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CMT-uno > Cardiomyopathy/CHF > Flashcards

Cardiomyopathy/CHF Flashcards

1
Q

3 compensatory responses for CHF

A
  1. sympathetic nervous system
  2. renin-angiotensin system
  3. natriuretic peptide system
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2
Q

1-sympathetic nervous system

A

Vasoconstriction, RAAS activity, Vasopressin, Heart rate, Contractility

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3
Q

2-renin angiotensin system

A

Vasoconstriction, Blood pressure, Sympathetic tone, Aldosterone, Hypertrophy, Fibrosis

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4
Q

3-Natriuretic peptide system

A

Vasodilation, Blood pressure, Sympathetic tone, Natriuresis/diuresis Vasopressin, Aldosterone, Fibrosis, Hypertrophy

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5
Q

Heart failure
General (3)

A

Hypervolemic
bad squeeze,
congestion

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6
Q
A
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7
Q

Dilated cardiomyopathy

A

is the most common 95%
EF < 40%
enlarged cavity with thin wall, pulls valve wide and leads to regurgitation
50% mortality at 5 years

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8
Q

dilated cardiomyopathy

causes

A

Idiopathic- viral
Ischemic
Genetics/Familial – Muscular dystrophy
Endocrine – DM, thyroid disease
Tachycardiac-induced cardiomyopathy

Toxic Cardiomyopathy
Alcohol abuse, Medication induced

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9
Q

dilated myopathy

S/Sx

A

Signs & Symptoms
Gradual development of Heart Failure Symptoms
Progressive dyspnea with exertion, impaired exercise capacity, orthopnea, and peripheral edema

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10
Q

dilated cardiomyopathy

Physical Exam (6) +-

A

Rales, cardiomegaly, S3
Peripheral edema, elevated JVP
Sinus tachycardia is common
+/- mitral regurgitation and tricuspid regurgitation
+/- arrhythmias

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11
Q

dilated cardiomyopathy

Dx

A

Always:
BNP, CMP, CBC, TSH
Echocardiogram: dilated left ventricle, decreased ejection fraction, ventricular hypokinesis

Possibly:
Heart Cath (R/L)
Cxray: cardiomegaly, pulmonary edema, pleural effusions

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12
Q

dilated cardiomyopathy

Tx
What do you avoid?

A

Always:
Heart Failure Therapy (4 drugs)
SGLT2, BB, ACE/ARB/ARNI, Spiralactone

Avoid cardiotoxic agents & CCB

Possibly:
ICD ( EF< 35% post 90 days GDMT)
CRT ( EF < 35% with wide QRS post 90 days GDMT)
Referral for LVAD/transplant

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13
Q

Which of the following tests can confirm diagnosis of Cardiomyopathy?
Echocardiogram
Pro-BNP
ECG
Stress test

A

Echocardiogram

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14
Q

Tako-tsubo CM “stress CM”
”broken heart” syndrome
post catecholamine surge

A

Postmenopausal women
Present with acute anterior MI- nL coronary arteries with apical left ventricular ballooning
Usually transient ( resolves 6 months with GDMT)

Rx management and repeat echo
Rx: bb, ace/arb/arni, spironolactone (just 3)
they stay on medicine even after it heals

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15
Q

hypertrophic cardiomyopathy

A

thickened septum makes ventricle smaller

LV hypertrophy NOT related to pressure or volume overload
Traditionally defined by LV outflow obstruction due to septal hypertrophy
LV wall > 1.5cm thick on echocardiogram
Affects 1 in 500 people
Most common genetic cardiovascular disorder

In approximately 70% of patients, HCM is caused by mutations in sarcomeric contractile protein genes

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16
Q

Hypertrophic Cardiomyopathy

Causes and Tx

A

Genetic – most common HOCM
Autosomal dominant trait
Other diseases
Fabry disease – lysosomal storage disease
Friedreich’s ataxia – difficult walking and impaired speech

Medications
Tacrolimus

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17
Q

Hypertrophic Cardiomyopathy

S/Sx

A

Dyspnea, chest pain, and post exertional syncope are the most common clinical manifestations
*Sudden cardiac death *(arrhythmias)

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18
Q

Hypertrophic Cardiomyopathy

Physical Exam

A

Harsh Systolic murmur, S4, bisferiens carotid pulse, enlarged PMI
Increase murmur: Valsalva, standing (decreased venous return)
Decrease murmur: squatting, supine, leg raise, hand grip (increased venous return)

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19
Q

Hypertrophic Cardiomyopathy

Diagnostics

A

EKG – LVH
Echocardiogram; repeat with exercise and Valsalva : asymmetric septal wall thickening ( > 1.5 cm), systolic anterior motion of the mitral valve with small LV chamber
Genetic testing all primary relatives
Pregnancy counseling ( LVOT > 50 mmHg)

refer to cardio

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20
Q

Hypertrophic Cardiomyopathy

Treatment
Avoid??

