Week 6 - HF, Cardiomyopathy, Pericarditis Flashcards
What are the commonest causes of exertional syncope?
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Arrhythmogenic cardiomyopathy
What is a cardiomyopathy?
Disease of the cardiac muscle
What is the difference between dilated and hypertrophic cardiomyopathy?
Dilated = LV wall is stretched and weakened
Hypertrophic - LV wall is thickened
What causes dilated cardiomyopathy?
Ischaemic causes = IHD - 70% (e.g. chronic ischaemia due to multi vessel disease)
Non-ischaemic causes =
- HT (2nd commonest cause)
- Congenital
- ETOH
- Viral
- Toxins (chemo drugs)
- Metabolic - hypothyroid, iron overload, thiamine deficiency
- Idiopathic
What type of HF is caused by dilated cardiomyopathy?
HFrEF
Dilated ventricle = high diastolic volume, impaired systolic function => reduced ejection fraction
What is the standard Rx for HFrEF?
ACEI
β blocker
Aldosterone antagonist
SGLT2 inhibitor
What is HF?
Clinical syndrome - heart is unable to deliver sufficient blood to the rest of the body - due to cardiac dysfunction.
What are the symptoms and signs of HF?
What sign is almost always present in HF - to the extent where if the P doesn’t have it you should consider a different diagnosis?
Elevated JVP
Which blood test can indicate HF?
BNP or NT Pro BNP (NICE recommended)
Why do we check LFTs in HF Ps?
They can develop hepatic derangement due to hepatic congestion
Liver failure can also mimic HF in Sx.
What causes of HF are potentially reversible?
Hypothyroidism
Iron overload
Anaemia
What investigations can be done for HF?
ECG
CXR
Echo
But is a clinical diagnosis
What is the ranges of ejection fractions in different types of heart failure?
HFrEF = <40%
HFpEF = >55%
HFmrEF = 40-55%
What other diagnoses mimic HF in terms of oedema or breathlessness?
At what measurement of BNP would chronic HF be likely?
> 2000
400-2000 = possible
<400 = unlikely
At what measurement of BNP would acute HF be likely?
> 300
What causes HFpEF?
Restrictive Cardiomyopathies
What causes peripartum dilated cardiomyopathy?
An adverse reaction to prolactin after birth
How can acute pericarditis appear on ECG in 60% of cases?
Concave upward ST elevation
PR depression is more specific
What are the Sx of acute pericarditis?
The chest pain (retrosternal) usually:
feels sharp or stabbing
spreads to your shoulders, arms or tummy
gets worse when you breathe in deeply, swallow, cough or lie down (especially when you lie down on your left side)
gets better when you lean forward
You may also feel hot and shivery or have a high temperature, cough or painful joints.
What do blood results show in acute pericarditis?
MAY show elevated CRP and WBCs
What causes acute pericarditis?
Infective
Idiopathic
Non-infective (AI, metabolic, neoplastic, trauma, aortic dissection, post-MI)
Which viruses commonly cause acute pericarditis?
Coxsackie
Herbes
Adenoviruses
Which bacteria commonly cause acute pericarditis?
Staphylococcus
TB
Which fungi commonly cause acute pericarditis?
Aspergillus
What is the Rx for acute pericarditis
NSAIDs (ibuprofen, high dose aspirin)
Colchicine (3m course)
What is constrictive pericarditis?
Chronic thickening and scarring around the heart - preventing diastolic filling
Causes elevated pressures in all 4 chambers
Caused by recurrent/chronic pericarditis, TB or post cardiac surgery complication
How can constrictive pericarditis present?
Refractory oedema, ascites
Fatigue, dyspnoea
Elevated JVP - often very very high - above the ear
Kussmaul’s sign - JVP elevates on inspiration
What is the Rx for constrictive pericarditis?
Loop diuretics (furosemide)
β blockers (bisoprolol) - to treat persistent tachycardia, inc diastolic duration and therefore inc diastolic filling
What is cardiac tamponade?
Pericardial effusion around the heart that compresses the heart and stops it filling adequately
If an echo showed fluid around the heart and diastolic collapse of RV or RA - what would be the diagnosis?
Cardiac tamponade
What are the acute and chronic causes of cardiac tamponade?
Acute - trauma, free wall rupture in MI, acute inflammatory pericarditis
Chronic - neoplastic cause
How do Ps with acute cardiac tamponade present?
With shock - low BP, tachycardia, cool & clammy peripheries
How do chronic pericardial effusions differ from acute?
Chronic - allows the fibrous pericardium to stretch as fluid accumulates.
Therefore often asymptomatic until very large! Dont get tamponade signs
What symptoms can you get with chronic pericardial effusions?
Dyspnoea
Fatigue
Nausea
Dysphagia
Hoarse voice
Hiccups
What is the commonest cause of AS, AR and MR?
Degeneration of the valve
What is the commonest cause of mitral stenosis?
Rheumatic disease (rheumatic fever)
Which is the commonest severe valve abnormality in the West?
Aortic stenosis
What type of murmur is heard with AS?
Systolic murmur
What complication of aortic stenosis can arise?
