Cardiology #1: Cardiomyopathies

Question 1

MC type of cardiomyopathy

Answer 1

Dilated cardiomyopathy

Question 2

Define Dilated Cardiomyopathy

Answer 2

Systolic dysfunction, leading to a weak, dilated heart

Question 3

Risk Factors for Dilated Cardiomyopathy

Answer 3

MC in men 20-60 years old

Question 4

Etiologies of Dilated Cardiomyopathy (Remember the 6 D’s)

Answer 4

-Idiopathic (MC)
-Infections (Viral, Enteroviruses - Coxsackievirus B)
-Alcohol Abuse
-Cocaine
-Doxorubicin
-Pregnancy, Autoimmune
-Vitamin B1 (Thiamine) Deficiency

Question 5

Symptoms of Dilated Cardiomyopathy

Answer 5

-Systolic HF Symptoms: dyspnea, fatigue, peripheral edema, JVD, hepatomegaly, GI symptoms
-S3 gallop hallmark**
-Mitral or tricuspid regurgitation

Question 6

Diagnostics for Dilated Cardiomyopathy
-What does each show?
–Echo
–CXR
–ECG

Answer 6

-Echo (DOC): left ventricular dilation, thin ventricular walls, decreased EF
-CXR: cardiomegaly, pulmonary edema, pleural effusion
-ECG: sinus tachycardia, LVH, LBBB

Question 7

What is stress (Takotsubo) Cardiomyopathy?

What is the pathophysiology behind this condition?

Answer 7

Transient regional systolic dysfunction of the LV that can imitate an MI, but in absence of CAD or evidence of plaque rupture.

-Due to catecholamine surge during physical or emotional stress

Question 7

Management of Dilated Cardiomyopathy

When do you implant an AICD?

Answer 7

-Standard Systolic HF Treatment: ACEi, BB, ARBs, Spironolactone
-Symptom control with diuretics, Digoxin
-AICD if EF 35-30%

Question 8

Risk Factors for Stress Cardiomyopathy

Symptoms as well

Answer 8

-RF: postmenopausal women exposed to physical or emotional stress

-Symptoms: substernal CP, dyspnea, syncope (much like ACS)

Question 9

Diagnostics for Stress Cardiomyopathy (What does each show)
-ECG
-Cardiac Enzymes
-Coronary Angiography
-Echocardiogram

Answer 9

-ECG: ST elevations (in anterior leads especially like an anterior MI)
-Cardiac Enzymes: often positive
-Coronary Angiography: absence of acute plaque rupture or CAD
-Echo: transient regional LV systolic dysfunction, apical left ventricular ballooning.

Question 10

Treatment for Stress/Takotsubo Cardiomyopathy

Answer 10

-Initial: Aspirin, Nitroglycerin, BB, Heparin, Coronary Angiography to rule out CAD

-Short-Term Management: Conservative and supportive care is mainstay (BB, ACEi for 3-6 months with serial imaging) because symptoms are transient

Question 11

Restrictive Cardiomyopathy
-Definition

Answer 11

Diastolic dysfunction in a non-dilated ventricle, which impedes ventricular filling (decreased compliance). The stiff ventricles fill with great effort

Question 12

Etiologies of restrictive cardiomyopathy

Answer 12

-Infiltrative disease: Amyloidosis (misfolded proteins), sarcoidosis (granulomas), and Hemochromatosis (iron deposits)

-Chemotherapy, radiation

Question 13

Symptoms of restrictive cardiomyopathy

Answer 13

-RHF > LHF Symptoms
–peripheral edema, JVD, hepatomegaly, ascites, GI symptoms
–Dyspnea MC complaint
-Kussmaul’s Sign: lack of inspiratory decline or increased in JVP with inspiration
-S3 may be heard

Question 14

Diagnostics for Restrictive Cardiomyopathy

Answer 14

-Echo (DOC): non-dilated ventricles with normal thickness. Diastolic dysfunction with marked dilation of both atria.
–Bright speckled myocardium with amyloidosis
-CXR: normal ventricle chamber size, enlarged atria
-ECG: low voltage QRS
-Increased BNP
-Endomyocardial Biopsy: definitive

Question 15

What is the gold standard diagnostic for restrictive cardiomyopathy? What does it show with Amyloidosis?

Answer 15

-Endomyocardial biopsy

-Apple-green birefringence with Congo-red staining

Question 16

Management for restrictive cardiomyopathy

Answer 16

-No specific treatment
-Treat underlying disorder
-Diuretics for symptoms as needed

Question 17

Hypertrophic Cardiomyopathy
-What is it?
-What type of inheritance pattern?

Answer 17

-Autosomal dominant genetic disorder of inappropriate LV and/or RV hypertrophy with diastolic dysfunction
-Obstruction worsens with increased contractility (exercise, Digoxin) or decreased LV volume (dehydration, Valsalva)

Question 18

HOCM
-Symptoms
-Exam Findings (Murmur)

Answer 18

-Dyspnea MC symptom
-Angina, Fatigue, Syncope
-Sudden cardiac death during times of extreme exertion due to Ventricular fibrillation
-Harsh systolic murmur at LSB
–Increases with decreased venous return (Valsalva, standing, amyl nitrate)
–Decreases with increased venous return (squatting, supine, leg raise, handgrip)
-Loud S4

Question 19

Patients with HOCM can experience sudden cardiac death during times of extreme exertion due to which arrhythmia?

Answer 19

Ventricular fibrillation

Question 20

Diagnostics for HOCM
-Echo
-ECG

Answer 20

-Echo (DOC): asymmetric ventricular wall thickness (especially septal) 15mm or greater
-ECG: LVH (Tall R and deep S waves)

Question 21

Management for HOCM

Answer 21

-Medical: BB’s **
-Surgical: Myomectomy in young patients refractory to medical therapy
-Alcohol Septal Ablation: alternative to myomectomy

Question 22

What things should patients with HOCM avoid?

Why?

Answer 22

-Dehydration, extreme exertion, exercise
-Digoxin, Nitrates, Diuretics

-Digoxin increases contractility
-Nitrates and diuretics decrease LV volume

Question 23

Why is HOCM considered a “low volume lover?”

Answer 23

The murmur increases with decreased venous return (Valsalva, standing, amyl nitrate)

The murmur decreases with increased venous return (squatting, supine, leg raise, handgrip)