Dilated Cardiomyopathy  

(definition, etiology, sx)

Definition: most common (95%), reduced ventricular strength--->dilation of LV, systolic d/f

Etiology: genetic (25-30%), alcohol, post-partum, chemo, myocarditis, idiopathic, M(esp. AA)>F

Si/Sx (20-60yo): HF signs:  SOB, DOE, orthopnea

Incidental:  cardiomegaly, conduction disturbance 

Dilated Cardiomyopathy

(PE, Labs/dx studies, tx)

PE:  vitals, inc HR.  cool skin, peripheral edema, JVD, s3+/-s4, +/-MR

Labs:  BNP

Studies:  ECG, CX, echo, arteriography (if angina)--->Dx if LV EF <40%, idiopathic if no CAD, myocard, no prim/sec muscle dz

tx:  tx for HF; ACE, bb, +/-diuretic--->transplant

Hypertrophic Cardiomyopathy

(def, etiology/facts, si/sx)

def:  4%, hypertrophy-mostly septum, outflow obstruction, small LV, diastolic d/f

eti:  genetic, sudden death >30 yo

si/sx: dyspnea (90%), syncope, cp, arrhythmias (AF/vent arr).  Sudden death-w/ extreme exertion

HCM

(PE, Lab/studies, tx)

PE: sys murmur increased w/ squat to stand at LSB, s4, bisferiens carotid pulse, 

ECG (LVH), CX, echo-asym LVH, sys ant motion of MV, dynamic pressure gradient across LV outflow tract, inc EF, dec diastolic fx

Myocardial perfusion studies

Tx:  bb, ccb, dual-ch pacer, septal ablation, myomectomy 

Restrictive Cardiomyopathy

(def, etiology/facts, si/sx)

Def:  fibrosis/infiltration 2/2 collagen d/f (amyloidosis, radiation, post-op, diabtes) others;sarcoid, hypereosinophilic syn, endomyo fibrosis, hemochromatosis, malignancy

s/s:  gradual worsening SOB, early fatigue, weakness, PND, abd pain, cp, palps (AF), syncope

RCM

(PE, dx studies, tx) 

PE: JVD, kussmaul sign, +/- s3, murmurs (MR/TR), ascites, edema

 studies: CBC, iron studies, BNP

CX-->cardiomegaly w/ pleural effusion, P-HTN

Echo-non-dilated/hypertrophied, normal contraction LV/RV, dilated atria, dec diastolic filling

 tx: underlying cause, tx HF, pacemaker, transplant

def/facts:  Most common, inc w/ age, etiologies include; rheumatic, valvular, dcm, asd, htn, cad, idiopathic-->may be initial sx of thyrotoxicosis

sx: few, fatigue, uncomfortable sensation in chest

dx: ECG, if new; thyroid fx, valve/cardiac dz r/o

Tx: if unstable (usually 2/2 rvr); hospitalization, cardioversion (pre-cardiov anticoag if >48hrs), if more stable-> bb, dig, ccb, amiodorone

anitcoagulation: warfarin (INR 2.0-3.0)

If refractory; node ablation w/ pacing 

Less common, usually assoc w/ COPD, or rheumatic, CAD, CHF, ASD or surgical repair of congenital defect.

can tx w/ ibultilide (class III anti-arrhythmic), or electrical cardioversion

most common paroxysmal tachy, often 2/2 reentry, which can is initiated or terminated by fortuitously timed atrial or ventricular premature beat

Most commonly AVNRT-dual pathway w/in AV node

Other is AVRT-reentry d/t accessory pathway b/w atrial+vent

s/s:  usually asx, may feel beat, sob, mild cp

Dx: ecg 140-240 bpm

tx: vagal maneuvers, then adenosine (6mg bolus, 1-2min later 12 mg bolus, then 3rd), verapamil (2.5mg bolus, f/by 2.5-5 q1-3 min, tot 20mg)

3 or more consecutive vent premature beats, rate = 160-240 bpm, moderatly regular, usually 2/2 reentry, complication of MI, DCM, HCM, MVP, myocarditis, other

Torsades de pointes-qrs twists around baseline, may occur spontaneously in setting of hypokalemia, hypomagnesemia, or after QT interval prolonging drugs

sustained >30s, non-sustained <30s

tx: ACLS guidelines 

1st deg:  PR interval >.21, 2/2 inc vagal tone, drugs

Mobitz type I (Weckebach):  progressive lengthening of PR, then dropped beat, inc vagal tone, drugs, usually nodal.

