cardiology 4: syncope HF pericardial disease Flashcards
what are the two big categories that can cause syncope?
decrease CO or decreased resistance (anything that causes brief decreased BP)
what are the things that decrease cardiac output in syncope?
- cardiogenic obstruction: AS, HOCM, PE, pulmonary HTN, pericardial effusion
- Hypovolemic (hemorrhage, fluid losses)
- Arrhythmia (brady/tachy)
- Shunting (subclavian steal, post-meal)
what are the causes of decreased resistance that can cause syncope?
- decreased sympathetic (med,s parkinsons, DM)
- Increased parasympathetic (vasovagal) - micturition, anything
- Vagal irritation - trigeminal reflex, carotid hypersensitivity, mediastinal tumor, ictal syncope
- Rare - hypoadrenal, amyloidosis, low thiamin, systemic mastocytosis
what is the tests used to work up high risk patient’s with syncope?
ECG, coronary angiogram, EP study
what classic medications can cause drug-related syncope?
BPH meds like prazosin, terazosin, and tamsulosin
what are the 3 main types of nonischemic cardiomyopathy?
- hypertrophic
- restrictive
- dilated
what are the risk factors for sudden death in HCM?
- septal thickness>30mm
- personal history of syncope
- FH of sudden death in 1st-degree family member
- NSVT on Holter monitor
- failure to augment SBP on ETT (<10mmg Hg increase at peak exercise)
what are the medical treatments for HCM?
- beta blockers (obstructive and non-obstructive)
- Verapamil (obstructive) improve diastolic filling by slowing HR
- Disopyramide with beta blockers to achieve symptom control
- IV phenylephrine (or other pure vasoconstrictors) for acute hypotension who do not respond to fluids
what are the main non-medical treatments for HCM?
- ICD placement if prior cardiac arrest, VFib, unstable VT, high-risk sudden death features)
- septal reduction therapy
- septal myectomy if severe drug-refractory HF
what are main causes of restrictive cardiomyopathy?
- lipid storage diseases
- amyloidosis
- sarcoidosis
- hemochromatosis
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what do you see on 2D echo for restrictive cardiomyopathy?
thickened myocardium with a granularity which suggests an infiltrative process
what are the important causes of DCM?
- familial
- idiopathic (viral - most common)
- cancer chemotherapy (anthracyclines)
- late hemochromatosis
- Chagas
- hypertension
- VHD
- peripartum pregnancy
Define HFrEF vs HFpEF?
HFrEF is <40%, HFpEF<50%
define stage A HF, goal of therapy, and meds?
- high risk for HF with no structural disease including any risk factor
- goal is to treat disorder and lifestyle modifications
- Ace/ARb/Statins
define stage B HF, goal of therapy, and meds?
- HF patients with structural heart disease w/o symptoms of HF
- includes patient who have history of MI, LVH, or low EF, VHD
- prevent HF symptoms and prevent further cardiac remodeling
- Ace/ARb, beta blockers, statin if history of MI/ACS
define stage c HF, goal of therapy, and meds?
- HF with structural heart disease with prior or current symptoms of HF
- goal is to control symptoms, patient education, qualify of life, and reduce hospitalizations and mortality
- loop diuretics, hydralazine/imdur for AAII,IV, aldosterone antagonists
define stage d HF, goal of therapy, and meds?
marked symptoms at rest, frequent hospitalizations despite max medical therapy
goals is to reduce symptoms, hospitalizations, qualify of life, establish end of life goals
consider all meds for stage C but heart transplantation etc
Most common causes of HFrEF?
- CAD
- DCM
- VHD
- HTN
how do most people die from HF?
50% die from actual pump failure, 40% is arrhythmias
what factors are associated with worse prognosis in HF?
- lower EF
- low sodium
- CKD /anemia
- Rhythms
- functional capacity
- higher NE and catecholamine levels
what is the sequence of events that worsen hF?
- decreased cardiac output
- causes increased A-a oxygen difference and decreased renal perfusion
- decreased renal perfusion causes the release of renin which allows conversion of Angiotensiongen –> Ang 1–> Ang 2, increase sympathetic tone and increase vasopressin.
- Ang 2 stimulates the secretion of aldosterone, which causes retention of sodium and water.
- causes increases in filling pressures, exacerbating heart failure.
- Increase in sympathetic tone and catecholamines to compensate for SV increases hr.
what do you need to monitor for while patients is on ACE/ARB?
renal impairment and hyperkalemia
which beta blockers reduce mortality in HF?
carvedilol, metoprolol succinate, and bisoprolol.
when have aldosterone antagonists shown to improve survival?
NYHA 2-4 with reduced EF<35%
when is dogixin beneficial for HF? MOA?
- in patients with reduced EF to decrease hospitalizations.