A

Medical Treatment
Beta blockers, CCB (non-DHP), Disopyramide*
“block them until they are pre syncopal”
AVOID DEHYDRATION!!!
Maintain NSR
Surgical myectomy
Alcohol ablation (if high sx risk/older)
+/- ICD/DDD pacing

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21
Q
A

Septal Myectomy for Hypertrophic Cardiomyopathy

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22
Q

18- year- old presents with SOB while playing basketball. Passed out once in game. On physical exam they have a systolic murmur

What would Valsalva likely do to murmur?
What ECG change might you see?
What other physical exam findings poss?
What test confirms diagnosis? What other tests may order once confirmed?
What instructions to patient while awaiting tests?
What is treatment HOCM?
What avoidance behavior?
Meds?

A

increase with valsava
LVH
Systolic harsh murmur, S4
Echo, ekg, blood test for family
No sports
BB, CCB(non-DHP) , disopyradine

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23
Q

RestrictiveCardiomyopathy

general

A

Restrictive cardiomyopathy is characterized by nondilated, rigid ventricles with impaired ventricular filling (diastolic dysfunction)
Usually have R > L heart failure with pulmonary HTN and decline activity tolerance

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24
Q

Restrictive Cardiomyopathy

Causes

A

Amyloidosis
Sarcoidosis
Carcinoid
Hemochromatosis
Fibrosis
Other: cancer, diabetes, radiation, chemotherapy

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25
Q

Restrictive Cardiomyopathy

S/Sx

A

Signs & Symptoms
Signs of both pulmonary and systemic congestion: dyspnea, peripheral edema, palpitations, fatigue, weakness, and exercise intolerance
Must r/o constrictive pericarditis

Amyloidosis – periorbital purpura, thickened tongue, hepatomegaly, diarrhea, weight loss
Kidney & Heart are most common organs involved

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26
Q

Restrictive Cardiomyopathy

Physical Exam
Sign??

A

Rt-sided failure, elevated JVP, ascites, edema
S3
Kussmaul’s sign: increase in jugular venous pressure with inspiration

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27
Q

Restrictive Cardiomyopathy

Diagnostics

A

EKG – low voltage
Echocardiogram
Thickened LV & RV walls, biatrial enlargement, elevated right atrial pressure, normal systolic function, poor diastolic function
Cardiac MRI (if you need more info than echo) – diffuse hyper enhancement
Pulmonary hypertension (High PCWP)
Biopsy ( endometrial vs rectal/abdominal fat/gingival)
*amyloidosis associated with apple-green birefringence with congo-red staining

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28
Q

Restrictive Cardiomyopathy

Treatment

A

Treat underlying disorder
Hemochromatosis: chelation
Sarcoidosis: glucocorticoid steroids
+/- Diuretics, Beta blockers
Amyloidosis – chemotherapy, +/- stem cell transplant
Light chain (AL) – melphalan + dexamethasone
Mutated transthyretin (ATTR) – tafamidis, liver transplant
Cardiac transplantation (if cardiac involvement only)

29
Q
A

(focus on HOCM)

30
Q

A) apical ballooning of LV with reduced ejection fraction
B) asymmetric thickened septum with anterior motion of the mitral valve during systole
C) dilated left ventricle with reduced ejection fraction
E) decreased LV cavity size with restrictive filling pattern

A

Tak tsubo
Hypertrophic cm
Dilated
restrictive

31
Q

CHF

general
Sx

A

Describes the symptoms of hypervolemia due to impaired cardiac function ( decreased filling/decreased squeeze)
Symptoms include: DOE, SOB, orthopnea, edema, abdominal bloating/distention, cough, decreased appetite
Important to determine if HFpEF vs HFrEF : must obtain echocardiogram to get the ejection fraction
“normal” EF= 55-65%

32
Q

HF

causes

A

Myocardial ischemia
Arrhythmia ( Afib/flutter, av block)
Uncontrolled HTN ( leads to hypertrophy)
Dietary/medication noncompliance
Substance abuse ( cocaine/ETOH)
Anemia
Hyperthyroidism
Sepsis
Pulmonary emboli
Acute kidney injury

33
Q

How do you treat a cocaine user differently?

