Cardiomyopathy Flashcards
types of cardiomyopathy
- hypertrophic
- dilated
- restrictive
classification of HF
ACC/AHA
Heart failure stage:
A. at risk but without symptoms or structural disease
B. structural heart disease but without failure
C. structural HD with prior or current HF symptoms
D. refractory HF requiring specialized interventions
Functional class:
I. asymptomatic
II. symptomatic with moderate exertion
III. Symptomatic with minimal exertion
IV. symptomatic at rest
cardiomyopathy overview
heart muscle disease
unable to pump or fill
Ischemic: diffuse coronary artery disease with muscle involvement
Non-ischemic:
dilated
restricted
hypertrophic
stress
right vs left HF
Right:
Congestion of peripheral tissues
dependent edema and ascites
liver congestion
GI tract congestion
cor pulmonale
Left:
decreased cardiac output
pulmonary congestion
impaired gas exchange
pulmonary edema
systolic vs diastolic
Systolic:
1. EF < 50%
2. heart fails to pump
Causes: CAD, HTN, AMI, NICM
Diastolic:
1. preserved EF
2. heart fails to fill
causes: chronic HTN NICM
Primary VS Secondary
Primary:
genetic vs. acquired vs mixed genetic and acquired
: predominantly affects myocardium
Secondary:
Systemic diagnosis affecting the myocardium
multi-organ and myocardial damage
Definitions
- EF normal 55-65%
- CO=HR x SV normal 4-8Lmin
- CI= CO /BSA normal 2.5-4.0
- stroke volume = CO x HR normal 60-100
- preload volume blood end diastole
- contractility force of muscle
- afterload pressure, heart muscle contracts against
Drugs
excitatory = inotropes increase contractility and increase output
chronotropic = change HR and Rythm
* beta blocker neg chronotropic effect
* atropine and dopamine positive chronotropic effect
Non ishcemic cardiomyopathy
three main types:
Dilated
Hypertrophic
Restrictive
Dilated Cardiomyopathy
Causes: Heridatory - idiopathic 2/3, endocrine, HIV, ESRD, ETOH
* infiltrative, inflammatory
signs:
LV dilatation , thinking and global dysfunction
RV dysfunction
50% mortality in 5 years
Dilated cardiomyopathy
Diagnostic
- EKG/Eon CHO
- ST
- LBBB
- Atrial arrhythmias
- ECHO: LV dysfunction and dilation
6 . CXR: cardiomegaly, pleural effusion R> L - Cardiac MRI: identify inflammatory or infiltrative DX
Dilated cardiomyopathy
signs and symptoms
Bi vent HF:
1. rales, JVP, S3, ascites , peripheral edema
2. Cheyne Stokes
3. pulsus allernans - strong weak alternating
4. pallor
5. cyanosis
Restrictive Cardiomyopathy
uncommon
most frequent cause is amyloidosis
other causes: storage with myocytes and fibrotic changes
Diastolic dysfunction: R-side symptoms
* must distinguish between pericarditis
absence of ventricular interaction during respiration
Restrictive cardiomyopathy
diagnostics
- EKG- low voltage with LVH highly suggestive
- ECHO- LVH, bright myocardium speckled appearance , Bi atrial enlargement
- Cardiac MRI- diffuse hyperenhancement
- Bone scan- deposits in myocardium
Restrictive cardiomyopathy signs and symptoms
right side symptoms
1. edema
2. abdominal discomfort
3. ascites
4. elevated JVP
5. PE
6. mild-moderate cardiomegaly
7. angina
8. syncope
9. peripheral neuropathy
10. periorbital purpura thicken tounge and hepatomegaly
Hypertrophic cardiomyopathy
inherited autosomal dominant trait
1. elderly individuals
2. HTN usual in older adults
3. LVH
4. no pressure or volume overload
5. non uniformed
6. L ventricle > 1.5cm
7. left ventricular outflow obstruction
compromises forward flow and increases afterload, resulting in hypertrophy and dilation
hypertrophic cardiomyopathy
diagnostic
- EKG- LVH, AF, vent arrhythmias
- ECHO-LVH enlarged atria, elevated EF, and Hyperdynamic
- Cardiac MRI- confirm hypertrophy
- myocardial perfusion study- septal wall ischemia
- cardiac cath - supports diagnosis and neg for CAD
HCM
Signs and Symptoms
- dyspnea
- chest pain
- syncope common
- coronary artery bridging one or more arteries tunnel through the myocardium
- S4
Stress cardiomyopathy
- Takoitsubo “broken heart”
- increase in catecholamine surge
- 2/3 report stressful event
- LV rounded ampulla
- myocardial stunning not following ischemia
- predominantly affects women postmenopause increased with neuro and psychic disorders
Stress cardiomyopathy
diagnosis
- EKG
- ECHO- LV atypical dyskinesia
- ST elevation anterior t wave inversion
