Cardiomyopathy/CHF Flashcards
3 compensatory responses for CHF
- sympathetic nervous system
- renin-angiotensin system
- natriuretic peptide system
1-sympathetic nervous system
Vasoconstriction, RAAS activity, Vasopressin, Heart rate, Contractility
2-renin angiotensin system
Vasoconstriction, Blood pressure, Sympathetic tone, Aldosterone, Hypertrophy, Fibrosis
3-Natriuretic peptide system
Vasodilation, Blood pressure, Sympathetic tone, Natriuresis/diuresis Vasopressin, Aldosterone, Fibrosis, Hypertrophy
Heart failure
General (3)
Hypervolemic
bad squeeze,
congestion
Dilated cardiomyopathy
is the most common 95%
EF < 40%
enlarged cavity with thin wall, pulls valve wide and leads to regurgitation
50% mortality at 5 years
dilated cardiomyopathy
causes
Idiopathic- viral
Ischemic
Genetics/Familial – Muscular dystrophy
Endocrine – DM, thyroid disease
Tachycardiac-induced cardiomyopathy
Toxic Cardiomyopathy
Alcohol abuse, Medication induced
dilated myopathy
S/Sx
Signs & Symptoms
Gradual development of Heart Failure Symptoms
Progressive dyspnea with exertion, impaired exercise capacity, orthopnea, and peripheral edema
dilated cardiomyopathy
Physical Exam (6) +-
Rales, cardiomegaly, S3
Peripheral edema, elevated JVP
Sinus tachycardia is common
+/- mitral regurgitation and tricuspid regurgitation
+/- arrhythmias
dilated cardiomyopathy
Dx
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
dilated cardiomyopathy
Tx
What do you avoid?
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
Which of the following tests can confirm diagnosis of Cardiomyopathy?
Echocardiogram
Pro-BNP
ECG
Stress test
Echocardiogram
Tako-tsubo CM “stress CM”
”broken heart” syndrome
post catecholamine surge
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
hypertrophic cardiomyopathy
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
Hypertrophic Cardiomyopathy
Causes and Tx
Genetic – most common HOCM
Autosomal dominant trait
Other diseases
Fabry disease – lysosomal storage disease
Friedreich’s ataxia – difficult walking and impaired speech
Medications
Tacrolimus
Hypertrophic Cardiomyopathy
S/Sx
Dyspnea, chest pain, and post exertional syncope are the most common clinical manifestations
Sudden cardiac death(arrhythmias)
Hypertrophic Cardiomyopathy
Physical Exam
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)
Hypertrophic Cardiomyopathy
Diagnostics
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
Hypertrophic Cardiomyopathy
Treatment
Avoid??
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
Septal Myectomy for Hypertrophic Cardiomyopathy
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?
increase with valsava
LVH
Systolic harsh murmur, S4
Echo, ekg, blood test for family
No sports
BB, CCB(non-DHP) , disopyradine
RestrictiveCardiomyopathy
general
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
Restrictive Cardiomyopathy
Causes
Amyloidosis
Sarcoidosis
Carcinoid
Hemochromatosis
Fibrosis
Other: cancer, diabetes, radiation, chemotherapy
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
Restrictive Cardiomyopathy
Physical Exam
Sign??
Rt-sided failure, elevated JVP, ascites, edema
S3
Kussmaul’s sign: increase in jugular venous pressure with inspiration
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
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)
(focus on HOCM)
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
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%
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
How do you treat a cocaine user differently?
no BB give CCB instead
classes defined by how much activity cause SOB
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
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
CHF Presentation
L vs R
Right sided
- pedal edema
-abdominal bloating
- nausea/decrease appetite
Left Sided
DOE/SOB
Orthopnea
Cough
Decline activity tolerance
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
CHF Physical Findings
Left Sided
Rales/crackles/wheezes
Dullness to percussion
S3, S4 or gallop
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
Work up for Heart Failure and Dx
Labs: BMP or CMP, BNP or pro-BNP, TSH, CBC
Diagnostics: Echocardiogram, ECG, Cxray
ECG
HF
Clinical correlation of CMP?
-hyponatremia ( dilution? Spiro)
-K+ level ( replacement? Ok RAAS agents?)
-Renal fxn
-LFTs ( passive congestion)
-low albumin ( can cause edema)
Work Up Heart Failure:ECG findings CHF
LVH ( uncontrolled HTN)
Atrial fibrillation/atrial flutter
LBBB ( suggests impaired EF)
Q waves ( old MI?)
LVH
Afib
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
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
what med do people with CABG take?
STATIN
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
Navigating Heart Failure
4 steps
first thing you do is diuretics (loop)
CHF
Tx
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)
GDMT: EF >50%:
Tx and goals
SGLT2-I
ARNI/ACE/ARB
Spironolactone
Goals Bp: < 120/80 HR: < 70 Euvolemic ( warm and dry)
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)
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!
SGLT2-I
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Canagliflozin (Invokana)
Benefit in patients EF < 50% with or without diabetes
25% mortality benefit
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)
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)
Beta Blockers for HF
Carvedilol
Metoprolol (succinate)
Decrease oxygen consumption
Increase filling time
Side effect fatigue
Decrease Bp
Decrease HR
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)
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
Summary
HFrEF
HFmEF
HFrEF: reduced , <40% EF
HFmEF: 40-50% EF
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)
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
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
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- DCM- from sustained prolonged tachy HR
B-DCM-
C-HCM
D-DCM
E-DCM
F-restrictive
G-HCM
