The cardiovascular system - Heart failure and cardiomyopathy Flashcards
What is heart failure?
Heart failure is a syndrome that results from an inability of the heart to maintain an adequate output
Describes the epidemiology of heart failure
- Incidence increases with age
- Median age at first presentation is 76 years
- Men most affected
Describe the aetiology of heart failure
Vascular
- Ischaemic/coronary heart disease (50%0
- Hypertension
Muscular
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy
- Congenital heart disease
Valvular
- Stenotic valve
- Regurgitant valves
Electrical
- Arrythmias
High output
- Anaemia
- Septicaemia
- Thyrotoxicosis
- Liver failure
Describe the pathophysiology of heart failure
As cardiac output begins to decline, compensatory mechanisms (both mechanical and neurohumeral) are activated to sustain adequate tissue perfusion
However, while these mechanisms may initially be beneficial, they eventually lead to worsening of heart failure over time as they decline their ability to compensate
Give 4 compensatory mechanisms that are activated to sustain an adequate cardiac output in heart failure
- Increasing preload
- Increasing heart rate
- Activation of the renin-angiotensin-aldosterone system
- Sympathetic nervous system activation
Describe how an increase in pre-load compensates for heart failure
Increase in pre-load causes an increase in end-diastolic volume (EDV) compensating for the reduced ejection fraction, thus maintaining cardiac output
Describe how the the activation of renin-angiotensin system compensates for heart failure
Angiotensin II increases preload and after load
This leads to increased cardiac output
Why does Ace inhibition cause the ace cough and angiodema
The ace cough develops because angiotensin converting enzyme catalyses bradykinin into inactive fragments
Ace inhibition therefore leads to an increase in bradykinin levels, which leads to side-effects of cough and angioedema
Give the 4 classifications of heart failure
- Acute vs chronic heart failure
- Systolic vs diastolic heart failure
- Left-sided vs right-sided heart failure
- High output vs low output heart failure
Describe acute vs chronic heart failure including the causes
Acute
- Characterised by rapid onset of symptoms and/or signs of heart failure that is usually life-threatening
- May present suddenly with cardiogenic shock or sub acutely with decompensation of chronic heart failure
- Requires urgent evaluation and treatment
- Most common cause include acute myocardial dysfunction, acute valvular, pericardial tamponade
Chronic
- Characterised by progressive symptoms with episodes of acute deterioration
- Due to progressive cardiac dysfunction from structural and/or functional abnormality
- Usually precipitated by conditions that affect muscle (e.g., cardiomyopathy), vessels (e.g., ischaemic heart disease), valves (e.g., aortic stenosis), or conduction (e.g., AF)
Describe systolic (HFrEF) vs diastolic heart failure (HFpEF) including the causes
Systolic
- aka heart failure with reduced ejection fraction (HFrEF)
- Poor ventricular contraction leads to reduced ejection fraction in left ventricle (< 40%)
- commonly seen because of ischaemic heart disease, dilated cardiomyopathy, myocarditis, infiltration (e.g., haemochromatosis or sarcoidosis)
Diastolic
- aka heart failure with preserved ejection fraction (HFpEF)
- Ventricles are unable to relax due to stiffness, resulting in inadequate filling of the heart during diastole (LVEF > 50%)
- Seen in restrictive cardiomyopathy, constrictive pericarditis, cardiac tamponade, hypertrophic obstructive cardiomyopathy
What is the LVEF in heart failure with reduced LVEF (HFrEF)?
LVEF < 40%
What is the LVEF in heart failure with reduced LVEF (HFmrEF)?
LVEF 40-49%
What is the LVEF in heart failure with preserved LVEF (HFrEF)?
LVEF >/= 50%
Describe left-sided vs right-sided heart failure
LHF
- Left-side is usually affected first
- Poor ventricular contraction causes blood ‘back up’ in the lungs
- This increases the pulmonary vein hydrostatic pressure, resulting in pulmonary oedema
RHF
- Most common cause of RHF is left heart failure
- An increase in the pressure of the pulmonary vasculature causes the right side of the heart to pump against increased resistance. The right side of the heat compensates with ventricular dilatation and eventual failure
What are the 3 broad categories that right-sided heart failure is related to?
- Pulmonary hypertension
- Pulmonary/tricsupid valve disease
- Pericardial diseases
a) What is cor pulmonale?
b) What is the ECG appearance of cor pulmonale?
a) Right heart failure secondary to long-standing pulmonary arterial hypertension e.g., COPD
b) Shows p pulmonale, which refers to tall, peaked p wave. It reflects right atrial enlargement
Describe low output vs high output heart failure including the causes
Low output
- Compensatory mechanisms eventually fail, resulting in a reduced cardiac output
- Caused by either failure of the pump (heart), increased preload or increased after load
- Characterised by weak pulse, cool peripheries, and low blood pressure
- Low-output states are seen in ischaemic heart disease, aortic stenosis
High output
- The heart is unable to meet the increased demand of perfusion despite normal or increased cardiac output
- The problem is with reduced vascular resistance, often due to diffuse arteriole vasodilation or shunting
- LVEF > 50% and abnormal diastolic filling
- Echocardiogram is typically normal
- It is generally due to states of increased metabolic demand (e.g., hyperthyroidism aka thyrotoxicosis), reduced vascular resistance (e.g., thiamine deficiency, sepsis) or significant shunting (e.g., large arteriovenous fistula), Paget’s disease, pregnancy, anaemia
- Characterised by warm peripheries and normal pulses
What are is low cardiac output and high cardiac output heart failure characterised by?
Low output
- Weak pulse
- Cool peripheries
- Low blood pressure
High cardiac output
- Warm peripheries
- Normal pulses
What does the echocardiogram in high-cardiac output heart failure look like?