Mobitz Type II:  dropped beats w/o PR lengthening, usually 2/2 block w/in his bundle

Complete (3rd deg):  lesion distal to his bundle, wide qrs, slow ventricular rate (<50bpm)

-Deterioration of sinus node's ability to generate impulse, atrial signal conduction-->slow ventricular rate, long pauses, organ hypoperf, pulse irregularities.

etiologies:  age related(fibrosis), CAD, Familial Sick sinus syndrome, Tachy-brady syndrome, bb,ccb, dig, endocrine (hypothyroidism, hypothermia), hypokalemia,hypocalcemia)

s/s: avg age=68,m=w, asx, fatigue, dizzziness, syncope, angina, HF sx, palps

PE:  slow heart rate (<60bpm w/ activity), +/- irreg pulse, sinus pause>3 sec to carotid sinus massage

Labs; e-, thyroid, ecg, holter, implantable loop recorder, exercise tolerance test, atropine/propranolol test

tx: pacemaker

Pericarditis

(definition, etiology, presentation)

Definition:  inflammation of pericardium, acute <6wks, sub-acute 6wks-6mo, chronic (constrictive) >6mo

etiology: Neoplastic, autoimmune, viral, bacterial, idiopathic, uremia, dressler's (s/p MI, cardiac injury)

Presentation:  +/- prodrome (malaise, myalgia, fever), CP (like acute MI, retrosternal, steady, severe, constricting, radiates, *improves w/ sitting up, leaning forward*, can be pleuritic

Pericarditis

(PE, Dx, Tx)

PE:  friction rub (85%), CP more common in acute, 

ECG:  diffuse ST elevations, w/ dep in aVr,+/-V1

Labs: ESR/CRP, WBC, CPK, CK-MB, Trops, make sure to r/o MI

Tx w/ NSAIDS, colchicine, steroids, ABx if bacterial

Constrictive Pericarditis

(def, etiology, dx, tx)

Occurs s/p resolution of acute pericarditis-TB, radiation, trauma, surgery, AI, uremia w/ CRF

presents w/ weakness, fatigue, jvd w/ +kussmauls, cong. Hepatomegaly

Dx w/ ECG-diffuse t wave flat/inv, Echo-pericardial thickening

Tx w/ resection of pericardium

Pericardial Effusion

(basics)

accumulation of fluid in pericardial space 2/2 inflammation or bleeding- presents w/ inc cardiac silheutte="water bottle", ewart's si=L scap angle increased fremitus, egophony

dx w/ TTE-small=<100ml, Lg=>500mL

Cardiac Tamponade

(definition, presentation, Dx, Tx)

Accumulation of enough fluid to obstruct inflow into ventricles

Rapid onset (hrs-days) as little as 200ml, Slow onset (mo-yrs) as much as 2000ml (presents like HF)

Presentation: Beck's triad: hypoT, distant hrt sounds, JVD-also might have pulses parodixus

Dx w/ echo, Tx w/ pericardiocentesis

Infective Endocarditis

(definition, Patho, RF)

Bacterial infection of endothelial surface of heart, typically valves, characterized by vegetations and systemic manifestations-occurs 2/2 turbulent flow 

Patho: bacteremia (IVDA, Dental)-->adherence of org-->invasion-->death

RF: valve damage by previous IE, valvular dz, congenital d/f, HIV, IVDU, indwelling caths

Infective endocarditis

(Etiology, Presentation) 

Staphylococci (42%), Streptococci (40%) in one study, others; enterococci, GNB, fungi

Presentation: Acute(<6wks) toxic-chills, fevers, rapid onset HF, palps, wt loss, HA, myalgias, Sub-acute (>6wks) milder sx

Infective Endocarditis

(Diagnostic Criteria)

Major Manifestations:  +bcx (at least 2 sets), evidence of endocardial involvement-+veg on echo, new onset murmur

Minor manifestations:  T>100 dg, +echo (not meeting major), +Bcx (not major), +IVDU, clinical signs-vascular, immunologic abnormalities

Needed: 2maj or 1maj/3min or 5min

Infective Endocarditis

("classic" signs)