AS = pressure overload on left ventricle
This can cause LVH on ECG
When is a murmur of mitral regurgitation heard?
Systolic murmur
What drugs are used for medical management of valve disease?
Diuretics (furosemide)
ACEIs or AR2Bs for LV dilation / dysfunction (not in severe AS!)
If AF - Bisoprolol or Digoxin (rate control) + DOAC
However if MS + AF = USE WARFARIN
What two things are needed for infective endocarditis to occur?
Bacteriaemia + Endovascular abnormality
Which valves are most commonly affected by infective endocarditis?
Aortic and mitral valves
Which Ps suffer more with endocarditis of the RHS valves?
IVDU Ps
What are the clinical features of endocarditis?
Fever, malaise, haematuria - almost always
arthralgia, dyspnoea, weight loss
Neurological Sx (emboli)
Murmurs, splinter haemorrhages, osler nodes, janeway lesions, Roth spots, clubbing, splenomegaly
What is the most common cause of infective endocarditis?
Viridans streptococci
Which is the most destructive organism involved in endocarditis?
Staph aureus
Which organism can cause endocarditis as a consequence of bowel malignancy?
Streptococcus bovis
If cultures are negative but endocarditis is suspected - what could be possible causative organisms?
Q fever
Legionella
Chlamydia
Bartonella
Fungi
What investigations can be done for endocarditis?
How can endocarditis appear on ECG?
PR prolongation (possible aortic root abscess near the SAN cause)
What is better at picking up IE - Transthoracic echo or transoesophageal echo?
TOE = >90%
TTE = 70%
What is the Duke Criteria?
How many criteria do you need for definitive and possible diagnoses under the Duke criteria?
Definitive =
- 2 major
- 1 major + 3 minor
- 5 minor
Possible =
- 1 major + 1 minor
- 3 minor
What is the Rx for infective endocarditis?
Prolonged Abx
What Abx should be given for viridian streptococcus?
2 weeks IV amox or gent
4 weeks oral amoxicillin
What Abx should be given for staphylococcus aureus causing IE?
6 w high dose IV fluclox or gent
What Abx should be given for IE on a prosthetic valve?
6 weeks IV Vanc / Gent
When should you consider valve surgery in infective endocarditis?
Acute HF
Poor response to Rx
Embolic events
S. aureus
Prosthetic valves involved
Root abscess
Large vegetations
Fungal infection
What is the cause of hypertrophic cardiomyopathy?
Is a congenital condition - AD.
Is not caused by HT or aortic stenosis - these can cause LVH but would not be considered to be hypertrophic cardiomyopathy (HCM).
What are the possible consequences of HCM?
Can become so large it causes outflow tract obstruction = hypertrophic obstructive myopathy (HCOM).
Can also cause MR = systolic anterior motion (SAM). Occurs due to outflow obstruction -> Venturi effect - pulls the mitral valve forward, the anterior leaflet is moved forward = systolic anterior motion of the valve = MR
What happens in HCM to the heart?
LV septum becomes bigger than the posterior wall = (asymmetrical LVH or ASH).
What are the two hallmarks of HCM?
ASH and SAM
ASH = asymmetrical LVH
SAM = systolic anterior motion (causing MR)
What is the commonest cause of SCD in under 30s?
HCM
How does HCM present?
Chest pain (hypertrophied muscle needs more blood than can be supplied by the coronary arteries = exertional angina).
Thickened heart can be stiff => high pressures which can be transmitted back to the lungs = SOB
Palpitations, dizziness, syncope, murmur (due to outflow obstruction or MR), abnormal ECG
Why does the Valsava manoeuvre cause a louder murmur in LVOT obstruction?
Valsalva manoeuvre - reduces venous return to the lungs and therefore to the left side of the heart => shrinkage of LV size. Smaller LV = greater obstruction - therefore increased (louder) murmur for LVOT obstruction.
What are the physical signs of HCM?
4th HS - caused by combination of LV hypertrophy and atrial systole - atrium contracts and squeezes blood through mitral valve and hits the hypertrophied ventricle wall = makes a low pitched sound that in timing is synchronous with atrial systole - just before 1st HS
Does the Valsava maneouvre increase or decrease a MR murmur in LVOTO?
Decreases - there is less blood flowing through the heart due to reduced venous return to the lungs. Therefore dampens the sound of MR.
What does this ECG show?
Typical ECG of HCM
- Shows LV hypertrophy - tallest R wave in V5 or V6 to deepest S wave in V1 - if more than 35 (or if the complexes run into each other or off the page)
Also - deep T wave inversion
How can you identify HCM on echo?
Asymmetric LVH (ASH)
LVOT gradient pressure drop
Systolic anterior motion of mitral valve (SAM)
MR
What genetic abnormalities may be seen in HCM?
β myosin heavy chain abnormalities
Troponin-T abnormalities
What factors exacerbate LVOTO symptoms?
Reduced venous return - hypovolaemia, Valsava
Exercise
Inotropic drugs
What is the medical management of HCM?
At what risk of morality in a 5 year period is a prophylactic ICD recommended?
