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Diagnosis and Management > Valvular Disease, HF, Cardiomyopathies > Flashcards

Valvular Disease, HF, Cardiomyopathies Flashcards

1
Q

Cardiac Anatomy & Physiology

Heart: (4) room house

With (2)

A
  • Right atrium
  • Right ventricle
  • Left atrium
  • Left ventricle
  1. Electricity
  2. Plumbing
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2
Q

Concepts and Objectives

Important Concepts to Understand

  • ___stole
  • ___stole
  • Myocardial o____ perfusion/consumption
  • E_____ Fraction

Objectives

  1. Review normal cardiac an____ and phys____
  2. Understand normal valvular f_____
  3. Explore common valvular d_____
  4. Discuss diagnosis and m______ of valvular disease
  5. Differentiate heart failure with r_____ and pr______ ejection fraction
  6. Evaluate common management strategies for heart _____
  7. Define and differentiate 3 common cardio_______
A

Important Concepts to Understand

  • Systole
  • Diastole
  • Myocardial oxygen perfusion/consumption
  • Ejection Fraction

Objectives

  1. Review normal cardiac anatomy and physiology
  2. Understand normal valvular function
  3. Explore common valvular disease
  4. Discuss diagnosis and management of valvular disease
  5. Differentiate heart failure with reduced and preserved ejection fraction
  6. Evaluate common management strategies for heart failure
  7. Define and differentiate 3 common cardiomyopathies
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3
Q

Valvular Function

Valvular Basic Information

Purpose in Life =

  • Essentials for proper function
    • Properly formed and fl_____
    • Opens all the way so blood can p____ through
    • Closes tightly so no blood l______ backwards
  • 4 valves
    • Location: Located on each end of the 2 ventricles
    • (3) valves with 3 cusps (tricuspid)
    • (1) valve with 2 cusps (bicuspid)
A

Purpose in Life: Prevention of backward flow of blood

  • Essentials for proper function
    • Properly formed and flexible
    • Opens all the way so blood can pass through
    • Closes tightly so no blood leaks backwards
  • 4 valves
    • Location: Located on each end of the 2 ventricles
    • 3 valves with 3 cusps (tricuspid)
      • Tricuspid, Aortic, Pulmonic
    • 1 valve with 2 cusps (bicuspid)
      • Mitral
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4
Q

Tricuspid Valve

=

  • Once right atrium f____, TV opens to allow __oxygenated blood to enter right ventricle.
  • As pressure changes in the right atrium and right ventricle, TV _____.
  • RV contracts>pumps deoxygenated blood through (1) valves into lungs
A

Forms the border between the right atrium and ventricle

  • Once right atrium fills, TV opens to allow deoxygenated blood to enter right ventricle.
  • As pressure changes in the right atrium and right ventricle, TV closes.
  • RV contracts>pumps deoxygenated blood through PV into lungs
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5
Q

Mitral Valve

=

  • Opens when LV relaxes (____) –which allows blood from LA to fill decom______ LV
  • When LV contracts (_______), increase in pressure within ventricle causes the valve to ____
  • Assures blood leaving the LV (s____ v_____) is ejected through (1) valve into aorta and to body
  • Function is dependent on complex interplay between the ann____, leaf____, and ___valvular apparatus
A

2 cusps (bicuspid) between left atrium and left ventricle

  • Opens when LV relaxes (diastole) –which allows blood from LA to fill decompressed LV
  • When LV contracts (systole), increase in pressure within ventricle causes the valve to close
  • Assures blood leaving the LV (stroke volume) is ejected through AV into aorta and to body
  • Function is dependent on complex interplay between the annulus, leaflets, and subvalvular apparatus
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6
Q

Pulmonic Valve

=

  • Opens to allow blood to be pumped from (1) to (1) (through pulmonary _____) > to get ______
  • Prevents ____flow from pulmonary artery to RV
A

3 leaflet valve that separates the RV from the pulmonary artery

  • Opens to allow blood to be pumped from RV to lungs (through pulmonary artery) >oxygenated
  • Prevents backflow from pulmonary artery to RV

Compared to other valves really doesn’t like any pressure, just a conduit, likes to chill

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7
Q

Aortic Valve

=

  • Separates (1) from (1)
  • Opens to allow blood to leave LV into aorta and then ____
  • Prevents ____flow of blood from aorta to LV
A

3 leaflet valve that separates the LV from the aorta

  • Separates LV from aorta
  • Opens to allow blood to leave LV into aorta and then body
  • Prevents backflow of blood from aorta to LV
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8
Q

Tricuspid Valve Disease

(2)

A

Tricuspid Regurgitation

Tricuspid Stenosis

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9
Q

Tricuspid Regurgitation Primary Causes

What is the most common cause?

  • Chest tr____
  • ______ endocarditis
  • Eb____ anomaly
  • Car____ syndrome
  • Myx______ degeneration
  • C_________ tissue disorder
  • Marantic endocarditis (l_____/rh_____ arthritis)
A

Rheumatic Disease*

  • Chest trauma
  • Infective endocarditis
  • Ebstein anomaly
  • Carcinoid syndrome
  • Myxomatous degeneration
  • Connective tissue disorder
  • Marantic endocarditis (lupus/rheumatoid arthritis)
  • IE and rheumatic are the biggest causes*
    • IE from dental infection, big one right now is IVDU*
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10
Q

Tricuspid Regurgitation Secondary Causes

  • ____ sided heart _____
  • ______ stenosis/regurgitation
  • P______ disease: PE, cor pulmonale, pulmonary HTN,
  • Hyper_____
  • S_____ of pulmonary artery or valve
A
  • Left sided heart failure
  • Mitral stenosis/regurgitation
  • Pulmonary disease: PE, cor pulmonale, pulmonary HTN,
  • Hyperthyroidism
  • Stenosis of pulmonary artery or valve

uncontrolled hyperthyroidism is a serious cause, i have seen people need heart transplants from hyperthyroidism

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11
Q

Tricuspid Stenosis Causes

  • ______ heart disease-almost always in conjunction with ____ stenosis
  • Infective _____ (chronic)
  • Car_____ syndrome
  • Systemic ____ erythematosus
  • Anti______ Antibody Syndrome
  • Eb______anomaly
  • F_____ Disease/Wh_____Disease
A
  • Rheumatic heart disease-almost always in conjunction with mitral stenosis
  • Infective endocarditis (chronic)
  • Carcinoid syndrome
  • Systemic lupus erythematosus
  • Antiphospholipid Antibody Syndrome
  • Ebstein’s anomaly
  • Fabry Disease/Whipple Disease
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12
Q

Mitral Valve Disease

(2)

A

Mitral Regurgitation

Mitral Stenosis

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13
Q

Mitral Regurgitation Causes

Most common cause?

  • Cardio_____
  • MV pr_____
  • Rh______ disease (Carey Coombs murmur)
  • In______ end______
  • Annular cal______
  • Chordae tendineae r________
  • Systemic _____ erythematosus- Libman-Sacks lesion
  • T______ (Atrial myxoma)
A

Ischemic heart disease - CAD*

  • Cardiomyopathy
  • MV prolapse
  • Rheumatic disease (Carey Coombs murmur)
  • Infective endocarditis
  • Annular calcification
  • Chordae tendineae rupture
  • Systemic lupus erythematosus- Libman-Sacks lesion
  • Tumors (Atrial myxoma)

bc most commonly sees anterior wall MI’s which is the part that feeds the mitral valve/papillary muscles

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14
Q

Mitral Regurgitation Acute Causes

(1)

  • Due to ischemia or MI may cause (1) dysfunction or rupture
  • MI or severe prolonged ischemia can cause __reversible papillary muscle dysf____ and sc_____
  • P_______ papillary muscle (supplied by PDA) is more vulnerable to ischemia than the anterolateral papillary muscle (supplied by both LAD and circumflex)

(1)

  • Can involve abscess formation, vegetation, rupture of chordae tendineae, and leaflet perforation

(1)

  • Due to trauma, mitral valve prolapse, endocarditis, or spontaneous rupture
A

CAD:

  • Due to ischemia or MI may cause papillary muscle dysfunction or rupture
  • MI or severe prolonged ischemia can cause irreversible papillary muscle dysfunction and scarring
  • Posteromedial papillary muscle (supplied by PDA) is more vulnerable to ischemia than the anterolateral papillary muscle (supplied by both LAD and circumflex)

Infective endocarditis

  • Can involve abscess formation, vegetation, rupture of chordae tendineae, and leaflet perforation

Chordae tendineae rupture

  • Due to trauma, mitral valve prolapse, endocarditis, or spontaneous rupture
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15
Q

Mitral Stenosis

Most common cause?

