Myocarditis and Cardiomyopathy 1.25.18 Flashcards
1
Q
What is the leading cause of congestive heart failure?
A
Idiopathic dilated cardiomyopathy
2
Q
Name the 3 main structural/functional categories of cardiomyopathy
A
- Dilated most common
- Hypertrophic
- Restrictive
3
Q
What is the primary indication for cardiac transplantation?
A
Idiopathic dilated cardiomyopathy
4
Q
What is the #1 cause of sudden death in competitive athletes <35 years?
A
Hypertrophic cardiomyopathy
5
Q
What is the least common type of cardiomyopathy (except in the tropics)?
A
Restrictive
6
Q
Right sided heart failure can occur from pulmonary hypertension, but most commonly is from ______?
A
Left sided heart failure
7
Q
NYHA Class I
A
(asymptomatic) heart disease which isn’t limiting physical activity and no dyspnea or fatigue
8
Q
NYHA Class II
A
- slight limitation in physical activity
- symptoms with ordinary activity but not at rest
9
Q
NYHA Class III
A
- marked limitation in physical activity
- HF symptoms with minimal activity
- No symptoms at rest
10
Q
NYHA Class IV
A
- inability to carry out physical activity without discomfort
- symptoms at rest
11
Q
ACC/AHA: Stage A
A
High risk, but no structural heart disease or symptoms of HF
12
Q
ACC/AHA: Stage B
A
- Structural heart disease
- No sign or symptoms of HF
13
Q
ACC/AHA: Stage C
A
- Structural heart disease
- Prior or current symptoms
14
Q
ACC/AHA: Stage D
A
-Refractory HF requiring specialized interventions
15
Q
Dilated cardiomyopathy
A
- Ventricular chamber enlargement and systolic dysfunction
- Left ventricular cavity size increases with little or no hypertrophy
- interstitial and endocardial fibrosis
16
Q
Etiology of most (50%) of cardiomyopathies?
A
Idiopathic
17
Q
What is the most common cause of heart failure due to systolic dysfunction?
A
Ischemic cardiomyopathy
18
Q
Ischemic cardiomyopathy
A
- LVEF <35-40%
- From coronary artery disease
19
Q
Ischemic cardiomyopathy treatment
A
- ASA
- High-intensity statin
- Beta blocker
- ACE inhibitor
- Loop diuretic if fluid overload
(consider potassium-sparing diuretic, nitrates)
20
Q
Hypertensive cardiomyopathy
A
- concentric left ventricular hypertrophy
- caused by uncontrolled and sustained HTN over a long period
21
Q
Alcoholic cardiomyopathy
A
- Increased risk in people who drink >90g (7-8 drinks) per day for at least 5 years
- Prolonged QTc (precurser to ventricular arrhythmias) more common in alchoholics
22
Q
What is the treatment for alcoholic cardiomyopathy
A
ABSTINENCE
23
Q
What electrolyte imbalance predisposes to ventricular arrhythmias?
A
- Hypomagnesemia
- Hypokalemia
24
Q
Peripartum cardiomyopathy
A
development of heart failure late in pregnancy to within 5 months of giving birth
25
Risk factors for peripartum cardiomyopathy
- Over age 30
- African descent
- Cocaine abuse
- Multiple fetuses
- Preeclampsia/eclampsia
26
Treatment in peripartum cardiomyopathy
heart transplant in 1/3 of these patients
27
Takotsubo cardiomyopathy
"broken heart syndrome" or "stress cardiomyopathy"
-Transient LV dysfunction with systolic apical ballooning
28
What popuation is most at risk for Takotsubo cardiomyopathy?
Post-menopausal women
29
Takotsubo cardiomyopathy: Labs and ECG
Labs: Troponin 7x upper limit of normal
ECG: ST-elevation
30
Signs of left sided heart failure (4)
*fluid in the lungs
1. Pulmonary congestion
2. Productive cough
3. Dyspnea
4. Crackles/wheezing
31
Signs of right sided heart failure (4)
*fluid backing up into systemic circulation
1. JVD
2. Hepatojugular reflux
3. Peripheral edema (pitting)
4. Ascites
32
Hyponatremia signifies what in CM?
poorer prognosis
33
Why would you get a CBC with cardiomyopathy?