Echocardiogram is typically normal
Heart failure
a) Symptoms
b) Signs
a)
- Shortness of breath
- Wheeze
- Fatigue
- Weight loss
- Orthopnoea (breathless lying down)
- Paroxysmal nocturnal dyspnoea (waking up at night breathless)
- Palpitations
b)
- Raised JVP
- Displaced apex
- Crackles]- Ankle oedema
- Heart sounds S3/S4
- Ascites (fluid collects in spaces within your abdomen)
- Pulses alternans (an alternating strong and wake pulse) - associated with severe LHF
- Right sided heart failure: peripheral oedema (pedal, scrotal or sacral), raised JVP, hepatomegaly and bloating
What are the symptoms and signs of left-sided heart failure?
Symptoms
- Dysponea
- Fatigue
- Tachycardia - gallop rhythm
- Orthopnoea
- Paroxysmal nocturnal dysponea
Signs
- Displaced apex beat
- Pleural effusion
- Bibasall crackles
- Pulsus alternans
What are the signs of right sided heart failure?
- Peripheral oedema (pedal, scrotal or sacral)
- Raised JVP
- Hepatomegaly
- Bloating
What are the differential diagnosis of heart failure?
- Obesity
- Chest disease: including lung, diaphragm or chest wall
- Venous insufficiency in lower limbs
- Drug-induced ankle swelling (e.g., dihydropyridine calcium channel blockers)
- edu-induced fluid retention (e.g., NSAIDs)
- Angina
- Hypoalbuminemia
- Intrinsic renal or hepatic disease
-Pulmonary embolic disease - Depression and/or anxiety disorder
- Severe anaemia or thyroid disease
- Bilateral renal artery stenosis
Describe the 4 class of the New York association clinical classification of heart failures based on: physical activity and symptoms
Class I - no limitation on physical activity and no symptoms
Class II - slight limitation on physical activity and symptoms are present with normal physical activity –> mild heart failure
Class III - marked limitation on physical activity and symptoms are present with less than normal physical activity –> moderate heart failure
Class IV - unable to do physical activity without discomfort and symptoms present at rest –> severe heart failure
Describe the investigations for cardiac failure, include what you are trying to exclude
Bedside
- Blood pressure
- ECG
- Urinalysis: for protein and glucose
Bloods
- FBC: exclude anemia, infetcive cause
U&Es: exclude renal failure as a cause of oedema
- LFT: exclude liver failure a s a cause of oedema
- TFT: exclude thyroid disease
- Cholesterol and HBA1c: cardiovascular risk stratification
- Brain natriuretic peptides (BNP and n-terminal pro BNP)
Imaging
- Echocardiogram (imaging modality): previous MI, LV strain/hypertrophy, conduction abnormalities/AF
- CXR
Other imaging
- Cardiac MRI
- Coronary angiogram
- Right heart catheterisation: reserved for the investigation of right-sided heart failure
- 24hr ECG: if arrhythmia is suspected
- Lung function tests: to exclude alternative pathology impacting on symptoms (e.g., breathlessness)
What are the x-ray findings in heart failure?
ABCDE
A: Alveolar oedema (with ‘batwing’ peripheral shadowing)
B: Kerley B lines (caused by interstitial oedema)
C: Cardiomegaly (cardiothoracic ratio > 0,5)
D: Upper lobe diversion
E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure
When would you used cardiac MRI to investigate heart failure?
Particularly useful when TTE images are poor/non-diagnostic due to obesity or chronic obstructive lung disease
What is pro brain natrieutic peptide and describe its role in heart failure (BNP)
pro-BNP is a protein released by cardiomyocytes in response to excessive stretching
It is used to assess the likelihood of heart failure
It has a high negative predictive value so good at excluding heart failure
Other than heart failure, what other conditions may raise BNP?
- Diabetes
- Sepsis
- Old age
- Hypoxaemia (PE and cold)
- Kidney disease
- Liver cirrhosis
a) What is a high bNP? and what must you do?
What is a raised bNP? and what must you do?
What is a normal bNP? and what must you do?
a) BNP>2000ng/L the patient needs an urgent 2-week referral for specialist assessment and an ECHO.
b) BNP 400-2000ng/L the patient should get a 6-week referral for specialist assessment and an ECHO.
c) BNP < 400ng/L and consider other diagnosis
What are the poor prognostic factors in heart failure?
