Myocardial and Pericardial lecture Flashcards
What is the cause of primary dilated cardiomyopathy?
Idiopathic-unknown cause
Toxic- alcohol, adriamycin, etc Post-partum (third trimester or after birth) Post infectious- myocarditis* Endocrine "Ischemic cardiomyopathy"
Secondary dilated cardiomyopathy
Patients present with signs and symptoms of HF which usually develops slowly.
Dilated cardiomyopathy
In dilated cardiomyopathy, left or biventricular failure, ______ dysfunction predominates.
Systolic
Right or Left dilated cardiomyopathy?
DOE, orthopnea, PND, weakness, fatigue, peripheral edema, etc.
Left sided
Right or Left dilated cardiomyopathy?
unexplained weight gain, peripheral edema, abdominal fullness (hepatomegaly, ascites).
Right sided
Cardiomegaly (PMI displaced laterally), low pulse amplitude (pulsus alternans when severe), often with ↓BP, pulmonary congestion, crackles, S3 gallop, MR murmur.
(left) Dilated cardiomyopathy
Elevated JVP, hepatomegaly, HJR, pitting edema, TR murmur.
(right) Dilated cardiomyopathy
right sided murmurs get louder with..
inspiration
Echocardiography/Doppler: LV/RV dilation, global LV dysfunction with reduced EF; Mitral regurgitation common.
Dilated cardiomyopathy
CxR: Cardiomegaly, pulmonary congestion, pleural effusions.
Dilated cardiomyopathy
Do you need to do a cardiac cath in a pt with dilated cardiomyopathy?
NO! Only used to rule out other dx
Tx like HF: Afterload reduction: ACEI or alternatives (ARB’s) Preload reduction: Diuretics, nitrates Beta Blockers Spironlolactone- class III and IV NYHA criteria Digoxin ICD’s if indicated, +/- antiarrhythmics Anticoagulation unless contraindicated*
Dilated cardiomyopathy
If dilated cardiomyopathy pt has an EF of 35% or less…
use ICD
Only meds that may improve survival rate in dilated cardiomyopathy:
ACEi (or ARB)
Beta blockers
Spironolactone
Genetically transmitted in >50% of cases.
Autosomal dominant with high penetrance.
*may require genetic counseling
(remaining cases occur spontaneously)
Hypertrophic cardiomyopathy
Marked increase in left ventricular mass, especially the septum - marked hypertrophy; remaining LV segments hypertrophied to a lesser degree; often called *ASH. Hypertrophy is unrelated to pressure overload; often present at birth, progressively worsens during childhood.
HCM
LV cavity small, systolic function normal or hyperdynamic early on.
Diastolic dysfunction common
Obstructive (below AoV) and non-obstructive forms
HCM
Asymmetric septal hypertrophy, AKA
HCM
When present LVOT obstruction is dynamic and varies with activity/rest, and LV volume.
Obstruction: MV moves abnormally towards the IVS, obstructing the LVOT.
HCM
Pathology: myocardial fiber hypertrophy and disarray, primarily in IVS.
Mitral valve often thickened and moves abnormally as noted above, well seen on echocardiogram.
HCM
Often asymptomatic in childhood; may be detected via ultrasound in the offspring of patients with known disease.
Symptoms: dyspnea, chest pain and syncope are most common. In some, sudden death may be presenting symptom. One of few causes of sudden death in young athletes.
HCM
Sudden death often occurs during strenuous activity.
Arrhythmias are common: ventricular and supraventricular; Afib may lead to sudden decompensation and is a bad prognostic sign.
HCM
Pulse brisk, often with bisferiens carotid pulse.
Double or triple apical impulse due to atrial filling wave and early and late systolic impulses.
Loud S4 and S3 gallops.
HCM
Loud harsh aortic outflow murmur (crescendo-decrescendo) best heard along left sternal border with characteristic features; MR common.
HCM
The murmur of HCM is increased with….
Standing and valsalva
HCM and… hypovolemia, tachycardia or increase in cardiac contractility (inotropes, exercise) causes…
increase in murmur
LVH with secondary ST-T changes common. Septal Q waves may mimic MI.
HCM
Must minimize strenuous physical exertion
***BETA BLOCKERS ARE CORNERSTONE THERAPY
HCM
What class of drug can be used instead of or along with beta blockers in treating HCM
Calcium channel blockers
Don’t use what class of calcium channel blockers in HCM
Dihydro CCBs
myomectomy, alcohol ablation used as surgical tx for..
HCM
Dual chamber pacemaker may improve septal motion and decrease progression of obstruction if severe
HCM
Which HCM patients may be candidates for implantable cardiac defibrillators (ICD)?
High risk!! (vtach, aborted sudden death)
or fam hx of sudden death
Hallmark: Abnormal diastolic function.
Ventricular walls excessively rigid and impede diastolic filling; systolic function may be normal or reduced.
Restrictive and infiltrative cardiomyopathies
Amyloidosis Hemochromatosis Fabry Disease Gaucher Disease Endomyocardial Fibrosis-Loeffler Endocarditis-hypereosinofilia syndrome
…all causes of?
Restrive and infiltrative cardiomyopathies
Jugular venous distention
S3 and/or S4
Inspiratory increase in venous pressure (Kussmaul’s sign)
Findings of Rt. Heart Failure may predominate i.e. edema, hepatomegaly.
