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Foundations of Clinical Practice II > Myocarditis and Cardiomyopathy 1.25.18 > Flashcards

Myocarditis and Cardiomyopathy 1.25.18 Flashcards

1
Q

What is the leading cause of congestive heart failure?

A

Idiopathic dilated cardiomyopathy

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2
Q

Name the 3 main structural/functional categories of cardiomyopathy

A
  1. Dilated most common
  2. Hypertrophic
  3. Restrictive
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3
Q

What is the primary indication for cardiac transplantation?

A

Idiopathic dilated cardiomyopathy

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4
Q

What is the #1 cause of sudden death in competitive athletes <35 years?

A

Hypertrophic cardiomyopathy

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5
Q

What is the least common type of cardiomyopathy (except in the tropics)?

A

Restrictive

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6
Q

Right sided heart failure can occur from pulmonary hypertension, but most commonly is from ______?

A

Left sided heart failure

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7
Q

NYHA Class I

A

(asymptomatic) heart disease which isn’t limiting physical activity and no dyspnea or fatigue

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8
Q

NYHA Class II

A
  • slight limitation in physical activity

- symptoms with ordinary activity but not at rest

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9
Q

NYHA Class III

A
  • marked limitation in physical activity
  • HF symptoms with minimal activity
  • No symptoms at rest
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10
Q

NYHA Class IV

A
  • inability to carry out physical activity without discomfort
  • symptoms at rest
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11
Q

ACC/AHA: Stage A

A

High risk, but no structural heart disease or symptoms of HF

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12
Q

ACC/AHA: Stage B

A
  • Structural heart disease

- No sign or symptoms of HF

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13
Q

ACC/AHA: Stage C

A
  • Structural heart disease

- Prior or current symptoms

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14
Q

ACC/AHA: Stage D

A

-Refractory HF requiring specialized interventions

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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
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16
Q

Etiology of most (50%) of cardiomyopathies?

A

Idiopathic

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17
Q

What is the most common cause of heart failure due to systolic dysfunction?

A

Ischemic cardiomyopathy

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18
Q

Ischemic cardiomyopathy

A
  • LVEF <35-40%

- From coronary artery disease

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19
Q

Ischemic cardiomyopathy treatment

A
  • ASA
  • High-intensity statin
  • Beta blocker
  • ACE inhibitor
  • Loop diuretic if fluid overload

(consider potassium-sparing diuretic, nitrates)

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20
Q

Hypertensive cardiomyopathy

A
  • concentric left ventricular hypertrophy

- caused by uncontrolled and sustained HTN over a long period

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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
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22
Q

What is the treatment for alcoholic cardiomyopathy

A

ABSTINENCE

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23
Q

What electrolyte imbalance predisposes to ventricular arrhythmias?

A
  • Hypomagnesemia

- Hypokalemia

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24
Q

Peripartum cardiomyopathy

A

development of heart failure late in pregnancy to within 5 months of giving birth

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25
Q

Risk factors for peripartum cardiomyopathy

A
  • Over age 30
  • African descent
  • Cocaine abuse
  • Multiple fetuses
  • Preeclampsia/eclampsia
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26
Q

Treatment in peripartum cardiomyopathy

A

heart transplant in 1/3 of these patients

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27
Q

Takotsubo cardiomyopathy

A

“broken heart syndrome” or “stress cardiomyopathy”

-Transient LV dysfunction with systolic apical ballooning

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28
Q

What popuation is most at risk for Takotsubo cardiomyopathy?

A

Post-menopausal women

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29
Q

Takotsubo cardiomyopathy: Labs and ECG

A

Labs: Troponin 7x upper limit of normal

ECG: ST-elevation

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30
Q

Signs of left sided heart failure (4)

A

*fluid in the lungs

  1. Pulmonary congestion
  2. Productive cough
  3. Dyspnea
  4. Crackles/wheezing
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31
Q

Signs of right sided heart failure (4)

A

*fluid backing up into systemic circulation

  1. JVD
  2. Hepatojugular reflux
  3. Peripheral edema (pitting)
  4. Ascites
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32
Q

Hyponatremia signifies what in CM?

A

poorer prognosis

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33
Q

Why would you get a CBC with cardiomyopathy?

A

Anemia

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34
Q

Why get a urine drug screen for CM?