- Low systolic bP
- Coronary disease
- Raised creatinine/eGFR
- Hyponatraemia
- Diabetes
- Anaemia
- Arrythmias
- AF
- Low EF (<30%)
Give the 4 bases of heart failure management
- Lifestyle modification
- Pharmacological therapy
- Devices and surgery
- Continuous monitoring
Describe the lifestyle modification to manage heart failure
- Weight control
- Dietary measures e.g., salt avoidance, optimising nutrition
- Reducing fluid intake including alcohol
- Smoking cessation
- Exercise (low intensity aerobic exercise/rehabilitation
- Pneumococcal and annual influenza vaccination
- Management of co-morbidities (diabetes, COPD)
- Screen for depression
Describe pharmacological therapy, 1st line and 2nd line to manage heart failure
1st line (ACEi + beta-blcokers)
- ACEi e.g., ramipril 2.5mg OD or ARBs if intolerable to side effects (e.g., losartan, candesartan) - improves diagnosis and symptoms
AND
- Beta-blockers e.g., bisporoplol 1.25mg OD (or carvedilol, metoprolol) - improves diagnosis and symptoms
MAYBE WITH
- Aldosterone antagonist e.g., eplerenone 25mg, spironolactone - can be added to ACEi and beta-blocker if symptoms persist
- Loop diuretics (e.g., furesomide), thiazides _ symptomatic relief of oedema only
2nd line
- Ivabradine
- Sacubitril/valsartan
- Hydralazine in combination with nitrates
- Digoxin
Describe pharmacological therapy, 1st line and 2nd line to manage heart failure
1st line (ACEi + beta-blcokers)
- ACEi e.g., ramipril 2.5mg OD or ARBs if intolerable to side effects (e.g., losartan, candesartan) - improves diagnosis and symptoms
AND
- Beta-blockers e.g., bisporoplol 1.25mg OD (or carvedilol, metoprolol) - improves diagnosis and symptoms
MAYBE WITH
- Aldosterone antagonist e.g., eplerenone 25mg, spironolactone - can be added to ACEi and beta-blocker if symptoms persist
- Loop diuretics (e.g., furesomide), thiazides _ symptomatic relief of oedema only
2nd line
- Ivabradine
- Sacubitril/valsartan
- Hydralazine in combination with nitrates
- Digoxin
What are the devices and surgery options to manage heart failure
- Cardiac resynchronisation (CRT)
- Implantable cardiac defibrillator (ICD)
- Revascularisation (PCI/CABG)
- Cardiac transplant
What are the 3 indications of an ICD in patients with cardiac failure
- QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III
- QRS interval 120-149ms without LBBB, NYHA class I-III
- QRS interval 120-149ms with LBBB, NYHA class I
Describe the initial management of acute heart failure (pulmonary oedema)
- Sit the patient up
- Oxygen therapy (aiming saturations > 94%)
- IV furosemide 40mg or more (with further doses as necessary) and close fluid balance (aiming for a negative balance)
- SC morphine - this is contentious with some studies suggesting that it might increase mortality by suppressing respiration
Describe the advanced manage of acute heart failure (pulmonary oedema) - occurring usually in ITU settings
- Continuous positive airway pressure (CPAP) : reduces hypoxia and may help push fluid out of alveoli
- Intubation and ventilation
- Furosemide infusion: continuous IV furosemide given over 24 hours to maximise diuresis
- Dopamine infusion: Continuous IV dopamine given over 24 hours. It works by inhibiting sympathetic drive and thereby increasing myocardial contractility.
- Intra-aortic balloon pump: if the patient is in cardiogenic shock
- Ultrafiltration: If resistant to or contraindicated diuretics
What are the common adverse effects of the following heart failure medications:
a) Beta-blockers
b) ACEi
c) Spironolactone
d) Furosemide
e) Hydralazine
f) Digoxin
a) Bradycardia, hypotension, fatigue, dizziness
b) Hyperkalaemia, renal impairment, dry cough, light- headedness, fatigue, GI disturbances, angioedema
c) Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes libido
d) Hypotension, hyponatraemia/kalaemia
e) Headache, palpitations, flushing
f) Dizziness, blurred vision, GI disturbances
What are the monitoring requirements ACEi when managing heart failure
Check renal function prior to initiation ; repeat tests within 1-2 weeks
What are the common adverse effects of the following heart failure medications:
a) Beta-blockers
b) ACEi
c) Spironolactone
d) Furosemide
e) Hydralazine
f) Digoxin
a) Bradycardia, hypotension, fatigue, dizziness
b) Hyperkalaemia, renal impairment, dry cough, light- headedness, fatigue, GI disturbances, angioedema
c) Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes libido
d) Hypotension, hyponatraemia/kalaemia
e) Headache, palpitations, flushing
f) Dizziness, blurred vision, GI disturbances
What is the genetic basis of Marfan syndrome?
inherited in an autosomal dominant pattern
What is the genetic basis of long QT syndrome?
Inherited in an autosomal dominant pattern
What is the genetic basis of Fabry disease?
Inherited as an X-linked disorder
Define cardiomyopathy
A disorder in which heart muscle is structurally and functionally abnormal (in the absence of other heart conditions severe enough to cause the heart abnormality)
a) Name the 2 most common cardiomyopathies
b) Name 3 uncommon cardiomyopathies
a)
- Hypertrophic cardiomyopathy
- Dilated cardiomyopathy
b)
- Arhythmogenic right ventricular cardiomyopathy
- Restrictive cardiomyopathy
- Unclassified cardiomyopathies: left ventricular non-compaction, takotsubo’s cardiopathy
What investigation is the diagnosis of cardiomyopathy deterred by?
Echocardiogram
What is hypertrophic cardiomyopathy?
An autosomal dominant genetic disorder that causes increased ventricular wall thickness or mass not caused by pathological loading
What is the genetic inheritance of hypertrophic cardiomyopathy
Autosomal dominnat
Describe the epidemiology of hypertrophic cardiomyopathy
- Commonest genetic cardiovascular condition
- Increase prevalence in males and the afro-caribbean and asian populations
- Most common cause of sudden death in under 35 years old
- Obstructive form i.e., hypertrophic obstructive cardiomyopathy (HOCM) seen in 2/3 of cases
Describe the aetiology of hypertrophic cardiomyopathy
HCM is commonly due to an abnormal gene that encodes one of the sarcomere proteins needed for myocardial contraction, which include:
- Cardiac troponin T and I
- Myosin regulatory light chains
The most common mutation is in the gene that encodes the beta myosin heavy chain and the inheritance is usually autosomal dominant
The myosin binding protein C is next commonly affected
What gene, is the most common mutation in hypertrophic cardiomyopathy found?
The gene that encodes the beta myosin heavy chain
Describe the pathophysiology of hypertrophic cardiomyopathy
In HCM there are mutations in genes encoding proteins that make up the sarcomere complex
Incorporation of these mutated peptides into the sarcomere –> impaired contractile function –> increased myocyte stress –> compensatory hypertrophy and increased fibroblasts –> chaotic and disorganised myocardial fibres
a) Describe the pathological consequences of HCM
b) Explain what these pathological changes lead to?
a) 1. Obstructive - left ventricular outflow obstruction
- Non-obstructive
- Mitral regurgitation
- Diastolic dysfunction
- Systolic dysfunction
- Arrhythmia
b) Heart failure with features of breathlessness, fatigue and overload. This is because of abnormal relaxation and filling, abnormal contraction and/or outflow obstruction.
