Cardio E2: CHF & Cardiomyopathies

What is the inability of the heart to pump blood forward at a sufficient rate to meet metabolic demands of the body?

HFrEF (systolic failure)

What is the inability to fill the heart due to abnormally high pressures?

HFpEF (diastolic failure)

Normal LVEF:

55-70%

HFrEF usually has EF of:

< 40%

HFpEF usually has EF of:

> 50%

HFmrEF usually has an EF of:

40-49%

HFmrEF should be treated the same as what?

HFrEF

What are the most prevalent causes of CHF?

CAD, HTN
(EtOH, DM, Valvular dx, Infection)

Which type of heart failure is the most common?

HFrEF

HFrEF has impaired _________ and increased __________

Impaired contractility, increased afterload

HFpEF has impaired what?

Filling

Dilated cardiomyopathy results in which type of heart failure?

Reduced ejection fraction (systolic failure)

What is the most common cardiomyopathy?

Dilated

What are some causes of dilated cardiomyopathy?

CAD, HTN, alcoholic, peri-partum

If left untreated, what can dilated cardiomyopathy can lead to?

Cor pulmonale

What are some physical exam findings associated with dilated cardiomyopathy?

S3 gallop, Mitral regurgitation, Low LVEF

What is seen on echo in dilated cardiomyopathy?

4 chamber enlargement with diffusely decreased contraction

To treat dilated cardiomyopathy, you must treat the associated what?

CHF (ACEIs, BBs, diuretics, digoxin)

To treat dilated cardiomyopathy, you should treat arrhythmias conservatively by using what type of device?

Automated implantable cardioverter defibrillator (AICD)

What is the most common cause of sudden death in the young?

Hypertrophic obstructive cardiomyopathy

What occurs if heart muscle cells enlarge and cause ventricle walls (usually left) to thicken?

Hypertrophic cardiomyopathy

What condition is when the thickening of the ventricles blocks blood flow out of the ventricles?

Hypertrophic obstructive cardiomyopathy

Hypertrophic cardiomyopathy results in which type of heart failure?

HFpEF (diastolic dysfunction)

In hypertrophic cardiomyopathy, the LVEF is ______

Normal or elevated

What should you beware of in patients with hypertrophic obstructive cardiomyopathy?

Diuretics (only give w/ fluid overload)

What are some physical exam findings associated with hypertrophic cardiomyopathy?

S4 gallop, Systolic murmur that increases with Valsalva, Murmur of MR

What EKG findings might be present in hypertrophic cardiomyopathy?

Abnormal Q waves in inferior/apical leads, Evidence of LVH

What CXR findings might be seen in hypertrophic cardiomyopathy?

Increased cardiothoracic ratio

What may be seen on echo in patients with hypertrophic cardiomyopathy?

Small LV chamber, Asymmetrical septal hypertrophy

Which classes of medications are used to treat hypertrophic cardiomyopathy?

BBs & CCBs

What are the goals of treatment for hypertrophic cardiomyopathy?

Improving diastolic dysfunction and minimizing LV outflow obstruction

What is rigid and decreased compliance of ventricles due to infiltrative process of the ventricles?

Restrictive cardiomyopathy

In restrictive cardiomyopathy, EF may be __?

Normal or decreased

In restrictive cardiomyopathy, the primary problem is _____________ dysfunction

Diastolic

What are some physical exam findings associated with restrictive cardiomyopathy?

S3, A fib, Increased P2, Cor pulmonale

"Glistening pattern" on echo is indicative of

Restrictive cardiomyopathy secondary to amyloidosis

What findings may be seen on echo in restrictive cardiomyopathy?

Abnormal relaxation of LV, Wall thickness, Small ventricular cavities, Atrial enlargement

What findings may be seen on CXR in restrictive cardiomyopathy?

Cardiomegaly, Signs of failure

What are some causes of restrictive cardiomyopathy?

Amyloidosis, Sarcoidosis, Hemachromatosis, Scleroderma, Radiation

To detect infiltrative dz (i.e. amyloidosis) in restrictive cardiomyopathy, you may need to perform what procedure?

Heart biopsy

What are the goals of treatment for restrictive cardiomyopathy?

Prevent atrial arrhythmias, Control HR, Treat symptoms of failure, Treat underlying causes

What is "Broken heart syndrome"?

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is mostly commonly it what type of pts?

older women brought on by sudden stress or death of a loved one

Which medications are used to treat Takotsubo cardiomyopathy?

Diuretics, BBs, ACEIs

What is high cortisol/catecholamines causing toxic effects on the myocardium + apical ballooning of ventricle walls is indicative of?

Takotsubo cardiomyopathy

In patients with heart failure, don't forget to ask about ___________

Pillow talk- how many pillows do they sleep on? (lying flat is uncomfortable)

What are some cardinal symptoms of HF?

DOE, orthopnea, peripheral edema

DOE, orthopnea, peripheral edema, & weight gain are symptoms of what?

Heart failure

Right or Left HF:
Peripheral edema

Right

Right or Left HF:
RUQ discomfort & Hepatomegaly

Right

Right or Left HF:
Pulmonary rales

Left

Right or Left HF:
Loud P2

Left

Right or Left HF:
JVD

Right

Right or Left HF:
S3 gallop (+/- S4)

Left

What will be elevated in HF?

BNP

What is ejection fraction measuring?

percentage of blood that is pumped out of the heart with each beat

Which NYHA functional class:
Asymptomatic

Class I

Which NYHA functional class:
Symptomatic w/ moderate exertion

Class II

Which NYHA functional class:
Symptomatic w/ minimal exertion

Class III

Which NYHA functional class:
Symptomatic at rest

Class IV

Which ACC/AHA HF stage:
High risk for HF, but without structural heart disease or symptoms of heart failure

Stage A

Which ACC/AHA HF stage:
Structural heart disease but without symptoms of heart failure

Stage B

Which ACC/AHA HF stage:
Structural heart disease with prior or current symptoms of heart failure

Stage C

Which ACC/AHA HF stage:
Refractory heart requiring specialized intervention

Stage D

What are some lifestyle changes that can be made in patients with HF?

Low salt DASH diet, Weight control, Some activity

LMNOP is used in treatment of what?

Acute HF/pulmonary edema

LMNOP

L- Lasix (IV Loop)
M- Morphine
N- Nitrates
O- Oxygen
P- Positioning

Nitrates are powerful ________ dilators

Venous

Hydralazine is a good ________ dilator

Arterial

BBs should only be used in _________ CHF patients

Stable- DO NOT USE BBs in ACUTE phase patients

What is a newer drug that is recommended ahead of ACE-Is/ARBs in HF patients?

Entresto (ARNi)

Avoid Entresto if a patient is taking ________ due to severe risk of angioedema

ACE-I

Digoxin is a ___________ inotrope

Positive

Digoxin has a morbidity benefit but NO __________ benefit

Mortality

What has the best effect for EF <25% and NYHA III/IV?

Digoxin

Dobutamine is a ___________

Beta agonist

What is it called when patients feel better after dobutamine infusion and tend to become asymptomatic going on a holiday?

"Dobutamine holiday"

What is the hallmark symptom triad of HF?

Orthopnea, PND, LE edema