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Cardiology > Diseases of the Heart Muscle and pericardial diseases > Flashcards

Diseases of the Heart Muscle and pericardial diseases Flashcards

1
Q

What is the prognosis of dilated cardiomyopathy

A

Within 5 years

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2
Q

What are the main causes of dilated cardiomyopathy?

A

1 CAD with prior MI
2 Toxic: Doxorubicin, alcohol, adriamycin
3 Infectious: Viral (recent virus causing myocarditis - end result is dilated cardio)
4 Chagas’ disease
5 Peripartum
6 Catecholamine: Pheochromocytoma and cocaine
7 Genetics

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3
Q

What are the symptoms of dilated cardiomyopathy (five things)

A
  1. ) BOTH left and right sided CHF
  2. ) Mitral/Tricuspid insufficiency (dilates)
  3. ) Cardiomegaly
  4. ) Coexisting arrhythmia
  5. ) Sudden death
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4
Q

How do you diagnose dilated cardiomyopathy?

A
  1. ) ECG (arrhythmia), CXR (cardiomegaly), echo (dilated ventricles with diffuse hypokinesia)
  2. ) Genetic testing as last resort
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5
Q

How do you treat dilated cardiomyopathy

A

1 Treat CHF: Diuretics, digoxin, vasodilators
2 Last resort: Cardiac transplantation
3 Consider anticoagulation to avoid embolization (increased risk)

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6
Q

What are the genetics of hypertrophic cardiomyopathy

A

Autosomal dominant (some sporadic cases)

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7
Q

What kind of dysfunction do you see with hypertrophic cardiomyopathy: Systolic or Diastolic

A

Diastolic - stiff ventricle therefore elevated diastolic filling pressures

Dilated cardiomyopathy had systolic dysfunction

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8
Q

What makes hypertrophic cardiomyopathy worse

A

Anything that increases HR and contractility (exercise), or decreases left ventricular filling (Valsalva)

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9
Q

What are the symptoms of hypertrophic cardiomyopathy

A
  1. Features of left outflow obstruction: Dyspnea on exertion, angina, syncope (after exertion or valsalva)
  2. Arrhythmias - Afib/ventricular arrhytmias (due to elvated atrial pressures)
  3. Heart failure, sudden death
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10
Q

What are the signs seen in hypertrophic cardiomyopathy

A

Sustained PMI, loud S4, bisferious pulse (carotid pulse with two upstrokes)

Systolic ejection murmur that increases with valsalva and standing (reduces LV filling), decreases with lying down, elevating legs, squatting, and handgrip because decreases aortic valve gradient

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11
Q

What are the effects of standing, valsalva, and leg raise for all murmurs, in comparison to squatting

A

They diminish all murmurs except HCM and MVP because LV filling decreased

Squatting: Increases all murmurs except HCM and MVP because LV filling increased

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12
Q

What maneuver must you do to distinguish between HCM and MVP

A

Handgrip - sustained decreases intensity of HCM by increasing systemic resistance, thereby decreasing aortic valve gradient

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13
Q

How do you establish the diagnosis of hypertrophic cardiomyopathy

A

Echocardiogram! With help of clinical and family history

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14
Q

What should you treat symptomatic patients with hypertrophic cardiomyopathy?

A
  1. ) B-blocker - decreases HR, allows more diastolic filling time, and reduces myocardial contractility reducing angina
  2. ) Calcium channel blocker - second line if B-blocker doesn’t works
  3. ) Treat Afib if present
  4. ) Myomectomy - relives symptoms, only if disease is severe
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15
Q

What is the pathophysiology of restrictive cardiomyopathy

A

Infiltration of myocardium - impaired diastolic filling due to decreased compliance (like hypertrophic), but systolic dysfunction in advanced disease

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16
Q

What are the 7 causes of restrictive cardiomyopathy

A

Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, carcinoid syndrome, chemo/radiation, idiopathic

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17
Q

What are the symptoms of restrictive cardiomyopathy

A

Dyspnea and exercise intolerance (like HCM for same reasons)

Right sided heart failure symptoms

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18
Q

How do you diagnose restrictive cardiomyopathy?