  • L_____
  • F_____ Disease
  • Wh_____ Disease
  • Cong____
  • Rheumatoid ar_____
  • Mal_____ carcinoid disease
  • Methy______ therapy
  • H________ H_____ phenotype (mucopolysaccharidosis) - what is this?
A

Rheumatic Fever is the most common cause of mitral stenosis

  • Lupus
  • Fabry Disease
  • Whipple Disease
  • Congenital
  • Rheumatoid arthritis
  • Malignant carcinoid disease
  • Methysergide therapy
  • Hunter Hurler phenotype (mucopolysaccharidosis) -like people with diabetes develop stiffening of arteries and valves - think of like dropping sugary water on any surface it becomes stiff
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16
Q

Rheumatic Fever as the most common cause of Mitral Stenosis

  • Stenosis of the MV usually occurs how long? following the episode of acute rheumatic myocarditis
  • The acute insult leads to inflammatory f___ in the endocardium and myocardium; small v______ along the border of the valves can be seen
  • Over time, the MV becomes th_____, cal_____, contracted commissural ad_____ occurs -> leads to stenosis
A
  • Stenosis of the MV usually occurs decades following the episode of acute rheumatic myocarditis
  • The acute insult leads to inflammatory foci in the endocardium and myocardium; small vegetations along the border of the valves can be seen
  • Over time, the MV becomes thickened, calcified, contracted commissural adhesions occurs -> leads to stenosis
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17
Q

Mitral Stenosis Notes

  • (1): the association of the atrial septal defect with rheumatic mitral stenosis
  • As the valve orifice decreases, the pressure gradient across the MV __creases to maintain adequate flow
  • Normal MV orifice area = _-_ cm2
  • Once the valve area is __-__ cm2 or less, pts may start to have symptoms that include (1) or (1) with moderate exercise; this is due to the increased gr_____ across the valve and increased LA pr______
A
  • Lutembacher Syndrome: the association of the atrial septal defect with rheumatic mitral stenosis (congenital defect - the hold in the heart is the cause of the rheumatic fever)
  • As the valve orifice decreases, the pressure gradient across the MV increases to maintain adequate flow
  • Normal MV orifice area = 4-6 cm2
  • Once the valve area is 2-2.5 cm2 or less, pts may start to have symptoms that include exertional dyspnea or tachycardia with moderate exercise; this is due to the increased gradient across the valve and increased LA pressure
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18
Q

Mitral Stenosis Notes

  • As the valve narrows progressively, the resting diastolic MV gradient and LA pressure increases -> leading to:
    • Transudation of fluid into the ____ interstitium
    • D_____ at rest or with minimal exertion
    • Atrial _______ (LA dilatation increases this risk)
    • Hemo____ (may occur if bronchial veins rupture)
  • Pulmonary ____ develops due to:
    • Retrograde transmission of left atrial pressure
    • Pulmonary arteriolar constriction
    • Interstitial edema
    • Changes in the pulmonary vascular bed (intimal hyperplasia & medial hypertrophy)
A
  • As the valve narrows progressively, the resting diastolic MV gradient and LA pressure increases -> leading to:
  • Transudation of fluid into the lung interstitium
  • Dyspnea at rest or with minimal exertion
  • Atrial fibrillation (LA dilatation increases this risk)
  • Hemoptysis (may occur if bronchial veins rupture)
  • Pulmonary HTN develops due to:
  • Retrograde transmission of left atrial pressure
  • Pulmonary arteriolar constriction
  • Interstitial edema
  • Changes in the pulmonary vascular bed (intimal hyperplasia & medial hypertrophy)
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19
Q

Mitral Stenosis Notes

  • As pulmonary arterial pressure increases, RV ______ and tricuspid ______ can occur → this leads to elevated J , l___ congestion, as____ and pe___ edema
  • Left ventricular end-diastolic pressure and cardiac output are typically ______ in pts with isolated mitral stenosis
  • As MS becomes more severe, cardiac output ____ below normal at rest and ____ to increase with exercise
  • Severe mitral stenosis = mean pressure gradient >__; MV area < __cm2
A
  • As pulmonary arterial pressure increases, RV dilation and tricuspid regurgitation can occur → this leads to elevated JVP, liver congestion, ascites and pedal edema
  • Left ventricular end-diastolic pressure and cardiac output are typically normal in pts with isolated mitral stenosis
  • As MS becomes more severe, cardiac output drops below normal at rest and fails to increase with exercise
  • Severe mitral stenosis = mean pressure gradient >10; MV area < 1cm2
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20
Q

Pulmonic Valve Disease

(2)

A

Pulmonic Regurgitation

Pulmonic Stenosis

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21
Q

Pulmonic Regurgitation

Diagnosis is usually what?

Mild PR common in ______ - usually _____

  • (2) are most common causes of iatrogenic PR and pathological PR overall
    • Surgical treatment for RV outflow tract obstruction – (1) congenital heart defect
  • (1) disease
  • Infective (1)
  • C_____ disease
  • Pulmonary artery ____
A

Physiological PR and is often considered an incidental finding on echo (pretty common)

Mild PR common in adolescents-usually benign (usually bc of hormonal changes)

  • Surgical valvulotomy and balloon valvuloplasty are most common causes of iatrogenic PR and pathological PR overall
    • Surgical treatment for RV outflow tract obstruction – Tetralogy of Fallot
  • Rheumatic heart disease
  • Infective endocarditis
  • Carcinoid disease
  • Pulmonary artery HTN
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22
Q

Pulmonic Stenosis

Most associated with (1)-(2)

  • Maternal r____ syndrome
  • Rh_____ heart disease
  • Previous CV s_____
  • Cardiac t_____
A

Most associated with congenital structural cardiac syndromes

Tetralogy of Fallot & Noonan Syndrome

  • Maternal rubella syndrome (not common anymore)
  • Rheumatic heart disease
  • Previous CV surgery
  • Cardiac tumor
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23
Q

Aortic Valve Disease

(2)

A

Aortic Insufficiency (regurgitation)

Aortic Stenosis

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24
Q

Aortic Insufficiency (Regurgitation)

In acute AI, retrograde backflow of blood causes a quick rise in the LV end-______ volume.

Acute increase in preload and afterload do not allow time for the LV to acc_____ to the rapid volume increase during diastole

A

In acute AI, retrograde backflow of blood causes a quick rise in the LV end-diastolic volume.

Acute increase in preload and afterload do not allow time for the LV to acclimate to the rapid volume increase during diastole.

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25
Q

Aortic Insufficiency Causes

  • Infective ______
  • Traumatic/non-traumatic _______ of ascending aorta (aortic cusp prolapse)
  • (1) processes:
    • SLE, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, Takayasu vasculitis, Marfan/Ehlers-Danlos syndromes, Behcet disease
  • _______ AI causes:
    • infective endocarditis, myxomatous valve degermation, bicuspid AV, AV calcification, aortic dissection, Whipple disease, Chrohn disease, systemic HTN
  • T_____ Syndrome
A
  • Infective endocarditis
  • Traumatic/non-traumatic rupture of ascending aorta (aortic cusp prolapse)
  • Rheumatologic processes:
    • SLE, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, Takayasu vasculitis, Marfan/Ehlers-Danlos syndromes, Behcet disease
  • Chronic AI causes:
    • infective endocarditis, myxomatous valve degermation, bicuspid AV, AV calcification, aortic dissection, Whipple disease, Chrohn disease, systemic HTN
  • Turner Syndrome
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26
Q

Aortic Stenosis

Is it common?