Anemia
34
Why get a urine drug screen for CM?
if suspicion for drug use leading to CM (cocaine, meth)
35
Name some CXR findings for CM
1. Enlargement of cardiac silhouette
2. Pulmonary vascular congestion
3. Pleural effusion (right sided)
4. Kerley B lines
36
Name 3 ECG findings of dilated cardiomyopathies
1. LVH
2. Conduction delay
3. Arrhythmias
37
Dilated cardiomyopathy treatment
- ACE/ARB
- Beta blocker
- Aldosterone antagonists (if class III-IV)
- Diurectic (if fluid overload)
- Nitrates (for symptoms)
- Sacubitril-valsartan (Angiotensin-neprilysin inhibitor): for patients with HF and reduced ejection fraction
38
What type of medication prevents cardiac remodeling
ACE-inhibitors
| Captopril, Enalapril, Lisinopril
39
Beta Blockers
- HFrEF and LVEF <40%
- Metoprolol succinate, carvedilol, bisoprolol (proven to reduce mortality/hospitalization rates)
-Decrease afterload
40
Beta Blocker: contraindications
- HR <50
- 2nd or 3rd degree AV block
- Asthma (COPD is NOT)
41
Beta Blocker: side effects
- asymptomatic hypoglycemia
- fatigue
- bronchospasm
- hyperkalemia
- depression
- sexual dysfunction
42
Surgical options for cardiomyopathies
1. LVAD - Left ventricular assist device
2. Cardiac resynchonization therapy (CRT)
3. Automatic implantable cardioverter-defibrillator (AICD)
4. Heart transplant
43
Hypertrophic cardiomyopathy
- Genetic
- High incidence of sudden cardiac death
- Maximal LV wall thickness >15mm
- subendocardial ischemia
- abnormally thickened intramural coronary arteries
44
When is the most common time to diagnose someone with hypertrophic cardiomyopathy?
30s
45
Is hypertrophic cardiomyopathy more common in men or women?
slight more common in men, but females will present younger age, and be more symptomatic
46
What does a higher dynamic outflow tract gradient suggest in hypertrophic cardiomyopathy?
more severe disease
47
What type of cardiomyopathy is mitral regurgitation (mitral valve systolic anterior motion- SAM) associated with?
Hypertrophic cardiomyopathy
48
What are the 2 types of hypertrophic cardiomyopathy?
1. Obstructive
| 2. Non-obstructive
49
What maneuver increases left ventricular outflow tract obstruction (decreasing preload, afterload and increasing inotropy)
- standing quickly or valsalva
| - calcium channel blockers (dihydropuridines)
50
What maneuver decreases left ventricular outflow tract obstruction (increase in chamber size, decreased inotropy)
- squatting
- supine with legs up
- Beta blockers
- CCB (verapamil/diltizaem)
51
Hypertrophic cardimyopathy puts pts at increased risk for what arrhythmias?
supraventricular arrythmias
52
Hypertrophic cardiomyopathy risk factors for stratifying risk (4)
1. history of syncope/family history of sudden cardiac death
2. LV wall thickness >30mm
3. Non-sustained ventricular tachycardia on ambulatory monitoring
4. Abnormal blood pressure in response to exercise
53
In adults, what does S3 usually signify?
congestive heart failure
54
Hypertrophic cardiomyopathy: physical exam
***Systolic ejection crescendo-decrescendo murmur
- Double apical impulse (forceful LA contraction against a non-compliant LV)
- paradoxical splitting of S2
- S3 , may be heard in children
- S4
55
Where is the best place to heard a systolic ejection crescendo-decrescendo murmur?
Between apex and LSB
56
In what situation will the murmur of hypertrophic cardiomyopathy increase?
Murmur will increase with decrease in preload/afterload
ex. Valsalva, nitrates, diuretics, vasodilators
57
If a patient performs a valsalava what effect will there be on the murmur of cardiomyopathy?
Increase
| decreased preload and afterload
58
Effect on murmur of cardiomyopathy when squatting?
decrease
| increased preload and afterload
59
In which two situations does the murmur of hypertrophic cardiomyopathy increase?
1. Valsalva
| 2. Standing
60
In which two situations does the murmur of hypertrophic cardiomyopathy decrease?
1. Squatting
| 2. Isometric handgrip
61
What test is the best diagnostic test for hypertrophic cardiomyopathy?
Transthoracic echocardiogram
| can also put ECG monitor on for 24-48 hours -assess for arrthymia
62
Risk stratification for hypertrophic cardiomyopathy sudden cardiac death must be done every 12-24 months, why?
reassess candidacy for ICD implantation
63
Can athletes with hypertrophic cardiomyopathy participate in sports?
NO
64
Hypertropic cardiomyopathy: What is first line treatment for patients with symptomatic arrhythmias?
-beta blocker
or
-antiarrhythmic
65
What pharmacologic treatment would be appropriate for a hypertrophic cardiomyopathy patient with Afib?
anticoagulation
66
What medication would be best to switch to in HCM if beta blocker is not adequate?
