HF Flashcards
Early conduction disease+ SCD
Familial DCM
such as lamin cardiomyopathy
Peripartum CM timing
Chemo induced meds
w/in 5 months
anthracyclines (rubicin), trastuzumab, HER2 antagonists, TKIs (-nibs), cyclophosphamide
ACEI to ARNI washout timing
36 hours
HFrEF GDMT
BB
ARNI
Spiro
Empa
HFpEF: empa, spiro
Significant HCM gradient
Symptomatic HCM despite BB
> 50
Septal myectomy/ ablation
INTERMACS
1: cardiogenic shock
2: progressive decline
3: stable but inotrope dependent
4: frequent admissions and recurrent HF relapses
5: exertion intolerant
6: exertion limited
Forrester
I: warm and dry
II: warm and wet
III: cold and dry
IV: cold and wet
HFpEF diagnosis
resting PCWP >15 mm Hg or exercise PCWP >25 mm Hg. Neither normal BNP nor E/e’ excludes diagnosis.
Peripartum CM risk factors
African-American race, gestation hypertension, advanced maternal age, and multiparity
LV noncompaction diagnosis
maximum end-diastolic noncompacted-to-compacted myocardial thickness ratio >2.3 and trabeculated LV mass >20% of the global LV mass.
Ratio >2 and LV trabecular LGE are associated with adverse events.
Chemo CM treatment
ACEI, BB
Chemo continuation is interdisciplinary decision
Peripheral and/or autonomic neuropathy: weight loss, diarrhea or constipation, and orthostatic hypotension
Hereditary ATTR amyloid: amino acid substitution in a transport protein
Anderson-Fabry
glycogen storage disease, caused by a mutation in the alpha-galactosidase gene and resulting in decreased lysosomal enzyme activity. GLA mutation
Dobu or norepi or milrinone for inotropy
Milrinone causes more hypotension?
Notch 1 mutation
bicuspid aortic valve and early aortic valve calcification.
T-box 5 (TBX5) mutation
Holt-Oram syndrome
Monitoring for chemo CM
Definition
Troponin, echo, BNP
reduction in LVEF of ≥10% or to a value of <53% in asymptomatic patients or ≥5% in symptomatic patients.
Galectin-3
fibrosis after organ injury,
associated with increased HF readmission rates, arrhythmias, and mortality
Symptomatic AF despite rate control
Pursue rhythm control with Amiodarone or dofetilide (QT prolongation and torsade de pointes) in HFrEF
Amyloid ECG.
AL amyloid pathophys
low voltage, pseudoinfarct.
plasma cell dyscrasia
ARVC diagnosis
RV WMA + FAC <33%
Anterior TWI
Get genetics
immune checkpoint inhibitor (-mabs) myocarditis
pembro: conduction disease, PVCs, VT , afib, pericarditis, pericardial effusion, myalgia. interstitial inflammation with lymphocytes on path. Treat with steroids
Pressure volume loops
Look at stroke volume, blood pressure and total volume
Advanced amyloid
palliative care
bone marrow biopsy is for AL amyloid
MYH7, myosin, actin alpha mutation
SCN5A
HCM
LQTS
Biopsy
New HF + HDUS
New HF+ dilated LV + arrhythmias or refractory to meds
frequent ventricular arrhythmias, rapidly progressive HF, and increased LV wall thickness possibly due to edema
giant cell myocarditis. treat with steroids
BNP sacubitril
elevated, use pro NT BNP instead
Cardiorenal syndrome
1: HF causes AKI due to increased renal venous pressure and subsequent kidney congestion. Increased renin, increased vasopressin, less intestinal perfusion
most common cause of HFrEF
CAD
decreased LVOT VTI despite the hyperdynamic LV ejection fraction
low forward flow due to things like MR. Weightlifters can get sudden chordal rupture.
VT/ v fib interrogation
greater number of ventricular electrograms compared to atrial electrograms
Septal myectomy instead of alcohol ablation
LBBB.
Disopyramide prolongs QT.