If >6%
Considered if >4%
What is a fatty infiltration of the RV free wall causing hypertrophy and dilation called?
Arrhythmogenic Cardiomyopathy (ACM)
How can Arrhythmogenic Cardiomyopathy present on ECG?
Epsilon waves
What conditions can cause restrictive cardiomyopathy (HFpEF)?
2 types of cause - infiltrative & non-infiltrative
Infiltrative =
Amyloidosis
Sarcoidosis
Inherited storage diseases (Fabry, Gaucher)
Non-infiltrative =
Post-irradiation (radiotherapy)
Carcinoid tumour
Endomyocardial fibrosis (lining of heart stiffens) - very rare
What is cardiac amyloidosis?
Disease in which abnormal proteins, known as amyloid fibrils, build up in cardiac tissue causing stiffening of the heart muscle. Often misdiagnosed as HFpEF
Which two types of cardiac amyloidosis affect the heart?
Light chain amyloidosis - younger Ps
ATTR amyloidosis - older Ps (senile amyloidosis) - transthyretin proteins
What are the clinical clues for cardiac amyloidosis?
Small complexes on ECG despite LVH on echo
Bright myocardium on echo
Multi-system problems with AL amyloid
What is the broken hearted cardiomyopathy called?
Takotsubo cardiomyopathy
What is thought to cause takotsubo cardiomyopathy?
Thought to be due to a catecholamine surge in the body - due to intense emotional or physical stress
Which AI condition can cause myocarditis?
Giant cell myocarditis
How can pericarditis present on ECG?
Pericarditic changes = concave upward ST elevation, PR depression and sometimes T wave inversion
What are the symptoms of myocarditis?
V similar to pericarditis - central chest pain improved by leaning forwards, viral Sx or as rapid onset HF
What are the layers of the pericardium?
Outer fibrous layer
Parietal serous layer
Visceral serous layer
If a catheter is introduced to the heart and all four chambers are found to have equal diastolic pressure, what is the diagnosis?
Constrictive pericarditis
Why do you get collapse of the RV or RA in diastole in cardiac tamponade?
The lowest pressure chamber of the heart is the one that gets squashed - this is often the RA or RV
How can you differentiate acute MI from cardiac tamponade?
Cardiac tamponade = no chest pain, no acute ECG changes, low troponin
How can you differentiate acute valvular dysfunction from cardiac tamponade?
Valvular dysfunction would cause a murmur - no murmur heard in cardiac tamponade
How can you differentiate cardiac tamponade from septic myocardial dysfunction?
In sepsis would get temperature and raised CRP
In cardiac tamponade - P would be pyrexial and have relatively low CRP
How can cardiac tamponade present on ECG?
Electrical alternans = QRS complexes are very high
How does cardiac tamponade appear on CXR?
Globular cardiomegaly
What unusual sign of the BP can occur in cardiac tamponade?
It can fall during inspiration = pulsus paradoxicus
How should pericardial effusions be managed for a P in shock?
Therapeutic drainage should occur
What is HF?
Clinical syndrome - heart unable to deliver sufficient blood to the body due to cardiac dysfunction.
Why does HF cause pulmonary and peripheral oedema?
Heart not pumping = backwards & forwards pressure.
Backwards pressure - through circulation to LV to LA to pul capullaries = pul oedema - back to RV and RA - high pressures then put pressure into systemic circulation = peripheral oedema
Low CO = results in RAAS activation and SS system = together inc Na and H20 retention. Inc in circulating vol inc venous return - incs contractility in part due to inc in preload.
What are the clinical features of HF?
Early days - breathlessness is exertion - progresses to orthopnoea and PND
SOB, JVP and oedema = universal signs
What investigations should you do for HF?
BNP! (NT Pro BNP preferred)
FBC - to rule out anaemia
Renal - may require diuretics and ACEIs can affect renal function
LFTs - HF Ps can develop hepatic derangement due to hepatic congestion, and liver failure can mimic HF
Thyroid and iron - may provide potentially reversible causes of HF
Hypothyroid can cause HF and iron overload due to haemochromatosis can be treated with iron chelation therapy.
Key test = BNP level - screening test for HF.
Always do ECG - rarely entirely normal in HF.
CXR - not mandatory - cardiomegaly is nonspecific on CXR.
Definitely do Echo - looking at LV function.
At what ejection fraction is a P deemed to be in HF?
HFrEF = <40%
HFpEF = >55%
HFmrEF = 40-55%
Normal EF = 55-70%
What are the DDs for HF?
At what measurement of BNF is
- chronic HF suspected?
- acute HF suspected?
Chronic - 400-2000 possible, 2000+ likely
Acute - 300+
What can cause chronic HF?
DCMs
Restrictive cardiomyopathies
Heart valve disease
Pericardial disease
What is the biggest cause of dilated cardiomyopathy?
Ischaemia (70%)
Causes LV weakness +/- dilation / thinning
What is the commonest cause of non-ischaemic DCM?
Hypertension
What is the standard medical management for HFrEF?
Diuretics = Furosemide
Vasodilators - ACEIs, AR2, ISMN
Β Blockers
Aldosterone antagonist
SGLT2 Inhibitor
