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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
Q

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

A

Outflow gradient >50mmHg

Genetics counseling

BBs

26
Q

What are the 6 Hypertrophic Cardiomyopathy criteria that put Pts at highest risk

What exercise stress test also indicates Pt is at increased risk

A

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
Q

Hypertrophic Cardiomyopathy Pts should not receive ? type of prophylaxis?

When do Pts w/ Hypertrophic Cardiomyopathy need to be referred

A

Endocarditis

Sx control is difficult
Syncope occurred
High risk features= prophylactic defibrillator consideration

28
Q

Define Restrictive Cardiomyopathy

What is the MC cause

Secondary Amyloidosis is rare but more common in ? populations

A

Impaired diastolic filling w/ preserved contractility, usually R>L sided failure

Amyloidosis- light chain MC type

Elderly AfAm- chronic inflammatory dzs

29
Q

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

A

Infil: Sarcoidosis Gaucher Hurler
Store: Hemochromatosis Fabry Glycogen

Low voltage EKG
Ventricular hypertrophy on Echo

Bone Scan- TxOC for Transthyretin Amyloidosis

30
Q

How is Restrictive Cardiomyopathy differentiated from Constrictive Pericarditis

What lab result can be used to differentiate?

What are S/Sxs of Restrictive Cardiomyopathy

A

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
Q

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

A

cMRI

Normal LV size, rEF
Small, thick LV w/ speckles

Rectal Abdominal fat Gingival

32
Q

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

A

Tafamidis

AL: Chemo/Melphalan then, Stem cell transplant
Light Chain Amyloidosis: chemo w/ stem cell rescue

BB ACEI/ARB Verapamil
Loop Thzd AAgonists

33
Q

What medication needs to be avoided in the Tx of Restrictive Cardiomyopathy

When do Restrictive Cardiomyopathy Pts need to be referred

A

Digoxin- precipitates arrhythmias

All w/ Dx
Unexplained LVH w/ preserved LVEF and Sxs of HF

34
Q

STOPPED

A

a

35
Q

What is the MC form of ASDs

What is a less common form

What other issues are commonly seen in the less MC form

A

Persistant Ostium Secundum- mid septum

Persistant Ostium Primum- low sptum

M/T valve cleft
VSD in upper atrial septum

36
Q

Why do VSDs develop

Why does cyanosis develop in ASD Pts

What named physiology is rare but possible in ASD Pts

A

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
Q

Eisenmenger Physiology is more common in ? type of ASD

ASDs predispose the Pt to ? issues in life

Paradoxical emboli are more common in ? Pts

A

POPrimum

Afib- RA enlargement
R to L emboli

PFO than true ASD

38
Q

R to L PFO shunting is more prominent in ? position

What is the name for this anomaly

Stopped

A

Supine

Platypnea Orthodeoxia

CLinical S/Sxs

IPAP (212 decks)

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