A

no BB give CCB instead

34
Q
A
35
Q
A

classes defined by how much activity cause SOB

36
Q

Patient presents with new diagnosis CHF. Echo shows EF 55%. Which of following is best documentation?
1- acute HFpEF
2-chronic HFpEF
3- acute HFrEF
4-chronic HFrEF

A

1- acute HFpEF

37
Q

Patient with CAD, HTN, elevated BMI presents with new DOE while doing ADLs no symptoms at rest, no daily rx. Physical exam : rales BLL and pitting edema BIL. Echo findings: EF 35% with moderate MR (mitral regurg)

1-acute/chronic
2-systolic/diastolic; HFrEF/HFpEF
3-acc stage
4-nyha class

A

Acute systolic HF or Acute HFrEF; acc stage C NYHA class II or III

dilated myopathy

38
Q

CHF Presentation

L vs R

A

Right sided
- pedal edema
-abdominal bloating
- nausea/decrease appetite

Left Sided
DOE/SOB
Orthopnea
Cough
Decline activity tolerance

39
Q

CHF Physical Findings

Right side

A

Right Sided
Distended neck veins, elevated JVP ( > 8 cm)
Abdominal distention
Pedal edema ( 1-4+)
Hepatojugular Reflux
Ascites
Liver enlargement/tenderness

40
Q

CHF Physical Findings

Left Sided

A

Rales/crackles/wheezes
Dullness to percussion
S3, S4 or gallop

41
Q

Hemodynamic assessment based on physical exam “Stevenson Profile”

A

Volume: wet vs dry
Perfusion: warm vs cold

goal is warm and dry
cold and wet = shock

42
Q

Work up for Heart Failure and Dx

A

Labs: BMP or CMP, BNP or pro-BNP, TSH, CBC
Diagnostics: Echocardiogram, ECG, Cxray
ECG

43
Q

HF

Clinical correlation of CMP?

A

-hyponatremia ( dilution? Spiro)
-K+ level ( replacement? Ok RAAS agents?)
-Renal fxn
-LFTs ( passive congestion)
-low albumin ( can cause edema)

44
Q

Work Up Heart Failure:ECG findings CHF

A

LVH ( uncontrolled HTN)
Atrial fibrillation/atrial flutter
LBBB ( suggests impaired EF)
Q waves ( old MI?)

45
Q
A

LVH

46
Q
A

Afib

47
Q

Work Up Heart Failure: Cxray
ABCDE

A

A:
Alveolar edema (bat wing opacities)
B:
Blunting of margins
Kerley B lines
C:
Cardiomegaly
D:
Dilated upper lobe vessels
E:
Pleural effusion
Pulmonary edema

48
Q

83-year-old man presents with labored breathing from nursing home
PMHx: CAD hx CABG, HTN, HLP
What rx should he be on?
What do you order?

A

Rx: asa. Statin ( goal LDL < 70),
Order: cmp, cbc, tsh, bnp; ECHO

49
Q

what med do people with CABG take?

A

STATIN

50
Q

Which of the following data does NOT suggest CHF?
1- elevated pro-BNP
2-vascular congestion on Cxray
3-elevated TSH
4- est EF 35% on echocardiogram

A

3-elevated TSH

51
Q

Navigating Heart Failure
4 steps

A

first thing you do is diuretics (loop)

52
Q

CHF

Tx

A
53
Q

GDMT: EF < 50%:
Tx and goals

A

SGLT2-I
ARNI/ACE/ARB (ARNI preferred and better )
Spironolactone
Beta-blockers ( metoprolol or carvedilol

Bp: < 120/80
HR: < 70
Euvolemic ( warm and dry)

54
Q

GDMT: EF >50%:
Tx and goals

A

SGLT2-I
ARNI/ACE/ARB
Spironolactone

 Goals Bp: < 120/80 HR: < 70 Euvolemic ( warm and dry)
55
Q

HFrEF ( < 40%)
TX and goals

A

SGLT2-I
ARNI/ACE/ARB
Spironolactone
Beta-blocker ( metoprolol or carvedilol)

 Goals Bp: < 120/80 HR: < 70 \+/- ICD (internal cardiac difib) qualify if EF < 35% and no response to meds in 90 days, CRT Euvolemic ( warm and dry)
56
Q

Loop Diuretics

A

Furosemide ( iv, po, im)
Torsemide ( iv, po)
Bumetanide ( iv, po)

*do NOT treat the disease- just the symptoms

Inhibit Na-K-CL uptake in the ascending loop of Henle
Side effect: hypoK, hypoMG, hyperuricemia, hypocalcemia
Watch labs for replacement and for drying someone out!

