Chapter 14- Cardiomyopathies and Selected Non-Cardiac Heart Disease Flashcards
define cardiomyopathy
idiopathic heart muscle dysfunction
- can be primary (genetic) or secondary with known cause (HTN, Valvular disease)
What is dilated cariomyopathy (DCM)?
characterized by enlargement and muscle dysfunction of one or both ventricles.
When DCM is classifed as Idiopathic dilated cardiomyopathy ( IDC)
when complete evaluation does not identify a recognized cause.
What are the major causes of dilated cardiomyopathy?
- myocarditis - infectious including viral, bacterial and others
- ischemic heart diease- common, generally caused by severe three vessel disease can require CA
- peripartum- related to pregnancy, can also be called postpartum or peurperal cariomyothay- recovery is complete in most cases
- hypertensive - longstanding verdivle overload
- vulvular- severe aortic or mitral disease results eventually in severe LV,
- infectious-HIV, lyme disease
- systemic- sarcoidosis, connective tissue disease
- Toxic- alcohol, cocaine, amphetamines, colbar, chemo, radiation
- metabolic- thyroid hormone excess or deficiency, dM
- neuromuscular-
- familial- FDV
How is dilated cardiomyopathy diagnosed?
clinical CHF, or via transthoracic echocardiogram (TTE) s.t sxs of dyspnea or syncope.
ECG will show impaired global LV function demonstrated by decreased EF and LV dilatation on TTE
How is Dilated cardiomyopathy treated?
- tx underlying cause.
1. ACE inhibitors
2. beta blockers
3. diuretics
4. digoxin or newer vasopressin antagonists for heart failure.
5. antriarrhythmic drugs
6. anticoagulants - pace maker or implantable carioverter defibrillator or heart transplant
What should an UW consider with dilated cardiomyopathy?
TTE studies every 3 years.
* EF >40% has a better prognosis
What are some unfavourable features of dialted cardiomyopathy?
- significant LV enlargement
- Lower EF
- Left bundle branch block (LBBB)
- A fib, AV block and ventricular arrhythmias are less favourable.
What is Hypertrophic cardiomyopathy (HCM)
characterized by Myocardial hypertrophy
Autosomal dominant, associated with DNA mytations
Define hypertrophy
What is hypertrophic obstruction cardiomyopathy (HOCM)
what are examples of obstructive hypertrophy cardiomyopathy?
- HOCM
- IHSS (Idiopathic hypertrophic subaortic stenosis)
- Hypertrophic non-obstructive cardiomyopathy (HCM)
- asymmetric septal hypertrophy (ASK)
- Apical hypertrophic cariomyopathy.
When is HCM investigated?
FX or EKG changes
- heartmurmurs, and CV sxs are investigated for HCM.
How is HCM diagnosed?
With a TTE, and MRI when available.
-disorder is suspected when septal wall thickness is greater than 15mmm, or septal anterior motion of MV.
- SAM (systolic anterior motion) is the is confirmatory for HCXM. and LV cavity is small at early stages.
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What is athletes heart
hypertrophy d/t athletic training, it seldome has a LV wall thickeness that exceeds 13mm.
- has a LV cavity dilation
What is Apical HCM?
when hypertrophy is localized to apex
- common in china and gene mutation
- dx by TEE, or CT or MRI
- no associted outflow tract obstruction but can inbvolve mid-ventricular obstruction.
- better prognosis, but higher rate of cardiac complications
How is hypertrophoc cardiomyopathy treated?
beta blockers
calcium channel blockers
to alleviate ischmia and heart failure
anticoagulants can be used in associated with A fib.
- possibla myocardial septum removal (septal myectomy)
- ablation to relive obstruction via alcohol.
- Implantavle cardioverter-defibrillator (ICD)
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What must an underwriter consider when UW those with hx of HCM?
- Fx, EKG and full TTE study.
- Sudden death prior to 40 in Fx
- ## review: sxs, Fx, septal wall thickness, outflow gradient, arrhythmias and A fib, Ventricular tachycaria, Low exercise capacity
What are HCM favourable factors?
