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Cardiomyopathies

• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy

Dilated Cardiomyopathy

• Left ventricle becomes stretched out
• 95% of cardiomyopathies
• 30% of congestive heart failure is caused by dilated cardiomyopathy
• The heart becomes weak and unable to empty the ventricles leading to dilation of the left ventricle.
• Signs and symptoms are similar to congestive heart failure

Causes

• Usually no identifiable cause
• Chronic alcohol abuse
• Myocarditis
• Does not go along with HTN, MI or other cardiac conditions

I came in to see my physician assistant because of…

• Shortness of breath
• Swelling in the lower extremities
• Fatigue

Physical exam

• Rales (Crackling fluid in the lungs)
• Cardiomegaly (displaced apical impulse)
• S3 gallop (third heart sound)
• Elevated jugular venous pressure (JVP)
• Enlarged liver
• Peripheral edema
• Tachycardia
• High or low blood pressure

Labs & Studies

• EKG
  • No distinct ECG findings
  • Sinus tachycardia
  • Left atrial enlargement
  • Atrial fibrillation
  • Left bundle branch block
  • Right access deviation
• Chest x-ray
  • Cardiomegaly
  • Pleural effusion
• Echo/Cardiac Cath
  • Cardiomegaly
  • Reduced systolic function
  • High diastolic pressure
  • Low cardiac output

Treatment

• Lower blood pressure
  • ACE inhibitors
  • Diuretics
  • Beta blockers
• Control Heart rate
  • Beta blockers
  • Antiarrhythmics
• Increase cardiac contractility
  • Digitalis

Hypertrophic Cardiomyopathy

• 4% of cardiomyopathies
• Massive hypertrophy typically of the septal wall resulting in left ventricular outflow obstruction.
• Sudden cardiac death in young athletes!

Causes

• Almost always autosomal dominant inheritance

I came in today to see my physician assistant because of…

• Dyspnea
• Angina
• Fatigue
• Syncope
• Routine physical exam

Physical Exam

• Sustained apical impulse (lasts longer than systole)
• Prominent “a” wave (abnormal jugular venous pulse caused by the right atrium contracting against resistance)
• Bisferiens carotid pulse (a double peak per cardiac cycle)
• Loud S4
• Systolic murmur that decreases with squatting

Labs & Studies

• Chest x-ray (typically negative)
• ECG
  • Left ventricular hypertrophy
  • Exaggerated septal Q waves
• Echo
  • Confirms diagnosis
  • Left ventricular hypertrophy
  • Small left ventricle

Treatment

• Avoid dehydration and vasodilation
  • No diuretics or ACEIs
• First line
  • Beta-blockers
    • Metoprolol 25 mg BID
• Second line if Beta blockers not tolerated
  • Calcium Channel blockers
    • Verapamil 240 mg daily
• Surgical removal of hypertrophic tissue
• Pacing and implanted defibrillator may be necessary

Restrictive Cardiomyopathy

• Only 1% of cardiomyopathies
• Poor diastolic filling
• Good ventricular contractions

Causes

• Amyloidosis
• Fibrosis most commonly

I came in today to see my physician assistant because of…

• Shortness of breath

Labs & Studies

• Chest x-ray
  • Enlarged heart
• Echo/cardiac catheterization
  • Reduced left ventricular function
• Biopsy
  • A biopsy of the myocardial tissue may be necessary for diagnosis

Treatment

• No good treatment
• Diuretics may be helpful

Hypertension (HTN)

• 30% of all Americans have HTN
• Primary (Essential ) HTN
  • No single identifiable cause.
  • 95% of HTN
• Secondary HTN
  • There is an identifiable cause
  • 5% of HTN
  • Think of this with kids or those with previously well controlled HTN that is now uncontrollable.

Causes of secondary HTN

• Sleep apnea
• Drugs
• Chronic kidney disease
• Primary aldosteronism
• Reno-vascular disease – Renal artery stenosis
• Cushing’s or long term corticosteroid use
• Pheochromocytoma – Adrenal tumor. Extremely rare
• Coarctation of the aorta
• Thyroid or parathyroid disease

HTN classifications

• Normal BP
  < 120 / 80
• Prehypertension
  120–139 / 80–89
• HTN stage 1
  140–159 / 90–99
• HTN: stage 2
  < 160/100-
• HTN: severe
  > 180 / >110
• HTN urgency
  > 220 / > 125
• Hypertensive urgency
  • A BP that must be reduced within hours. BP >220 / > 125
• Hypertensive emergency / malignant hypertension –
  • A BP that must be reduced within one hour. Acute impairment of one or more organ systems including heart, brain, retina, kidneys or aorta.

I came in today to see my physician assistant because of…

• Routine examination
• Headaches
• Mental status changes
• Chest pain
• Dyspnea
• Visual changes

Physical Exam

• HTN = BP > 140 / 90 on two or more separate occasions
• Looking for end organ damage
• Papilledema

Labs & Studies

• Urinalysis
• CXR
• ECG
• Blood work
• CBC – for thrombocytopenia
• Creatinine
• BUN
• Troponin
• Creatine kinase

Treatment

• Secondary HTN – treat the cause
  • Sleep apnea – cpap, weight reduction
  • Drugs – stop the offending agent
  • Chronic kidney disease – We will discuss at a later time
  • Primary aldosteronism – Spironolactone (aldosterone agonist)
  • Reno-vascular disease – ACEI
  • Cushing’s or long term corticosteroid use – Surgical removal or stop steroid
  • Pheochromocytoma – Surgical removal
  • Thyroid or parathyroid disease – Removal of offending tissue
• Primary HTN
  • Behavior modification
    • Weight reduction
    • DASH diet
    • Reduce sodium intake
    • Increase physical activity
    • Limit alcohol consumption
  • Medication
    • Diuretics
    • β- blockers
    • Renin inhibitors
    • Angiotensin-converting enzyme inhibitors
    • Calcium Channel Blockers
    • Angiotensin II receptor blockers
    • Aldosterone receptor blockers
    • α-Adrenoceptor antagonist
    • Central sympatholytic acting drugs
    • Arteriolar dilators

Study Tip

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<< Click here to get 22 Cardiology questions straight from my book, The Final Step >>