Leads to left ventricular (1)

  • LV obstruction caused by AS increases LV ____tolic pressure and LV ejection t____ , and LV end-_____tolic pressure.
  • AS ___creases aortic pressure
  • ___creased afterload/volume overload >LV dys_____/f______
  • Myocardial oxygen consumption __creases with increased LV systolic pressure/LVET (ejection time)
A

Common

Leads to LVOT Obstruction

  • LV obstruction caused by AS increases LV systolic pressure and LV ejection time , and LV end-diastolic pressure.
  • AS decreases aortic pressure
  • Increased afterload/volume overload >LV dysfunction/failure
  • Myocardial oxygen consumption increases with increased LV systolic pressure/LVET
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27
Q

Aortic Stenosis Causes

  • ______ (bicuspid/unicuspid) leaflet deformities
    • ___cuspid disease most common cause for pts < 70
  • Cal_____
  • Rh______ disease (most common cause in developing countries)
  • S _ _
  • R_____ of chest
  • Homozygous Type II L______emia
  • F_____ Disease
  • ________ cardiomyopathy (subvalvular stenosis)
A
  • Congenital (bicuspid/unicuspid) leaflet deformities
    • Bicuspid disease most common cause for pts < 70
  • Calcification
  • Rheumatic disease (most common cause in developing countries)
  • SLE
  • Radiation of chest
  • Homozygous Type II Lipoproteinemia
  • Fabry Disease
  • Hypertrophic cardiomyopathy (subvalvular stenosis)
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28
Q

What murmur does this describe?

Holosystolic, the larger the defect, the quieter the murmur.

A

Ventral Septal Defect

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29
Q

What murmur does this describe?

Mid-systolic, crescendo-decrescendo in character radiating towards the neck. Quieter with Valsalva or standing.

A

Aortic Stenosis (AS)

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30
Q

What murmur does this describe?

Early systolic murmur with a mid-systolic click heard best at the cardiac apex

A

Mitral valve prolapse (MVP)

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31
Q

What murmur does this describe?

Mid-systolic, crescendo-decrescendo murmur that increases in intensity during inspiration. In severe PS, the S2 heart sound is widely-split.

A

Pulmonic Stenosis (PS)

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32
Q

What murmur does this describe?

Holosystolic, heard best at the lower left sternal border with radiation to the right lower sternal border. TR, compared to MR, increases on inspiration.

A

Tricuspid regurgitation (TR)

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33
Q

What murmur does this describe?

Mid-systolic, also radiates and is heard best at the left sternal border and is important to distinguish from MR. The murmur is louder with Valsalva and standing

A

Hypertrophic Cardiomyopathy (HCM)

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34
Q

What murmur does this describe?

Mid-systolic, S2 heart sound is fixed-split and does not change with inspiration

A

Atrial septal defect (ASD)

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35
Q

Tricuspid Regurgitation Diagnostics

Patient will present with clinical signs of what type of heart failure?

  1. Echo
    1. right atrium = (1)
    2. right ventricle = (1)
    3. right ventricle function = (1), ____dynamic, or r_______
  2. CXR
    1. (1) heart size with severe TR
    2. As____/Pleural ______
  3. Labs
    1. MAY see abnormal (1) function, hyper______ 2/2 to hepatic congestion
A

Right sided heart failure

  1. Echo
    1. right atrium = dilated
    2. right ventricle = dilated
    3. right ventricle function = normal, hyperdynamic, or reduced
  2. CXR
    1. Cardiomegaly heart size with severe TR
    2. Ascites/Pleural effusion
  3. Labs
    1. MAY see abnormal liver function, hyperbilirubinemia 2/2 to hepatic congestion
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36
Q

Tricuspid Regurgitation Physical Exam

  • As_____
  • J_____ v____ distension
  • S__ gallop (extremely _____ RV)
  • ___systolic murmur
  • J_____
  • Atrial _______
  • Peripheral e_____
  • Cach______
A
  • Ascites
  • Jugular vein distension
  • S3 gallop (extremely dilated RV)
  • Pansystolic murmur
  • Jaundice
  • Atrial fibrillation
  • Peripheral edema
  • Cachexia
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37
Q

Tricuspid Regurgitation Medical Tx

➢D______

➢Anti_______

➢A____

➢Anti________*

A

➢Diuretics

➢Antiarrhythmics

➢ARBs

➢Anticoagulants*

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38
Q

Tricuspid Regurgitation Surgical Tx

For Severe TR

➢ _______ tricuspid valve replacement rare

➢Usually, will do (1)

A

Severe TR

➢ Isolated tricuspid valve replacement rare

➢Usually, will do along with left sided valve repair/replacement

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39
Q

Tricuspid Stenosis Physical Exam

Murmur: ____ frequency, ___-systolic, mid-diastolic murmur: best heard at (1)

  • Lungs are _____ in isolated TS
  • Reduced ex______ capacity (exertional s_____ as TS worsens), fa___, leg e____, as____, hepatic c_____, anasarca, and other signs of RV failure
A

Murmur: low frequency pre-systolic, mid-diastolic murmur: best heard at lower left sternal border 4th intercostal space

  • Lungs are clear in isolated TS
  • Reduced exertional capacity (exertional syncope as TS worsens), fatigue, leg edema, ascites, hepatic congestion, anasarca, and other signs of RV failure
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40
Q

Tricuspid Stenosis Diagnostics

  • ECG = Tall, peaked __ waves in (3) leads (if pt is in sinus rhythm)
  • Echo = will show _______
  • Cardiac MRI = vs echo?
A
  • ECG = Tall, peaked p waves in II, III, and aVF (if pt is in sinus rhythm)
  • Echo = will show stenosis
  • Cardiac MRI = preferred over echo to evaluate RV
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41
Q

Tricuspid Stenosis Medical Tx

➢ (1)* (prevent/limit systemic and hepatic congestion in severe symptomatic TS). ***Caution***

➢Invasive intervention in every case?

➢ Appropriate treatment of ______ causes most helpful (i.e. SLE)

A

➢Loop diuretics (prevent/limit systemic and hepatic congestion in severe symptomatic TS). ***Caution***

➢Not every case needs invasive intervention

➢ Appropriate treatment of underlying causes most helpful (i.e. SLE)

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42
Q

Tricuspid Stenosis Surgical Tx

(1) 1, 2, or 3 balloons used
(1) preferred over (1)

  • If repair cannot be done, o____ is preferred over trans______
  • No difference between bioprosthetic vs mechanical except with car____ syndrome
  • Best done in conjunction with ____ sided valve surgery
A

Valvotomy 1, 2, or 3 balloons used

Repair preferred over Replacement

  • If repair cannot be done, open is preferred over transcatheter
  • No difference between bioprosthetic vs mechanical except with carcinoid syndrome
  • Best done in conjunction with left sided valve surgery
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43
Q

Mitral Regurgitation Diagnosis

Crucial to think broadly when creating differential diagnoses

Can determine if MR is acute or chronic if we initially have focused H/P> helps narrow possible etiologies

  • Significant _______ at rest, exacerbated in _____ position
  • C____, with clear or p___, fr____ sputum
  • May have (1) r_____ to neck, jaw, shoulders, etc. (sxs associated with myocardial ischemia)
  • Tachycardia OR bradycardia (if i______ involvement of con____ system)
  • _____pnea, hy_____, cy_____, ____tension
  • J_ , diffuse cr_____ in lungs,
  • Apical holosystolic murmur with radiation to axilla
A
  • Significant dyspnea at rest, exacerbated in supine position
  • Cough, with clear or pink, frothy sputum
  • May have chest pain radiating to neck, jaw, shoulders, etc. (sxs associated with myocardial ischemia)
  • Tachycardia OR bradycardia (if ischemic involvement of conduction system)
  • Tachypnea, hypoxemia, cyanosis, hypotension
  • JVD, diffuse crackles in lungs,
  • Apical holosystolic murmur with radiation to axilla
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44
Q