- age over 40
- no sign of progression over 5 ys on echo
- no sxs
- no Fx of suddent bdeath
- intravbentricular septum less than 16mm
- no outflow gradient or <10 mmHG
- no hx of arrythmias
- no strenuous exercise activities.
What is athletes heart?
myocardial hypertrophy (cardiac remodelling) due athletic training. - heart usually returns to high normal within two year of stopping serious training => Need to cypher from other enlarged heart disorders.
Athletes heart can result in changes to the resting EKG such as……
- sinus bradycardia, heart rate 40-50 beats per min
- first-degree atrioventricular (AV) block, PR interval orolongation
- possible wenckebach 2nd degree AV block
- early repolarization, ST elevation
- primary T wave inversions suggesting Myocadial disease
- Complete RBBB or LBBB
What can an ECHO show noting Athletes heart?
- heart diameter that can be increased by 5-10% max
- increased LV posterior wall and septum thickness, >13mm uncomoon
- calculated heart volume index and cardiac mass index that be >25% above published normal values because of the increased wall thickeness and cardiac dilation
What is restrictive cariomyopathy
rare.
heart chambers are unable to properly fill with blood due to heart stiffness. Occues with amyloidosis and sarcoidosis and has poor prognosis
What is arrhythmogenic right ventricular cardiomyopathy (ARVC) also called arrhythmogenic right ventricular dysplasia (ARVD)
rare
replacement of the right ventricular free wall with fiber and fat.
- Serious ventricular arrhythmias can occur including ventricular tachycardia (VT) and LBBB pattern
How is ARVC/ARVD treated?
ICD, ablattion, Rx.
* recurrence is no common
What is Lt ventricular non-compaction cardiomyopathy (LVNC)
rare cardiomyopathy- familial
- myocardial wall alternations with prominent traveculae and deep intertrabecular recesses.
- associated with heart failure, thrombosis, and ventricular arrhythmias
What is the pericardium?>
the sac that surronds the heart and consist of a strong outer fibrous layer attached to the diaphram sternum and costral cartilage and a think inner serous layer over the hearts surface and acts as a protective barrier.
What causes pericardial disease?
- Viral (HIV)
- BActerial, including tuberculosios
- metabolic-
- malignancy
- autoimmune disease
- mediastinal radiation
- Myocarial infaction
- cardiac surgery or interventions
- chest trauma
- drug or toxins
- idiopathic
What is pericarditis?
inflammation of the pericadium
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In regards to actue pericarditis
- sxs
- common forms
- causes
- Diagnosis
- Prognosis
- CP radiating to shoulder, relief while standing, scratching sound, EKG changes
- idiopathic (assumed viral) and viral.
- uremia, bacteria infections, acute MI, pericariotomy following surgery, tuberculosis, malignancy, trauma
- EKG - ST elevations d/t injury cauysed by inflammation to outer myocardium. confirmation is done with fluid is seen on ECHO
- usually self-limited,complications arrise with recurrent or redisuals. Depends on underlying disorders.
How is pericardium treated?
anti-inlammatory mediation, NSAIDS, tx specific to underlying cause.
What is pericardial effusion?
abnormal collection of fluid in the pericardial space. Caused by response to injury from causes associated with acute pericarditis
- excess fluid usually resovled as inflammation subsides.
- well tolerated and full recovery, unless poor underlying disease.
What are the sxs of pericardial effiusion?
- Small usually unnoticed, maybe dull CP or pressure
- large, >120ml, can causes increase pressure wihtin the pericardial space. causes sxs of CP, syncope and cough. Mechanical can cause dysphagia frm compression and dyspnea from lung compression.
- can interfere with heart function.
Pericardial effusion can occur in hospitalized patients. When it does, its usually caused by what?
- idiopathic
- infection
- malignancy
- autoimnue
- toxic
- post– MI
- renal failure, uremia
- Myxedema associated with hypothryoidism
- Trauma, Anticoagulation bleed, aortic dissection
- serious illness
How is pericardial effusion diagnosed?
TTE, CT, MRI - used for improved visualization of amount and composition of fluids. EKG changes are described in the acute pericarditis section above.
What is pericardioventesis?
a procedure of needle aspiration of the effision, can be performed for both diagnositc and therapeutic reasons.
