Heart 5

oelomar's version from 2016-05-02 16:49


Question Answer
What is the most common type of cardiomyopathy?Dilated (90% of cases).
What is dilated cardiomyopathy, what is its major abnormality, and how does it affect left ventricular cavity size, ejection fraction, and wall thickness?A condition in which the heart becomes enlarged and cannot pump blood efficiently. Major abnormality = impaired contractility. Left ventricular cavity size is increased. Ejection fraction is decreased. Wall thickness is decreased.
What are the signs/symptoms of dilated cardiomyopathy?Dilated cardiomyopathy may not cause symptoms significant enough to impact on quality of life. However, it may present as CHF, systemic or pulmonary emboli, arrhythmias, sudden death (major cause of mortality due to fatal arrhythmia).
What are the major risk factors for developing dilated cardiomyopathy?Alcohol, cocaine, family history, and obesity.


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What is the leading cause of sudden cardiac death in young people?Hypertrophic cardiomyopathy.
What is hypertrophic cardiomyopathy, what is its major abnormality, and how does it affect left ventricular cavity size, ejection fraction, and wall thickness?A primary disease of the myocardium in which a portion of the myocardium is hypertrophied (thickened) creating functional impairment of the cardiac muscle. Major abnormality = impaired relaxation. Left ventricular cavity size is decreased. Ejection fraction is normal/increased. Wall thickness is increased.
What is the main cause of hypertrophic cardiomyopathy?The majority of cases are familial autosomal dominant.
What are the symptoms of hypertrophic cardiomyopathy?May be asymptomatic (very common, therefore screening is important), SOB on exertion, angina, presyncope/syncope (due to LV outflow obstruction or arrhythmia), CHF, arrhythmias, sudden cardiac death.
What are the signs of hypertrophic cardiomyopathy?Pulses: rapid upstroke, "spike and dome" pattern in carotid pulse (in HCM with outflow tract obstruction); precordial auscultation: normal or paradoxically split S2, S4, harsh systolic diamond-shaped murmur at left-lower sternal border or apex; often with pansystolic murmur due to mitral regurgitation.


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What is restrictive cardiomyopathy, what is its major abnormality, and how does it affect left ventricular cavity size, ejection fraction, and wall thickness?A rare form of cardiomyopathy in which the walls are rigid, and the heart is restricted from stretching and filling with blood properly. Major abnormality = impaired elasticity. Left ventricular cavity size is increased (not as much as in dilated cardiomyopathy). Ejection fraction is normal/decreased. Wall thickness is increased.
What are the causes of restrictive cardiomyopathy?Infiltrative causes: amyloidosis (most common), sarcoidosis. Non-infiltrative causes: scleroderma, idiopathic myocardial fibrosis. Haemochromatosis can cause both restrictive and dilated cardiomyopathies.
What are the clinical manifestations of restrictive cardiomyopathy?CHF, arrhythmias, elevated JVP with prominent x and y descents, Kussmaul's sign (elevation of JVP with inspiration), S3, S4, mitral regurgitation, tricuspid regurgitation, thromboembolic events.
What investigations can be carried out in restrictive cardiomyopathy?A chest x-ray will show mild cardiac enlargement. Cardiac catheterisation will show increased end-diastolic ventricular pressures (this is diagnostic). Endomyocardial biopsy can determine the aetiology (especially for infiltrative restrictive cardiomyopathy).


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Myocarditis is an important cause of dilated cardiomyopathy. What are the causes of myocarditis?50% is idiopathic. In Western societies, the commonest causes of infective myocarditis are Coxsackie or adenoviral infection. Chagas’ disease is one of the commonest causes of myocarditis worldwide. Additionally, toxins (including prescribed drugs), physical agents, hypersensitivity reactions and autoimmune conditions may also cause myocardial inflammation.
What are the signs and symptoms of myocarditis?Clinical presentations range from an asymptomatic state associated with limited and focal inflammation to fatigue, palpitations, chest pain, dyspnoea, and fulminant cardiac failure due to diffuse myocardial involvement. Physical examination includes soft heart sounds, a prominent third heart sound, and often a tachycardia. A pericardial friction rub may be heard.
Are troponin levels elevated in myocarditis?Yes. Elevated troponin T/I without evidence of an MI confirm the diagnosis.
What is the prognosis of myocarditis?Usually self-limited and often unrecognised, many recover. Sudden death in young adults. May progress to dilated cardiomyopathy. Few may have chronic myocarditis.
What is Chagas’ disease and what are its clinical features?This is a tropical parasitic disease caused by the protozoan Trypanosoma cruzi (endemic in South America where upwards of 20 million people are infected). Acutely, features of myocarditis are present with fever and CHF. Chronically, there is progression to a dilated cardiomyopathy with a propensity towards heart block and ventricular arrhythmias.