CCB (non-dihydropyridine)
ex. Verapamil
67
What can be added to either beta blocker or CCB if symptoms persist?
Disopyramide (Class 1a antiarrhythmic
| anticholinergic effect - so can't give to patient with BPH
68
Name 2 non-pharmacologic treatments in HCM?
1. Surgical septal myectomy (removal of some septal muscle to widen the LV outflow tract)
2. Alcohol septal ablation (creates localized myocardial infarction in the area where SAM septal contact is occurring
69
When is the strongest indication for implantable cardioverter-defibrillator (ICD)
prior cardiac arrest or sustained VT
| Class I -recommendation
70
Dynamic left ventricular outlow tract gradient and systolic anterior motion of the mitral valve are characteristics of what?
hypertrophic cardiomyopathy
71
Systolic ejection crescendo-decrescendo murmur are associated with what?
Hypertrophic cardiomyopathy
72
What two medications can be used to manage hypertrophic cardiomyopathy
1. Beta blocker
| 2. Non-dihydropyridine CCB
73
Which type of cardiomyopathy is most rare?
Restrictive (5% of all cardiomyopathies)
74
Which types of cardiomyopathy is characterized by diastolic dysfunction, non-dilated, non-hypertrophied ventricles with impaired LV filling
Restrictive cardiomyopathy
75
Bi-atrial enlargement is associated with which type of cardiomyopathy?
Restrictive
76
What is the primary cause of restrictive cardiomyopathy?
idiopathic
77
What is the most common cause of restrictive cardiomyopathy in the US?
Amyloidosis
78
What is the most common cause of restrictive cardiomyopathy worldwide?
Loeffler eosinophilic endocardial disease
79
Restrictive cardiomyopathy: Clinical presentation
- progressive exercise intolerance
- SOB
- Fatigue
- Orthopnea
- Palpitations (frequently causes atrial fibrillation)
- Thromboembolic complications
- orthostatic hypotension and syncope
- Autonomic neuropathy may be present with amyloidosis**
80
What might you see on ECG of restrictive cardiomyopathy?
Low voltage QRS (with infiltrative disease)
81
Restrictive cardiomyopathy: Physical exam
- right sided heart failure (JVD, pitting edema, ascites, hepatomegaly)
- Cardiac cachexia
- Amyloidosis systemic signs: easy bruising, periorbital purpura, macroglossia ***
+Kussmaul sign: JVP increases (normally will decrease) with inspiration
82
How is restrictive cardiomyopathy diagnosed?
- echocardiogram is "front line"
- non-infiltrative disease: normal ventricles, dilated atria
- infiltrative disease: concentric LV hypertrophy interatrial septal thickening, valvular thickening, specific stran patterns*
Cardiac MRI: highly accurate
83
What blood test is very important for distinguishing restrictive cardiomyopathy and constrictive pericarditis?
NT-pro-BNP, will be elevated in restrictive CM (not in pericarditis)
84
Name the 4 different types of amyloidosis
1. Primary/Amyloid light chain - HORRIBLE PROGNOSIS
2. Secondary (due to inflammatory conditions)
3. Senile/Wild type
4. Familial/Hereditary mutant: rare
85
Periorbital purpura is associated with what?
Cardiac amyloidosis
86
Cardiac cachexia
Cardiac cachexia is unintentional severe weight loss caused by heart disease. (common in CHF)
87
Restrictive CM
- Rare
- Primary versus Secondary causes
- Amyloidosis is most common cause in US
- Bi-atrial enlargement
- Can resemble contrictive pericarditis
- Treatment: BB, CCB, diuretics
88
What is the diagnostic gold standard for myocarditis?
endomyocardial biopsy
89
Name the 4 types of myocarditis
1. Fulminant: severe compromise, happens quickly
2. Acute: less distinct onset
3. Chronic active:mild to moderate fibrosis on biospy, development of ventricular systolic dysfunction
4. Chronic persistent: persistent histologic infiltrate, no systolic dysfunction
90
Who is more likely to have myocarditis?
- peripartum (african descent)
| - young males
91
What is the most common etiology of myocarditis?
Idiopathic ~50% of the time, but virus suspected.
92
Myocarditis: Prognosis
generally have a good prognosis, 1/3 develop cardiomyopathy.
Mild symptoms: recover completely
93
If a patient presents with acute decompensation of heart failure without underlying cardiac dysfunction or low cardiac risk after viral infection, what should you suspect
myocarditis
94
Treatment: myocarditis
- supportive
| - manage like heart failure
95
Name 2 types of mechanical circulatory support
1. Impella (inside the heart)
| 2. ECMO, Extracorporeal Membrane Oxygenation (external machine)