A

if suspicion for drug use leading to CM (cocaine, meth)

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35
Q

Name some CXR findings for CM

A
  1. Enlargement of cardiac silhouette
  2. Pulmonary vascular congestion
  3. Pleural effusion (right sided)
  4. Kerley B lines
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36
Q

Name 3 ECG findings of dilated cardiomyopathies

A
  1. LVH
  2. Conduction delay
  3. Arrhythmias
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37
Q

Dilated cardiomyopathy treatment

A
  • 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
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38
Q

What type of medication prevents cardiac remodeling

A

ACE-inhibitors

Captopril, Enalapril, Lisinopril

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39
Q

Beta Blockers

A
  • HFrEF and LVEF <40%
  • Metoprolol succinate, carvedilol, bisoprolol (proven to reduce mortality/hospitalization rates)

-Decrease afterload

40
Q

Beta Blocker: contraindications

A
  • HR <50
  • 2nd or 3rd degree AV block
  • Asthma (COPD is NOT)
41
Q

Beta Blocker: side effects

A
  • asymptomatic hypoglycemia
  • fatigue
  • bronchospasm
  • hyperkalemia
  • depression
  • sexual dysfunction
42
Q

Surgical options for cardiomyopathies

A
  1. LVAD - Left ventricular assist device
  2. Cardiac resynchonization therapy (CRT)
  3. Automatic implantable cardioverter-defibrillator (AICD)
  4. Heart transplant
43
Q

Hypertrophic cardiomyopathy

A
  • Genetic
  • High incidence of sudden cardiac death
  • Maximal LV wall thickness >15mm
  • subendocardial ischemia
  • abnormally thickened intramural coronary arteries
44
Q

When is the most common time to diagnose someone with hypertrophic cardiomyopathy?

45
Q

Is hypertrophic cardiomyopathy more common in men or women?

A

slight more common in men, but females will present younger age, and be more symptomatic

46
Q

What does a higher dynamic outflow tract gradient suggest in hypertrophic cardiomyopathy?

A

more severe disease

47
Q

What type of cardiomyopathy is mitral regurgitation (mitral valve systolic anterior motion- SAM) associated with?

A

Hypertrophic cardiomyopathy

48
Q

What are the 2 types of hypertrophic cardiomyopathy?

A
  1. Obstructive

2. Non-obstructive

49
Q

What maneuver increases left ventricular outflow tract obstruction (decreasing preload, afterload and increasing inotropy)

A
  • standing quickly or valsalva

- calcium channel blockers (dihydropuridines)

50
Q

What maneuver decreases left ventricular outflow tract obstruction (increase in chamber size, decreased inotropy)

A
  • squatting
  • supine with legs up
  • Beta blockers
  • CCB (verapamil/diltizaem)
51
Q

Hypertrophic cardimyopathy puts pts at increased risk for what arrhythmias?

A

supraventricular arrythmias

52
Q

Hypertrophic cardiomyopathy risk factors for stratifying risk (4)

A
  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
Q

In adults, what does S3 usually signify?

A

congestive heart failure

54
Q

Hypertrophic cardiomyopathy: physical exam

A

***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
Q

Where is the best place to heard a systolic ejection crescendo-decrescendo murmur?

A

Between apex and LSB

56
Q

In what situation will the murmur of hypertrophic cardiomyopathy increase?

A

Murmur will increase with decrease in preload/afterload

ex. Valsalva, nitrates, diuretics, vasodilators

57
Q

If a patient performs a valsalava what effect will there be on the murmur of cardiomyopathy?

A

Increase

decreased preload and afterload

58
Q

Effect on murmur of cardiomyopathy when squatting?

A

decrease

increased preload and afterload

59
Q

In which two situations does the murmur of hypertrophic cardiomyopathy increase?

A
  1. Valsalva

2. Standing

60
Q

In which two situations does the murmur of hypertrophic cardiomyopathy decrease?

A
  1. Squatting

2. Isometric handgrip

61
Q

What test is the best diagnostic test for hypertrophic cardiomyopathy?

A

Transthoracic echocardiogram

can also put ECG monitor on for 24-48 hours -assess for arrthymia

62
Q

Risk stratification for hypertrophic cardiomyopathy sudden cardiac death must be done every 12-24 months, why?