What is constrictive pericarditis?
thickened pericardium restricts diastolic flling of the heart.
- uncome sequela following acute pericarditis, and other pericarditis. but is often idiopathic.
What are sxs of constrictive percarditis and tx?
edema, pleural effusion sna educed exercise capacity - may require surgery.
subsequent mortality is variable.
Without surgery chronic constrictive pericarditis is a progressive disease with an unfavourable prognosis.
What are some underwriting considerations?
acute is self-limiting and has a prognosis
pericarditis or pericardial effiusion associated with systemic disease depends on underlying disorder.
What is endocarditis?
inflammation of the endocardium (innermost lining of the chambers of the heart)
- characterized by the presence of vegetation on the hear valves, endocardium or on the septal deffects.
What is the typical cause of endocarditis?
infective bacteria in the blood stream.
- fungus, or other infection associated to lupus, rheumatic fever, thrombosis or tumours.
How is endocartitis detected?
changing heart murmur, fever, and vefatations on echo
- TEE, or TTE, EKG changes can be present
How is endocarditis treated
preventative abx prior to dental or other procedsures.
- tx can be high-dose intravenous abx, valve replacement or heart abscess drainage.
What is prognosis for endocarditis?
less favourable >60 yo, delayed tx, resistant organism, heart failyre, valve infolvement, prosthetic valve infection, recurrent.
Define Congestive Heart Failure (CHF)
a clinical diagnosis based on the findings of lung congestion, edema, and liver enlargmenet.
When does heart failure tend to occur?
develops after other conditions have damaged the heart, which weakens the organ resulting in decrease to blood being pumped efficinetly throughout the body.
Events that can damage the myocardium and result in HF:
1. MI, CAD
2. Cardiomyopathies,
3. myocarditis, sarcoidosis, chagas disease,
4. neuromusclar disorders
5. infiltrative disorders
6. drugs and chemicals that imapir Myocardial funtion (steroids, beta blockets, etc)
7. Postpartum heart failure
What are some conditions that can cause cardiac overload resulting in heart failure?
- Pressure overload (HTN, valvular stenosis)
- valvular heart disease wtih regurg and volume overload
- iatrogenic volume overload (rapid blood transfusion)
- sevre anemia,
- peripheral arteriovenous shunts with high cardiac output,
- Chronic tachycardias
- pregnancy
- endocrine disorers
- Excessive physical activity in individuals with borderline heart fundtion from other cause such a mild cardiomyopathy or valvular disease.
What are the signs and symptoms of HF?
- paroxysmal nocturnal dyspnea or orthopnea or dyspnea with ordinary acitvity
- Dyspnea, cough, and lung congestion unrelated to penumonia.
- elevated jugular venous pressure (JVP) which indicates increase Rt atrial pressure
- Rales on chest ausculation
- enlarged heart, S3 gallop rhythm
- Acute Pulmonary edema
- liver enlargement and congestion
8, increased heart rate, - Atrial fibrillation with HR at 150mp
- Ankle or leg edema
- Loss of more than 4 KG in weight with a single dose of diuretic
How is Congestive heart failure diagnosed?
- CXR: heart enlargment, pulmonary congestion, pleural effusion, Kerly B lines
- echocardiogram: dilated and pooly contracting LV and/or Rt ventricle , chamber enlargement, Eright ventricle pressure >40mmHG, systolic HF, ef <45%,
- HEart catheterization: Enddiastrolic Lt vent press, >15mmHG, Rt atrial mean press >10mmHG, Lt atrial mean pressure >20mmHG.
- BNP
What is Brain Natriuretic peptide (BNP)
a hormone that promotes urine sodium excretion.
- increased levels are associated with HF and LV dysfunction, A fib, TIA, and increased mortality.
- produced as a large inactive molecure terms prohormone, when released it splits and becomes cardiac-active BNP and inactive but stable NT-proBNP.
What is Diastolic dysfunction?
impaired filling of the heart during diastole,.
- phenomenon of aging, prevelance increased with age.
- slightly better prognosis then systolic dysfunction.
How is Heart Failure treated?
Whats the prognosis?
tx’ underlying cause and decrease workload on heart.
-prognosis is poor, 5yr survival rate is 50%.
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