How does left ventricular outflow obstruction in hypertrophic cardiomyopathy occur?
There is narrowing of the ventricular outflow tract due to thickened interventricular septum
Explain how the symptoms: syncope, sudden death, shortness of breath and chest pain come about in myocyte hypertrophy
Myofibres in disarray –> ventricular arrhythmia and sudden death
Left ventricular hypertrophy –> impaired relxation –> increased Left ventricular end-diastolic pressure (LVEDP) –> SOB
Left ventricular hypertrophy –> increased myocardial O2 demand –> chest pain
Hypertrophic cardiomyopathy
a) Symptoms
b) Signs
a)
- Most people are asymptomatic
- Fatigue
- Shortness of breath
- Orthopnoea
- Ankle swelling
- angina
- Presyncope or syncope
- Palpitations (AF)
- Sudden death
b)
- May be normal
- Ejection systolic murmur (left ventricular outflow obstruction)
- Mid-late systolic murmur (mitral regurgitation): occurs at the apex/may be pansystolic
- Heave (visible or palpation pulsation)
- Thrill
- Signs of LV outflow obstructions are exaggerated by standing up (reduce venous return), inotropes and vasodilators (e.g., GTN spray)
- Features of heart failure: raised JVP, crackles on lung auscultation, peripheral oedema
What exaggerates the signs of LV outflow obstruction?
- Standing up (reduced venous return)
- Inotropes
- Vasodilators (e.g., GTN spray)
Describe the 1st line and 2nd line investigations for hypertrophic cardiomyopathy?
1st line
- Echocardiography (gold standard)
- ECG
- Bloods: including LFTs, electrolytes, BNP, TNTs
- Genetic testing
2nd line
- Cardiac MRI
Describe the ECG appearance of hypertrophic cardiomyopathy
- Amplitude of QRS increased (shows LV hypertrophy with a strain pattern)
- T wave inversion
What re the 4 principles of management in hypertrophic cardiomyopathy?
What are the 4 principle of management in hypertrophic cardiomyopathy?
- Education and reassurance
- Management of symptoms and complications
- Risk stratification/prevent complication in HCM
- Family screening
Describe education and reassurance needed to be provided to patients with hypertrophic cardiomyopathy
- Most patients have no symptoms and a normal life expectancy
- Encourage ALL patients to undertake low-moderate intensity exercise
Describe the management of symptoms and complications in hypertrophic cardiomyopathy
- Beta-blocker or rate limiting calcium channel blocker
- Myomectomy/alcohol septal ablation (for those who do respond best to medical therapy)
Describe the role of beta-blockers and rate limiting calcium channel blockers in hypertrophic cardiomyopathy
They decrease heart rate and force of contraction –> increased diastolic filling time and decrease myocardial oxygen demand
When is myomectomy/alcohol septal ablation given as a method of treatment in hypertrophic cardiomyopathy?
For those with obstruction form that do not respond best to medical therapy
Describe the risk stratification/management required in hypertrophic cardiomyopathy to prevent complications
- Anti-arrhythmic drugs for any arrhythmia
- Patients with AF should receive treatment with DOAC/Warfarin
- Patients at risk of sudden death may benefit from an implantable cardioverter defibrillator (ICD)
a) What features make a patient with hypertrophic cardiomyopathy at highest risk?
b) What treatment is recommended?
a)
- Risk of sudden cardiac death
- Sustained VT
b) ICD
a) What features make a patient with hypertrophic cardiomyopathy at intermediate risk?
b) What treatment should be considered?
a)
- FH of sudden cardiac death
- Massive LVH
- Syncope
- LV aneurysm
- Impaired LV function
- NSVT
- Extensive scar on cardiovascular magnetic resonance (CMR)
b) ICD
Describe the family screening management in hypertrophic cardiomyopathy
- Genetic counselling should be offered to all patients (as 50% chance of passing gene to children)
- If detected, then cascade family screening can be offered to first degree relatives
- If no clear mutation detected, then first degree relatives should undergo regular follow up with ECG and ECHO
a) What is the role of mavacamten in hypertrophic cardiomyopathy
b) Describe how it works
a) It is a targeted inhibitor of cardiac myosin that improve symptoms in the obstructive form of HCM
b) Reduces the number of crossbridges in HCM sarcomere –> decrease contractility –> increased relaxation
What is dilated cardiomyopathy (DCM)
DCM is enlargement of one or both ventricles leading to impaired contractile function i.e., systolic dysfunction
Describe the aetiology of dilated cardiomyopathy
Idiopathic
Genetic - familial and neuromuscular
Inflammatory
- Infections: post viral (e.g., influenza, adenovirus, Coxsackie A and B)
- Non-infectious: connective tissue disease, permpartum cardiomyopathy, sarcoidosis
Toxic - alcohol, chemotherapy
Metabolic - hypothyroidism, hereditary hemochromatosis
Tachycardia induced
Describe the pathophysiology of dilated cardiomyopathy
Myocyte injury –> systolic dysfunction (decrease contractility) –> decrease stroke volume –> increased ventricular filling pressure (leads to pulmonary and systemic congestion) + LV dilatation (leads to mitral regurgitation) + decrease CO
Dilated cardiomyopathy
a) Symptoms
b) Signs
a)
- Asymptomatic
- Heart failure symptoms: breathlessness, peripheral oedema, fatigue, syncope, sporadic chest pain
- Arrhythmia e.g., AF or sudden cardiac death due to ventricular arrhythmia
- Thromboembolism
c)
- Displaced heartbeat secondary to LV dilatation
- Signs of heart failure
- S2 and S4 gallop
Describe the 1st and 2nd line investigations for dilated cardiomyopathy
1st line
- Echocardiography (gold standard)
- ECG: changes are non-specific
- CXR: features of heart failure, cardiomegaly
- Bloods
2nd line
- Cardiac biopsy (an establish definitive diagnosis but its use is controversial)
- Cardiac MRI
Describe the management of dilated cardiomyopathy
Management of DCM = management of systolic heart failure
- Beta-blockers and ACEi/ARBs
- Loop and thiazide diuretics
- Spironolactone
Prevent complications - anticoagulation if AF/LV thrombus
Cardiac transplantation
What is restrictive cardiomyopathy?