A

reassess candidacy for ICD implantation

63
Q

Can athletes with hypertrophic cardiomyopathy participate in sports?

64
Q

Hypertropic cardiomyopathy: What is first line treatment for patients with symptomatic arrhythmias?

A

-beta blocker

or

-antiarrhythmic

65
Q

What pharmacologic treatment would be appropriate for a hypertrophic cardiomyopathy patient with Afib?

A

anticoagulation

66
Q

What medication would be best to switch to in HCM if beta blocker is not adequate?

A

CCB (non-dihydropyridine)

ex. Verapamil

67
Q

What can be added to either beta blocker or CCB if symptoms persist?

A

Disopyramide (Class 1a antiarrhythmic

anticholinergic effect - so can’t give to patient with BPH

68
Q

Name 2 non-pharmacologic treatments in HCM?

A
  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
Q

When is the strongest indication for implantable cardioverter-defibrillator (ICD)

A

prior cardiac arrest or sustained VT

Class I -recommendation

70
Q

Dynamic left ventricular outlow tract gradient and systolic anterior motion of the mitral valve are characteristics of what?

A

hypertrophic cardiomyopathy

71
Q

Systolic ejection crescendo-decrescendo murmur are associated with what?

A

Hypertrophic cardiomyopathy

72
Q

What two medications can be used to manage hypertrophic cardiomyopathy

A
  1. Beta blocker

2. Non-dihydropyridine CCB

73
Q

Which type of cardiomyopathy is most rare?

A

Restrictive (5% of all cardiomyopathies)

74
Q

Which types of cardiomyopathy is characterized by diastolic dysfunction, non-dilated, non-hypertrophied ventricles with impaired LV filling

A

Restrictive cardiomyopathy

75
Q

Bi-atrial enlargement is associated with which type of cardiomyopathy?

A

Restrictive

76
Q

What is the primary cause of restrictive cardiomyopathy?

A

idiopathic

77
Q

What is the most common cause of restrictive cardiomyopathy in the US?

A

Amyloidosis

78
Q

What is the most common cause of restrictive cardiomyopathy worldwide?

A

Loeffler eosinophilic endocardial disease

79
Q

Restrictive cardiomyopathy: Clinical presentation

A
  • 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
Q

What might you see on ECG of restrictive cardiomyopathy?

A

Low voltage QRS (with infiltrative disease)

81
Q

Restrictive cardiomyopathy: Physical exam

A
  • 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
Q

How is restrictive cardiomyopathy diagnosed?

A
  • 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
Q

What blood test is very important for distinguishing restrictive cardiomyopathy and constrictive pericarditis?

A

NT-pro-BNP, will be elevated in restrictive CM (not in pericarditis)

84
Q

Name the 4 different types of amyloidosis

A
  1. Primary/Amyloid light chain - HORRIBLE PROGNOSIS
  2. Secondary (due to inflammatory conditions)
  3. Senile/Wild type
  4. Familial/Hereditary mutant: rare
85
Q

Periorbital purpura is associated with what?

A

Cardiac amyloidosis

86
Q

Cardiac cachexia

A

Cardiac cachexia is unintentional severe weight loss caused by heart disease. (common in CHF)

87
Q

Restrictive CM

A
  • Rare
  • Primary versus Secondary causes
  • Amyloidosis is most common cause in US
  • Bi-atrial enlargement
  • Can resemble contrictive pericarditis
  • Treatment: BB, CCB, diuretics
88
Q

What is the diagnostic gold standard for myocarditis?

A

endomyocardial biopsy

89
Q

Name the 4 types of myocarditis

A
  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
Q

Who is more likely to have myocarditis?

A
  • peripartum (african descent)

- young males

91
Q

What is the most common etiology of myocarditis?

A

Idiopathic ~50% of the time, but virus suspected.

92
Q

Myocarditis: Prognosis

A

generally have a good prognosis, 1/3 develop cardiomyopathy.

Mild symptoms: recover completely

93
Q

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

A

myocarditis

94
Q

Treatment: myocarditis

A
  • supportive

- manage like heart failure

95
Q

Name 2 types of mechanical circulatory support

A
  1. Impella (inside the heart)

2. ECMO, Extracorporeal Membrane Oxygenation (external machine)

Foundations of Clinical Practice II (25 decks)

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