57
Q

SGLT2-I

A

Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Canagliflozin (Invokana)

Benefit in patients EF < 50% with or without diabetes
25% mortality benefit

58
Q

Neprilysin Inhibitor

A

Entresto (ARNI)

Sacubitril + valsartan
Drug class: ARB + neprilysin inhibitor
Dosages: 24/26mg bid, 49/51 mg bid, 97/103 mg bid

preferred for EF < 50

*must have 36 hour wash out of ace-I
Prevents the breakdown of natriuretic peptides
Watch BP and volume status
Watch GFR/ K ( just like ace/arb)

59
Q
A
60
Q

MRA
mineralocorticoid receptor antagonist

A

Spironolactone
Eplerenone ($$)

Inhibits aldosterone
Prevents myocardial remodeling/fibrosis
Prevents sodium retention and K loss
Hyperkalemia
Hypomagnesemia
GI side effects
Gynecomastia ( eplerenone)

61
Q

Beta Blockers for HF

A

Carvedilol
Metoprolol (succinate)

Decrease oxygen consumption
Increase filling time
Side effect fatigue
Decrease Bp
Decrease HR

62
Q

Drugs to AVOID EF < 40%
5

A

-NSAIDS or COX-2 inhibitors
-CCBs Diltiazem/Verapamil
-ACE / ARB / ARNI combination
-Thiazolidinediones (pioglitazone and rosiglitazone)
-sulfonylureas ( make people retain fluid)

63
Q

Patient with established DCM EF 38% presents to office as work in for worsening DOE , weight gain, pedal edema. Rx: lisinopril 10 mg bid, carvedilol 6.25 mg po BID, spironolactone 25 mg daily. VS: 125/70, hr 78.
1- start po furosemide
2-increase lisinopril 20 mg po bid
3- increase carvedilol 12.5 mg po bid
4- increase spironolactone 50 mg po daily
5- dc lisinopril 36 hours and start entresto
6-start dapagliflozin

A

HFrEF, stage C,
needs SGL2, could switch lisinopril to entresto
1- yes
2-no
3-no HR is fine
4- could benefit
5- switch to entresto

64
Q

Summary

A
65
Q

HFrEF
HFmEF

A

HFrEF: reduced , <40% EF
HFmEF: 40-50% EF

66
Q

TA 48-year-old patient with DCM presents to heart failure clinic. They are on GDMT The patient is NYHA class III. Todays echocardiogram shows ejection fraction of 35%. ECG shows normal sinus rhythm with QRS 168ms and left bundle branch block.

What 4 drug classes should the patient be on ?
Which of the following interventions is indicated at this time?
ICD
CRT
Cardiac Biopsy
Mitral Clip
Palliative care referral

A

fantastic 4
CRT (they qualify for ICD)

67
Q

Which of the following cxray findings suggests CHF?
a. consolidation
b. infiltrates
c. Kerley B lines
d. widened mediastinum
e. blunting of costovertebral margins

A

c. Kerley B lines
e. blunting of costovertebral margins

widened mediastinum-> aortic aneurism

68
Q

Right or Left Sided HF
a. abdominal distention
b. basilar crackles on pulmonary auscultation
c. hepatojugular reflux
d. bilateral pedal edema
e. S3
f. jugular venous distention
g. S4

A

A-R
B-L
C-R
D-R
E-L
F-R
G-L

69
Q

What type of CM? dilatedrestrictivehypertrophic
a. Alcohol
b. Catecholamine surge
c. Genetic disease of the sarcomeres
d. Postpartum
e. Tachyarrhythmias
f. radiation exposure
g. uncontrolled hypertension

A

A- DCM- from sustained prolonged tachy HR
B-DCM-
C-HCM
D-DCM
E-DCM
F-restrictive
G-HCM

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