Subungual (splinter) hemorrhages, Osler Nodes(tender nodules on digits), Janeway lesions (NT maculae on palms/soles), Roth spots (retinal hemorrhages)

Infective Endocarditis

(Treatment)

Acute stabilization:  tx HF

Empiric Therapy:  Penicillin G/Ampicillin + Nafcillin/Oxacillin+Gentamicin

If IVDU/Prosthetic valve: vanco+gentamycin

Identify org, then narrow tx

Surgery may be needed

myocarditis

(Definition, etiology, Presentation)

Inflammation of myocardium-infectious, immune-mediated, toxic exposure

World wide-chagas dz, western-coxsackie B, adeno, parvo B19

Presents: viral prodrome-fever, myalgias, resp/GI sx--> si of heart failure (CP, fatigue, SOB)

Myocarditis

(PE, two variants)

PE:  may be absent, or include tachycardia, S3, b/l rales, JVD, may include fulminant HF and sudden cardiac death

Fulminant:  severe hemodynamic instability, distinct onset of HF sx, fever, viral illness w/in 2wks

Acute(non-fulminant):  Hemodynamically stable, no clear onset of HF sx, no fever-->DCM, endstage HF later in life

Myocarditis:

(Dx, Tx)

ECG:  non-specific (t wave flat/inv, slight st elevation or dep)-not very dx

labs not overly helpful-cbc, esr, trops

+echo abnormalities-impaired systolic fx of LV, w/ absent dilation

Cardiac MRI study

Gold-standard is biopsy-restricted to fulminant, giant-cell, others

Myocarditis

(Management)

Supportive mostly!

HF tx-ace, bb, diuretic

mechanical LVAD, transplantation

Steroids may help for Giant cell only or if sarcoidosis?

Mitral Stenosis

(Definition, Etiology, Presentation)

Mital valve thickening, calcification, fusion of leaflets, papillary muscle thickening/calcification

Etiology: Rheumatic fever/HD considered main cause

Presentation: Insidious onset, 20-40yo.  Exertional dyspnea, orthopnea, PND.  Rarely, hemoptysis 2/2 P-HTN, or hoarse voice 2/2 Ortner's syndrome (impingement of recurrent Laryngeal n).

Mitral Stenosis

(PE, DX, TX)

PE:  opening snap, diastolic murmur best @apex, afib might be first presentation.

Dx:  BNP (HF), r/o MI, echo-->leaflet thickening, motility, orifice size, etc.  ECG-->LAE (p mitrale in II, biphasic P in V1)

Tx:  CHF, Afib, primary prophylaxis (tx GAS w/in 7-9days), *Surgical repair/replace of valve

Mitral Valve Prolapse

(Basics)

Systolic billowing of 1 or both leaflets, +/-MR, etiology mostly unknown (genetic?), usually young, otherwise healthy females

s/s:  asx, maybe cp, palps, sob, PE:  mid-systolic click, followed by murmur if MR

dx w/ echo, tx usually unecessary, unless major sx->repair/replace

Mitral Regurgitation

(Acute vs Chronic)

acute: rapid back-up-->LAE-->flash p edema.  Etiologies-MI (pap m d/f), endocarditis->leaflet perf, MVP->ruptured chordae tendinae

Chronic:  asx,->HF (dyspnea, fatigue,etc)->p congestion,edema.  Etiologies-MVP, annular calcifications, cardiomyopathy, rheumatic HD, MI/Endocarditis 

Mitral Regurgitation

(PE, Dx, tx)

Pan-systolic murmur, blowing quality, @apex->axil->scap.  S3, laterally displaced apical impulse 2/2 dilation

dx:  Echo(GS)->gradation mild,mod,sev

CXR->LAE,LV dilation, Pcongestion

Tx: acute->stat surgical repair/replace.  Chronic->scheduled repair/replace(severe sx, EF<60%, HF)

Aortic Stenosis

(Etiology, Presentation,PE)

Congenital (bicusp/unicusp valve), genetics, degenerative or calcific AS (25% of >65yo, 35% of >70yo)

S/S:  stable angina, exercise assoc. syncope, CHF

PE: Harsh Sys murmur t/o precordium, best @RSB->neck

Aortic Stenosis

(Dx, Tx)