Acute Mitral Regurgitation

Typically related to (1) from ACS or fulminant destruction of valvular apparatus 2/2 to acute bacterial endocarditis

A

Typically related to papillary muscle rupture from ACS or fulminant destruction of valvular apparatus 2/2 to acute bacterial endocarditis

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45
Q

Chronic Mitral Regurgitation

  • May remain asymptomatic until late in course
    • F____, d____ on exertion, o____pnea, p_____ nocturnal dyspnea, weight ____, pulse pressure begins to ______, apical ____systolic murmur with radiation to _____, dependent e____, J _ _
    • ______ cases: cyanosis, syncope/near syncope, digit clubbing, hepatomegaly, ascites with fluid wave, pleural and/or pericardial effusions
A
  • May remain asymptomatic until late in course
    • Fatigue, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, weight gain, pulse pressure begins to widen, apical holosystolic murmur with radiation to axilla, dependent edema, JVD
    • Advanced cases: cyanosis, syncope/near syncope, digit clubbing, hepatomegaly, ascites with fluid wave, pleural and/or pericardial effusions
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46
Q

Mitral Regurgitation Diagnostics

  • (1): primary and essential diagnostic test
  • CXR: With chronic MR, cardio______ 2/2 to left atrial and/or right sided heart enlargement
  • ECG: (1) is most common ECG finding in pts with MR
  • Cardiac MRI: Helps assess _____ of MR, also helps with RV and LV s___/fun____
A
  • Echo: primary and essential diagnostic test
  • CXR: With chronic MR, cardiomegaly 2/2 to left atrial and/or right sided heart enlargement
  • ECG: Atrial fibrillation is most common ECG finding in pts with MR
  • Cardiac MRI: Helps assess severity of MR, also helps with RV and LV size/function
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47
Q

Mitral Regurgitation Medical Tx

➢___/___

➢ (1): not useful in primary MR but have been shown to help in secondary MR

➢ (1)

A

➢ACE/ARB

➢ Beta blockers: not useful in primary MR but have been shown to help in secondary MR

➢Loop diuretics

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48
Q

Mitral Regurgitation Surgical Tx

➢(1) preferred over (1)when possible except when there is extensive tissue destruction or infective endocarditis

➢(1) valve preferred over (1)

A

Repair preferred over replacement when possible except when there is extensive tissue destruction or infective endocarditis

➢Mechanical preferred over bioprosthetic

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49
Q

Mitral Stenosis Physical Exam

  • 1st heart sound usually l___ and may be pal_____ 2/2 to force with MV closing
  • P2 (pulmonic) part of 2nd heart sound will be ____ if severe pulmonary ____ is cause of MS
  • Mid-diastolic rum____ murmur with pre-systolic accentuation heard (____ pitch). Best heard with stethoscope ____ at ____
A
  • 1st heart sound usually loud and may be palpable 2/2 to force with MV closing
  • P2 (pulmonic) part of 2nd heart sound will be loud if severe pulmonary HTN is cause of MS
  • Mid-diastolic rumbling murmur with pre-systolic accentuation heard (low pitch). Best heard with stethoscope bell at apex
50
Q

Mitral Stenosis Most Common Symptoms

  • (1) pnea and (1) pnea
  • May have pal_____, chest p___, and ____ptysis (left atrial volume increased)
  • Ascites, edema, and hepatomegaly (____-sided heart failure) 41 Mitral Stenosis
A
  • Orthopnea and paroxysmal nocturnal dyspnea
  • May have palpitations, chest pain, and hemoptysis (left atrial volume increased)
  • Ascites, edema, and hepatomegaly (right-sided heart failure) 41 Mitral Stenosis
51
Q

Mitral Stenosis Diagnotics

Presents usually when and due to what?

(1) imaging most useful

But if above does not reveal enough (1)* is favored diagnostic

A

Presents 20-40 years after episode of rheumatic fever

Echo most useful

If echo does not reveal enough detail, cardiac catheterization is favored diagnostic

52
Q

Mitral Stenosis Medical Treatment

=

A

➢No medical therapy can relieve fixed obstruction

➢ Medical therapy focuses on preventing endocarditis, decreasing new cases of rheumatic fever, thromboembolic risk, etc.

53
Q

Mitral Stenosis Surgical Treatment

(1)

(1) if above not possible

A

➢Mitral balloon valvuloplasty

➢Mitral valve replacement if valvuloplasty not possible

54
Q

Pulmonic Regurgitation Physical Exam

S__, ___stolic __crescendo murmur (__nd/__rd intercostal spaces) increases during (1) and decreases with (1) maneuver

A

S3, diastolic decrescendo murmur (2nd/3rd intercostal spaces) increases during inspiration and decreases with Valsalva maneuver

55
Q

Pulmonic Regurgitation Diagnosis

  • Most patients are a______
  • Exertional ______ (because of decreased cardiac ______ 2/2 volume overload)
  • Decreased ex_____ tolerance
  • Severe PR: ____ heart failure: peripheral (esp pedal) edema, congestive hepatomegaly, and rarely jugular vein distension
A
  • Most patients are asymptomatic
  • Exertional dyspnea (because of decreased cardiac output 2/2 volume overload)
  • Decreased exercise tolerance
  • Severe PR: Right heart failure: peripheral (esp pedal) edema, congestive hepatomegaly, and rarely jugular vein distension
56
Q

Pulmonic Regurgitation Diagnostics

  • (1): Best way to detect
  • (1) will not really yield anything
  • (1): Used to assess risks associated with progressive RV dilation
A
  • Echo: Best way to detect
  • CXR will not really yield anything
  • Exercise stress ECG: Used to assess risks associated with progressive RV dilation
57
Q

Pulmonic Regurgitation Treatment

No treatment recommended unless at least __/__ criteria are met then _____ is recommended

  1. Mid or moderate RV or LV (1)
  2. Severe RV ______(hypertrophy) (RV end diastolic volume < ___ ml/m2)
  3. RV ventricular systolic pressure due to RV outflow tract < _/_ of systemic pressure
  4. Progressively reduced (1)
A

No treatment recommended unless at least 2/4 criteria are met then surgery is recommended

  1. Mid or moderate RV or LV systolic dysfunction
  2. Severe RV dilation (RV end diastolic volume < 160 ml/m2)
  3. RV ventricular systolic pressure due to RV outflow tract < 2/3 of systemic pressure
  4. Progressively reduced exercise tolerance
58
Q

Pulmonic Stenosis Physical Exam

  • Requires significant provider diagnostic _____
  • Parasternal h____
  • ______ upper sternal border-systolic ______ murmur that radiates to the ____
  • May hear __th heart sound and tricuspid _____
A
  • Requires significant provider diagnostic skill
  • Parasternal heave
  • Left upper sternal border-systolic ejection murmur that radiates to the back
  • May hear 4th heart sound and tricuspid regurgitation
59
Q

Pulmonic Stenosis Symptoms

Most patients are _______

  • Those who are symptomatic have:
    • _______ on exertion and f_____
    • Occurence of-angina/sudden cardiac arrest?
    • Associated ______ defect: cyanosis
A

Most patients are asymptomatic

  • Those who are symptomatic have:
    • Dyspnea on exertion and fatigue
    • Rarely-angina/sudden cardiac arrest
    • Associated septal defect: cyanosis
60
Q

Pulmonic Stenosis Diagnostics

(1) imaging is best way to detect

(1) will not really yield anything

A

Echo: Best way to detect

CXR will not really yield anything

61
Q

Pulmonic Stenosis Treatment

➢Asymptomatic =

➢Symptomatic: (1) for doppler gradient > 500 mm hg and domed PV

➢Surgical intervention for _____ pulmonary stenosis

A

➢Asymptomatic: Follow up with echos

➢Symptomatic: Balloon valvotomy for doppler gradient > 500 mm hg and domed PV

➢Surgical intervention for severe pulmonary stenosis

62
Q

Aortic Insufficiency Diagnosis

  • H_______ is extremely important!
  • Those with acute AI can present as if they are experiencing a rapid onset of cardiogenic ____
  • Cough, dyspnea on exertion, chest pain, and palpitations common
A
  • History is extremely important!
  • Those with acute AI can present as if they are experiencing a rapid onset of cardiogenic shock
  • Cough, dyspnea on exertion, chest pain, and palpitations common
63
Q

