IMC Flashcards

1
Q

Dilated myopathy is defined as ?

? metabolic Dzs can cause dilated cardiomyopathy

What nutritional deficiency Dzs can lead to it

A

HFrEF w/ LVEF <40%
Reduced contractility w/out abnormal loading (HTN, Valve Dz)

COASTED IG
Celiac Obesity Acromegaly SLE Thyroid ETOH DM Idiopathic GH deficient

Thiamine Selenium Carnitine

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2
Q

Dilated cardiomyopathy can be induced by ? cardiac Hxs

What is normally seen on PE during dilated cardiomyopathy

What will be seen if the case is severe HF

A

Prolonged tachycardia:
RV pacing
PVCs >15% of heart beats
Supraventricular arrhythmias

REAMS ME:
Rales Elevated JVP Ascites
Megaly S3
M/T regurg Edema

Cyanosis
Pallor
Cheyne-stoke breathes
Pulsus alternans

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3
Q

What are common EKG/CXR findings of dilated myopathy

Pts w/ Dilated Cardiomyopathy that have ? Sx need to have ? Dx study

What 3 forms of Doppler will help Dx?

A
Sinus tachy
A/V arrhythmia
LBBB
CXR=
Megaly
Effusion R>L

Dyspnea= BNP, establishes prognosis/severity

Mitral: diastolic dysfunction
Color: T/M regurgitation
Continuous: PA pressures

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4
Q

Cardiac MRI is particularly helpful when imaging Dilated Myopathy of ? etiology

This is also the image of choice for ? cardiac issue

When is a cardiac biopsy most useful

A

Hemochromatosis
Inflammatory/Infiltration Sarcoidosis

RV dysplasia

Transplant rejection

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5
Q

All Pts w/ Dilated Cardiomyopathy, regardless of etiology, are Tx how?

What is the next step if still symptomatic

Why should PTs w/ Dilated Cardiomyopathy NOT be given ACEI, ARB and AAgonist?

A

ACEI and BB

Add Aldosterone antagonist (-one), replace ACEI/ARB w/ ARNI (Sacubitril/Valsartan)

HyperK risk

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6
Q

CCBs need to be avoided in Dilated Myopathy except for ? instances

What is added if congestive Sxs are still present

Dilated Cardiomyopathy HF Class 2-4 w/ Sxs need ? medications added when LVEF is <35%

A

Ventricular control during A-fib/flutter

Diuretic
Aldosterone antagonist

Aldosterone antagonist

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7
Q

The use of mineralcorticoid receptor antagonists in Dilated Myopathy Tx needs to be done cautiously when ? two factors are present?

All DM Pts should be taking mineralcorticoid receptor antagonists when?

? medication is FDA approved for BP control in PTs w/ Dilated Cardiomyopathy HF Class 2-4

A

GFR <30mL/min
Elevated K+

LVEF 40% or <

Angiotensin receptor-neprilysin inhibitor: Sacubitril/Valsartan

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8
Q

What medication is used to slow HR in Dilated Myopathy w/ HR >70, LVEF <35% and chronic, but stable HF?

? medication is used second line and why may it be preferred

What normally avoided therapy is added to AfAm Pts w/ Dilated Myopathy

A

Ivabradine- not to replace BBs

Digoxin- reduces hospitalizations and controls ventricular response in AFib

Hydralazine-nitrate

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9
Q

When is cardioversion recommended for PTs w/ Dilated Myopathy in AFib

What type of anti-coagulation is preferred for these Pts

When is an ICD implant recommended to prevent sudden death in Dilated Myopathy Pts

A

+MR and QRS >150msec

DOAC > Warfarin, unless +MS

ASx ischemic myopathy w/ LVEF <30% AND
On medical therapy and, 40days or > post-MI

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10
Q

When would Dilated Myopathy Pts benefit from LVADs?

What two etiologies of Dilated Myopathy have better prognosis’?

