Diseases of the Heart Muscle and Pericardium

Question 1

Most common type of cardiomyopathy

Answer 1

Dilated Cardiomyopathy

Question 2

Dilated Cardiomyopathy pathogenesis

Answer 2

An insult (ischemia, infection, alcohol, etc) —>dysfunction of LV contractility –>Dilated LV

*50% of cases are idiopathic

Question 3

Treatment of dilated cardiomyopathy

Answer 3

Similar to treatment of CHF because signs and symptoms of both R and L sided failure are likely present

Digoxin
Diuretics
Vasodilators
Heart Transplant

Question 4

What sort of prophylaxis should be considered in patients with dilated cardiomyopathy?

Answer 4

Anticoagulation because these patients are at increased risk of embolization

Question 5

most cases of hypertrophic cardiomyopathy are due to….

Answer 5

Inheritance of an autosomal dominant trait

Question 6

What kind of cardiac dysfunction will hypertrophic cardiomyopathy cause?

Answer 6

Diastolic dysfunction due to a stiff, hypertrophied ventricle with increased diastolic filling pressures that increase further with elevated heart rate and contractility (as with exercise)

Question 7

Patients with hypertrophic cardiomyopathy may have this obstruction:

Answer 7

dynamic outflow obstruction due to assymmetric hypertrophy of the interventricular septum

Question 8

young athlete experiences sudden death: may be the first manifestation of….

Answer 8

hypertrophic cardiomyopathy

Question 9

Clinical signs of HCM

Answer 9

sustained PMI
Loud s4
systolic ejection murmur
rapidly increased carotid pulse with 2 upstrokes (bisferious pulse)

Question 10

Systolic Ejection murmur in HCM is best heard at….

Answer 10

the lower left sternal border

Question 11

standing, the valsalva maneuver, and leg raises diminish the intensity of which murmurs?

Answer 11

Diminish intensity of all murmurs except in Mitral Valve Prolapse and HCM

*These maneuvers decrease LV volume, thus make these two murmurs worse

Question 12

Squatting increases the intensity of all murmurs except….

Answer 12

Mitral valve prolapse murmur and HCM murmur

Question 13

Sustained hand grip decreases intensity of this murmur

Answer 13

HCM murmur

Sustained hand grip increases systemic resistance

Question 14

All HCM patients should avoid…..

Answer 14

strenuous exercise including competitive sports

Question 15

What is the initial drug used in symptomatic HCM patients? What is an alternative drug choice?

Answer 15

Beta blockers: decrease symptoms by improving diastolic filling via decreased HR and increasing diastole duration and decreasing contractility (and thus O2 consumption)

Calcium Channel Blockers (Verapamil) are alternatives if patient is not responding to the Beta Blockers (via similar mechanism)

Question 16

This procedure is reserved for HCM patients with severe disease

Answer 16

Myomectomy: excision of part of the myocardial septum (Has high success rate for relieving symptoms)

Question 17

Pathogenesis of Restrictive Cardiomyopathy

Answer 17

Infiltration of myocardium —> impaired diastolic ventricular filling due to decreased ventricular compliance

Question 18

Causes of RCM

Answer 18

Amyloidosis
Sarcoidosis
Scleroderma
Carcinoid Syndrome
Chemo/Radiation therapy
Hemochromatosis
Idiopathic

Question 19

RCM on echocardiogram will show:

Answer 19

Thickened myocardium
Increased RA and LA size with normal LV and RV size

*Possible systolic ventricular dysfunction

Question 20

Signs and Symptoms of RCM

Answer 20

Dyspnea
Exercise intolerance
R-sided HF signs and symptoms (due to increased filling pressures)

Question 21

Echo findings show myocardium appearing righter than normal with a possibly speckled appearance; you should suspect….

Answer 21

RCM caused by amyloidosis

Question 22

In the treatment of RCM, you must treat the underlying disorder. You can give digoxin if systolic dysfunction is present, except when….

Answer 22

Patient has cardiac amyloidosis because these patients have increased incidence of digoxin toxicity

Question 23

Myocarditis Causes

Answer 23

Inflammation of the myocardium caused by:
virus
bacteria
SLE
medications
idopathic

Question 24

“Classic Case” for myocarditis

Answer 24

Patient that is a young male

may present with fever, fatigue, chest pain, pericarditis, CHF, arrhythmia

Question 25

Should look for these labs in myocarditis

Answer 25

cardiac enzymes elevated | ESR elevated

Question 26

Cardinal manifestations of acute pericarditis

Answer 26

Chest pain Pericardial friction rub ECG changes: diffuse ST elevation and PR depression Pericardial effusion (with or without tamponade)

Question 27

How can you differentiate the chest pain of pericarditis from that of an MI?

Answer 27

Chest pain in acute pericarditis is pleuritic (associated with breathing) this is not the case in MI

Question 28

Chest pain in acute pericarditis is aggravated by....

Answer 28

lying supine coughing swallowing deep inspiration

Question 29

Chest pain in acute pericarditis is relieved by....

