HF/ Cardiomyopathy Flashcards
headaches/fatigue
OSA tx
Central apnea
sleep apnea
CPAP
optimize volume and GDMT
rapidly progressive HF, may be in refractory shock+ ventricular arrhythmias+ h/o autoimmune d/o in young, previously healthy person
endomyocardial biopsy to eval for giant cell myocarditis
VAD complications
Bleeding, stroke, driveline infection, RV dysfunction, and device failure/thrombosis
myocarditis presentation
long term
mild dyspnea or chest pain that resolves spontaneously to arrhythmias and cardiogenic shock dilated cardiomyopathy (DCM) with heart failure
restrictive cardiomyopathy (amyloid, infiltrative, inflammatory, and endomyocardial processes) hemochromatosis, myocarditis, tachy CM, peripartum CM, takotsubo
biventricular HF, severely elevated BNP, low voltage, biatrial enlargement dilated CM (increased EDV, decreased EF, and increased eccentric myocardial mass)
myocarditis treatment
standard HF therapy, no immunosupression
Heart block/ ventricular arrhythmias + cardiomyopathy
lyme disease
chagas ECG
chagas echo
right bundle branch block, left anterior fascicular block, and atrioventricular block
ventricular dysfunction, segmental wall motion abnormalities, and apical aneurysms
hypersensitivity myocarditis
diagnosis
temporal association b/w onset of HF and new med
biopsy
chemo (anthracyclines, HER2 antagonists, and TKI therapy) induced cardiomyopathy definition
decrease in global EF/ more severe in septum
CHF signs and symptoms
LVEF drop of ≤5-55% with signs/symptoms
LVEF drop of ≤10-55% with signs/symptoms
MUGA is equivalent to echo
pulm htn in HFpEF
related to elevated left heart filling pressures
treat BP, diurese, control ventricular rate
hypotension in patients with obstructive CM
Avoid increasing contractility (will increase gradient and reduce output)
Choose agents that increase afterload (phenylephrine), alpha agonists)
excitation-contraction coupling
calcium enters cell-> calcium released from SR-> binds to troponin C-> displaces tropomyosin-> cross bridge formation
greatest risk factors for HF
hypertension and CAD
lifetime risk for development of HF at age 40
1 in 5
ICD in HCM
personal history of sudden cardiac death (SCD), ventricular fibrillation, or hemodynamically significant VT, first-degree relative with SCD, maximum wall thickness >30 mm, and one or more recent syncopal episodes, hypotension with exercise
HFpEF facts
50% of HF, as fatal as HFrEF
female, older, and hypertensive
prevalence increasing
torsemide> furosemide because
better oral bioavailability
switch if lasix is not working
Risk factors for anthracycline CM
lifetime dose, intravenous bolus admin, higher single doses, h/o of mediastinal radiation, use of other cardiotoxic agents such as cyclophosphamide, trastuzumab, and paclitaxel, female, underlying cardiovascular disease, extremes of age, increased time since therapy completion, prechemo EF <50%
most common viruses to cause myocarditis in the West
parvovirus B19 and HHV-6
spironolactone for HFpEF
TOPCAT, neutral
subgroup analysis in North American patients positive, but jury is still out
hypertensive acute heart failure
use vasodilators: nitroglycerin, isosorbide mononitrate, isosorbide dinitrate, and sodium nitroprusside, captopril?
Brockenbrough sign (HOCM)
post PVC increased contractility-> interventricular septum to anterior leaflet of mitral valve-> obstruction -> stroke volume and aortic pulse pressure falls
Post PVC
increased contractility and increased preload-> increased pressure gradient
in AS, subaortic membrane, and HOCM
Inotropy for palliation
end stage HF
continuous, intermittent has not been studied
Cardiac transplant or VAD-> continuous inotropy if not a candidate for others
preservation of the base and a large segment of apical ballooning, severely elevated BNP
treatment
takotsubo
ACEI/ BB
peripartum cardiomyopathy + severely reduced EF
anticoagulation, avoid preg
renal dysfunction in acute HF
venous congestion (hypervolemia without shock), low renal perfusion (cardiogenic shock), and dysfunctional autoregulation of the kidney
ventricular arrhythmias in HF
amiodarone, search for ischemia, electrolyte disturbances, or drug-induced QT prolongation
high RA pressure+ blunted y descent
steep x+ y descents
tamponade
constriction
survival after heart transplant
90% at 1 year, 70-75% at 5 years, and 50% beyond 10 years.