Aortic Insufficiency Physical Exam

  • (1) murmurs: Best heard at 3rd or 4th intercostal space at left sternal border
  • A____ F____ Murmur: Mimics mitral stenosis-low-pitched and rumbling (mid/late diastolic) ….best heard at apex. Caused by regurgitant jet of AI
  • Pulsus bis_____: biphasic pulse with 2 systolic peaks seen on pressure tracings
A
  • Diastolic murmurs: Best heard at 3rd or 4th intercostal space at left sternal border
  • Austin Flint Murmur: Mimics mitral stenosis-low-pitched and rumbling (mid/late diastolic) ….best heard at apex. Caused by regurgitant jet of AI
  • Pulsus bisferiens: biphasic pulse with 2 systolic peaks seen on pressure tracings
64
Q

Aortic Insufficiency PE signs

  • (1): Bounding pulse in large arteries (e.g. carotids) that expands and suddenly collapses and empties between beats
  • (1) Head nodding with every heartbeat
  • (1): Systolic pulsation of uvula
  • (1): Repeatedly alternating blushing/blanching of capillaries in nail folds when palpated
A
  • Corrigan sign: Bounding pulse in large arteries (e.g. carotids) that expands and suddenly collapses and empties between beats
  • De Musset Sign: Head nodding with every heartbeat
  • Muller Sign: Systolic pulsation of uvula
  • Quincke Sign: Repeatedly alternating blushing/blanching of capillaries in nail folds when palpated
65
Q

Aortic Insufficiency PE Signs

  • (1) Sign: Pistol shot sounds heard on femoral artery when artery compressed
  • (1)r Pulse: Peripheral pulses are either rapidly faint or bounding.
  • ______ AI: Widened pulse pressure
  • May have l_____/in_____ displaced apical impulse
A
  • Traube’s Sign: Pistol shot sounds heard on femoral artery when artery compressed
  • Waterhammer Pulse: Peripheral pulses are either rapidly faint or bounding.
  • Chronic AI: Widened pulse pressure
  • May have laterally/inferiorly displaced apical impulse
66
Q

Aortic Insufficiency Diagnostics

  • Gold standard =
  • (1) : Class I indication if echo does not provide enough information
  • ECG: Nonspecific __-__ wave changes may be noted
    • Signs of LV_
A
  • Echocardiogram gold standard
  • Cardiac MRI: Class I indication if echo does not provide enough information
  • ECG: Nonspecific ST-T wave changes may be noted
    • Signs of LVH
67
Q

Aortic Insufficiency Medical Tx

HTN Management

  • A__, A___, (1) Blockers
  • (1) for aortic dissection

(1): Avoid for severe AI dt Increase diastolic filling time

  • Allow for reg______ blood flow
  • Block compensatory ____cardia that is needed
A

HTN Management

  • ACE, ARBs, Calcium Channel Blockers
  • β-blockers for aortic dissection

BB: Avoid for severe AI dt Increase diastolic filling time

  • Allow for regurgitant blood flow
  • Block compensatory tachycardia that is needed
68
Q

Aortic Insufficiency Surgical Tx

(1)

  • Stage D AI or Stage C AI with LVEF < 50% or needing cardiac surgery for other reason
  • Not recommended for pts with LVEF <35% in most cases because of poor postoperative outcomes

(1)

  • appropriate in high-risk patients depending on causal factors
A

Aortic Valve Replacement

  • Stage D AI or Stage C AI with LVEF < 50% or needing cardiac surgery for other reason
  • Not recommended for pts with LVEF <35% in most cases because of poor postoperative outcomes

Transcatheter Aortic Valve Replacement

  • appropriate in high-risk patients depending on causal factors
69
Q

Aortic Stenosis

  • ___-leaflet c_____ stenosis = Present after age 70
  • __cuspid aortic valve = Begin presenting between ages 50-70
A
  • Tri-leaflet calcific stenosis = Present after age 70
  • Bicuspid aortic valve = Begin presenting between ages 50-70
70
Q

Aortic Stenosis S/S

  • Cardiac symptoms
    • Exertional d_____, an____, f____, p____ n____ dyspnea, o___pnea, and progressively decreasing ex_____ tolerance
  • Non-cardiac:
    • Cerebral perfusion issues: start with (1) then progresses to (1)
    • G__ bleeds, cerebral em____
A
  • Cardiac
    • Exertional dyspnea, angina, fatigue, paroxysmal nocturnal dyspnea, orthopnea, and progressively decreasing exercise tolerance
  • Non-cardiac:
    • Cerebral perfusion issues: start with mild memory/cognitive deficits then progresses to pre-syncope –syncope
    • GI bleeds, cerebral emboli
71
Q

Aortic Stenosis Physical Exam

  • Pulsus p____ et t____
    • Slow-rising, late-peaking and low amplitude carotid impulse in severe AS
  • 2nd heart sound may lack a split
  • Systolic ______ murmur
    • Late peaking
    • Heard best at heart b____ and radiates to c_____
A
  • Pulsus parvus et tardus
    • Slow-rising, late-peaking and low amplitude carotid impulse in severe AS
  • 2nd heart sound may lack a split
  • Systolic ejection murmur
    • Late peaking
    • Heard best at heart base and radiates to carotids
72
Q

Aortic Stenosis Diagnostics

Gold Standard =

(1) = Good to assess LV mass function and volume (if not available from above test)

A

Gold Standard = Echo

Cardiac MRI = good to assess LV mass function and volume (if not available from echo)

73
Q

Aortic Stenosis Medical Treatment

➢Aortic valve (1) superior to (1) therapy in severe symptomatic AS

➢_______ management of HTN in severe AS because of fixed afterload

➢Cautious use of ______ can help decrease congestion

A

➢Aortic valve replacement (AVR) superior to medical therapy in severe symptomatic AS

➢Cautious management of HTN in severe AS because of fixed afterload

➢Cautious use of diuretics can help decrease congestion

74
Q

Aortic Stenosis Surgical Treatment

➢(1) indicated in pts with heart _____ and volume ______ and all patients who are s______, regardless of severity

➢AVR also indicated in as______ pts with severe AS with LVEF > ___% who undergo C____ or other cardiac surgery procedure

➢(1) has become gold standard for patients at high mortality risk for standard sternal approach to aortic valve replacement

➢ **Used to be common to give huge amounts of fluid after AVR because of dependence on preload. We now know that this brings on RV much quicker

A

➢AVR indicated in pts with heart failure and volume overload and all patients who are symptomatic, regardless of severity

➢AVR also indicated in asymptomatic pts with severe AS with LVEF > 50% who undergo CABG or other cardiac surgery procedure

➢TAVR (Transcatheter aortic valve replacement) has become gold standard for patients at high mortality risk for standard sternal approach to aortic valve replacement

➢ **Used to be common to give huge amounts of fluid after AVR because of dependence on preload. We now know that this brings on RV much quicker

75
Q

Heart Failure

3 components

  • Inability of heart to keep up with the d______ put on it
  • Inefficiency in p______ blood
  • Inability to provide adequate blood flow to other ______ within the body
  • May be due to failure of right or left or b____ ventricles
  • Symptoms will depend on which _____(s) is involved
A
  • Inability of heart to keep up with the demands put on it
  • Inefficiency in pumping blood
  • Inability to provide adequate blood flow to other organs within the body
  • May be due to failure of right or left or both ventricles
  • Symptoms will depend on which side(s) is involved
76
Q

HF with reduced EF

Also known as ___stolic dysfunction/failure = _____ PROBLEM

  • Represents ~ 50% of HF cases
  • Most common cause: (1)
    Other causes: V_____ disease, H__, _____thyroidism, myocardial ______, a___, d_____ _____
A