Symptoms include dyspnea, exercise intolerance and fatigue.
Restrictive cardiomyopathy
AKA Stress Cardiomyopathy: ∼90% cases are women, often associated with a significant stressful event.
Tako-tsubo Cardiomyopathy
Presentation mimics STEMI: Chest pain, SOB, ECG changes with modest elevation of troponins.
Echocardiogram: Marked LV dysfunction with anterior, apical and inferior ballooning, marked ↓EF.
Tako-tsubo Cardiomyopathy
Absence of obstructive CAD at catheterization.
Pathophysiology: stressful event leads to outpouring of catecholamines →transient LV insult.
Tako-tsubo Cardiomyopathy
A primary inflammatory process of the myocardium, most often caused by an infectious agent.
Myocarditis
Unrecognized myocarditis may be the initial event culminating in an…
idiopathic dilated cardiomyopathy
Most common type of myocarditis?
Viral
Coxsackievirus (B>A)*** CMV Echovirus* Adenovirus* HIV* Influenza Infectious mononucleosis Rubella, Rubeola
Viral causes of myocarditis
Chest pain, fatigue, dyspnea, palpitations are common initial symptoms. Often progresses to HF.
Myocarditis
often start asymptomatic
The initial presentation of myocarditis might be..
Heart failure
Exam : Tachycardia, elevated temp, muffled heart sounds; signs of HF in severe cases.
Myocarditis
Avoid which type of drugs in myocarditis
NSAIDS
Tx for myocarditis
Supportive treatment only
tx HF if present
This drug class may make myocardial damage worse
NSAIDS
A syndrome due to inflammation of the pericardium characterized by chest pain, a pericardial friction rub, and serial ECG abnormalities.
Acute pericarditis
Viral most common; same spectrum of viruses as seen with myocarditis- Coxsackie B most common.
Pericarditis
Tx for Pericarditis ONLY!
NSAIDs
must make sure pt does not also have myocarditis
Idiopathic (non specific) Tuberculosis Acute bacterial infections Fungal Uremia-untreated or with dialysis. Radiation Autoimmune-RA, SLE, scleroderma, PAN
Causes of pericarditis (other than viral causes)
Chest pain-frequent; quality and location variable; retrosternal and often left sided.
Pain is intense-aggravated by lying supine, with inspiration, coughing, swallowing, laughing; improved sitting up, leaning forward, shallow inspiration.
Pericarditis
Pain worse laying down, better sitting up
Feels better to breathe shallow
Pericarditis
Pericardial Friction Rub- pathognomonic-scratching, grating, high pitched sound due to friction between the pericardium and epicardium.
*hear 2 components (systole and diastole)
Pericarditis physical exam
Best heard with diaphragm at LLSB, best heard w patient sitting, leaning forward in full expiration
Pericardial friction rub
ST elevation everywhere except aVR, V1 (occasionally aVL)
**every other lead will have significant ST elevation
Pericarditis
how do you tell MI vs pericarditis EKG?
MI is localized ST elevation!! you can tell if its anterior, lateral, etc.
Pericarditis is almost everywhere! ST elevation seen in all leads except aVR, V1 and aVL
All patients with pericarditis must have a…
Echo-doppler (cardiac ultrasound)
must make sure no pericardial effusion
Determine etiology where possible.
Bed rest until pain and fever resolved.
Pain rapidly responds to NSAIDs**
Pericarditis
Oral _____ should be avoided in patients with pericarditis
anticoagulants
Pericarditis symptoms usually resolve in….
2-4 weeks
Colchicine can be used to tx..
Pericarditis
Can occur with all forms of pericarditis
Symptoms (if present) include chest pressure, dyspnea, hiccups, nausea, abd. fullness, cough.
Pericardial effusion
Best diagnostic to dx pericardial effusion?
Echo!
CXR- mild cardiomegaly if greater than 250 cc fluid
Pericardial effusion
Increasing pericardial fluid raises intrapericardial pressure resulting in compression of the heart.
***There is progressive limitation of ventricular diastolic filling leading to reduction of stroke volume and cardiac output.
Cardiac tamponade
fatal if not recognized and aggressively treated
Hemodynamics - marked elevation and equilibration of LV and RV diastolic pressures; LA and RA pressures elevated.
**marked decrease in CO
Cardiac tamponade
Echo shows RA and RV collapse
*Beck’s triad: decline in arterial pressure, elevation of systemic venous pressure, quiet heart
Cardiac tamponade
Decline in arterial pressure
Elevation of systemic venous pressure
Quiet heart
Beck’s triad
*seen in cardiac tamponade
Classic physical finding of cardiac tamponade**
Pulsus paradoxus
Pulsus paradoxus has a systolic BP drop greater than…
10 mm
may be life saving; IV fluids given to increase preload; *should be done with Rt Ht Cath to optimize hemodynamics
*subxiphoid approach with flouroscopic guidance is successful in 95%
fluid is cultured and sent for cytology and chemistry analysis.
Pericardiocentesis
done in cardiac tamponade
Obliteration of the pericardial space with fusion of the pericardium to the epicardium.
*Restriction of filling of all cardiac chambers.
Constrictive pericarditis
Initial episode of pericarditis/effusion proceeds to a chronic stage with fibrosis, calcification and marked thickening of the pericardium.
Constrictive pericarditis
