Cardiomyopathies. Puja Chopra October 27, 2011 PGY-2 . Thanks To Dr. Margriet Greidanus !. Objectives. Hypertrophic Cardiomyopathy Obstructive Treatment EKG Dilated Cardiomyopathy Etiologies Treatment Restrictive Cardiomyopathy Etiologies Constrictive pericarditis. Case.
Cardiomyopathies Puja Chopra October 27, 2011 PGY-2
Objectives • Hypertrophic Cardiomyopathy • Obstructive • Treatment • EKG • Dilated Cardiomyopathy • Etiologies • Treatment • Restrictive Cardiomyopathy • Etiologies • Constrictive pericarditis
Case 56 YO F, post cardiac arrest Hx. Waiting surgery for HCM
Hypertrophic Cardiomyopathy • A refresher
Obstruction: • Ventricle size is small, mitral valve contacts the ventricle • Venturi effect high flow through obstruction
Atrial dilation and back flow into the pulmonary vasculature • Dyspnea with increased oxygen consumption (90%) • Reduced Cardiac Output • Syncope (30%) • Thickened ventricular arterioles with reduced lumen • Angina (30%)
P/E: • LVH • Sustained PMI • Irregularly Irregular Pulse • Mid systolic ejection murmur
Back TO the Case: HR 140, RR(intubated and bagged at 12) Sats100%, BP 95/60
(Case 1) Normal sinus rhythm with large-amplitude QRS complexes consistent with LVH and nonspecific T-wave abnormality. Deep narrow Q waves are also present in the lateral leads I, aVL, V5, and V6.
Normal sinus rhythm with LVH and deep narrow Q waves in the lateral leads I, aVL, V5, and V6.
Normal sinus rhythm with LVH and deep narrow Q waves in the lateral leads I and aVL.
EKG • LVH: high voltage R waves in the anterolateral leads (V4, 5, 6, I and avL) • Deep and narrow Q waves can be seen in the inferior leads and in the lateral leads (over the septum) (most specific findings)
Beta Blockers! • Prolongs time in diastole • Reduces inotropic demand • Vasopressors: • - Increased SVR reduces venturi effect • Avoid Preload Reduction Agents: • Diuretics • Nitroglycerine • Nitropursside • Avoid Inotropic Agents
Surgical Mymectomy: • This is reserved for patients with a high outflow tract obstruction (>50 mmHg) and those that have failure to medical management • 90% of patients have improvement in their outflow gradient with persistent symptomatic improvement at 5 years • Reduced amount of SCD in those with surgical mymectomy
Anticoagulation - 6% rate of strokes in these patients
25 yo male syncope with exercise 25 yo male light headed post exercise 30 yo male chest pain with exercise
23% of patients had an appropriate discharge at follow-up period of 3 years
Take Home • Hypertrophic Crisis: • Beta blocker • No positive intropic agents • ECG • LVH • Q waves in lateral and inferior leads • A. Fib • Stroke Risk: Anticoagulate
63 YO female brought to ED with central crushing chest pain and shortness of breath
On Exam: Pulmonary edema • Blood pressure: 70/40 • ?Management
35 YO female, unwell Respiratory Distress Unable to speak full sentences Sitting up ?Asthma Exacerbation HR: 130, BP 95/67, 88% 15 L non re-breather
But wait….. She had a baby 1 week ago!
Cardiac failure in the last month of pregnancy or within the five months post partum • No determinable cause of the heart failure • No heart disease before the onset of the last month of pregnancy • LV dysfunction seen on echocardiogram
Dilated Cardiomyopathy • Another Refresher
Etiologies: • Toxins • Ethanol, • Chemotherapeutic Agents, • Antiretrovial agents, • Cobalt, Lead, Cocaine, Mercury • Metabolic • Nutritional: Thiamine, selenium, carnitine • Endocrine: Hypothyroid, acromegaly, thyrotoxicosis, cushings, pheochromocytoma, Diabetes • Inflammatory or Infections: • Collagen Vascular Disesae: Sclerodermia, lupus, Sarcidosis • Peripartum • Infectious: • Viral Myocarditis: Parvovirus B19, Herpes, coxsackievirus, influenza virus, adenovirus, HIV • Chagas Disease: Protozoa (leading cause in SA and Central America) • Lymes Disease • Neuromuscular: • Muscular Dystrophies • Freidreich’s ataxia • Tachycardia • Familial • Stress Induced • Idiopathic
Back to the Case • Treatment: • A • B • C • Future Pregnancies • Complications • ?anti-coagulation
Treatment • Identify the cause of the cardiomyopathy and determine what can be reversed or prevented • Treatment goals include: • Prevention of progression • Prolonging survival by targeting the poor prognostic indexes • Symptomatic treatment • Preventing complications: • CHF • SCD approx 12% of patients will die suddenly • VTE Clinical predictors of poor prognosis: • Syncope • S3 gallop • RHF on exam • AV block, BBB (note that an av block in an idependent risk factor for death) • Elevated creatinine • Cardiothoracic ratio • EF less than 35%
Take Home • Takotsubo Cardiomyopathy • 10 to 15% have LV outflow obstruction • Treat like CHF
Restrictive Cardiomyopathy • Amyloidosis • Sarcoidosis • Hemachromatosis • Scleroderma • Neoplastic • Cardiac Infiltration • Radiation Heart Disease • Fabry’s Disease • Gaucher’s Disease • Idiopathic