Also known as systolic dysfunction/failure = PUMP PROBLEM

  • Represents ~ 50% of HF cases
  • Most common cause: CAD
    Other causes: Valvular disease, HTN, hyperthyroidism, myocardial infarction, age, diabetes mellitus,
77
Q

HF with reduced EF

Well established management ______ established

Characteristics

  • LV re_____ with d_____
  • Impaired con______ (pumping)
  • Th___ LV
A

Well established management algorithms established

Characteristics

  • LV remodeling with dilation
  • Impaired contractility (pumping)
  • Thin LV
78
Q

HF with Preserved EF

Also known as ___stolic dysfunction/failure = _________ PROBLEM

  • Expected to increase in prevalence because of ______ population in U.S.
  • Common for pts with HFpEF to have higher rate of chronic co_____ with about ½ having 5 or more of them
  • 3 most common characteristics: Gender (1), Age (1), Body habitus (1)
A

Also known as diastolic dysfunction/failure = RELAXATION PROBLEM

  • Expected to increase in prevalence because of aging population in U.S.
  • Common for pts with HFpEF to have higher rate of chronic comorbidities with about ½ having 5 or more of them
  • 3 most common characteristics: Female, older, obese
79
Q

HF with Preserved EF Common Comorbidities

  • H___ (60-89% prevalence)
  • ob_____
  • C_ _
  • D_____ ______
  • atrial ______
  • hyperl______
  • ________ HTN
  • an_____
  • C _ _
  • C_ _ _
  • fr______
  • obstructive _____ ____
A
  • HTN (60-89% prevalence)
  • obesity
  • CAD
  • diabetes mellitus
  • atrial fibrillation
  • hyperlipidemia
  • pulmonary HTN
  • anemia
  • CKD
  • COPD
  • frailty
  • obstructive sleep apnea
80
Q

HFrEF vs. HFpEF

  • Borderline HFpEF is an EF of __%-__%. These patients fall into a b_____ or inter_____ group.
  • Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HF_EF
A
  • Borderline HFpEF is an EF of 41%-49%. These patients fall into a borderline or intermediate group.
  • Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF
81
Q

Who is more likely to develop HFpEF

  • Age and gender may also play
  • Different roles in the prevalence of HFpEF vs. HFrEF
  • Prevalence increases overall for HFpEF and HFrEF with increasing age, with higher rates of HFpEF typically seen in what age, gender?
A
  • Age and gender may also play
  • Different roles in the prevalence of HFpEF vs. HFrEF
  • Prevalence increases overall for HFpEF and HFrEF with increasing age, with higher rates of HFpEF typically seen in older women
82
Q

HFrEF Symptoms

(Systolic Dysfunction) Acronym

F

A

C

E

S

A

Fatigue

Activities, limited

Cough

Edema

Shortness of breath

83
Q

HFrEF Physical Findings

  • Cr_____/r____
  • J_ _
  • D_____/p____ n_____ dyspnea
  • Pulmonary ed____
  • Weight ____
  • S_ gallop
  • Hepatojugular reflux __
  • Hepato_____
  • C___ at night
  • Ankle e_____
  • Pleural eff_______
  • ____cardia
A
  • Crackles/rales
  • JVD
  • Dyspnea/paroxysmal nocturnal dyspnea
  • Pulmonary edema
  • Weight gain
  • S3 gallop
  • Hepatojugular reflux +
  • Hepatomegaly
  • Cough at night
  • Ankle edema
  • Pleural effusions
  • Tachycardia
84
Q

Diagnostics Used in HFrEF

  • (1): cardiomegaly, pleural effusions, interstitial edema, alveolar edema, dilated prominent upper lobe vessels
  • (1): Atrial abnormality, conduction abnormalities/arrhythmias, ventricular hypertrophy (early)
  • (1): Used to differentiate systolic/diastolic dysfunction, reduced LVEF (<45%), may have valvular malfunction, dilated LV with thin walls (later)
  • Labs: CBC (an____), BMP (r_____ function, __+ levels, electrolytes), m_____, th_____ function tests (_____thyroidism can bring on HF/hypothyroidism exacerbates), B__
A
  • CXR: cardiomegaly, pleural effusions, interstitial edema, alveolar edema, dilated prominent upper lobe vessels
  • ECG: Atrial abnormality, conduction abnormalities/arrhythmias, ventricular hypertrophy (early)
  • Echo: Used to differentiate systolic/diastolic dysfunction, reduced LVEF (<45%), may have valvular malfunction, dilated LV with thin walls (later)
  • Labs: CBC (anemia), BMP (renal function, Na+ levels, electrolytes), magnesium, thyroid function tests (hyperthyroidism can bring on HF/hypothyroidism exacerbates), BNP
85
Q

BNP

  • Functions of Natriuretic peptides (ANP and BNP)
  1. Downregulates (1) nervous system and R_____
  2. Facilitates natriuresis and di_____
  3. Increase smooth muscle re______ and __creases peripheral resistance
  • Uses in Heart Failure
  1. A ______ result rules out disease more effectively than a ______ result rules in disease
  2. Predictor of pr______
  3. Mon______
A
  • Functions of Natriuretic peptides (ANP and BNP)
  1. Downregulates sympathetic nervous system and RAAS
  2. Facilitates natriuresis and diuresis
  3. Increase smooth muscle relaxation and decrease peripheral resistance
  • Uses in Heart Failure
  1. A negative result rules out disease more effectively than a positive result rules in disease
  2. Predictor of prognosis
  3. Monitoring
86
Q

BNP Levels

  1. <100 pg/ml: Heart failure _____
  2. 100-250 pg/ml: Comp_____ heart failure
  3. 250-500 pg/ml: Both (1) and (1) dysfunction
  4. 500-1000 pg/ml: De_______ heart failure
  5. >1000 pg/ml: Increased risk of sub______ heart failure
A
  1. <100 pg/ml: Heart failure unlikely
  2. 100-250 pg/ml: Compensated heart failure
  3. 250-500 pg/ml: Both diastolic and systolic dysfunction
  4. 500-1000 pg/ml: Decompensated heart failure
  5. >1000 pg/ml: Increased risk of substantial heart failure
87
Q

HFrEF Mortality

  • C__ Causes (80-85%)
  • Worsening HF
    • Cardiogenic sh____
    • Low _____ state
    • ~40% of cases
  • (1)
    • Ventricular tachyarrhythmia
    • Bradyarrhythmia
  • Non CV
    • Infection/s_____
    • Ren______
    • Res_______
    • Mal________
A
  • CV Causes (80-85%)
  • Worsening HF
    • Cardiogenic shock
    • Low output state
    • ~40% of cases
  • Sudden Death
    • Ventricular tachyarrhythmia
    • Bradyarrhythmia
  • Non CV
    • Infection/sepsis
    • Renal
    • Respiratory
    • Malignancy
88
Q

HFrEF Management

B

A

N

D

A

I

D

D

A

Beta blockers

ACE Inhibitors/ARBs

Nitrates (dinitrate)/hydralazine

Diuretics

Aldosterone antagonist

Ivabradine

Devices (AICD, CRT, or both)

Digoxin

89
Q

HFpEF Presentation

  • (1), especially with exertion
  • (1), peripheral and abdominal
  • Severe f______
A
  • Shortness of breath, especially with exertion
  • Edema, peripheral and abdominal
  • Severe fatigue
90
Q

HFpEF Physical Findings

  • Comparable to what is seen in HFrEF in many cases
  • Heart sounds: S__ heard just before S1 –representative of non______ LV (Sometimes, not necessarily a reliable sign
  • Physical Examination in most cases of heart failure will not really help you differentiate HFrEF vs HFpEF. An (1) will help
A
  • Comparable to what is seen in HFrEF in many cases
  • Heart sounds: S4 heard just before S1 –representative of noncompliant LV (Sometimes, not necessarily a reliable sign
  • Physical Examination in most cases of heart failure will not really help you differentiate HFrEF vs HFpEF. An echocardiogram will help
91
Q