The ventricles becomes stiff, non-dilated which leads to abnormal ventricular filling with preserved systolic function
Describe the aetiology of of restrictive myocarditis
Commonly the result of infiltrative diseases where there is a deposition of substance in the myocardium such as amyloid, iron or granulomas:
- Amyloidosis
- Hemochromatosis (iron overload)
Describe the pathophysiology of restrictive myocarditis
Stiff ventricular myocardium –> increased diastolic ventricular pressure –> venous congestion –> signs of right sided heart failure (raised JVP, hepatomegaly and ascites, peripheral oedema)
Stiff ventricular myocardium –> decreased ventricular filling –> decreased CO –> weakness and fatigue
Describe the 1st line and 2nd line investigations for restrictive cardiomyopathy
1st line
- Echocardiography
- ECG: changes are non-specific
- CXR: reveals features of heart failure
- Bloods
2nd line
- Endomyocardial biopsy
- Complex imaging modalities (e.g., CT, MRI) and diagnostic angiography are particularly used to distinguish restrictive cardiomyopathy from constrictive pericarditis because of latter is correctable with surgery
Describe the CXR appearance in restrictive cardiomyopathy
Reveals feature of heart failure - alveolar effusion, kerley b lines, cardiomegaly, upper blood diversion
“sparkling” on ECG
Why are complex imaging modalities (e.g., CT, MRI) and diagnostic angiography used when investigating for restrictive cardiomyopathy
They are used to distinguish restrictive cardiomyopathy from constrictive pericarditis because constructive pericarditis is correctable with surgery
What are the symptoms and signs of restrictive cardiomyopathy?
Symptoms
- Weakness
- Fatigue
Signs
- Jugular vein distention
- Hepatomegaly and ascite
- Peripheral oedema
Describe the management of restrictive cardiomyopathy
- Aim to treat the underlying cause, other symptomatic treatment
- May require heart transplantation in later stages
- Prevent complications
- Individuals with AF must be offered anticoagulation unless contraindicated as they are at an increased risk of thromboembolism
What is arrhythmogenic cardiomyopathy?
It is an inherited heart muscle disease characterised by progressive replacement of the myocardium by fibrofatty tissue
Describe the epidemiology of arrhythmogenic cardiomyopathy
Presents in young-middle age
Describe the aetiology of arrhythmogenic cardiomyopathy
Genetics - due to mutation in a desmosomal gene in 40-60% of cases
Acquired - e.g., Chagas disease
Describe the pathophysiology of arrhthmogenic cardiomyopathy
It is a disease of the desmosome
Arrhthmogenic cardiopathy is a progressive disease with 3 clinical phases. Describe the 3 phases
Concealed phase - patient is asymptomatic but still at risk sudden cardiac death
Electrical phase - symptomatic ventricular arrythmias
Advanced phase - characterised by RV or biventricular failure
Arrythmogenic cardiomyopathy is a progressive disease 3 clinical phase: concealed phase, electrical phase and advanced phase.
Describe the features of each phase
Concealed phase - patient is asymptomatic but still at risk sudden cardiac death
Electrical phase - symptomatic ventricular arrythmias
Advanced phase - characterised by RV or biventricular failure
Describe the symptoms of arrythmogenic cardiomyopathy
- Asymptomatic
- Palpitations
- Syncope
- Chest pain
- Breathlessness
- Features of heart failure
- Sudden death
Describe the investigations for arrythmogenic cardiomyopathy
- Echocardiography with/without cardiac MRI
- ECG
- CXR
Describe the ECG appearance in arrhythmogenic cardiomyopathy
- T wave inversion
- Localised prolongation of QRS interval in right precordial leads (V1-V3)
- LBBB VT if arrhythmogenic cardiomyopathy of RV and RBBB if arrhythmogenic cardiomyopathy of LV
Describe the 4 principles of management of arrhythmogenic cardiomyopathy
- Risk stratification for sudden death
- defibrillators are indicated in the highest risk patients - Improve symptoms and quality of life
- Ventricular arrhythmias: beta lockers, antiarrhtymic drugs, catheter abaltion
- Heart failure: diuretics, beta blockers and ACEi, aldosterone antagonists - Prevent disease progression (exercise restriction)
- Vigorous exercise associated with accelerated progressive of disease and greater risk of ventricular arrhythmias
- Participation in high intensity recreational exercise or competitive sports is NOT recommended in patients with arrhythmogenic cardiomyopathy - Screening of family members
Takatosubo’s cardiomyopathy?
a) What is is also known as?
b) Aetiology
b) Epidemiology
c) Pathophysiology
d) Pathognomonic features of echocardiogram
e) Symptoms and signs
f) Management
a) ‘broken-heart syndrome’ or stress-induce cardiomyopathy
b) Cause is unknown but often brought on by stressful situations which are usually acute and severe
c) Preferentially affects postmenopausal women
d) Apical ballooning of the LV
e) Symptoms and signs may mimic MI (e.g., central crushing chest pain with ST elevation – which is often anterior) but patients have non-obstructive coronary arteries on angiography
f) The condition is self-limiting, but there is a risk of sudden death due to arrhythmia or ventricular free-wall rupture so monitoring in early stages and treatment with beta blockers and ACEi recommended
What is myocarditis?