What three etiologies have relatively poor outcomes

A

Bridge to transplant
Temp until cardiac function returns

Peripartum/Stress induced

HIV infection
Infiltrative Dzs
Doxorubicin therapy

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11
Q

When do Pts w/ Dilated Myopathy need to be referred

When do Dilated Myopathy Pts need to be admitted

A

New/Worsening Sxs
Continuous Sxs and LVEF <35%= ICD consideration
Advance/Refractory Sxs- LVAD/transplant consideration

Hypoxia
Fluid overload
PulmEdema not resolved in clinic

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12
Q

Define Hypertrophic Cardiomyopathy

Hypertrophic Cardiomyopathy may present w/ ? 3 Sxs

? is Dx and ? defines the Dz

A

LVH unrelated to pressure/volume overload

Syncope Angina* Dyspnea* d/t diastolic dysfunction

Echo= >1.5cm wall thickness reduces LV systolic stress and inc EF

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13
Q

Where is the hypertrophic abnormality located in some cases

This hypertrophy causes ? issue and ? abnormal valve response

What factors can cause Hypertrophic Cardiomyopathy to worsen

A

Mid-ventricle>posterior wall
Apex- especially Asians

Narrowed systolic outflow
Anterior MV leaf pulled inward

Increased contractility-
Post extra-systolic beats
Sympathetic stimulation
Digoxin

Decreased LV filling-
Valsalva
Peripheral dilators

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14
Q

What is the consequence of the hypertrophy in Hypertrophic Cardiomyopathy

What rarely develops later in this Dz process

LV>RV in this Dz and ? are also usually enlarged which predisposes Pts to ?

A

Inc LV diastolic pressure

Systolic dysfunction

Enlarge atria- AFib risk

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15
Q

How is Hypertrophic Cardiomyopathy acquired

What type of protein mutations at the genetic level can cause this to develop

How is Hypertrophic Cardiomyopathy differentiated from athletic induced hypertrophy

A

Autosomal dominant

Myosin heavy chains
Ca+ regulation

Athletes won’t have diastolic dysfunction

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16
Q

Hypertrophic Cardiomyopathy in older adults is usually in association w/ ? other issue/Dx

What distinct finding solidifies this Dx

A

HTN

Sigmoid interventricular septum w/ knob of muscle below AV

17
Q

What may be seen on PE of Hypertrophic Cardiomyopathy Pts

What kind of JVP changes can be seen

Where are Hypertrophic Cardiomyopathy murmurs heard

A

Bisferiens carotid pulse
Loud S4
Triple apical impulse

Prominent A-waved d/t dec RV compliance

Systolic murmur along left sternal border

18
Q

What types of maneuvers cause Hypertrophic Cardiomyopathy murmur to be louder

What causes Hypertrophic Cardiomyopathy murmurs to become quieter

How is Hypertrophic Cardiomyopathy murmur differentiated from AS on PE

A

Upright posture
Valsalva

Squatting

HC: dec LV volume increases outflow obstruction, murmur increases
AS: dec stroke volume decreases murmur

19
Q

What other murmur is frequently present on Hypertrophic Cardiomyopathy PE

? EKG finding is nearly universal in Hypertrophic Cardiomyopathy Pts EKG

Echo can help differentiate Hypertrophic Cardiomyopathy from ? other mimicker

A

MR

LVH
Exaggerated septal Q-waves inferolaterally

Ventricular Noncompaction- marked trabeculation that partially fills LV cavity

20
Q

What abnormality can occur in the septal arteries during Hypertrophic Cardiomyopathy

What f/u test is recommended after Hypertrophic Cardiomyopathy Echo/cMRI to to assess for ventricular arrhythmia

Why would Loop monitoring be indicated

A

Arterial bridging- coronary squeezed during systole

Exercise studies

Determine ventricular ectopy

21
Q

What is the initial medication of Tx for Sx Pts and what med is later indicated

What is the risk of using BB/Verapamil in Hypertrophic Cardiomyopathy Tx

How should Afib be Tx

A

BB
Verapamil- more potent on myocardium
Disopyramide- negative ionotropic effects for atrial arrhythmia

Improved diastolic function but dilation effect increases outflow obstruction= HOTN

Anti-arrhythmics
Radiofrequency ablation

22
Q

What Tx can help reduce progression of hypertrophy and obstruction in Hypertrophic Cardiomyopathy

A

Dual chamber pacing w/ short AV delay biventricular pacing

23
Q

When is it reasonable to consider ICD for Hypertrophic Cardiomyopathy Tx

What is the next step for Pts that don’t improve

When are Hypertrophic Cardiomyopathy considered as candidates for transplant

A

Malignant ventricular arrhythmia
Wall thickness 30mm
Unexplained syncope <6mon
Sudden death in 1* relative

Myotomy-myomectomy- excision of outflow septum
Alfieri stitch- binds mid-ant/post leaflets together

