Cardiomyopathies Flashcards
problem with structure and function of the myocardium
HF
ventricular filling issue from rigid/scarring/hypertrophic walls resisting filling and increase filling pressures
diastolic HF
ejection of blood issue from cardiac muscle is weak/thin, poorly perfused, uncoordinated or severely dilated –> poor pumping
systolic HF
EF 41-49%
mid range HFmrEF
Class II - III, EF 35% or less, ARS>150ms w/ LBBB what device would you choose for HrEFHF?
CRT (cardiac resynchronization therapy w/ biventricular pacing)
IF EF <35%, what is recommended?
ICD (implantable cardioverter defibrillator
if a HrEFHF patient has Severe mitral regurg, what do you treat them with?
Transcatheter mitral valve repair (tMVR)
If a patient is NYHA class 3-4 symptomatic following hospitalization, how do you manage?
Wireless pulmonary arterial pressure monitors
Diagnostic approach to HF:
CXR
BNP
★Echo to differentiate between right + left sided
Right heart cath
Measures pressures + can confirm diagnosis
PCWP>18 = LHF
EKG
Assess for MI
What is key in diagnosis for HF
echo
INCREASING afterload → unable to fill LV
Normal LVEF
“Hypertrophy” - filling issue
heart failure w/ preserved ejection fraction
DIASTOLIC
LOWER contractility in LV → lower LVEF
“Dilated” – flow issue
SYSTOLIC
heart failure w/ reserved ejection fraction
Most common - dilation + impaired contraction of ventricles “floppy heart”
Peripheral/pulmonary edema, fatigue, ascites, Cheyne-Stokes breathing, pallor, cyanosis, pulsus alternans
dilated cardiomyopathy
In who is dilated cardiomyopathy common?
Genetic!
Black patients 3x as often
Male
What does this cause:
Hereditary, viral myocarditis, chronic alcohol use, pregnancy, cocaine, peripartum, HIV, idiopathic
Ventricular dilation → thin muscle → weak contractions → reduced ejection fraction → ultimate RV failure → functional mitral + tricuspid regurgitation
Systolic dysfunction + dilation NOT from cardiac disease processes
dilated cardiomyopathy
What does this indicate:
S3 gallop, displaced PMI, elevated JVP, MR or TR murmur
EKG: nonspecific findings like sinus tach, LBBB, atrial or ventricular arrhythmias
BNP/pro-BNP = elevated
CXR: cardiomegaly, fluid overload
TTE: Systolic dysfunction EF <40% if low LVEF
dilated cardiomyopathy
After an echo, what do you do
refer for more tests
How do you treat dilated CMP?
Control BP + cholesterol (statin!)
Mirrors HFrEF if EF<40% = 4 pillars
Diuretics for symptom management (thiazides)
Consider DOAC if a fib present
What are lifestyle changes for dilated cardiomyopathy?
Drug, alcohol, smoking cessation
Managing obesity, diabetes
salt/fluid restriction
CPAP for OSA
What can be done for severe dilation cardiomyopathy?
ICD, LVAD
What does this indicate:
Dyspnea, DOE, and chest pain
Syncope also common and post-exertional
Arrhythmias from chronic elevation + means poor prognosis - a fib, v fib is common
Sudden death may occur after exertion
HCM
What can predispose someone to hypertrophic cardiomypathy?
Athletes - family history of death from heart problems, unexpected/unexplained sudden death before 50 years
Marfan syndrome, QT syndromes, Brugada syndrome, heart problems, pacemaker, ICD, unexplained fainting, seizures, drowning
Hx of HTN, murmur, HLD, Kawasaki disease, infection, syncope, dizziness, angina, palpitations, abnormal EKG, dyspnea
Hypertrophy of septum wall – from genetic mutations of autosomal dominance with incomplete penetrance → diastolic dysfunction
→ associated with subaortic LV outflow obstruction (narrowed) and worsens with increased contractility (digoxin, beta agonists, exercise) and less LV volume (dehydration or Valsava)
hypertrophic cardiomyopathy
What does this indicate:
Harsh, systolic crescendo-decrescendo murmur heard best at LLSB WITHOUT carotid radiation
Decreased by handgrip and increased venous return (squatting)
Increased by decreased venous return (valsalva)
Bisferiens carotid pulse (biphasic pulse)
Triple apical impulse
Loud S4
JVP = prominent A wave
Femoral pulses are NORMAL (rule out coarctation of aorta)
hypertrophic cardiomyopathy
What’s the most senstive test for hypertrophic cardiomyopathy?
EKG - LVH, exaggerated septal Q waves inferolaterally
What’s diagnostic for HCM?
echo
What’s the first thing you do when you suspect HCM?
If you suspect HCM, get a cardiologist - needs to go home with an external defibrillator (LifeVest)
Complete activity restriction until evaluation/management
Avoid dehydration + extreme exertion
What do you prescribe for HCM?
Beta blockers
CCBs (verapamil)
Disopyramide
What are procedures you can do for HCM?
Myomectomy of septum
Ethanol septal ablation
ICD placement
What’s a medication you can add for NYHA class II-III?
Mavacamten
If HCM has a fib, always
add DOACs
Least common
RHF: pitting edema, JVD, Kussmauls, hepatic congestion
restrictive cardiomyopathy
Restrictive filling + reduced diastolic volume
Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, MCTD
RHF>LHF
restrictive cardiomyopathy
PE: periorbital purpura, thickened tongue, hepatomegaly
EKG: low voltage
High levels of BNP>400
Echo= primary TOC → marked dilation of both atria, ventricles non-dilated, diastolic dysfunction
Cardiac MRI: hyperenhancement w/ amyloidosis
Biopsy needed to confirm if amyloidosis (apple-green with Congo red stain)
restrictive cardiomyopathy
How do you treat restrictive cardiomyopathy
Treat underlying cause, diuresis for symptoms
Angina, dyspnea, arrhythmia, substernal chest pain
takotsubo cardiomyopathy
Who’s at risk for takotsubo cardiomyopathy?
Postmenopausal women after large stress, after death
Broken heart syndrome – LV apical ballooning
takotsubo cardiomyopathy
EKG: ST elevation and deep anterior TWI in anterior leads
CXR: fluid overload
Elevated troponin
Echo: LV apical dyskinesia and ballooning NOT consistent with any coronary distribution
Cath is normal
takotsubo cardiomyopathy
diagnosis of exclusion that can only be made after angiography!
takotsubo cardiomyopathy
How do you treat takotsubo cardiomyopathy?
Similar to any acute MI
Long term therapy if LV dysfunction persists
Aspirin + BBs + ACE-Is
Refer to cardio