Inflammation of the myocardium
Describe the aetiology of myocarditis
External triggers
- Infection (most commonly viral e.g., Coxsackie and influenza A and B)
- Drugs/Toxins
Internal triggers (immune mediated)
- Hypersensitivity reaction to vaccines
- Autoimmune disease
What are the 4 main clinical presentation of myocarditis
- Asymptomatic
- Symptomatic
- Chest pain
- Arrhythmias (AV block, ventricular arrhythmias)
- Heart failure (acute/chronic)
Describe the investigations for myocarditis
- ECG
- Troponin
- Echocardiogram
- Cardiac MRI
- Endomyocardial biopsy via cardiac catheterisation is the gold standard diagnostic
a) What is the gold standard diagnostic tool for for myocarditis?
b) What are the risks?
a) Endomyocardial biopsy via catheter catheterisation
b) Invasive test so bleeding can occur
Describe the ECG appearance in myocarditis
Non-specific ST segment and T wave changes (which may be regional, depending on degree and location of myocardial involvement), along with ectopic beats and arrhythmias if present
Describe the troponin levels in myocarditis
Markedly elevated
Describe the echocardiogram changes in myocarditis
Can reveal ventricular dysfunction if present (in the form of diastolic dysfunction or regional wall motion abnormalities)
Describe the structure of the pericardium
A two-layered sac that encircles the heart
1. Parietal pericardium –> bought outer fibrous layer
2. Visceral pericardium –> inner serial layer
Pericardial space: contains a small amount of serous fluid <50ml
What are the 3 main role of the pericardium?
- Anchors the heart to the thorax
- Acts as barrier to the infection
- Limits sudden dilatation of the heart
Is the pericardium essential for life?
No
Describe the aetiology of pericardial disease
Idiopathic
Infectious
- Bacteria
- TB
- Viral
Non-infectious
- Auto immune
- Cancer
- Metabolic
- Trauma
- Radiation
- Drugs
What 3 things can go wrong in the pericardium?
- Effusion
- Pericarditis (inflammation)
- Constriction (fibrosis)
What is acute pericarditis?
The inflammation of the pericardium
Describe the epidemiology of acute pericarditis
Majority of patients are males aged 20-50
Describe the pathophysiology of acute pericarditis
The pericardial sac is acutely inflamed with infiltration of immune cells secondary to an acute infection or as a manifestation of systemic disease
Describe the aetiology of acute pericarditis
Usually idiopathic/viral (often due to coxsackievirus B but also influenza, adenovirus etc)
Can also be
- Uraemia
- Surrounding organ involvement
- Malignant disease
- Autoimmune hypersensitivity
- Inflammatory disorders e.g., Behcets syndrome
Clinical features of acute pericarditis
a) Symptoms
b) Signs
a)
- Chest pain: pleuritic (worse on inspiration), worse lying down and better on leaning forward and sitting up
- Fever: usually low grade
- Breathlessness
- Fatigue
- Cough
b)
- Pericardial friction rub (high pitched scratchy sound best heard at left sternal border with patient leaning forward with held inspiration)
- Features of cardiac tamponade: muffled hear sounds, distended KBP, pulses paradoxus (fall n BP > 10mmHg during inspiration), hypotension
Describe the 1st line and 2nd investigations for acute pericarditis
1st line
- 12 lead ECG
- Blood tests: FBC (for infection), troponin
- CXR
- Echocardiography (for structural heart abnormality)
2nd line - to detect other possible aetiologies and in diagnostic uncertainty
- ANA testing
- HIV serology
- Tuberculin skin test (tuberculosis)
Describe the findings for pericarditis for the following investigations
a) Bloods
b) CXR
a) Elevated WCC, ESR and CRP and elevated troponin (may suggest myocardial involvement - myopericarditis)
b) Often normal, but may show pericardial effusion - globular appearance of heart
Describe the ECG appearance of acute pericarditis
Widespread saddle-shaped ST elevating with PR depression and a downward sloping T-P line (Spodick’s sign)
Describe the management of acute pericarditis
1st line - Ibuprofen
2nd line - Colchicine (can be given as an adjunct to NSAID treatment or a primary therapy in patients with contraindications)
3rd line - Corticosteroids
What are the complications of acute pericarditis
- Haemodynamic compromise
- Pericarditis affection +/- tamponade
Describe how rapid effusion and slow effusion affects the haemodynamic impact in cardiac tamponade
Rapid effusion - if accumulation occurs acutely it can lead to rapid development of haemodynamic compromise (i.e., hypotension)
Slow effusion - if accumulation occurs slowly, it may take several weeks before clinical symptoms and features of haemodynamic compromise occur
What is cardiac tamponade
A life-threatening condition that causes compression of heart from pericardial content
Describe the aetiology of cardiac tamponade
Common causes
- Pericarditis
- Tuberculosis
- Iatrogenic
- Trauma
- Post pacemaker implantation or post cardiac surgery
- Malignancy
Uncommon causes
- Connective tissue disease
- Radiation-induced
- Uraemia
- Post-myocardial infraction
- Aortic dissection
- Bacterial infection
Describe the investigations for cardiac tamponade
- Echocardiography (urgent)
- ECG
- CXR
- CT/MRI
- Pericardiocentesis
What are the findings on ECG for cardiac tamponade
- Sinus tachycardia
- Electrical alternans
- Low voltage of the QRS complex
- PR segment depression
Describe the ECG appearance for cardiac tamponade