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What is takotsubo cardiomyopathy?A type of non-ischaemic cardiomyopathy in which there is a sudden temporary weakening of the muscular portion of the heart. This weakening is triggered by profound psychological stress such as the death of a loved one for example.
How does takotsubo cardiomyopathy present, and what does coronary angiography show?Patients with condition present acutely with chest pain and breathlessness associated with ECG changes and elevated cardiac biomarkers consistent with acute MI. Diagnostic coronary angiography typically demonstrates unobstructed coronary arteries with characteristic akinesia of the mid-apical segments of the left ventricle on ventriculography with preserved basal function.
What is peri-partum cardiomyopathy, who does it affect, and what are its implications?This rare condition affects women in the last trimester of pregnancy or within 5 months of delivery. It presents as a dilated cardiomyopathy, is more common in obese, multiparous women over 30 years old and is associated with pre-eclampsia. Nearly half of patients will recover to normal function within 6 months but in some patients it can causes progressive heart failure and sudden death.
What is an atrial myxoma, what are its symptoms, and how is it treated?This is the most common primary cardiac tumour. Histologically they are benign. The majority are in the left atrium and attached by a pedicle to the atrial septum. The tumour may obstruct the mitral valve or may be a site of thrombi that then embolise. It is also associated with constitutional symptoms including dyspnoea, syncope, or a mild fever. Surgical removal is curative.


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What are the causes of acute pericarditis?Most are idiopathic. The most common viral causes are Coxsackie B virus and echovirus. It can also be caused by an MI and Dressler’s syndrome.
What are the signs and symptoms of acute pericarditis?Diagnostic triad: chest pain, friction rub, and ECG changes. The chest pain is typically alleviated by sitting forward.
How is acute pericarditis diagnosed?ECG is diagnostic. There is a saddle-shaped ST elevation. These changes evolve over time, with resolution of the ST elevation, T wave flattening/ inversion and finally T wave normalisation.
What is the first-line treatment for acute pericarditis?Oral NSAIDs.
About 20% of cases of acute pericarditis go on to develop idiopathic relapsing pericarditis. True or false?True.


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What is pericardial effusion and cardiac tamponade?A pericardial effusion is a collection of fluid within the potential space of the serous pericardial sac, commonly accompanying an episode of acute pericarditis. When a large volume collects in this space, ventricular filling is compromised leading to embarrassment (difficulty functioning) of the circulation. This is known as cardiac tamponade (cardiac tamponade is the compression of the heart by an accumulation of fluid in the pericardial sac).
What are the clinical features of pericardial effusion?Symptoms of a pericardial effusion commonly reflect the underlying pericarditis. On examination: heart sounds are soft and distant; apex beat is commonly obscured; friction rub may be evident due to pericarditis in the early stages; Ewart’s sign (rarely).
What is Ewart’s sign and when is it found?Dullness to percussion below the angle of the left scapula, found in people with a pericardial effusion. It occurs rarely when the effusion compresses the base of the left lung.
As pericardial effusion worsens, signs of cardiac tamponade may become evident. What are the clinical features of cardiac tamponade?Raised JVP with sharp rise and y descent (Friedreich’s sign); Kussmaul’s sign (rise in JVP/increased neck vein distention during inspiration); pulsus paradoxus (an exaggeration in the normal pulse pressure seen with inspiration such that there is a drop in systolic blood pressure of ≥10mmHg) (note that this is always seen); reduced cardiac output.
What investigations can be carried out in pericardial effusion and cardiac tamponade?ECG reveals low-voltage QRS complexes. Chest x-ray shows cardiomegaly, and the heart appears “globular”. Echocardiography is diagnostic. Pericardial biopsy may be needed.
How is pericardial effusion and/or cardiac tamponade treated?An underlying cause should be sought and treated if possible. Most pericardial effusions resolve spontaneously. However, when the effusion collects rapidly, tamponade may result. Pericardiocentesis is then indicated to relieve the pressure – a drain may be left in temporarily to allow sufficient release of fluid.
What is Beck’s triad and when is it found?This is a collection of three medical signs associated with acute cardiac tamponade, and are hypotension, distant and muffled heart sounds, and a raised JVP (distended jugular veins). (The 3 D’s: decreased arterial pressure, distended jugular veins, distant heart sounds).


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What is constrictive pericarditis?A fibrosed, thickened, adherent, and/or calcified pericardium as a result of chronic pericarditis.
What are the clinical features of constrictive pericarditis?The signs and symptoms of constrictive pericarditis occur due to: Systemic venous congestion (ascites, dependent oedema, hepatomegaly, and raised JVP); pulmonary venous congestion (dyspnoea, cough, orthopnoea) less commonly; reduced cardiac output (fatigue, hypotension, reflex tachycardia); etc.
What investigations can be carried out in constrictive pericarditis?Chest x-ray will show pericardial calcification and effusions. Echo/CT/MRI will show pericardial thickening. Cardiac catheterisation will show equalisation of end-diastolic chamber pressures (this is diagnostic).
Restrictive cardiomyopathy is a close mimic of constrictive pericarditis, and investigations may therefore not help much in distinguishing the two conditions from one another. True or false?True.
How is constrictive pericarditis treated?The treatment for chronic constrictive pericarditis is complete resection of the pericardium. This is a risky procedure with a high complication rate.
What is “pericardial knock” and when is it heard?An early diastolic sound at the left lower sternal border that is variant of the third heart sound, but occurring distinctly earlier, due to rapid ventricular filling being abruptly halted by the restricting pericardium; a true “knocking” quality is uncommon. It is heard in constrictive pericarditis.

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