Dx: Echo (GS)->severity-critical=(>50mmHg, area<.08cm^2), Normal=0 mmHG, 3-4cm), *cardiac cath for assessment of CAD if surg is planned

Tx: symptomatic pt, asx pt w/ gradient >64mmHg-->bioprosthetic (elderly,10-15 year lifespan), mechanical (requires anticoagulation INR 2.0-2.5)

*Caution*-nitro,bb,diuretics.  *Avoid alpha blockers*

Aortic Regurgitation

(definition, etiology, Presentation, PE)

Blood flowing back into LV during diastole, -->HTN, cong bicuspid v, endocarditis

S/S:  Asx until LV dysfunction-->HF signs (dyspnea, fatigue, orthopnea, angina)

PE:  Diastolic murmur @Erbs, LSB, austin flint->extra blood vibrating against mitral?,  water-hammer (corrigan) pulse-rapid rise/fall, widened pulse, low diastolic pressure

Aortic Regurgitation

(Dx, TX)

Dx:  ECG-LVH, Echo (perform annually to monitor)->amount of regurg, LV d/f

Tx: Afterload reduction-nifedipine, hydralazine, ACE inh

Surgery indicated-severe LV d/f (EF<55%, others)-bioprosthetic vs mechanical

Tricuspid Stenosis & Regurg

(Basics)

TS-rheumatic or 2/2 carcinoid syndrome->RAE, R HF, initial tx w/ diuretics, definitive tx w/ replacement

TR-Caused by RV dilation, R HF, tx underlying cause of RV dilation

Pulmonary Regurgitation

(basics)

CAD

(Main Arteries)

Left main coronary artery

left anterior descending

left circumflex

Right coronary artery

Chronic stable Angina

(Definition)

Ischemia resulting from imbalance between O2 supply and demand.

Exertional sx, relieved by rest or nitro

Reproducible by similar level of exertion

Unchanged pattern x6mo

Chronic Stable Angina

(Sx-oldcart)

Chronic Stable Angina

(PE, Dx, tx)

PE;  usually normal, maybe apical sys murmur, HTN->HoTN, levine si, 

Dx:  Labs: cbc-anemia, thyroid function-hyperthyroid can cause CP/palps, hsCRP?

ECG: +/-ST changes?/depressions, Exercise ECG, exercise tolerance test

Tx: Nitroglycerin (0.3, 0.4, 0.6 mg SL/ 0.4 buccal spray) rpt q3-5min prn

Chronic Stable Angina

(Prevention/prophylaxis)

Risk modification-quit smoking, lose weight, healthy diet/statins (cholesterol), tx HTN, exercise

Long acting nitrates-isosorbide dinitrate/mononitrate, Nitropaste, nitro patch, BB, CCB, ranolzane, aspirin/clop-last resort=PCI/CABG

Unstable Angina & NSTEMI

(Definiton-basics)

-Detachment of stable clot/plaque;  -partial obstruction by emboli, clot, or spasm;  -obstruction leads to ischemia

Unstable angina/NSTEMI

(si/sx, PE)

Similar to stable angina, but sx of ischemia at rest or w/ minimal exertion;  -if h/o stable angina, sx will be similar; - +/-dyspnea, nausea, diaphoresis, syncope

PE: usually normal, maybe-3/4th heart sound, transient MR, evidence of LV dysfunction (pulmonary congestion, edema, diaphoresis, HoTN), arrhythmias 

ACS: Unstable/NSTEMI

(DX/LABS)

ECG-50% normal, might show transient ST depressions or elevations;  T wave inversions, flattening, peaking

LABS:  Cardiac enzymes- normal in UA;  Elevated in NSTEMI

[image]

Unstable/NSTEMI Risk assessment

(Low Risk)

Unstable/NSTEMI Risk assessment

(Intermediate Risk)

Unstable/NSTEMI risk assessment

(High Risk)

Unstable/NSTEMI

(tx)

Initial tx=MONA-morphine (or fentanyl), O2, sublingual and/or IV nitro, aspirin 162-325mg, clopidogrel 300-600 loading dose

High risk NSTEMI=aggressive care-aspirin, clopidogrel, unfx heparin or LMWH, platelet glycoprotein IIb/IIIa (tirofiban, eptifibatide), BB

All categories may ultimately recieve angiography followed by PCI/CABG, whether it is emergent or not depends on work-up/presentation