In large pericardial effusion the QRS complexes may be small and vary in height from heart to beat (electrical alternates)
Clinical features of cardiac tamponade
a) Symptoms
b) Signs
a)
- Chest pain
- Dysponea
- Collapse
- Fatigue
- Confusion
- Peripheral oedema (subacute)
b)
“Tamponade quadrad’
1. Hypotension
2. Tachycardia
3. Raised JVP
4. Pulsus paradoxus (fall in blood pressure > 10mmHg during inspiration)
+ Pericardial friction rub
+ other features of shock: cool extremities, peripheral cyanosis, reduced urine output
+ Beck’s triad (hypotension, muffled heart sound, raised JVP
Describe the management off cardiac tamponade
Urgent needed pericardiocentsis (drainage of the pericardial fluid via a needle)
Give 4 complications of pericardiocentesis
- Pneumothorax
- Damage to the myocardium
- Coronary vessels
- Thrombus
- Arrhythmias/cardiac arrest
- Damage to the peritoneum
What is restrictive pericarditis
Progressive thickening, fibrosis and calcification of the pericardium, which limits the filling of the chambers
Describe the aetiology of restrictive pericarditis
- Most commonly idiopathic (but can be due to any cause of pericarditis)
- Post-cardiac surgery
- Radiotherapy
- Connective tissue disorders
- Tuberculosis
- Others: malignancy, trauma, uraemia pericarditis
Describe the pathophysiology of restrictive pericarditis
Chronic damage to the pericardium causes thickening, fibrosis and calcification of the sac. This makes it relatively inelastic and unable to expand optimally during diastole
As the disease progresses, venous return is impeded as the right atrium fails to expand leading to a fluid overload state
Eventually there is reduced ventricular and stroke volume, leading to a low cardiac output
Clinical features of constrictive pericarditis
a) Symptoms
b) Signs
a)
- Fatigue
- Breathlessness
- Peripheral oedema
b)
- Kussmaul’s sign (raised JVP on inspiration)
- Pericardial knock
- Raised JVP
- Pulsus paarodxus
- Signs of heart failure (peripheral oedema, ascites, hepatomegaly)
- Pleural effusion
- Cachexia (in severe disease)
Describe the 1st line and 2nd line investigations for constrictive pericarditis
1st line
- Echocardiogram (diagnostic)
- ECG
- CXR
2nd line
- CT chest (to evaluate pericardial calcification associated with constrictive pathology and can identify extent of pericardial effusion)
- Coronary angiogram (if echocardiography is non-diagnostic and before pericardiectomy to visualise the coronary vessel anatomy)
Describe the management of constrictive pericarditis
Pericardiectomy - indicated in both acute and chronic pericardial constriction
Medical therapy - NSAIDs, colchicine and/or steroids can be used to control symptoms if unsuitable or as a bridge to surgery
Describe the prognosis of restrictive pericarditis
- Curable if diagnosed early
- Long-term prognosis after medical therapy alone is poor
- Life expectancy is also poor in untreated children and patients with acute onset of symptoms
What is syncope?
A transient loss of consciousness due to global cerebral hypoperfusion
Describe the causes of transient loss of conscious
- Non-traumatic
- Global cerebral hypoperfusion
- NOT due to global cerebral hyoperfusion –> epilepsy, psychogenic - Traumatic (head injury)
Describe the characteristics of syncope due to global cerebral hypoperfuion causes vs not due to global cerebral hypoperfuon
Global cerebral hypoperfusion characterised by:
- Rapid onset
- Short duration
- Spontaneous complete recovery
NOT due to global cerebral hypoperfusion is NOT characterised by:
- rapid onset
- Short duration
- Spontaneous complete recovery
Give the 4 causes of syncope and how common they are
Reflex - 60%
Orthostatic - 15%
Cardiac - 15%
Unknown - 10%
Describe the characteristics of reflex syncope
- Can occurs at any age (but more common in younger patients and less common in elderly)
- Occurs in response to a trigger (emotional stress or real/threatened/imagine injury due to e.g., pain, sight of blood or having blood taken)
- Mainly occurs when standing up
- There is usually a prodrome lasting between 30 seconds to several minutes where the patient feels fatigue, yawns, feels hot, sweat, nauseous and has dimming of their vision followed by a loss of consciousness)
- During the episode the patient appears pale and diaphoretic
- Sometime the prodrome is vert short or not present at all
- Loss of consciousness is brief (30 to a few minutes)
- Occasionally there is a seizure-like activity (happens because of lack of blood flow to brain)
- Recovery is rapid although patient can feel fatigued afterwards
What are the 3 types of reflex syncope?
- Vasovagal
- Situational
- Carotid sinus syndrome
Give 4 common triggers of vasovagal syncope
- Prolong standing
- Pain
- Fear
- Having blood taken
Describe the pathophysiology of vasovagal syncope
In vasovagal syncope messages from higher brain centres (triggered by pain or emotion or from the heart triggered by prolonged standing) go to the brainstem and trigger an abnormal reflex consisting of withdrawal of sympathetic activity.
This leads to peripheral vasodilatation and hypotension - this is call the vasopressor effect. Also leads to increase vagal parasympathetic activity which results in slowing of the heart, called the cardioinhibitory effect
These cause cerebral hypoperfusion and syncope
What are the symptoms of vasovagal syncope?