A

Echo showing thickened myocardium, with enlarged RA and LA, but normal RV and LV
ECG: Low voltages, arrhythmias, afib

biopsy could help

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19
Q

How do you treat restrictive cardiomyopathy (Five things)

A

Treat underlying cause

  1. ) Hemochromastosis: Phlebotomy or deferoxamine
  2. ) Sarcoidosis - glucocorticoids
  3. ) Amyloidosis - nothing
  4. ) Digoxin - only if systolic dysfunction (like dilated cardiomyopathy), except in amyloidosis
  5. ) Diruetics and vasodilators with caution (decreases preload)
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20
Q

What is the pathophysiology of myocarditis

A

Inflammation of myocardium

  1. ) viruses (Coxsackie, parvovirus, HHV6)
  2. ) bacteria (group A strep rheumatic fever, lyme disease, mycoplasma)
  3. ) sulfonamides
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21
Q

What is the classic patient for myocarditis

A

Young male

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22
Q

What can you see in labs for myocarditis

A

Increased cardiac enzyme levels and erythrocyte sedimentation rate (inflammation marker, also in rheumatoid arthritis)

  1. ) cardiac enzyme levels
  2. ) esr elevated
23
Q

How do you treat myocarditis

A

Supportive

24
Q

What are the causes of pericarditis

A
  1. ) Postviral - recent flu or GI infection
  2. ) Infectious - coxsackievirus echovirus, adenovirus, EBV, TB
  3. ) 24 hours within MI
  4. ) Collagen vascular diseases and amyloidosis
  5. ) Drug induced lupus syndrome (procainamide, hydralazine)
  6. ) Dressler syndrome - weeks to months after MI
  7. ) Neoplasm - hodgkins, breast, lung cancer
25
Q

When do the majority of patients recover with pericarditis

A

Within 1 to 3 weeks

26
Q

What are the two complications of pericarditis

A
  1. ) Pericardial effusion

2. ) Cardiac tamponade - 15% of patients

27
Q

Describe the chest pain of pericarditis

A

Pleuritic (changes with breathing), relieved by sitting up and leaning forward

28
Q

What is pericardial friction rub

A
  • Very specific for pericarditis- Caused by friction between visceral and parietal pericardial surfaces
  • Scratching high pitched sound best heard with patient sitting up
29
Q

How do you diagnose pericarditis

A

ECG (not echo, often normal)

30
Q

What do you expect to see on ECG of patient with pericarditis in sequence

A
  1. ) Diffuse ST elevation and PR depression**
  2. ) ST segments normal after 1 week
  3. ) T wave inverts
  4. ) T wave returns to normal
31
Q

What is the mainstay of therapy for pericarditis

A

First line: NSAIDS, can also use colchicine
Second line: Glucocorticoid

Contraindicated if MI was cause of pericarditis

32
Q

Should you keep pericarditis patients as inpatient

A

No, treat as outpatient unless fever and leukocytosis or pericardial effusion

33
Q

What is the pathophysiology of constrictive pericarditis

A

Fibrous scarring of pericardium - obliterates pericardial cavity

34
Q

What is the consequence of constrictive pericarditis for the heart?