myocarditis treatment
GDMT
MRA indication
NYHA class II-IV heart failure with an LVEF of 35% or less, cr <2.5 in men and <2 in women, potassium < 5
heart failure diagnosis
go by exam
isordil/hydra
AA, NYHA class III-IV heart failure and reduced EF on ACEI+ BB Or anyone who cannot be given ACEI/ARB
risk factor that confers worst prognosis
inability to tolerate ACE inhibitors due to either hypotension or renal failure
others are hyponatremia, renal insufficiency, anemia, elevated natriuretic peptides, and elevated troponins
RHC indication
ADHF-> not responding as expected
in consideration for inotropes, LVADs, transplant
best predictors for hospital mortality in ADHF
blood urea nitrogen (≥43 mg/dl), followed by low SBP (<115 mm Hg), and high serum creatinine (≥2.75 mg/dl)
Fabry’s disease
alpha-galactosidase A deficiency
HFpEF+ chest pain, normal coronary arteries, LV hypertrophy, and renal dysfunction
family history of HF in males, X linked
endocardial thickening and mural thrombi as well as peripheral eosinophilia
Loeffler endocarditis
HF+ atrioventricular block or ventricular arrhythmias
sarcoid
5 yr mortality rate in new HF
50%
ADHF in hospital diuresis
loop diuretics
bumex to lasix
initial IV dose should equal or exceed home dose, drip is not better
lasix, bumex (more potent)
2 mg IV bumex= 80 mg IV lasix
beta blocker therapy complication
volume retention-> increase diuretic, do not decrease beta blocker
pressure volume loop change in area
shift up/down
shift left/right
change in stroke volume (preload/ afterload)
change in LV stiffness
change in contractility (decreased by BB/CCB, increased by inotropy)
Familial cardiomyopathy (different from Fabry) diagnosis
clinical, 3 generations affected
myocardial remodeling in MI
Endothelin activator
prevent remodeling with
activation of the sympathetic nervous system+ RAAS= endothelin-1, collagen turnover, reduced nitric oxide activity, and cellular apoptosis-> increased ventricular size and sphericity, decreased contractile performance, and eventually HF
angiotension (use ACEI/ARB)
NO, ANP, and BNP
heart failure workup
only get cath if you suspect CAD (for ex not in 25 yo), biopsy is not routine (get it for things like giant cell), do it for new-onset heart failure of 2 weeks to 3 months with a dilated LV and new ventricular arrhythmias, second- or third-degree heart block, or failure to respond to usual care within 1 to 2 weeks.
CM+ high grade heart block differential
lyme, chagas, giant cell, sarcoid
weird increase in o2 sat in swan
distal migration to pulmonary vein (RA o2 can be higher than PA depending on where it is sampled, IVC can be higher)
prevent anthracycline CM with
dexrazoxane, use of liposomal anthracycline preparations, and use of prolonged continuous infusions rather than boluses, ACEI/BB if indicated?
TIA/CVA event+ carotid artery disease
aspirin+ statin
no advantage of PFO closure
risk factors for peripartum CM
Treatment
Advanced maternal age, multiparous status, multi-fetal gestation, African descent, history of hypertension/pre-eclampsia, and cocaine abuse
If hemodynamically stable, ACEI+BB
can consider advanced therapies if not recovering
HFpEF diagnosis (exertional dyspnea and fatigue w/o clear hypervolemia)
an exaggerated elevation in systemic blood pressure and intracardiac filling pressure response to exercise, augmentation in cardiac output is blunted, lack of chronotropic response
grade I DD
grade II DD
normal filling pressures, E/A ratio <0.8; DT >200 msec and averaged E/e’ ratio 2, decrease of E/A ratio of >0.5 with Valsalva; DT <160 msec, and averaged E/e’ ratio >13
moderately elevated filling pressures, Left atrial volume index >34 cc/m2, E/A ratio: 0.8-1.5; change with Valsalva >0.5, (DT) (msec): 160-200, E/e’ ratio: septal >15; lateral >12 or averaged >13.
markers of advanced HF
recurrent hospitalization, narrow pulse pressure, resting tachycardia, intolerance to ACE inhibitor, dilated ventricle, and electrical instability
CI to cardiac transplant
ongoing substance abuse, pulmonary hypertension, advanced age, obesity, or poor renal function
treatment of central sleep apnea in HF
optimize HF treatment
amyloid diagnosis
endomyocardial biopsy
most common cause of death in first 30 days after heart transplant
first year post transplant
primary graft failure (older donor age, more ischemia), then infection
rejection
best assessment of HF prognosis
functional capacity (CPET) oxygen consumption <14cc/kg/min-> transplant
severe decompensated HF in patient awaiting transplant
inotropy-> LVAD
chemo agents that cause CM
anthracyclines, trastuzamab (herceptin), TKIs (sunitinib)
target BB dose
coreg 25 mg BID, metop sux 200 mg daily
CI to impella
CI to IABP
CI to TandemHeart
CI to VA-ECMO
LV thrombus
moderate / severe AR
left atrial thrombus
severe PVD
lower cholesterol in HF
worse prognosis, related to poor nutritional status/ cachexia
HF exam+ hpi kings
JVP and orthopnea are most consistent w/ congestion
HF epidemiology
more common in older men than women
treatment of BP in people > 80 yo significantly reduces HF
At 40 years, the lifetime risk of developing HF is 20%
low voltage despite LVH
infiltrative disease (amyloid)
recurrence of CM in recovered peri partum cm
persistent peripartum cm
20%, no deaths
44%, 19% risk of mortality
HCM assessment with inconclusive echo
Obtain MRI, varied presentations as far as which walls are hypertrophic and clinical presentation
Reduce HF readmissions with
GDMT, disease education