HFpEF Diagnostic Tools

  • Labs: Same as with HFrEF
    • BNP is often just as (if not more) ______ in HFpEF as is seen in HFrEF
  • (1) –helps reveal increased ventricular diastolic pressure with preserved systolic function and normal ventricular volumes. Will also see increased left atrial and pulmonary capillary wedge pressures
  • CXR: May/may not have edema. Many have _____ cardiac silhouette.
  • Echo: Used most often
    • Measures LV _ _
    • Easily identifies LV__
    • Presence/absence of v______ heart disease
    • Left a____ size
A
  • Labs: Same as with HFrEF
    • BNP is often just as (if not more) elevated in HFpEF as is seen in HFrEF
  • Cardiac catheterization –helps reveal increased ventricular diastolic pressure with preserved systolic function and normal ventricular volumes. Will also see increased left atrial and pulmonary capillary wedge pressures
  • CXR: May/may not have edema. Many have normal cardiac silhouette.
  • Echo: Used most often
    • Measures LVEF
    • Easily identifies LVH
    • Presence/absence of valvular heart disease
    • Left atrial size
92
Q

HFpEF Management

2 Major Objectives with HFpEF Management

  1. Reverse con______ of diastolic dysfunction (venous congestion)
  2. Eliminate or reduce the factors ______ for diastolic dysfunction, fibrosis, and/or myocardial hypertrophy
A

2 Major Objectives with HFpEF Management

  1. Reverse consequences of diastolic dysfunction (venous congestion)
  2. Eliminate or reduce the factors responsible for diastolic dysfunction, fibrosis, and/or myocardial hypertrophy
93
Q

Use of Healthcare Resources

Who uses more health care resources, those with HFpEF or HFrEF?

A

Patients with HFpEF Utilize More Health Care Resources than Patients with HFrEF

94
Q

HFpEF Mortality

More than __% of HFpEF patients may die within __ years

A

More than 50% of HFpEF Patients May Die Within 5 Years

95
Q

The Impact of Prior Hospitalization on Future Outcomes is High

  • Data indicate that patients with HFpEF have ____ rates of mortality, which increase after HF-related hospitalizations.
  • In-hospital mortality ranges from 2.4% to 4.9% in observational studies
  • Death rate is 5% within 30 days
  • Death rate is 9.5% within 60-90 days
  • At 1-year post-hospitalization, 20%-29% of patients may die
  • Prior hospitalization can increase mortality rates
  • Within __ years, at least __% of patients may die, with published mortality estimates ranging from 53% to 74%
A
  • Data indicate that patients with HFpEF have high rates of mortality, which increase after HF-related hospitalizations.
  • In-hospital mortality ranges from 2.4% to 4.9% in observational studies
  • Death rate is 5% within 30 days
  • Death rate is 9.5% within 60-90 days
  • At 1-year post-hospitalization, 20%-29% of patients may die • Prior hospitalization can increase mortality rates
  • Within 5 years, at least 50% of patients may die, with published mortality estimates ranging from 53% to 74%
96
Q

Likelihood of Diastolic Dysfunction with Different types of LVH

100% likelihood of diastolic dysfunction with what type of LVH?

(1) LVH = “volume overload” mitral regurg, athlete
(1) LVH = “pressure overload”, chronic HTN or aortic stenosis

A

100% likelihood of diastolic dysfunction with concentric LVH

Eccentric LVH = “volume overload” mitral regurg, athlete

Concentric LVH = “pressure overload”, chronic HTN or aortic stenosis

97
Q

Heart Failure Classifications

ACC/AHA Grades A-D

NYHA Functional Class I-IV

A
98
Q

HF Recommendations

A
99
Q

A disorder that involves the heart muscle, where the muscle is structurally and functionally abnormal in the absence of CAD, HTN, valvular disease, and congenital heart disease sufficient to explain the observed myocardial abnormality.

A

Cardiomyopathies

100
Q

Types of Cardiomyopathies

(3) Common ones

  • Peripartum
  • Arrhythmogenic RV Dysplasia
  • LV Non-compaction
  • Transthyretin Amyloid
A

Dilated

Hypertrophic

Restrictive

  • Peripartum
  • Arrhythmogenic RV Dysplasia
  • LV Non-compaction
  • Transthyretin Amyloid
101
Q

Most common type of non-ischemic cardiomyopathy

  • 1/2500 people affected
  • Men > women
  • Onset most often in middle age but does occur in children
A

Dilated Cardiomyopathy

102
Q

Dilated Cardiomyopathy Causes

Most are (1)

  • Vi_____
  • Familial (g_____)
  • Val____
  • ET___
  • Illicit/toxic d____ use
  • D_
  • Th____ disease
A

Most are idiopathic

  • Viruses
  • Familial (genetic)
  • Valvular
  • ETOH
  • Illicit/toxic drug use
  • DM
  • Thyroid disease
103
Q

Dilated Cardiomyopathy S/S

LV is en____, dil____, and w____ → pump ____

Often _________ until advanced then comparable to HFrEF

  • *(1)** = when diseased myocardium develops without obvious cause
  • *(1)** = develops because of another cause
A

LV is enlarged, dilated, and weak → pump fails

Often asymptomatic until advanced then comparable to HFrEF

  • *Primary CM** = when diseased myocardium develops without obvious cause
  • *Secondary CM** = develops because of another cause
104
Q

Dilated Cardiomyopathy Diagnostics

➢CXR: Cardio____, pleural _____

➢Echo: LV di_____ with normal/th_____ walls and _____ EF

➢Cardiac Cath: done to exclude _____ disease

➢Cardiac biopsy can help differentiate c_____

➢EKG: atrial ______, LAE, ventricular arr_____ common
➢Genetic Testing: (1) mutations

A

➢CXR: Cardiomegaly, pleural effusions

➢Echo: LV dilation with normal/thinned walls and reduced EF

➢Cardiac Cath: done to exclude ischemic disease

➢Cardiac biopsy can help differentiate cause

➢EKG: atrial fibrillation, LAE, ventricular arrythmias common
➢Genetic Testing: TTN mutations

105
Q

Dilated Cardiomyopathy Management

Similar to (5) Rx, (1) Diet

Devices (2)

Surgery (1)

A

Similar to HFrEF

  • ACE/ARB
  • Beta blockers
  • Diuretics
  • Low Na+ diet
  • Anticoagulants

Devices

  • Cardiac resynchronization therapy
  • AICD

Surgery

  • Transplant
106
Q

Most common genetic cardiac disease

  • Autosomal dominant inheritance pattern (40% have B-myosin heavy chain mutation)
  • 1/500 regardless of race/gender
A

Hypertrophic Cardiomyopathy

107
Q

Hypertrophic Cardiomyopathy

  • Other causes: F_____ disease, Fri_____ ataxia, meds like t______
  • Leading cause of (1) in young (1) in the US
  • Country (1): huge issues → began screening in teen athletes (high prevalence in (2))
  • Mortality for HCM now
A
  • Other causes: Fabry disease, Friedreich’s ataxia, meds like tacrolimus
  • Leading cause of sudden death in young athletes in the US
  • Italy: huge issues → began screening in teen athletes (high prevalence in greek/italian)
  • Mortality for HCM now <1% therefore large scale screening not done in US, UK, or Canada, does continue in Italy
108
Q

Hypertrophic Cardiomyopathy S/S

Many live entire life (1) symptom, however HCM also major cause of (1)

Myocardial walls become ______ without an obvious ______

  • (2) parts of the heart most often affected
  • Causes heart to not be able to p_____ blood effectively
  • Can also cause con_____/arr______ issues
A

Many live entire life asymptomatic, however HCM also major cause of sudden cardiac death

Myocardial walls become thickened without an obvious cause

  • Interventricular septum and ventricles most often affected
  • Causes heart to be able to pump blood effectively
  • Can also cause conduction/arrhythmia issues
109
Q

Hypertrophic Cardiomyopathy S/S

  • Leg _____
  • Shortness of _____
  • Chest ____
  • Syn____
  • Atrial and ventricular arr______
  • Heart f_______
  • ______ cardiac death
A
  • Leg edema
  • Shortness of breath
  • Chest pain
  • Syncope
  • Atrial and ventricular arrhythmias
  • Heart failure
  • Sudden cardiac death
110
Q