- no mortality benefit.
- reset the baroreceptors and dampen RAAS with very little inotropic effect.
what can you use for african americans with NYHA III/IV HF?
hydralazine and isosorbide dinitrate recommended to reduce morbidity and mortality as adjunctive therapy to ACE/ARB and BB.
name common meds that increase digoxin level?
- Alprazolam
- amiodarone
- macrolines
- tetracycline
- itraconazole
- omeprazole
- spirinolactone
when is CRT indicated for HF patients? what is CRT?
- CRT involves pacing the left and right ventricles
- Recommended for patients NYHA 2/3 with EF<35% sinus rhythm, LBBB with QRS duration of >150
- NYHA class IV despite optimal medical therapy
what short term agents can you use with severe ventricular failure?
inotropes like dopamine, dobutamine, or milrinone
what does dopamine do at low doses <,2ug/kg/min for HF?
causes mesenteric dilation
what does dopamine do at low doses 2 - 5ug/kg/min for HF?
predominantly beta agonist effect (positive ionotropy) and increases renal perfusion
what does dopamine do at low doses >10 ug/kg/min for HF?
has alpha-agonist effect and causes vasoconstriction
what is Mechanical circulatory support beneficial for HF?
beneficial in selected patients with stage D HFrEF in which definitive management or cardiac recovery planned.
what conditions do you see high output ventricular failure?
- peripheral shunting (large AV fistulas, severe hepatic hemangiomatosis, and paget disease)
- low systemic vascular resistance (gram negative sepsis)
- hyperthyroidism, beriberi, carcinoid, anemia
what is the treatment for acute pulmonary edema?
- legs dangling to decrease venous return
- oxygen, morphine
- lasix
- nitro
- dobutamine if SBP<90
most common cause of non-constrictive pericarditis?
viral in origin with preceding URI or gastroenteritis
the classic presentation of pericarditis?
severe chest pain sometimes pleuritic improves when leaning forward with pericardial friction rub, fever, and tachycardia.
what are the 4 stages of ECG changes with non-constrictive pericarditis?
- stage 1: diffuse ST elevation with upward concavity with PR depression
- stage 2: normalization of ST segments after several days
- Stage 3: inverted T waves
- Stage 4; weeks or months after onset of acute pericarditis, ECG returns to normal.
why does constrictive pericarditis occur?
resorption of pericardial effusion is followed by obliteration of the pericardial cavity with scarring.
what is the pathophysiology of constrictive pericarditis?
ventricular filling is normal in early diastole but reduces abruptly when the elastic limit of the pericardium is reached.
what are the 2 clinical hallmarks of constrictive pericarditis?
- Kussmaul sign: the heart is encased in a shell, negative pressure during inspiration transferred to the venous inflow tract, causing a lack of normal decrease in JVD during inspiration.
- Large right-sided X and Y descents: Seen as a brisk collapse of the jugular veins during diastole.
what CXR finding is pathognomic for constrictive pericarditis?
lateral CXR shows calcification of the RV (pericardial calcification)
how can you differentiate restrictive cardiomyopathy vs constrictive pericarditis?
RCM has an element of HF thus BNP is elevated.
what thickness of the heart is suggestive of constrictive pericarditis?
>5mm
what is the treatment for constrictive pericarditis?
open thoracotomy and pericardiectomy
what is the treatment of recurrent pericarditis?
NSAID, colchicine, and glucocorticoids
what are the 3 hallmarks of acute tamponade?
- hypotension and muffled heart sounds
- pulsus paradoxus (SBP>10mg during inspiration)
- JVD with no collapse during diastole (attenuated y descent)
what are the most common causes of pericardial tamponade?
trauma, cancer, uremia, and acute pericarditis.
what is the most common congenital abnormality found initially in adults?
bicuspid aortic valve, ostium Secundum ASD
what EKG and CXR findings do you see ostium secundum ASD?
RAD and/or RBBB. CXR shows enlarged RV with shunt vasculature.
when should surgery be performed for ostium secundum ASD?
if there is a 2:1 left to right pulmonary;/systemic shunt even if the patient is asymptomatic, the patient will need open surgical closure.
what is the most common congenital defect in children?
VSD
what abnormality is correlated with coarctation of the aorta?
bicuspid aortic valve
what are the 2 most common causes of sudden death in an exercising young person?
HCM followed by coronary anomalies
syncope during exercise with exertional chest pain.
anomalalous coronary artery
what are the 2 cardiac related absolute contraindications for pregnancy?
PAH and eisenmenger syndrome
what do you need to rule out in a pregnant patient with new onset A-fib and pulmonary edema?
mitral stenosis and secundum ASD
what can a maternal rubella infection during pregnancy cause in baby?
supravalvular AS, pulmonic stenosis, and other congenital heart defects
