Cardiac Manifestations of Systemic Diseases Flashcards
What percentage of ischemic events are silent (in diabetic patients)?
90%
- requires lower threshold for testing
- more likely to have atypical symptoms
Diabetes is related to: (3)
Restrictive Cardiomyopathy
- without evidence of epicardial artery disease
- abnormal relaxation
- hypertension
Interstitial fibrosis
-increased collagen, glycoprotein, triglycerides, and cholesterol in interstitium
Increase risk of clinically symptomatic heart failure
Treatment of Diabetes
Aspirin
Control blood sugar (A1c <7)
Control HTN (controversial, ACEI/ARB)
Control Lipids (statins, LDL<70)
Obesity
● Truncal (upper body) obesity ● Cardiometabolic syndrome ○ HTN ○ Dyslipidemia (low HDL, High TG) ○ Glucose intolerance ● Eccentric cardiac hypertrophy with ventricular dilation ○ Increased circulating blood volume ○ Increased cardiac output ○ Increased LV filling pressures ● Weight reduction ○ Rapid may lead to arrythmias ○ Sudden death due to electrolyte abnormalities
Thyroid
● Thyroid hormone increase total body metabolism
● Increases oxygen consumption
● Direct inotropic and chronotropic effects on the
heart
● Increase synthesis of myosin and N-K-ATPase
● Increase # of β adrenergic receptors
● Both hypo and hyperthroidism effect the CV
system through direct and indirect mechanisms
Hyperthyroid
● Palpitations ○ Forceful contraction ○ Sinus tachycardia ○ Atrial fibrillation ● Systolic HTN ● Fatigue ● Pulmonary HTN ● Angina ● Heart failure
Hyperthyroidism- diagnostic signals
● Hyperdynamic precordium ● Widened pulse pressure ● Increased first heart sound ● Increased LV mass and LV hypertrophy ● 3rd heart sound
Hyperthyroidism- treatment
● β-blocks to control symptoms ○ Propranolol (120-160 mg/day) • Decrease the conversion of T4 to T3 • Takes 7-10 days ○ Atenolol (50 mg/day) ● Anticoagulation for patients in a-fib ● Heart failure ○ Diuretics ○ Digitals ● Treat hyperthyroidism ○ Radioactive iodine ○ Anti-thyroid (PTU, mithimazol)
Hypothyroidism
● Decreased cardiac output ○ Bradycardia ○ Decreased stroke volume ● Hypertension ○ Increase in systemic vascular resistence ● Fatigue ● Decreased exercise tolerance ● Dyspnea on exertion ● Heart failure and angina in pts with heart disease
Signals of HypOthyroidism
● Pericardial effusions ● Hypercholesterolemia ● Hyperhomocysteinemia ● Lower extremity edema ● Treatment ○ T4 replacement ○ Caution of iatrogenic hyperthyroidism
Pheochromocytoma
● Classic triad ○ Sweating ○ Tachycardia ○ Episodic headache ● Paroxysmal hypertension ● Orthostatic hypotension ○ Decrease plasma volume ● Dilated cardiomyopathy ○ Toxic effect of catecholamines ○ Secordary erythocytosis
Acromegaly
● HTN
○ Suppression of RAS
○ Increase in total body sodium and plasma volume
● LV hypertrophy
● Cardiomyopathy
○ Diastolic dysfunction
○ Arrythmias
● Increased prevalence of valvular heart disease
● Treatment (octreotide) does improve some of the
cardivascular effects
Rheumatoid Arthritus
● Increased risk of CAD ○ Inflammation ○ Vasculitis ● Increased risk of heart failure ● Pericarditis ○ Usually clinically silent ○ Pericardial effusion found on echo in 10-50% ○ Treatment with prednisone can help reduce symptoms if NSAIDS do not work ○ Tamponade is rare ● Myocarditis ○ Inflammatory granulomas ○ Possible cause of heart failure
Systemic Lupus Erytematosus
● Cardiac disease is very common in SLE ○ Pericardial ○ Myocardial ○ Coronary artery disease ○ Valvular heart disease
Lupus (SLE) Valvular Disease
● Systolic murmurs ○ Structual ○ Anemia ○ Fever ○ Tachycardia ● Mitrial valve is most commonly effected ○ Mitrial valve prolapse ○ Valvular vegetations ○ Valvular regurgitation ○ Valvular stenosis ● Libman-Sacks endocarditis (verrucous endocarditis)
Libman-Sacks endocarditis
● Most common of aortic and mitrial valves
○ Usually near the edge
● Consist of immune complexes, monocytes, fibrin, platelets
● Typically asymptomatic
○ Can break off and cause systemic emboli
○ Healing results in scar formation
● Diagnosis with negative blood cultures (new murmur) and echocardiogram (trans-esophageal is more sensitive.
● Antibiotic prophylaxis is recommended in patients with SLE valvular disease
● Treat with valve replacement in those with severe dz
SLE; Pericarditis
● Most common cause of symptomatic cardiac
involvement
○ Occurs at some point in over half of patients
● Usually asymptomatic
● May present with sub-sternal chest pain
● Pericardiocentesis needed if signs of tamponade
are present
○ Fluid may be postive for ANA and immune complexes
○ Testing fluid is not helpful in diagnosis
● Treat with NSAIDs and steroids
SLE; Myocarditis
● Rare
● May cause conduction abonormalities
● Often asymptomatic
● Suspect if there is resting tachycardia with with
unexplained cardiomegaly (usually pts will not have
fever)
● Systolic and/or diastolic dysfunction
● May present with heart failure symptoms
SLE; conduction abnormalities
● First degree heart block; often transient
● Higher degrees of heart block and arrythmias are
uncommon in adults
● Congenital heart block as part of neonatal lupus
○ Presents of antibodies in mothers of infants
○ Recommend testing for antibodies in pregnant women with
SLE
○ Anti-Ro and anti-La
Malnutrition
● Severe protein calorie malutrion
○ Weakened, hypokinetic heart muscle
○ Generalized edema from decreased oncotic pressure
○ AIDS, anorexia nervosa, heart failure patients
● Thiamine deficiency
○ Beriberi
○ High-out failure, tachycardia, and elevated ventricular filling
pressures
○ Rapid response to thiamine replacement
● Vit B6, B12, Folate deficiency
○ Hyperhomocyteinemia
• Increased atherosclerotic vascular risk
High Output Cardiac Failure
● High Cardiac Output
○ Elevated Cardiac index
● Low Systemic Vascular resistance
● Physical Findings
○ Tachycardia, bounding pulse (pistol shot)
● Causes
○ Systemic arteriovenous fistulas
○ Hyperthyroidism
○ Anemia, including the anemia of renal failure
○ Beriberi
○ Dermatologic disorders (eg, psoriasis)
○ Renal disease
○ Hepatic disease
○ Skeletal disorders (eg, Paget’s disease, multiple myeloma)
○ Hyperkinetic heart syndrome