Obstructive Hypertrophic Cardiomyopathy

  • (1) part of the heart thickens
  • LV walls become st____
  • Septum or LV wall may reduce/bl____ blood from LV to aorta
  • (1) (SAM) of mitral valve can occur with HOCM
    • Displacement of the _____ portion of the _____ leaflet of MV _____ the LVOT obstruction
    • 31-61% prevalence in HCOM
    • those with SAM, 25-50% have resting LVOT ______ (SAM increases risk of (1) death)
A
  • Septum thickens
  • LV walls become stiff
  • Septum or LV wall may reduce/block blood from LV to aorta
  • Systolic anterior motion (SAM) of mitral valve can occur with HOCM
    • Displacement of the distal portion of the anterior leaflet of MV toward the LVOT obstruction
    • 31-61% prevalence in HCOM
    • those with SAM, 25-50% have resting LVOT obstruction (SAM increases risk of sudden cardiac death)
111
Q

Non-Obstructive Cardiomyopathy

  • LV _____
  • Difference between non-obstructive and obstructive?
A
  • LV stiff
  • Blood flow not blocked
112
Q

Hypertrophic Cardiomyopathy Diagnostics

ECG: May see signs of (1)

(1): 80% accuracy

(1): Gold standard

  • Really useful to see segmental lateral ventricular ______
  • LVH may not be seen in children under age ___
A

ECG: May see signs of LVH

Echo: 80% accuracy

Cardiac MRI: Gold standard

  • Really useful to see segmental lateral ventricular hypertrophy
  • LVH may not be seen in children under age 13
113
Q

Hypertrophic Cardiomyopathy Medical Management

Must stay _____!*

(1) 1st line agents, because increases (1), decreases (1)

(1) Extreme caution should be used, may cause increased mortality in pts with severe outflow obstruction

(1): Reduces LV contractility and subaortic gradient, Reduces afterload, Slows LV ejection acceleration

(1) (*Rarely used)

A

Must stay hydrated!

Β-blockers: 1st line agents, Increases diastolic filling, Decreases contractility

Calcium channel blockers: Extreme caution should be used, May cause increased mortality in pts with severe outflow obstruction

Disopyramide: Reduces LV contractility and subaortic gradient, Reduces afterload, Slows LV ejection acceleration

Diuretics (*Rarely used)

114
Q

Hypertrophic Cardiomyopathy Surgical Tx

(2)

Which one may need permanent pacemaker or more often reintervention

A

Surgical Myectomy

Alcohol Ablation

ASA similar mortality but 1/10 need pacemaker vs 1 /25 myectomy, 1/13 needs reintervention

115
Q

Hypertrophic Cardiomyopathy Other Surgical Interventions

(1)

  • Used to cause asynchronous contraction of LV
  • For pts who have one of the major risk factors for sudden cardiac death, an AICD or PPM/AICD may be recommended

(1)

  • Used to correct motion of the mitral valve in those with severe obstructive HCM
  • Not established as long-term reliability of myectomy or alcohol septal ablation but being used more often to give option

(1)

  • For end-stage HF
  • Must occur before pulmonary HTN, significant kidney disease, and/or thromboembolism occur for it to be successful
A

Implantable pacemaker/defibrillator

  • Used to cause asynchronous contraction of LV
  • For pts who have one of the major risk factors for sudden cardiac death, an AICD or PPM/AICD may be recommended

MitraClip

  • Used to correct motion of the mitral valve in those with severe obstructive HCM
  • Not established as long-term reliability of myectomy or alcohol septal ablation but being used more often to give option

Transplantation

  • For end-stage HF
  • Must occur before pulmonary HTN, significant kidney disease, and/or thromboembolism occur for transplant to be successful
116
Q

Restrictive Cardiomyopathy Causes

(1) Most common cause

(1)

  • DES, CRYAB, FLNC mutations

(1)

  • Idiopathic, Diabetic CM, Scleroderma, myofibrillar myopathies, pseudoxanthoma elasticum, Werner’s syndrome

(1)

  • Amyloidosis, sarcoidosis, primary hyperoxaluria

(1) Diseases

  • Carcinoid heart disease, endomyocardial fibrosis, idiopathic, hypereosinophilic syndrome, chronic eosinophilic leukemia, endocardial fibroelastosis, radiation, and meds (serotonin, methysergide, ergotamine, mercurial agents, anthracyclines, busulfan
A

Most common cause-Amyloidosis

Genetic

  • DES, CRYAB, FLNC mutations

Non Infiltrative

  • Idiopathic, Diabetic CM, Scleroderma, myofibrillar myopathies, pseudoxanthoma elasticum, Werner’s syndrome

Infiltrative

  • Amyloidosis, sarcoidosis, primary hyperoxaluria

Storage Diseases

  • Carcinoid heart disease, endomyocardial fibrosis, idiopathic, hypereosinophilic syndrome, chronic eosinophilic leukemia, endocardial fibroelastosis, radiation, and meds (serotonin, methysergide, ergotamine, mercurial agents, anthracyclines, busulfan
117
Q

Restrictive Cardiomyopathy Symptoms

  • Decreased ex______ tolerance
  • F_____
  • J_ _
  • Peripheral ______
  • As____
  • (1) and conduction blocks
A
  • Decreased exercise tolerance
  • Fatigue
  • JVD
  • Peripheral edema
  • Ascites
  • Arrhythmias and conduction blocks
118
Q

Restrictive Cardiomyopathy Signs

  • Bi-atrial en_____
  • ______ LV walls with _____ chamber size
  • ______ RV free wall with _____ chamber size
  • ______ right atrial pressure (> ___ mm Hg)
  • Moderate pulmonary ___
  • ______ systolic function
  • ______ diastolic function (Grade II-IV diastolic HF)
A
  • Bi-atrial enlargement
  • Thickened LV walls with normal chamber size
  • Thickened RV free wall with normal chamber size
  • Elevated right atrial pressure (> 12 mm Hg)
  • Moderate pulmonary HTN
  • Normal systolic function
  • Poor diastolic function (Grade II-IV diastolic HF)
119
Q

Least common of 3 original subtypes of CM

Cardiac walls are _____, not thickened

  • Heart restricted from st_____ and f____ with blood
  • Rhythmicity and contractility may be _____, but the stiff walls of atria/ventricles cause reduced ____load and end-diastolic volume
  • Over time, they develop _____stolic dysfunction and eventually diastolic heart ______
A

Restrictive Cardiomyopathy

Cardiac walls are rigid, not thickened

  • Heart restricted from stretching and filling with blood
  • Rhythmicity and contractility may be normal, but the stiff walls of atria/ventricles cause reduced preload and end-diastolic volume
  • Over time, they develop diastolic dysfunction and eventually diastolic heart failure

Not the same as constrictive pericarditis = Very similar presentation but markedly different treatment and prognosis

120
Q

Restrictive Cardiomyopathy Tx

  1. Treatment of conditions causing issues (example: sarcoidosis → give (1)) and slowing the pr_______ of CM
  2. __+ restricted diet, d______, (1) inhibitors, and anti_______ may be helpful
  3. (1)-: Contraindicated 2/2 to negative inotropic effect, especially if amyloidosis is underlying cause
  4. D_____ and ____-adrenergic meds: generally, not helpful except with RCM with atrial fibrillation
  5. Vaso________ usually ineffective because systolic function is normal
  6. Most common treatment: (1) or (1) until transplantation can occur
A
  1. Treatment of conditions causing issues (example: sarcoidosis → give corticosteroids) and slowing the progression of CM
  2. Na+ restricted diet, diuretics, ACE inhibitors, and anticoagulants may be helpful
  3. Calcium channel blockers-: Contraindicated 2/2 to negative inotropic effect, especially if amyloidosis is underlying cause
  4. Digoxin and beta-adrenergic meds: generally, not helpful except with RCM with atrial fibrillation
  5. Vasodilators usually ineffective because systolic function is normal
  6. Most common treatment: Transplantation or LVAD until transplantation can occur

Diagnosis and Management (36 decks)

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