cardio 9-17

high yield

What are the clinical criteria of cardiogenic shock?

1. SBP <90 mmHg for >30 min

2. Hemodynamic support necessary to maintain SBP < 90 mmHg and urine output <30 mL/hr

What are the hemodynamic criteria of cardiogenic shock?

1. Depressed cardiac index (<2.2 L/min/body surface area²)

2. An elevated PCWP > 15 mmHg

What are causes of cardiogenic shock?

Acute MI, myocardial dysfunction, valvular disease, arrhythmias/heart block, drugs, elecrolyte abnormalities, restrictive pericarditis, tamponade, infiltrative disorders

What are signs of cardiogenic shock?

Cool extremities, weak distal pulses, altered mental status, diminished urinary output

What are lab findings for cardiogenic shock?

Elevated lactate, elevated BNP, inc creatinine, elevated liver enzymes, metabolic acidosis

What is the cure for VFib?

Shock and CPR

What is the most common cause of cardiogenic shock?

Acute MI

What are RF of cardiogenic shock after STEMI or NSTEMI?

Age > 70 years, SBP <120 mmHg

What are compensatory mechanisms for cardiogenic shock?

Peripheral vasoconstriction to improve coronary perfusion at the cost of increased after load; Tachycardia increases myocardial oxygen demand and worsens myocardial ischemia

What are management options for cardiogenic shock?

Intra-aortic balloon pump (IABP), microaxial pumps (Impella), extracorporeal membrane oxygenation (ECMO), ventricular assist device (LVAD, RVAD)

Revascularization (PCI, CABG): aspirin, heparin

What pts have better outcomes with an ECMO

Children and small adults

What are pharmaceutical therapies for cardigoenic shock?

Norepinephrine, Dopamine, Dobutamine, Milrinone, Diuretics

When do we use NE for cardiogenic shock?

Preferred in severe hypotension or hypotension unresponsive to other meds

What is dopamine a/w?

Higher rates of arrhythmias and higher risk of mortality

What are the effects of dobutamine?

Does not cause renal vasodilation, vasodilatory — promotes hypotension

What is milrinone used for?

To reduce left ventricular filling pressures

When do we take diuretics for cardiogenic shock?

When volume overload exists — care must be taken to monitor SBP and renal status

What is required when using an LVAD in prep for cardiac transplant?

Must be anticoagulated on warfarin to avoid VTE; managed as an oupatient — requires strict pt compliance (batteries, INR)

What are uses for LVAD?

• Preparation for cardiac transplant

• Supportive measures, monitored in specialized clinics

What is the most common and least expensive mechanical support device?

Intra-aortic balloon pump (IABP)

What are balloon inlflation and deflation timed to?

The cardiac cycle (synchronized with ECG)

What are the CIs for an IABP?

Severe aortic regurgitation, aortic dissection, uncontrolled sepsis, uncontrolled bleeding disorders

What does the IABP follow?

Aortic valve

What is required with an IABP

Therapeutic anticoagulation, Daily labs (CMP/CBC)

Does an IABP provide any mortality benefit?

NO

T/F: Impella devices are catheter-based

True

Where are impella devices placed?

Cath lab

How does an impella device compare to an IABP?

• Increase coronary artery blood flow vs IABP

• More favorable hemodynamic profile compared to IABP

• Increased vascular complications and hemolysis

What cannot be performed in a pt with a VAD?

• ECG due to EMI (noise)

• Traditional blood pressure measurement

What is the mortality rate for cardiogenic shock?

Highly variable from 30-80%

What is a frequent cause of cardiomyopathy?

Genetics

What are the 4 types of cardiomyopathy?

1. Dilated cardiomyopathy (DCM)

2. Hypertrophic cardiomyopathy (HCM)

3. Restrictive cardiomyopathy (RCM)

4. Arrythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)

What is DCM?

Dilation and impaired contraction of one or both ventricles (LVEF<40%)

What is the most common cardiomyopathy in adults <50?

DCM

What does DCM result in?

Cardiac hypertrophy

How can DCM present?

Heart failure or SCD

What are common causes of DCM?

Virus and gene mutations (common)

What should we do if genetic cause discovered for DCM?

Screen first-degree relatives

Is SCD a mechanical or electrical problem?

Electrical (usually d/t ventricular arrhythmia)

What are RF of DCM?

• Men > women

• Familial or genetic predisposition

• ETOH and/or drug abuse

• Peripartum cardiomyopathy

What does ventricular dilation lead to?

Significant tricuspid and mitral valve insufficiency

What are early compensatory mechanisms of DCM?

Increased HR and peripheral vascular system tone → l/t ventricular remodeling and worsening myocardial injury + increase in circulating levels of catecholamines and natriuretic peptides

What are symptoms of DCM?

Dyspnea, Fatigue, PND, orthopnea, SOB/DOE, malaise, weakness

What are s/sx of DCM in more severe cases?

Thromboembolism, conduction disturbances, arrhythmias/SCD

What are PE findings of DCM?

JVD, Peripheral edema, S3 gallops, crackles, laterally displaced PMI, tricuspid or mitral regurgitation murmurs, + HJR

What do we test for DCM?

CBC/DIFF, CMP, Thyroid, BNP, CXR, ECG, Echo

What indicates a poor prognosis for DCM?

Oxygen consumption per minute of less than 14 ml/kg/min

If we get an EKG for chest pain from an ER pt, what should we do next?