Answer 29

sitting up and leaning forward

Question 30

A pericardial friction rub is heard best under these conditions:

Answer 30

Heard best during expiration with patient sitting up and stethoscope placed firmly against chest

Question 31

In acute pericarditis, the ECG may show 4 changes in sequence:

Answer 31

1. diffuse ST elevation and PR depression 2. ST segment returns to normal around 1 week 3. T wave inverts (does not occur in all patients) 4. T wave returns to normal

Question 32

Treatment of acute pericarditis

Answer 32

NSAIDs are the mainstay | Most cases are self limited and resolve in 2-6 weeks

Question 33

Pathophysiology of constrictive pericarditis

Answer 33

Fibrous scarring of pericardium---> rigidity and thickening of the pericardium --->obliterates pericardial cavity---> diastolic dysfunction

Question 34

Compare diastolic dysfunction of constrictive pericarditis to that of cardiac tamponade

Answer 34

Constrictive pericarditis: Early diastole has rapid filling, late diastole has halted filling In cardiac tamponade, ventricular filling is impeded throughout diastole

Question 35

Patients with constrictive pericarditis typically present in 1 of 2 ways:

Answer 35

1. symptoms characteristic of overload: edema, ascites, pleural effusion 2. symptoms related to decreased C.O.: dyspnea on exertion, fatigue, decreased exercise tolerance, cachexia

Question 36

most prominent physical finding in restrictive pericarditis:

Answer 36

JVD (may have kussmaul sign) with prominent x and y descent waveforms

Question 37

Kussmaul sign

Answer 37

JVD fails to decrease during inspiration

Question 38

If a patient has clinical signs of cirrhosis and distended neck veins, you need to considers and rule this out:

Answer 38

restrictive pericarditis

Question 39

how is the diagnosis of restrictive pericarditis made?

Answer 39

by finding thickened pericardium on echocardiogram or CT/MRI

Question 40

Treatment of restrictive pericarditis

Answer 40

must treat underlying condition!! Diuretics to relieve symptoms of overload Surgical pericardiectomy (indicated in most cases)

Question 41

often, restrictive pericarditis progresses to.....

Answer 41

worsening C.O. and hepatic and/or renal failure

Question 42

pericardial effusion can occur in association with

Answer 42

ascites and pleural effusion in CHF, cirrhosis, and nephrotic syndrome

Question 43

diagnosis of pericardial effusion made by....

Answer 43

echocardiogram findings (most sensitive and specific method) CXR may show cardaic silhouette enlargement when >250mL of fluid present, without pulmonary vascular congestion

Question 44

pericardial effusion is important clinically when it...

Answer 44

develops rapidly because it may lead to cardiac tamponade

Question 45

when would pericardiocentesis be indicated?

Answer 45

when there is evidence of cardiac tamponade

Question 46

what is the most important factor in fluid accumulation that leads to cardiac tamponade?

Answer 46

It is the RATE of fluid accumulation that is important, not the amount When fluid accumulates slowly, the pericardium has opportunity to stretch and adapt to the increasing volume

Question 47

In cardiac tamponade, how do the various pressures in and around the heart affect the C.O.?

Answer 47

Pressures in the RV, LV, RA, LA, pulmonary artery and pericardium equalize during diastole---> Impaired diastolic ventricular filling---> Decreased stroke volume----> decreased C.O.

Question 48

Causes of Cardiac tamponade

Answer 48

Penetrating trauma to thorax Iatrogenic causes: central line placement, pacemaker insertion etc. Pericarditis: idiopathic neoplastic, or uremic Post MI with free wall rupture

Question 49

What is the most common finding in cardiac tamponade?

Answer 49

increased jugular venous pressure Venous waveforms: prominent x descent and absent y descent

Question 50

Pulsus Paradoxus

Answer 50

exaggerated decrease in arterial pressure during inspiration (>10mmHg drop) Decrease in amplitude of femoral or carotid pulse with inspiration and strong pulse with expiration Seen in Cardiac Tamponade

Question 51

What is the Beck Triad for Cardiac Tamponade

Answer 51

Hypotension Muffled Heart Sounds JVD

Question 52

Diagnosis of cardiac tamponade made by....

Answer 52

echocardiogram (most sensitive and specific non-invasive test)

Question 53

Electrical Alternans on ECG

Answer 53

Alternate beat variation in the direction of the ECG wave forms due to pendular swinging of the heart within the pericardial space causing a motion artifact

Question 54

Treatment for hemodynamically stable non-hemorrhagic tamponade

Answer 54

Closely monitor with Echo and ECG If there is known renal failure---> dialysis would be more appropriate than pericardiocentesis

Question 55

Treatment of hemodynamically unstable non-hemorrhagic tamponade

Answer 55

Pericardiocentesis

Question 56

Treatment of hemorrhagic cardiac tamponade secondary to trauma

Answer 56

Emergency surgery!!! Pericardiocentesis is NOT a definitive treatment, though it may alleviate symptoms. Surgery should NOT be delayed to perform pericardiocentesis.