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 to heart failure (HFrEF) treatment guidelines
Plus anginal symptoms: Start nadolol 40 mg qd
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