVOT VTI is decreased due to less forward flow

Answer 45

In patients with chronic, symptomatic, New York Heart Association (NYHA) class II or III HFrEF who tolerate an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, replacement by an angiotensin receptor–neprilysin inhibitor (ARNI) is recommended to further reduce morbidity and mortality.

Answer 46

Ivabradine can be beneficial to reduce heart failure hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving guideline-directed medical therapy, including a beta-blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of ≥70 bpm at rest (class IIa indication).

Answer 47

Plasma ultrafiltration for fluid removal in patients with heart failure was associated with more adverse events than diuretic therapy in the AVOID-HF (Aquapheresis versus Intravenous Diuretics and Hospitalization for Heart Failure) and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) trials.

Answer 48

CIMP occurs in 8% of patients who received an anthracycline with cyclophosphamide, but increases to 27% with the addition of trastuzumab. Patients will often develop asymptomatic LV dysfunction prior to developing symptomatic signs of heart failure. Unlike anthracyclines, CIMP due to trastuzumab is not related to a cumulative dose and does not appear to cause myocyte death. LV dysfunction can be reversible with treatment discontinuation, including the ability to rechallenge patients after recovery. Echocardiography to assess LVEF is mandatory to establish a baseline for serial monitoring of cardiac function when using a chemotherapeutic agent known to be associated with LV dysfunction. It is important to obtain precise measurements of LVEF using the biplane method of discs with the use of ultrasonic contrast to aid in endocardial border definition and volume calculations. Three-dimensional echocardiography may also be valuable because it is considered the most accurate LVEF measurement by echocardiography. CIMP is usually defined as a reduction in LVEF of ≥10% in asymptomatic patients or ≥5% in symptomatic patients. Cardiac biomarkers (troponin and B-type natriuretic peptides [BNP]) can be used to monitor for the development of cardiac dysfunction. Reduction in left ventricular ejection fraction (LVEF) can be a late phenomenon in chemotherapy-induced cardiomyopathy (CIMP), and troponin and BNP may provide incremental value in identifying patients at a higher risk for developing CIMP. This may be particularly useful for patients receiving trastuzumab, as left ventricular (LV) dysfunction is often asymptomatic.

Answer 49

If a chronic heart failure patient has atrial fibrillation with RVR and treated with cardioversion with restoration to NSR, we need a rhythm control strategy. In patients with structural heart disease such as heart failure with reduced ejection fraction we use amiodarone or dofelitide

Answer 50

Heart failure (dyspnea, edema) Peripheral neuropathy Carpel tunnel syndrome Lumbar spinal stenosis Self-curing hypertension (hypertension not requiring pharm treatment) EKG shows discordance between electrocardiogram voltage and echocardiographic wall thickness BUT IS PRESENT IN MINORITY OF PATIENTS

Answer 51

Nuclear scanning with technetium-labeled bone-avid tracers such as technetium-99m (Tc-99m) pyrophosphate (PYP; is specific for ATTR cardiac amyloidosis as a noninvasive alternative to myocardial biopsy. Serum kappa and lambda light chain (AL) measurement and serum and urine protein immunofixation have supplanted serum protein electrophoresis for screening for AL amyloid. In cases of suspected cardiac amyloid with evidence of a monoclonal protein, consultation with hematology and a bone marrow biopsy may be helpful. Bone marrow biopsy is not indicated for ATTR amyloid.

Answer 52

IV iron therapy should be used when there is New York Heart Association (NYHA) functional class II or III heart failure and either one of the following criteria are met: 1) the ferritin level is \<100 ng/mL; or 2) the ferritin level is between 100-299 ng/mL and the iron saturation is \<20%. Treatment is recommended even if the patient has no anemia

Answer 53

IRON-5 (Short Term Oral Iron Supplementation in Systolic Heart Failure Patients Suffering From Iron Deficiency Anemia) and IRONOUT-HF (Oral Iron Repletion Effects on Oxygen Uptake in Heart Failure), were both negative for any clinical improvement or surrogate endpoint improvement with oral iron. Studies using erythropoietin suggest harm, and its use is now a Class III recommendation in the 2017 ACC/AHA/HFSA focused update. In the RED-HF (Reduction in Events by Darbepoetin Alfa in Heart Failure) trial, a randomized double-blind study of 2,278 patients, there was no improvement in the primary endpoints of death or recurrent hospitalization, and there was an increase in both thromboembolic events and ischemic stroke

Answer 54

Pulmonary involvement as suggested by the chest X-ray with bilateral perihilar and right paratracheal lymphadenopathy ("lambda sign") Restrictive cardiomyopathy, conduction abnormalities, heart failure symptoms

Answer 55

Echocardiography reveals thinning and akinesis of the basal interventricular septum. BUT CMR or FDG-PET required for diagnosis Cardiac magnetic resonance imaging, which usually shows midmyocardial and epicardial late gadolinium enhancement, particularly in the basal septum and basal lateral wall; T2 imaging can also detect active inflammation in some cases. Positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) can also confirm active inflammation in a pattern suggestive of sarcoid.

Answer 56

Cancer therapies including anthracyclines, human epidermal growth factor receptor-2 (HER2) antagonists, immune checkpoint inhibitors, and select tyrosine kinase inhibitors may be associated with the development of left ventricular (LV) dysfunction and have emerged as important etiologies of cardiomyopathy. Regular surveillance of LV function is important during treatment with cardiotoxic agents. LV dysfunction may be an indication for temporary or permanent interruption of cancer therapy. A European Society of Cardiology (ESC) position paper proposes a prophylactic regimen including angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEIs/ARBs) and beta-blockers if there are multiple cardiac risk factors. The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of Patients With Heart Failure recommends the initiation of both beta-blockers and ACEI/ARB therapy once evidence of left ventricular dysfunction occurs. The American Society of Echocardiography (ASE) defines chemotherapy cardiotoxicity as a drop in the LVEF of \>10 percentage points or to a value of \<53%.