Myocardial and Pericardial lecture Flashcards Preview

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Flashcards in Myocardial and Pericardial lecture Deck (77):
1

What is the cause of primary dilated cardiomyopathy?

Idiopathic-unknown cause

2

Toxic- alcohol, adriamycin, etc
Post-partum (third trimester or after birth)
Post infectious- myocarditis*
Endocrine
"Ischemic cardiomyopathy"

Secondary dilated cardiomyopathy

3

Patients present with signs and symptoms of HF which usually develops slowly.

Dilated cardiomyopathy

4

In dilated cardiomyopathy, left or biventricular failure, ______ dysfunction predominates.

Systolic

5

Right or Left dilated cardiomyopathy?
DOE, orthopnea, PND, weakness, fatigue, peripheral edema, etc.

Left sided

6

Right or Left dilated cardiomyopathy?
unexplained weight gain, peripheral edema, abdominal fullness (hepatomegaly, ascites).

Right sided

7

Cardiomegaly (PMI displaced laterally), low pulse amplitude (pulsus alternans when severe), often with ↓BP, pulmonary congestion, crackles, S3 gallop, MR murmur.

(left) Dilated cardiomyopathy

8

Elevated JVP, hepatomegaly, HJR, pitting edema, TR murmur.

(right) Dilated cardiomyopathy

9

right sided murmurs get louder with..

inspiration

10

Echocardiography/Doppler: LV/RV dilation, global LV dysfunction with reduced EF; Mitral regurgitation common.

Dilated cardiomyopathy

11

CxR: Cardiomegaly, pulmonary congestion, pleural effusions.

Dilated cardiomyopathy

12

Do you need to do a cardiac cath in a pt with dilated cardiomyopathy?

NO! Only used to rule out other dx

13

Tx like HF:
Afterload reduction: ACEI or alternatives (ARB’s)
Preload reduction: Diuretics, nitrates
Beta Blockers
Spironlolactone- class III and IV NYHA criteria
Digoxin
ICD’s if indicated, +/- antiarrhythmics
Anticoagulation unless contraindicated*

Dilated cardiomyopathy

14

If dilated cardiomyopathy pt has an EF of 35% or less...

use ICD

15

Only meds that may improve survival rate in dilated cardiomyopathy:

ACEi (or ARB)
Beta blockers
Spironolactone

16

Genetically transmitted in >50% of cases.
Autosomal dominant with high penetrance.
*may require genetic counseling
(remaining cases occur spontaneously)

Hypertrophic cardiomyopathy

17

Marked increase in left ventricular mass, especially the septum - marked hypertrophy; remaining LV segments hypertrophied to a lesser degree; often called *ASH. Hypertrophy is unrelated to pressure overload; often present at birth, progressively worsens during childhood.

HCM

18

LV cavity small, systolic function normal or hyperdynamic early on.
Diastolic dysfunction common
Obstructive (below AoV) and non-obstructive forms

HCM

19

Asymmetric septal hypertrophy, AKA

HCM

20

When present LVOT obstruction is dynamic and varies with activity/rest, and LV volume.
Obstruction: MV moves abnormally towards the IVS, obstructing the LVOT.

HCM

21

Pathology: myocardial fiber hypertrophy and disarray, primarily in IVS.
Mitral valve often thickened and moves abnormally as noted above, well seen on echocardiogram.

HCM

22

Often asymptomatic in childhood; may be detected via ultrasound in the offspring of patients with known disease.
Symptoms: dyspnea, chest pain and syncope are most common. In some, sudden death may be presenting symptom. One of few causes of sudden death in young athletes.

HCM

23

Sudden death often occurs during strenuous activity.
Arrhythmias are common: ventricular and supraventricular; Afib may lead to sudden decompensation and is a bad prognostic sign.

HCM

24

Pulse brisk, often with bisferiens carotid pulse.
Double or triple apical impulse due to atrial filling wave and early and late systolic impulses.
Loud S4 and S3 gallops.

HCM

25

Loud harsh aortic outflow murmur (crescendo-decrescendo) best heard along left sternal border with characteristic features; MR common.

HCM

26

The murmur of HCM is increased with....

Standing and valsalva

27

HCM and... hypovolemia, tachycardia or increase in cardiac contractility (inotropes, exercise) causes...

increase in murmur

28

LVH with secondary ST-T changes common. Septal Q waves may mimic MI.

HCM

29

Must minimize strenuous physical exertion
***BETA BLOCKERS ARE CORNERSTONE THERAPY

HCM

30

What class of drug can be used instead of or along with beta blockers in treating HCM

Calcium channel blockers

31

Don't use what class of calcium channel blockers in HCM

Dihydro CCBs

32

myomectomy, alcohol ablation used as surgical tx for..

HCM

33

Dual chamber pacemaker may improve septal motion and decrease progression of obstruction if severe

HCM

34

Which HCM patients may be candidates for implantable cardiac defibrillators (ICD)?

High risk!! (vtach, aborted sudden death)
or fam hx of sudden death

35

Hallmark: Abnormal diastolic function.
Ventricular walls excessively rigid and impede diastolic filling; systolic function may be normal or reduced.

Restrictive and infiltrative cardiomyopathies

36

Amyloidosis
Hemochromatosis
Fabry Disease
Gaucher Disease
Endomyocardial Fibrosis-Loeffler Endocarditis-hypereosinofilia syndrome

...all causes of?

Restrive and infiltrative cardiomyopathies

37

Jugular venous distention
S3 and/or S4
Inspiratory increase in venous pressure (Kussmaul’s sign)
Findings of Rt. Heart Failure may predominate i.e. edema, hepatomegaly.
Symptoms include dyspnea, exercise intolerance and fatigue.

