Differentiate pulmonary hypertension (PH) and pulmonary arterial hypertension (PAH)
Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure >25mmHg. Most frequently this is due to heart failure or lung diseases. Pulmonary arterial hypertension (PAH) is a sub-group of PH caused by narrowing of pulmonary vessels. It occurs in isolation and is very rare.
List 3 symptoms of pulmonary arterial hypertension (PAH)
Dyspnoea Fatigue Weakness Angina Syncope Abdominal distension
List 3 signs of pulmonary arterial hypertension (PAH)
Left parasternal heave: right heart hypertrophy Loud P2 heart sound Soft pansystolic murmur: tricuspid regurgitation Early diastolic murmur: pulmonary regurgitation Right heart failure: JVP distension, ascites, peripheral oedema, and hepatomegaly
A group of diseases of the myocardium that affect the mechanical or electrical function of the heart.
Classify the types of cardiomyopathies
Hypertrophic cardiomyopathy (HCM) Arrhythmogenic cardiomyopathies (ACs) Dilated cardiomyopathy (DCM) Secondary cardiomyopathies
Name 3 causes of secondary cardiomyopathy
Infiltrative: amyloidosis, Gaucher's disease Storage-related: haemochromatosis Drugs: alcohol (esp dilated), cancer therapy Inflammatory: sarcoidosis Autoimmune: SLE
Define hypertrophic cardiomyopathy
A group of inherited conditions that produce variable hypertrophy of the myocardium that frequently involves the interventricular septum asymmetrically. HCM occurs in the absence of alternative cause (e.g. aortic stenosis or HTN).
Describe the inheritance pattern of hypertrophic cardiomyopathy
Majority are familial autosomal dominant
List the symptoms of hypertrophic cardiomyopathy
Symptoms: many asymptomatic Chest pain Dyspnoea Syncope/Pre-syncope: typically with exertion Cardiac arrhythmias Sudden death*: commonest cause of sudden cardiac death in young people (up to 6%)
List 3 signs of hypertrophic cardiomyopathy
4th heart sound: atrial contraction Jerky carotid pulse: rapid ejection and sudden obstruction in systole Ejection systolic murmur: late in systole Pansystolic murmur: mitral regurgitation Irregular pulse: AF
How is hypertrophic cardiomyopathy investigated?
ECG: LV hypertrophy, ST- and T-wave changes, Q waves Echo*(usually diagnostic): asymmetrical LV hypertrophy of interventricular septum, systolic anterior movement of mitral valve, vigorously contracting LV Genetic analysis: confirm diagnosis and provide prognostic information.
What is the prevalence of HCM?
1 in 500 people Commonest cause of sudden cardiac death in young
Describe the pathophysiology of hypertrophic cardiomyopathy
25% have dynamic left ventricular outflow tract (LVOT) obstruction due to combined effects of hypertrophy, systolic anterior motion of anterior mitral valve leaflet, and rapid ventricular ejection. Abnormal intramural coronary arteries, causes anginal chest pain. Chaotic disorganised LV architecture predisposes to arrhythmias.
Outline the management of hypertrophic cardiomyopathy
Treatment of symptoms -Chest pain and dyspnoea: Beta-blockers and CCB -Dual chamber pacing -Surgical resection of septal myocardium Prevention of sudden death -Amiodarone -ICD insertion: if 2+ risk factors of sudden cardiac death
Name 3 risk factors for sudden cardiac death
Massive LV hypertrophy (>30mm) FHx of sudden cardiac death (<50yr) Non-sustained VT on 24h Holter Prior unexplained syncope Abnormal BP response to exercise
Name 5 causes of sudden cardiac death
Coronary artery disease -STEMI -Chronic ischaemic heart disease -Following coronary artery bypass -After resuscitation for cardiac arrest -Congenital anomaly of coronary arteries -Coronary arteritis Non-coronary artery disease -Hypertrophic cardiomyopathy -Dilated cardiomyopathy -Arrhythmogenic RV cardiomyopathy -Congenital long QT syndrome -Brugada syndrome -Valvular heart disease +/- infective endocarditis -Cyanotic heart disease: Tetralogy of Fallot, transposition -Acyanotic heart disease: VSD, PDA
Define arrhythmogenic cardiomyopathy
Uncommon (1 in 1000-5000) inherited condition that predominantly affects the RV with fatty/fibro-fatty replacement of myocytes, leading to dilatation.
How can arrhythmogenic cardiomyopathy present?
Asymptomatic Symptomatic ventricular arrhythmia Syncope Sudden cardiac death RV failure occurs in late stages
How is arrhythmogenic cardiomyopathy treated?
Amiodarone or sotalol ICD Cardiac transplant
Define dilated cardiomyopathy
Dilatation of ventricles with systolic dysfunction, despite preserved wall thickness. Rare: 7-12 in 100,000 Seen more commonly with alcoholics
Describe the presentation of dilated cardiomyopathy
Heart failure Cardiac arrhythmias Conduction defects Thromboembolism Sudden death
How is dilated cardiomyopathy treated?
Heart failure treatment If NYHA III/IV: cardiac resync (pacemaker) or ICD
What is the inheritance pattern of Marfan's syndrome?
Define Marfan's syndrome
An autosomal dominant connective tissue disorder that affects the heart, eyes, and skeleton. Requires 2 of 3 major systems to be involved.
What is the cause of Marfan's syndrome?
Mis-sense mutations in gene encoding for fibrillin 1. 2/3 due to familial transmission 1/3 due to sporadic mutations
How is a diagnosis of Marfan's syndrome confirmed?
Studying family linkage to causative gene, or Demonstrating mutation in Fibrillin 1 gene
Describe the clinical features of Marfan's syndrome
Cardiac: -Aortic aneurysm, dissection, regurgitation -Mitral valve prolapse and regurgitation: systolic murmur Eye: -Lens dislocation, retinal detachment, glaucoma Skeleton: -Pectus excavatum or carinatum -Long arms and legs, arachnodactyly, scoliosis Lungs: -Spontaneous pneumothorax, apical blebs
How should Marfan's syndrome be investigated?
Echocardiogram: repeated annually CMR or CT: show entire aorta for monitoring Ambulatory ECG monitoring if symptomatic
Outline the non-pharmacological management of Marfan's syndrome
Genetic counselling Psychological support: chronic inheritable disease Advise to avoid over-exertion: fatal aortic dissection Avoid weightlifting, scuba diving, gymnastics
Outline the medical management of Marfan's syndrome
Beta-blockers: slows aortic dilatation ACEi: slows aortic dilatation