Dilated Cardiomyopathy

45 y/o pt with h/o autoimmune disease, DM, Hep C, HIV, alcoholism, malignancy s/p radiation/chemotherapy presents with SOB. Pt has noted new onset palpitations and was recently treated for DVT. Reports family h/o dilated cardiomyopathy. Tachycardia, lower extremity edema on exam.

  • Obtain CMP

  • EKG shows T wave changes, septal Q waves, bundle branch block

  • Echo shows ventricular enlargement with normal left ventricular wall thickness and reduced ejection fraction

  • Reduced ejection fraction: Start lisinopril 5 mg qd, metoprolol succinate 25mg qd

  • NYHA class 2 or greater with reduced ejection fraction and GFR>30: Start Entresto (sacubitril/valsartan) 24/26 mg s/p 36 hour washout period for previous ACE

Notes

  • Approximately 30% of cases are familial

  • ACEs/ARBs provide significant mortality benefit in patients with reduced ejection fraction

Hypertrophic Cardiomyopathy

Pt with h/o dyspnea on exertion presents with recurrent, acute chest pain. Chest pain generally occurs during meals or exercise and is more common during summer months. Family h/o sudden, unexplained cardiac death. Systolic murmur with increased intensity during Valsalva on exam.

  • EKG shows left ventricular hypertrophy (LVH), Q-waves

  • Echocardiogram shows LVH with decreased chamber volume

  • LVEF < 50%

  • Refer for implantable cardioverter-defibrillator (ICD) placement for any of the following:

    • H/o sudden death in 1st degree relative

    • Ventricular wall thickness > 30mm

    • Sustained ventricular tachycardia and/or cardiac arrest

  • Pt counseled that alcohol septal ablation or surgical myomectomy may be necessary for end-stage heart failure

Notes

  • Prevalence 1:500

  • Chest pain worse with dehydration

  • Valsalva reduces preload/filling, resulting in less blood in the heart

Takotsubo Cardiomyopathy

Postmenopausal female presents with acute-onset chest pain. Reports recent dyspnea, syncope, emotional/physiologic stressors. No h/o myocarditis, pheochromocytoma, cocaine use. Tachycardia, hypotension, respiratory distress, cold extremities on exam.

  • Labs

    • Initial troponin >0.02

    • Obtain troponin x3, pro-BNP; consider UDS to r/o cocaine use

    • Strict I&O's; monitor for oliguria

  • Imaging

    • EKG shows ST-segment elevation and/or T wave inversion

    • Echocardiogram shows LV dysfunction and LV apical ballooning; no evidence of obstructive coronary disease

    • Angiography shows no evidence of acute plaque rupture

  • Treatment

    • Manage acute cardiogenic shock per ACS guidelines

    • Once stable, start lisinopril 10 mg daily, metoprolol succinate 25 mg daily, HCTZ 25 mg daily

    • Loss of LV wall motion on echocardiogram: Start abixaban 5mg BID x4 months for thrombus ppx

  • Pt counseled that symptoms typically resolve within 1 month

Notes

  • Prevalence

    • Affects 1 in every 5,000 hospitalized patients

    • Responsible for 1 in every 75 cases of troponin-positive ACS