- signs and symptoms atypical of ACS
Cardiomyopathy Diagnositic
Testing
- non invasive immaging and labs-
CXR, EKG, CBC, CMP, TSH, BNP, UA - ECHO- reduced LV proceed to 3
- If the stress test is negative, order
*lexiscan, dobutamine stress test, and stress echo. If normal, proceed to 5. If 7. abnormal procede to 4 - L and R heart cath
- Cardiac MRI
- Myocardial biopsy
- transesophageal echocardiogram - if valvular abnormality cardiovert
heart failure drugs
goals
1. alleviate symptoms
2. prevent ventricular remodeling
3. extend survival
drug therapy
BB
ARB/ACE I
ARN I
SGLT I
digoxin
diuretics
alderstrone anagonist
loop diuretic
vasodilator
hydrolazine
nitrates
alternative; ace /arb/arn not tolerated
angiotensin-converting enzyme inhibitor
first-line therapy
examples: captopril, lisinopril, enalapril ramipril and quinapril
* first-line agent when EF < 40%
improves mortality and morbidity, exercise tolerance
* improves EF
* reduce ventricular remodeling
* reduce afterload
* reduce preload
* reduction of aldosterone secretion
PT should be euvolemic can cause aKI, dry cough, angio edema , FETAL TOXIC
angiotensin receptor blockers
Examples:
Losartan, Irbesartan,Candesartan
ARB antagonist of angiotension II
indication: refractory treatment with ace/bb aldosterone inhibitor
expensive
caution in use with vasodilators
Angiotension Receptor Neprilysin
ARN I
example: Entresto
inhibits neprilysin, breaks down bradykinin, is a potent endothelium vasodilator, and is a mild diuretic
* selective blocks binding of angiotensin ll to AT receptor
expensive
Blocks RAAS system
maintains hemostasis
sodium glucose cotransportor 2 inhibitor
Jariance
improvement in ventricular loading
preload and afterload
cardiac energy supply in the form of cardiac keytones
direct inhibition Na Nitrogen
decrease LV mass and improvement
in diastolic function
improve endothelium dysfunction
increase glucagon secretion
recommended for **
HRrEF
HRpEF
with and without DM II
diuretics
decrease symptoms of overload
decrease extra cell volume
decrease venous return
chronic management;
symptomatic control
no effect on mortality
watch for dehydration
aldactone - hype K
thiazides- decrease Na
aldosterone _ K sparing
diuretic examples
loop diuretics:
bumex , furosemide, toresmide
thiazides:
HCTZ , metolazone
Potassium-sparing:
amiloride, spironolactone, triamerene
aldosterone anagonists
spironolactone or eplerenone
aldosterone inhibition
minimize K loss
prevents NA and H20 retention
prevents endothelial dysfunction
and myocardial fibrosis
common to use with
Heart failure class;
II to IV with EF < 35%
beta blockers
Toprol, carvedilol , metroprol
inhibits the sympathetic nervous system
increase beta receptor sensitivity
anti-arrhythmic properties
antioxidant properties
decreases remodeling
improves contractility and blocks adrenaline
* hold or decrease in HF
cardiac glycoside
Digoxin
2nd line for CHF in AF
positive inotrope = alter force and contraction
negative inotrope= effects HR
restores vagal tone
abolish sympathetic overactivity
adverse: toxicity , N /V psychosis
bigeminy av block brady
need digabind HD not effective
vasodilator
Nitroglycerin:
angina,lowers preload
Pulm congestion
nitroprusside:
Decrease preload and afterload
* Use in ICU can cause cyanide poising
Adverse reaction:
Hypotension and thiocyanate toxic
Inotropes
Milrinone:
increase myocardial contractility
vasodilating effect
Dobutamine:
stimulate beta adrenic receptors
produce + inotrope response produce mild vasodilation in smaller doses
treatment plan for ICM
ACE I and ARB +
BB +
CCB avoid
diuretics +
Surg procedure: LHC, cabbage
treatment plan for Dilated Cardiomyopathy
ACE/ARB I +
BB +
CCB - avoid
diuretics +
OAC
NOAC
procedures: ICD ,LVAD, transplant
treatment for Hypertrophic cardiomyopathy
ACE / ARB I +/-
BB + first line
CCB +
Diuretics +
Disopyramide
procedures: myotomy, MVR ablation
treatment for Restrictive cardiomyopath
ACE/ ARB I +
BB +
CCB +
diuretics +
tafamidis for amyloid, steroid for chemo sarcoid
Procedures : BM Tx
Stress cardiomyopathy treatment
ACE I/ARB +
BB +/-
CCB -
diuretics +
procedures -
advanced therapies
continue inotrope
milrinone or dobutamine
LVAD
bridge to transplant or bridge to decision
transplant
selection process
approximate 10% mortality
