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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
# Restrictive Cardiomyopathy S/Sx
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
26
# Restrictive Cardiomyopathy Physical Exam Sign??
Rt-sided failure, elevated JVP, ascites, edema S3 Kussmaul’s sign: increase in jugular venous pressure with inspiration
27
# Restrictive Cardiomyopathy Diagnostics
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
28
# Restrictive Cardiomyopathy Treatment
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
(focus on HOCM)
30
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
Tak tsubo Hypertrophic cm Dilated restrictive
31
# CHF general Sx
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
# HF causes
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
How do you treat a cocaine user differently?
no BB give CCB instead
34
35
classes defined by how much activity cause SOB
36
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
1- acute HFpEF
37
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
Acute systolic HF or Acute HFrEF; acc stage C NYHA class II or III dilated myopathy
38
# CHF Presentation L vs R
Right sided - pedal edema -abdominal bloating - nausea/decrease appetite Left Sided DOE/SOB Orthopnea Cough Decline activity tolerance
39
# CHF Physical Findings Right side
Right Sided Distended neck veins, elevated JVP ( > 8 cm) Abdominal distention Pedal edema ( 1-4+) Hepatojugular Reflux Ascites Liver enlargement/tenderness
40
# CHF Physical Findings Left Sided
Rales/crackles/wheezes Dullness to percussion S3, S4 or gallop
41
# Hemodynamic assessment based on physical exam “Stevenson Profile”
Volume: wet vs dry Perfusion: warm vs cold goal is warm and dry cold and wet = shock
42
Work up for Heart Failure and Dx
Labs: BMP or CMP, BNP or pro-BNP, TSH, CBC Diagnostics: Echocardiogram, ECG, Cxray ECG
43
# HF Clinical correlation of CMP?
-hyponatremia ( dilution? Spiro) -K+ level ( replacement? Ok RAAS agents?) -Renal fxn -LFTs ( passive congestion) -low albumin ( can cause edema)
44
Work Up Heart Failure: ECG findings CHF
LVH ( uncontrolled HTN) Atrial fibrillation/atrial flutter LBBB ( suggests impaired EF) Q waves ( old MI?)
45
LVH
46
Afib
47
Work Up Heart Failure: Cxray ABCDE
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
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?
Rx: asa. Statin ( goal LDL < 70), Order: cmp, cbc, tsh, bnp; ECHO
49
what med do people with CABG take?
STATIN
50
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
3-elevated TSH
51
Navigating Heart Failure 4 steps
| first thing you do is diuretics (loop)
52
# CHF Tx
53
GDMT: EF < 50%: Tx and goals
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
GDMT: EF >50%: Tx and goals
SGLT2-I ARNI/ACE/ARB Spironolactone Goals Bp: < 120/80 HR: < 70 Euvolemic ( warm and dry)
55
HFrEF ( < 40%) TX and goals
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
Loop Diuretics
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
SGLT2-I
Dapagliflozin (Farxiga) Empagliflozin (Jardiance) Canagliflozin (Invokana) Benefit in patients EF < 50% with or without diabetes 25% mortality benefit
58
Neprilysin Inhibitor
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
60
MRA mineralocorticoid receptor antagonist
Spironolactone Eplerenone ($$) Inhibits aldosterone Prevents myocardial remodeling/fibrosis Prevents sodium retention and K loss Hyperkalemia Hypomagnesemia GI side effects Gynecomastia ( eplerenone)
61
Beta Blockers for HF
Carvedilol Metoprolol (succinate) Decrease oxygen consumption Increase filling time Side effect fatigue Decrease Bp Decrease HR
62
Drugs to AVOID EF < 40% 5
-NSAIDS or COX-2 inhibitors -CCBs Diltiazem/Verapamil -ACE / ARB / ARNI combination -Thiazolidinediones (pioglitazone and rosiglitazone) -sulfonylureas ( make people retain fluid)
63
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
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
# Summary
65
HFrEF HFmEF
HFrEF: reduced , <40% EF HFmEF: 40-50% EF
66
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
fantastic 4 CRT (they qualify for ICD)
67
Which of the following cxray findings suggests CHF? a. consolidation b. infiltrates c. Kerley B lines d. widened mediastinum e. blunting of costovertebral margins
c. Kerley B lines e. blunting of costovertebral margins widened mediastinum-> aortic aneurism
68
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-R B-L C-R D-R E-L F-R G-L
69
What type of CM? dilated restrictive hypertrophic a. Alcohol b. Catecholamine surge c. Genetic disease of the sarcomeres d. Postpartum e. Tachyarrhythmias f. radiation exposure g. uncontrolled hypertension
A- DCM- from sustained prolonged tachy HR B-DCM- C-HCM D-DCM E-DCM F-restrictive G-HCM

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