- Fainting
- Feeling warm
- Nausea
- Skin feels cold and clammy
- Ringing in ears
- Dizziness or light-headedness
- Blurred or tunnel vision
- Turning pale
Situation syncope is a form of reflex syncope caused by specific triggers. Describe the specific triggers
GI tract
- micro nutrition syncope: fainting occurring shorter after or during urination
GI
- Defaecation
Respiratory
- Coughing
- Laughing
Describe the carotid sinus reflex
Increase in BP –> carotid baroreceptors stimulated by arterial stretch –> send messages to brain stem
This leads to:
- Decrease sympathetic activity to ventricular muscle –> decreased contractility and decreased SV -> decreased CO (BP = TPR X CO)
- Decreased sympathetic activity to venous system causing increased compliance
- Decreased peripheral arterial vascular resistance –> decreased BP (BP = TPR X CO)
- Increase parasympathetic activity (decrease HR and contractility) –> decrease CO –> decrease BP ( BP = TPR x CO)
What is the carotid sinus massage and what is a normal response to it?
A simple bedside test to test the carotid sinus reflex
A normal response is a slight drop in HR and/or BP
Carotid sinus syndrome
a) What is it?
b) Who does it occurs in the most?
c) Name 3 triggers
d) What can help it?
a) Syncope without warning and exaggerated carotid sinus massage response with reproduction of syncope
b) Occurs in older patients (particularly men)
c) Head turning, shaving, tight collar
d) Pacing can help if carotid massage causes a decrease in HR
What is orthostatic hypotension?
Drop in systolic blood pressure ≥ 20mmHg (or ≥ 10mmHg DPB) ≤ 3 mins of standing
OR
Drop in systolic blood < 90mmHg on standing
Describe the pathophysiology of orthostatic hypotension
Standing from a Supine position causes 10-15% of our blood volume to be redistributed to the abdomen and lower limbs thereby reducing venous return –> undefilled LV –> reduced stroke volume –> reduced cardiac output –> and without compensatory mechanisms there would be a drop in BP
Underfilled LV –> vigorous LV contraction –> Inappropriately activates stretch receptors in LV (this overrides baroreceptor reflex) –> decrease sympathetic activity and increase parasympathetic activity –> vasodilatation and decrease HR –> BP decreased
What causes orthostatic hypotension?
Drugs
- anti-hypertensives
- anti-anginals
- anti-BPH
- anti-depressants
- anti-psychotics
- anti-parkisonian
- alcohol
Hypovolaemia - dehydration, Addison’s disease
Autonomic failure - Primary (Parkinson’s) and secondary (ageing, diabetes)
Why are elderly patients more susceptive to hypotensive effects of drugs?
Because of reduced baroreceptor sensitivity, decreased cerebral blood flow, renal sodium wasting and impaired thirst mechanism that develops with ageing
When is orthostatic symptoms worse and when are they better?
Symptoms are worse
- On standing
- In the morning
- After meals
- After exercise
- In hot environments
Symptoms are better
- When lying down or sitting
Describe the management of reflex syncope and orthostatic hypotension
- Reassurance, education, and lifestyle changes
- Let patient know it’s benign and not life threatening
- Patient should be educated about triggers and prodromal symptoms of feeling hot, sweaty, light-headedness and to sit down if possible and about counter-pressure manoeuvres
- Advise patients to drink 6 pints of water daily and increase salt intake (to 120 mol/day) - Counter-pressure manoeuvres
- Crossing the leg and squeezing them together
- Squatting
- Linking the fingers together without letting them go
Describe the management of reflex syncope and orthostatic hypotension
- Reassurance, education, and lifestyle changes
- Let patient know it’s benign and not life threatening
- Patient should be educated about triggers and prodromal symptoms of feeling hot, sweaty, light-headedness and to sit down if possible and about counter-pressure manoeuvres
- Advise patients to drink 6 pints of water daily and increase salt intake (to 120 mol/day) - Counter-pressure manoeuvres
- Crossing the leg and squeezing them together
- Squatting
- Linking the fingers together without letting them go - If symptoms due to low BP –> give drugs that increase BP
- Fludrocortisones
- Midodrine - Stop/reduce BP lowering drugs
- If symptoms due to slow HR then consider pacing (selected patients with reflex syncope)
When should you consider pacing in patients with reflex syncope?
In recurrent syncope despite medical therapy (particularly if little warning and associated injury + bradycardia or systole pauses)
What causes cardiac syncope
Arrhythmia (2/3)
- Bradycardia –> sinus node disease, AV block
- Tachycardia –> VT, SVT
Strutural (1/3)
- Cardiac –> Aortic stenosis, ACS, cardiomyopathy
- Vascular –> PE, aortic dissection
What are the 6 key point in the history taking of syncope
Before
- Provoking factors
- Posture
- Prodrome (symptoms beforehand)
- PMH, DH, FH
During
- Passer-by account
After
- Post event
Describe the investigations for syncope
- ECG
- ECHO (if structural heart disease is suspected)
- Cardiac rhythm monitoring
1. Holter
2. Loop recorder - Tilt test
What are high risk features on ECG of syncope
- Signs of acute MI
- Arrhythmias e.g., sinus node disease, complete heart block, VT
- Conduction disease e.g., LBBB, Left ventricular hypertrophy, Q wave
- Structural heart disease e.g., channelopathy, long QT interval
Describe the role of an implantable loop recorder in syncope
- Useful in diagnosis of recurrent syncope of unknown origin
- Suggests arrhythmic syncope when high risk arrhythmias are detected in an asymptomatic patient
- Can still be useful in patient without an arrhythmic cause for syncope by excluding arrhythmia at the time of the patient’s symptoms
a) Describe the tilt table test
b) Describe the role of the tilt table test in syncope
c) What is a positive test?
a) Patient starts off supine, gradually tilt to upright position
b)
- Used to provoke reflex syncope in laboratory setting
- Used to confirm a diagnosis of reflex syncope in a patient with syncope of unknown cause (where reflex syncope is suspected but not proven)
- Not used much
c)
Decrease systolic BP (vasopressor response) or decrease heart rate (cardioinhibitory response) or decrease BP and decrease HR (mixed response)