Restrictive cardiomyopathy

38

AKA Stress Cardiomyopathy: ∼90% cases are women, often associated with a significant stressful event.

Tako-tsubo Cardiomyopathy

39

Presentation mimics STEMI: Chest pain, SOB, ECG changes with modest elevation of troponins.
Echocardiogram: Marked LV dysfunction with anterior, apical and inferior ballooning, marked ↓EF.

Tako-tsubo Cardiomyopathy

40

Absence of obstructive CAD at catheterization.
Pathophysiology: stressful event leads to outpouring of catecholamines →transient LV insult.

Tako-tsubo Cardiomyopathy

41

A primary inflammatory process of the myocardium, most often caused by an infectious agent.

Myocarditis

42

Unrecognized myocarditis may be the initial event culminating in an...

idiopathic dilated cardiomyopathy

43

Most common type of myocarditis?

Viral

44

Coxsackievirus (B>A)***
CMV
Echovirus*
Adenovirus*
HIV*
Influenza
Infectious mononucleosis
Rubella, Rubeola

Viral causes of myocarditis

45

Chest pain, fatigue, dyspnea, palpitations are common initial symptoms. Often progresses to HF.

Myocarditis

(often start asymptomatic)

46

The initial presentation of myocarditis might be..

Heart failure

47

Exam : Tachycardia, elevated temp, muffled heart sounds; signs of HF in severe cases.

Myocarditis

48

Avoid which type of drugs in myocarditis

NSAIDS

49

Tx for myocarditis

Supportive treatment only

(tx HF if present)

50

This drug class may make myocardial damage worse

NSAIDS

51

A syndrome due to inflammation of the pericardium characterized by chest pain, a pericardial friction rub, and serial ECG abnormalities.

Acute pericarditis

52

Viral most common; same spectrum of viruses as seen with myocarditis- Coxsackie B most common.

Pericarditis

53

Tx for Pericarditis ONLY!

NSAIDs

(must make sure pt does not also have myocarditis)

54

Idiopathic (non specific)
Tuberculosis
Acute bacterial infections
Fungal
Uremia-untreated or with dialysis.
Radiation
Autoimmune-RA, SLE, scleroderma, PAN

Causes of pericarditis (other than viral causes)

55

Chest pain-frequent; quality and location variable; retrosternal and often left sided.
**Pain is intense-aggravated by lying supine, with inspiration, coughing, swallowing, laughing; improved sitting up, leaning forward, shallow inspiration.**

Pericarditis

56

Pain worse laying down, better sitting up
Feels better to breathe shallow

Pericarditis

57

Pericardial Friction Rub- pathognomonic-scratching, grating, high pitched sound due to friction between the pericardium and epicardium.
*hear 2 components (systole and diastole)

Pericarditis physical exam

58

Best heard with diaphragm at LLSB, best heard w patient sitting, leaning forward in full expiration

Pericardial friction rub

59

ST elevation everywhere except aVR, V1 (occasionally aVL)
**every other lead will have significant ST elevation

Pericarditis

60

how do you tell MI vs pericarditis EKG?

MI is localized ST elevation!! you can tell if its anterior, lateral, etc.

Pericarditis is almost everywhere! ST elevation seen in all leads except aVR, V1 and aVL

61

All patients with pericarditis must have a...

Echo-doppler (cardiac ultrasound)

(must make sure no pericardial effusion)

62

Determine etiology where possible.
Bed rest until pain and fever resolved.
*Pain rapidly responds to NSAIDs***

Pericarditis

63

Oral _____ should be avoided in patients with pericarditis

anticoagulants

64

Pericarditis symptoms usually resolve in....

2-4 weeks

65

Colchicine can be used to tx..

Pericarditis

66

Can occur with all forms of pericarditis
Symptoms (if present) include chest pressure, dyspnea, hiccups, nausea, abd. fullness, cough.

Pericardial effusion

67

Best diagnostic to dx pericardial effusion?

Echo!

68

CXR- mild cardiomegaly if greater than 250 cc fluid

Pericardial effusion

69

Increasing pericardial fluid raises intrapericardial pressure resulting in compression of the heart.
***There is progressive limitation of ventricular diastolic filling leading to reduction of stroke volume and cardiac output.

Cardiac tamponade

(fatal if not recognized and aggressively treated)

70

Hemodynamics - marked elevation and equilibration of LV and RV diastolic pressures; LA and RA pressures elevated.
**marked decrease in CO

Cardiac tamponade

71

Echo shows RA and RV collapse
*Beck's triad: decline in arterial pressure, elevation of systemic venous pressure, quiet heart

Cardiac tamponade

72

Decline in arterial pressure
Elevation of systemic venous pressure
Quiet heart

Beck's triad

*seen in cardiac tamponade

73

Classic physical finding of cardiac tamponade********

Pulsus paradoxus

74

Pulsus paradoxus has a systolic BP drop greater than...

10 mm

75

may be life saving; IV fluids given to increase preload; *should be done with Rt Ht Cath to optimize hemodynamics
*subxiphoid approach with flouroscopic guidance is successful in 95%

fluid is cultured and sent for cytology and chemistry analysis.

Pericardiocentesis

(done in cardiac tamponade)

76

Obliteration of the pericardial space with fusion of the pericardium to the epicardium.
*Restriction of filling of all cardiac chambers.

Constrictive pericarditis

77

Initial episode of pericarditis/effusion proceeds to a chronic stage with fibrosis, calcification and marked thickening of the pericardium.

Constrictive pericarditis