IMC Flashcards
Dilated myopathy is defined as ?
? metabolic Dzs can cause dilated cardiomyopathy
What nutritional deficiency Dzs can lead to it
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
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
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
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?
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
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
Hemochromatosis
Inflammatory/Infiltration Sarcoidosis
RV dysplasia
Transplant rejection
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?
ACEI and BB
Add Aldosterone antagonist (-one), replace ACEI/ARB w/ ARNI (Sacubitril/Valsartan)
HyperK risk
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%
Ventricular control during A-fib/flutter
Diuretic
Aldosterone antagonist
Aldosterone antagonist
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
GFR <30mL/min
Elevated K+
LVEF 40% or <
Angiotensin receptor-neprilysin inhibitor: Sacubitril/Valsartan
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
Ivabradine- not to replace BBs
Digoxin- reduces hospitalizations and controls ventricular response in AFib
Hydralazine-nitrate
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
+MR and QRS >150msec
DOAC > Warfarin, unless +MS
ASx ischemic myopathy w/ LVEF <30% AND
On medical therapy and, 40days or > post-MI
When would Dilated Myopathy Pts benefit from LVADs?
What two etiologies of Dilated Myopathy have better prognosis’?
What three etiologies have relatively poor outcomes
Bridge to transplant
Temp until cardiac function returns
Peripartum/Stress induced
HIV infection
Infiltrative Dzs
Doxorubicin therapy
When do Pts w/ Dilated Myopathy need to be referred
When do Dilated Myopathy Pts need to be admitted
New/Worsening Sxs
Continuous Sxs and LVEF <35%= ICD consideration
Advance/Refractory Sxs- LVAD/transplant consideration
Hypoxia
Fluid overload
PulmEdema not resolved in clinic
Define Hypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy may present w/ ? 3 Sxs
? is Dx and ? defines the Dz
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
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
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
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 ?
Inc LV diastolic pressure
Systolic dysfunction
Enlarge atria- AFib risk
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
Autosomal dominant
Myosin heavy chains
Ca+ regulation
Athletes won’t have diastolic dysfunction
Hypertrophic Cardiomyopathy in older adults is usually in association w/ ? other issue/Dx
What distinct finding solidifies this Dx
HTN
Sigmoid interventricular septum w/ knob of muscle below AV
What may be seen on PE of Hypertrophic Cardiomyopathy Pts
What kind of JVP changes can be seen
Where are Hypertrophic Cardiomyopathy murmurs heard
Bisferiens carotid pulse
Loud S4
Triple apical impulse
Prominent A-waved d/t dec RV compliance
Systolic murmur along left sternal border
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
Upright posture
Valsalva
Squatting
HC: dec LV volume increases outflow obstruction, murmur increases
AS: dec stroke volume decreases murmur
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
MR
LVH
Exaggerated septal Q-waves inferolaterally
Ventricular Noncompaction- marked trabeculation that partially fills LV cavity
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
Arterial bridging- coronary squeezed during systole
Exercise studies
Determine ventricular ectopy
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
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
What Tx can help reduce progression of hypertrophy and obstruction in Hypertrophic Cardiomyopathy
Dual chamber pacing w/ short AV delay biventricular pacing
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
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
How is a non-surgical septal ablation performed for Hypertrophic Cardiomyopathy Tx
Pg 1033
Alcohol injection into septal branches of LCA to create controlled MI in areas of greatest wall thickness
Tx Flow Chart
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
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
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
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
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
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
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
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
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
STOPPED
a
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
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
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
R to L PFO shunting is more prominent in ? position
What is the name for this anomaly
Stopped
Supine
Platypnea Orthodeoxia
CLinical S/Sxs