IABP/Impella CI
LV thrombus
Increased SCD in HCM
Family history of first-degree or close relative <50 yo SCD,
Prior cardiac arrest or sustained VT,
Recent arrhythmic syncope,
LVH >30 mm,
LV apical aneurysm,
End-stage HCM with LV ejection fraction <50%,
NSVT, extensive LGE
Coxsackie myocarditis
diffuse interstitial edema and dense lymphocytic infiltrates, painful blisters
Viral myocarditis most common causes
Parvovirus B19 and human herpes virus 6
HF iron deficiency
ferritin <100 ng/mL; or ferritin 100-299 ng/mL or iron saturation is <20%.
treat with intravenous (IV) iron sucrose or ferric carboxymaltose until the iron saturation is >20%
ARVC diagnosis
genetic testing before biopsy in borderline cases
Dilated CM+ ferritin >300, + serum iron/TIBC of >50%, transferrin sat >55%, transaminase elevation, and DM
(T2* <20 msec on CMR
(C282Y) gene
hemochromatosis
Phlebotomy regardless of hgb level-removing iron, not hgb
HFpEF workup
always look for CAD.
Hemochromatosis CMR
decreased T2 times and decreased myocardial signals on T2-weighted images
asymptomatic first-degree relatives of patients with familial DCM
serial echo q 3 years
Serial echos for anthracycline chemo
Before, after, 6 months post. If the cumulative dose is >240 mg/m2, then an echocardiogram is recommended prior to each successive dose of 50 mg/m2.
ACEI/ARNI mechanism
inhibit kinase-> increase bradykinin
increase levels of substance P by inhibiting degradation
systolic murmur heard throughout the precordium that increases in intensity with the Valsalva maneuver
HCM
Acute HF tests
EKG and echo
carpal tunnel syndrome, lumbar spinal stenosis, “self-curing” hypertension, peripheral neuropathy
ATTR amyloid
idiopathic dilated cardiomyopathy workup
three-generational family history
HFrEF bad prognostic factors
VO2 max of <14 mL/kg/min or <50% of predicted, mitral E/A ratio of >2, dilated LV
Untreated AL amyloid prognosis
<1 year, treat with systemic chemotherapy and/or autologous stem cell transplant
myocarditis pathophys
1) injury and activation of innate immunity; 2) acute, antigen-specific myocardial inflammation; and 3) chronic inflammatory dilated cardiomyopathy.
Vacuolated cardiomyocytes seen in
doxorubicin-associated cardiomyopathy
ARVC (disease of the desmosome) and HCM screening
all first degree relatives
drug that causes atrial tachyarrhythmia
theophylline
NSAIDs in HF cause
sodium and water retention, diuretic resistance, and increased systemic vascular resistance. Avoid.
HFrEF BNP
HFpEF BNP may not be elevated in
Always elevated
women, younger, obesity
Echo HF
higher E/e’ ratios, higher transmitral E/A ratios
sarcoid LGE
subepicardium and midmyocardium in the septum and basal lateral wall
*sarcoid also causes scleral and conjunctival injection and rash.
chemotherapy-related cardiac dysfunction
Type I CRCD: anthracyclines (i.e., doxorubicin) and generally results in myocyte destruction and clinical heart failure, permanent
Type II: trastuzumab, loss of myocardial contractility, reversible
Cyclophosphamide cardiac toxicity
myocardial ischemia but not a cardiomyopathy
most specific finding for hemochromatosis
T2* <20 msec
Post transplant SOB
Risk factors for rejection
r/o rejection with biopsy
younger age, female recipient, and African-American, cyclosporine+ mycophenolate
Post transplant complications
Coronary allograft vasculopathy timing
HF: first abnormality is often diastolic dysfunction, atrial arrhythmias.
After 1 year
Best predictor of long term survival in AL amyloid. Macroglossia is pathognomonic.
troponin, NT-proBNP
LBBB, avoid this type of stress test
ETT
Exercise nuclear (false positives), do pharm nuclear instead
ARVC + recurrent VT/ appropriate/inappropriate ICD therapies from sinus tachycardia, SVT, or atrial fibrillation (AF) or flutter with rapid ventricular rate
BBs
