Chest pain Quiz - Ch 24 Flashcards
what is the difference between primary and secondary cardiomyopathy
primary - effect myocardium
secondary - associated with other specific systemic disorders.
What is the MC type of cardiomyopathy? what are the subtypes of this cardiomyopathy?
dilated
peripartum dilated CM
idiopathic dilated CM (MC)
what is the clinical presentation of DCM (both symptoms and PE)
- Systolic heart failure symptoms (dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea)
- PE shows rales, dependent edema, enlarged liver, holosystolic murmur.
what are the diagnostic studies used in DCM and what do they show?
- EKG - LVH, LAE, Q waves, poor R wave progression
- Echo - decreased ejection fraction, ventricular enlargement, increased systolic/diastolic volumes. (definitive)
- CXR - enlarged cardiac silhouette, biventricular enlargement, pulmonary vascular congestion.
what is the process of ER care for a patient with DCM exacerbation
- establish IV, O2, and cardiac monitoring
- heart failure standard therapy (diuretics and vasodilators?)
- complex ventricular ectopy = amiodarone 150mg IV over 10 min then 1 mg/min for 6 hours
what is the chronic therapy for DCM
- diuretics and digoxin (symptomatic not for survival)
- ACE and carvedilol (improves survival)
- LVAD while awaiting heart transplant
what is the MCC of dilated cardiomyopathy
myocarditis
what is myocarditis and what causes it
inflammation of myocardium due to systemic disorder or a viral or bacterial etiology
what is the clinical presentation of myocarditis
- nonspecific sx such as myalgias, HA, rigors, fever, and tachycardia.
- commonly presents with pericarditis so may see chest pain and pericardial friction rub
- severe = DOE, rales, pedal edema, cardio shock
what are the diagnostic studies used in myocarditis and what do they show
- EKG - normal or nospecific findings (AV block, prolongs QRS, ST elevation, PR depression)
- CXR - norm or pulm congestion if severe
what is the treatment of myocarditis patients in ED
- admission w supportive care
- abx
- if heart failure sx then ICU admission
what do LVADs do
aids in augmenting left ventricular output, used in severe cardiomyopathies
what are key concepts to recall if a patient comes into the ED with an LVAD
- do not do CPR (if you dislodge the LVAD it can cause hemorrhage)
- auscultate for the “Whirr” of the LVAD. if its not heard, consider changing the battery and controller but DO NOT disconnect it.
- if Whirr is heard obtain BP via doppler, place pt on monitor, obtain IV access, admin normal saline bolus.
What are common complications of LVAD and how do you treat them
- infection of abdominal wall - Abx
- anemia secondary to red cell destruction from pump or hemorrhage from anticoags - blood transfusion
- thromboembolic events - heparin
if a patient presents with an LVAD and has none of the common complications and has hypotension and/or right ventricular failure, what do you do?
admin pressors and contact LVAD coordinator
what characterizes hypertrophic cardiomyopathy
- assymetric left and/or right ventricular hypertrophy primarily involving the intraventricular septum.
- decreased compliance of LV and diastolic dysfunction
- normal EF
- hereditary!
what is the presentation of hypertrophic cardiomyopathy
- DOE, chest pain, palpitations, syncope
- PE - S4, systolic ejection murmur heard best at lower sternal border or apex. no radiation
- murmur enhanced by valsalva/standing and decreased with squatting
What are the diagnostic studies used in hypertrophic cardiomyopathy and what do they show
- EKG - LAE and LVH. deep S waves with large septal Q waves
- echo - septal hypertrophy
what is the mainstay of treatment for hypertrophic cardiomyopathy
beta blockers (atenolol)
what is restrictive cardiomyopathy and what usually causes it
- a disorder where ventricular filling is restricted (diastolic dysfunction)
- caused by sarcoidosis, amyloidosis, scleroderma, hemachromatosis, ect.
what is the clinical presentation of restrictive cardiomyopathy
- dyspnea, orthopnea, pedal edema in the absence of cardiomegaly or systolic dysfunction
- PE shows S3/4 gallop, rales, JVD, inspiratory JVD, hepatomefaly, ascited
what are the diagnostic studies for hypertrophic cardiomegaly
- EKG - nonspecific
- CXR - signs of heart failure but no cardiomegaly
what is the plan for someone who comes into the ED with acute exacerbation of hypertrophic cardiomyopaty
- symptom control w ACE and diuretics
- corticosteroids for sarcoidosis
- chelation for hemochromatosis
what is pericarditis and its etiologies
- inflammation of layers covering the heart
- viral, fungal, bacterial.
- could also be post myocarial infarction (dresslers syndrome)
what is the presentation of a patient with pericarditis
- sharp/stabbing precordial or restrosternal chest pain that may radiate to the back, neck or shoulder or arm (left trapezial ridge MC)
- worse with supine, better with sitting up and forward
- Viral prodrome, fever, dyspnea, dysphagia
- pericardial friction rub at lower left sternal border
what are the four stages of pericarditis that present on the EKG
- diffuse ST elevation with PR depression
- ST’s normalize and T wave amplitude decreases
- T wave inversion.
- resolution and normal EKG
what would a CXR show in pericarditis
usually normal but could show enlarged cardiac silhouette is a large pericardial effusion is present.
what is the treatment for patients in the ED with pericarditis
NSAIDS
(ibuprofen or colchicine)
what is non traumatic cardiac tamponade? what does it result in?
when fluid accumulates in the pericardial space and eventually exceeds the filling pressure of the right ventricle, cardiac tamponade occurs resulting in restricted filling and decreased cardiac output.
what is the clinical presentation of nontraumatic cardiac tamponade
- mild-severe shock.
- MC complaint is dypsnea
- PE - tachycardia, low systolic BP, narrow pulse pressure.
- pulsus paradoxus!!!! (drop in systolic >10 mmHg during normal inspiration
what are the diagnostic studies used in nontraumatic cardiac tamponade
- EKG - low voltage QRS complexes and ST elevations with PR depression. (similar to pericarditis)
- electrical alternans is classic but uncommon
- echo - large pericardial effusion w RA or RV collapse.
what is the treatment plan for nontraumatic cardiac tamponade in hte ER
- 2 large bore IVs, O2, continuous cardiac monitoring
- IV fluid bolus
- pericardiocentesis
what is constrictive pericarditis and what does it result it
pericardial injury and inflammation that leads to abnormal diastolic filling of the cardiac chambers
what is the presentation of constrictive pericarditis
- exertional dyspnea, pedal edema, hepatomegaly, ascities.
- Kussmaul’s sign!! (inspiratory neck vein distention)
what are the diagnostics for constrictive pericarditis
- EKG - nonspecific but can see low volt QRS and inverted T waves
- CT, MRI , or Doppler echo helpful for dx!
what is the tx for constrictive pericarditis?
surgical pericardiectomy