A

Restricted diastolic filling, unimpeded only in first half of filling (limit of stiffness reached) unlike tamponade, which is throughout the entire diastole

35
Q

What is the most common cause of constrictive pericarditis

A

Idiopathic

36
Q

What are the two sets of symptoms that patients with constrictive pericarditis come with

A
  1. ) Fluid overload - edema, ascites, pleural effusions

2. ) Diminished CO - dyspnea with exertion, decreased exercise tolerance

37
Q

What are the signs seen in constrictive pericarditis

A

1.) JVD (elevated central venous pressure with prominent x and y descents)
2.) Kussmaul’s sign - JVD doesn’t decrease during inspiration
3.) Pericardial knock - abrupt halt in ventricular filling
4.) Ascites
5.) Dependant edema
It’s like restrictive cardiomyopathy, with (4) and (5) being right sided heart failure

38
Q

What are three diagnostic modalities you can use for constrictive pericarditis

A
  1. ) Echo - sees thickening in half of patients
  2. ) CT/MRI - adjunct - shows thickening, aids in diagnosis
  3. ) Cardiac catheterization - elevated/equal diastolic pressures in all chambers, with y descent looking like SQUARE ROOT sign
39
Q

What is the treatment of constrictive pericarditis

A

TREAT UNDERLYING cause

Can also give diuretics to treat fluid overload, and treat coagulopathy

40
Q

What is pericardial effusion

A

Any exudation of fluid into pericardial space from acute pericarditis

41
Q

What are the physical exam signs of pericardial effusion

A

Very non-specific - muffled heart sounds, soft PMI

42
Q

What is the imaging procedure of choice for pericardial effusion

A

Echo - although cannot see acute pericarditis, must do anyways because needed to rule out effusion, can detect 20ml

43
Q

Besides echo, what are four more diagnostic procedures you can do for pericardial effusion

A
  1. ) CXR - detects 250 ml, water bottle appearance but should not see pulmonary congestion to make dx
  2. ) ECG - low QRS and T waves, very non-specific
  3. ) CT/MRI - accurate, but unnecessary because of echo
  4. ) Pericardial fluid analysis - clarifies cause of effusion
44
Q

What is the algorithm for treatment of pericardial effusion

A
  1. ) If effusion small, repeat echo 1 to 2 weeks

2. ) Pericardiocentesis - don’t do unless cardiac tamponade

45
Q

What is cardiac tamponade?

A

Pericardial effusion that impairs diastolic filling of heart, has to happen over very rapid rate for this to occur

Impaired ventricular filling, leading to decreased stroke volume and cardiac output

46
Q

How much fluid needs to develop over short term and long term to cause cardiac tamponade

A

Short term - 200ml

Long term - 2L

47
Q

What do you expect to happen for pressures in all parts of heart in cardiac tamponade

A

Pressures in RV, LV, RA, LA, pulmonary artery, pericardium equalized

48
Q

What are four causes of cardiac tamponade

A
  1. ) Penetrating trauma
  2. ) Iatrogenic - central line, pacemaker, pericardiocentesis
  3. ) Pericarditis
  4. ) Post MI with free wall rupture
49
Q

What is the classic Beck’s triad of cardiac tamponade

A

1.) Hypotension
2,) Muffled heart sounds
3.) JVD

50
Q

What are the clinical features of cardiac tamponade

A

Narrowed pulse pressure (decreased SV), with pulsus paradoxus (arterial pressure falls >10 during inspiration)

51
Q

What is a complication of cardiac tamponade

A

Cardiogenic shock - tachycardia and hypotension with JVD

52
Q

What is the best test to diagnose cardiac tamponade

A

Echo - diagnostic

53
Q

What other tests can you use to diagnose cardiac tamponade besides echo

A
  1. ) CXR - 250ml accumulation but clear lung fields
  2. ) ECG - electrical alternans (alternate beat variation) due to heart swinging in pericardial space - not 100% diagnostic
  3. ) Cardiac catheterization - all pressures equal, elevated right atrial pressure with loss of y descent
54
Q

What is the algorithm for treatment of cardiac tamponade

A
  • First see if its nonhemorrhagic vs. hemorrhagic
  • If hemorrhagic, emergency surgery to stop bleeding, preferred way over pericardiocentesis
  • if nonhemorrhagic, see if they are hemodynamically stable
  • if unstable, pericardiocentesis is indicated, if stable, then monitor closely with echo, dialysis if renal failure

Cardiology (9 decks)

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