Download - Cardiomyopathies
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Cardiomyopathies
Puja ChopraOctober 27, 2011
PGY-2
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• Thanks To Dr. Margriet Greidanus!
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Objectives
• Hypertrophic Cardiomyopathy– Obstructive– Treatment– EKG
• Dilated Cardiomyopathy– Etiologies– Treatment
• Restrictive Cardiomyopathy– Etiologies– Constrictive pericarditis
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Case
56 YO F, post cardiac arrestHx. Waiting surgery for HCM
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Hypertrophic Cardiomyopathy
• A refresher
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Obstruction: - Ventricle size is small, mitral
valve contacts the ventricle- Venturi effect high flow
through obstruction
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• Abnormal Relaxation
• Stiff Ventricle
Hypertrophic Ventricular
Muscle
Increased LA and LV ED pressure
Decreased Diastolic
Filling
- 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%)
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P/E: - LVH - Sustained PMI- Irregularly Irregular Pulse- Mid systolic ejection murmur
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Back TO the Case:HR 140, RR(intubated and bagged at 12)Sats 100%, BP 95/60
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(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.
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Normal sinus rhythm with LVH and deep narrow Q waves in the lateral leads I, aVL, V5, and V6.
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Normal sinus rhythm with LVH and deep narrow Q waves in the lateral leads I and aVL.
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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)
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Treatment
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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
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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
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Anticoagulation- 6% rate of strokes in these patients
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25 yo male syncope with exercise25 yo male light headed post exercise30 yo male chest pain with exercise
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23% of patients had an appropriate discharge at follow-up period of 3 years
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Take Home• Hypertrophic Crisis:
– Beta blocker– No positive intropic agents
• ECG– LVH– Q waves in lateral and inferior leads
• A. Fib– Stroke Risk: Anticoagulate
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63 YO female brought to ED with central crushing chest pain and shortness of breath
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• On Exam: Pulmonary edema
• Blood pressure: 70/40
• ?Management
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35 YO female, unwellRespiratory DistressUnable to speak full sentencesSitting up
?Asthma Exacerbation
HR: 130, BP 95/67, 88% 15 L non re-breather
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But wait…..She had a baby 1 week ago!
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DDX of Shock
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- 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
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Dilated Cardiomyopathy
• Another Refresher
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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
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Back to the Case
• Treatment: – A– B– C
• Future Pregnancies
• Complications– ?anti-coagulation
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Treatment1. Identify the cause of the cardiomyopathy and determine what can be reversed or prevented
2. Treatment goals include: 1. Prevention of progression 2. Prolonging survival by targeting the poor prognostic indexes3. Symptomatic treatment4. Preventing complications:
1. CHF2. SCD approx 12% of patients will die suddenly3. 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%
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Take Home
• Takotsubo Cardiomyopathy– 10 to 15% have LV outflow obstruction
• Treat like CHF
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Restrictive Cardiomyopathy
- Amyloidosis- Sarcoidosis- Hemachromatosis- Scleroderma- Neoplastic- Cardiac Infiltration- Radiation Heart Disease- Fabry’s Disease- Gaucher’s Disease- Idiopathic
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Restrictive Cardiomyopathy vs Constrictive Pericarditis
Feature Restrictive Cardiomyopathy Constrictive Pericarditis
Physical Exam Prominent Apical Impulse Pericardial knock may be present
ECG Amyloidosis will have lower QRS voltageQ wavesBBBAV conduction A Fib
Repolarization changes
Chest Radiograph Atrial Enlargment Calcific Pericardium
Echocardiography Atrial EnlargementVentricular wall thickness increased
Pericardial Thickening
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Take Home
• Constrictive Pericarditis: – Pericardial knock– ECHO
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QUESTIONS?