Progression to LV dilation
Intractable Sxs

24
Q

How is a non-surgical septal ablation performed for Hypertrophic Cardiomyopathy Tx

Pg 1033

A

Alcohol injection into septal branches of LCA to create controlled MI in areas of greatest wall thickness

Tx Flow Chart

25
When is pregnancy a concern for PTs w/ Hypertrophic Cardiomyopathy What is indicated for these Pts prior to planned conception Pregnant Pts w/ Hypertrophic Cardiomyopathy should have ? continuous therapy
Outflow gradient >50mmHg Genetics counseling BBs
26
What are the 6 Hypertrophic Cardiomyopathy criteria that put Pts at highest risk What exercise stress test also indicates Pt is at increased risk
1: Hx ventricular arrhythmia 2: survival of sudden death 3: FamHx of sudden death 4: unexplained syncope 5: non-sustained V-tach (3 or more beats at 120bpm) 6: max LV wall thickness 30mm or > Failure of BP to decrease by 20mmHg or more
27
Hypertrophic Cardiomyopathy Pts should not receive ? type of prophylaxis? When do Pts w/ Hypertrophic Cardiomyopathy need to be referred
Endocarditis Sx control is difficult Syncope occurred High risk features= prophylactic defibrillator consideration
28
# Define Restrictive Cardiomyopathy What is the MC cause Secondary Amyloidosis is rare but more common in ? populations
Impaired diastolic filling w/ preserved contractility, usually R>L sided failure Amyloidosis- light chain MC type Elderly AfAm- chronic inflammatory dzs
29
DDx for Restrictive Cardiomyopathy include ? Infiltrative and ? Storage Dzs How is Restrictive Cardiomyopathy Dx and confirmed What type of scan is used to detect myocardial infiltrates
Infil: Sarcoidosis Gaucher Hurler Store: Hemochromatosis Fabry Glycogen Low voltage EKG Ventricular hypertrophy on Echo Bone Scan- TxOC for Transthyretin Amyloidosis
30
How is Restrictive Cardiomyopathy differentiated from Constrictive Pericarditis What lab result can be used to differentiate? What are S/Sxs of Restrictive Cardiomyopathy
Restrictive: no ventricular accentuation w/ inspiration, elevated PA-pressure CP: + accentuation, normal PA-pressure BNP, elevated in Restrictive Cardiomyopathy Periorbital purpura Thick tongue Hepatomegaly Syncope Angina Peripheral neuropathy Stroke
31
What is a useful screening test for Restrictive Cardiomyopathy What results would be seen on Echo Biopsies from ? three locations can help confirm systemic involvement of Restrictive Cardiomyopathy
cMRI Normal LV size, rEF Small, thick LV w/ speckles Rectal Abdominal fat Gingival
32
What medication is used for Restrictive Cardiomyopathy, Familial Amyloidosis (ATTR) Tx and dec hospitalizaiton/improves QoL How is Restrictive Cardiomyopathy Tx by etiology What other meds can be used for this condition and it's effects
Tafamidis AL: Chemo/Melphalan then, Stem cell transplant Light Chain Amyloidosis: chemo w/ stem cell rescue BB ACEI/ARB Verapamil Loop Thzd AAgonists
33
What medication needs to be avoided in the Tx of Restrictive Cardiomyopathy When do Restrictive Cardiomyopathy Pts need to be referred
Digoxin- precipitates arrhythmias All w/ Dx Unexplained LVH w/ preserved LVEF and Sxs of HF
34
STOPPED
a
35
What is the MC form of ASDs What is a less common form What other issues are commonly seen in the less MC form
Persistant Ostium Secundum- mid septum Persistant Ostium Primum- low sptum M/T valve cleft VSD in upper atrial septum
36
Why do VSDs develop Why does cyanosis develop in ASD Pts What named physiology is rare but possible in ASD Pts
Failure of embryotic SVC to merge w/ atria Shunt starts L to R RV dec, inc RA pressure R to L shunt develops Eisenmenger: P-HTN w/ cyanosis
37
Eisenmenger Physiology is more common in ? type of ASD ASDs predispose the Pt to ? issues in life Paradoxical emboli are more common in ? Pts
POPrimum Afib- RA enlargement R to L emboli PFO than true ASD
38
R to L PFO shunting is more prominent in ? position What is the name for this anomaly Stopped
Supine Platypnea Orthodeoxia CLinical S/Sxs