REPEAT EKG → then troponins, CBC, CMP, etc

What does outpatient management of DCM include?

• Oral diuretics (loop a/o thiazide)

• ACE-I or ARB or ARNI

• Beta-blockers (carvedilol, bisoprolol, metoprolol succinate)

• SGLT2-I

• Isosorbide dinitrate plus hydralazine

What med was shown to increase survival if poor renal function or angioedema w/ ACE?

Isosorbide dinitrate plus hydralazine

What do we place in pts for primary prevention of SCD if EF < 30%?

Implanted cardioverter defibrillators (ICD)

When is cardiac resynchronization therapy (CRT) recommended by heart failure guidelines?

LVEF <35% on GDMT and/or high number of ventricular arrhythmias, history of SCD

What pts need heart transplant?

Refractory cardiogenic shock, ventricular arrhythmias, dependence on high levels of inotropes and IABP or VAD dependency

What is the most common cause of SCD in pts <35 years old?

HCM

What is HCM classified as?

Increased ventricular wall thickness or mass not caused by pathologic loading conditions (eg, hypertension or valve disease)

What is left ventricular volume and diastolic function in HCM?

Left ventricular volume is normal or reduced and diastolic dysfunction is usually present

T/F: Most people afflicted with HCM do NOT live a normal life

False!

What are the different paths of HCM?

SCD, symptomatic HCM heart failure, end-stage cardiomyopathy, Afib, stroke

What are RF of HCM?

• Autosomal dominant inheritance (60-70% of pts have a family member)

• Males > females

What contributes to the pathophysiology of HCM?

Outflow tract obstruction and systolic anterior mitral valve motion (SAM)

Can we see SAM in pts without HCM?

Yes

What is present in almost all HCM pts?

Diastolic dysfunction

Can diastolic dysfunction precede hypertrophy?

Yes

What procedures can be used to reduce posterior MR in HCM pts?

Surgical myomectomy or alochol septal ablation (only for pts with lt ventricular outflow obstruction)

What can occur during exercise in HCM pts?

Drop in SBP >20 mmHg d/t outflow obstruction and inappropriate vasodilation despite an appropriate inc in CO

What is seen/heard on PE for HCM pts?

• Late systole, moderate MR murmur

• Systolic murmur harsh and crescendo decrescendo that does not radiate to the carotids

What may be seen on ECG for HCM?

LVH, Q waves, T wave inversions, ± arryhtmias

T/F: Echocardiogram is essential for HCM

True

What is the purpose of an ECHO for HCM?

Determine degree of obstruction

What imaging/testing should we do for HCM?

• ECG

• ECHO

• Cardiac MRI

• Left and right heart cath

• Genetic testing for 1st degree relatives

What may mimic HCM?

Athlete’s heart — LVH is symmetric, HCM is not

What is pharmological treatment for HCM?

Amiodarone, Diuretics

What pts should we use amiodarone in?

Particularly pts with (ventricular) arrythmias but should be avoided in younger populations

Should we use diuretics at home with HCM?

No; avoid at home and only in pts with volume overload w/HOCM

T/F: Avoid vasodilators in HCM tx

True

What surgery for HCM has a 65% sucess rate?

Septal myectomy

What are the risks of septal myectomy?

Risk of septal perforation and development of complete heart block especially in patients with existing RBBB

Who performs alcohol septal ablation?

An interventionalist

What do we implant in HOCM pts?

ICD for presentation of SCD

What is poorly tolerated in HCM pts?

Atrial fibrillation is poorly tolerated d/t loss of atrial kick

What are other options for HCM Tx?

AAD therapy (amiodarone, sotalol, dofetilide) depending on renal clearance and age ± DCCV

What is RCM?

Nondilated, non-thickened ventricles w/ impaired ventricular filling and biatrial enlargement (inc atrial pressure)

What is RCM characterized by?

Small stiff ventricales w/ progressive impairement of diastolic filling, low preload, and high filling pressures

Is systolic function impacted in RCM?

Systolic function remains normal (early in dx)

What may cause increased LV wall thickness in RCM?

Infiltrative disease (sarcoidosis, amyloidosis) and storage disease (Fabry dx)

Does hypertrophy typically occur in RCM?

No

Where is RCM a frequent cause of death d/t endomyocardial fibrosis incidence?

Africa, India, South and Central America, and Asia

What is the most common type of RCM?

Amyloid

What is amyloid RCM d/t?

Extracellular deposition of insoluble proteins (AL or ATTR)

T/F: Delay in diagnosis of amyloid RCM is common

True

What do amyloid deposits in arterioles cause?

Angina, MI is rare

What is at increased risk in amyloid RCM?

Afib, thrombosis, thromboembolism

What is a key finding of amyloid RCM?

LVH on echo without LVH on ECG – Cardiac MRI

T/F: Treatment is simple for amyloid RCM

False

What meds are poorly tolerated in amyloid RCM?

Afterload reducing agents (ACEI, ARB, ANRI, isosorbide-hydralazine)

What meds are generally tolerated in Amyloid RCM?

Diuretics

What meds are recommended for amyloid RCM?

Anticoagulation, CRT-D (b/c arrythymia and heart block are common)

What is the hallmark finding of Sarcoidosis RCM?

Noncaseating granulomas (multiorgan dx)

What organs are generally involved in sarcoidosis?

Lungs, skin, reticuloendothelial, Cardiac (25%)

What commonly presents w/ cardiac sarcoid?

Conduction block or malignant arrhythmias; less commonly w/ HF