Shot Through the Heart & You’re to Blame,You Give Love a Bad Name: CHF & Cardiomyopathy...

Shot Through the Heart & Shot Through the Heart & You’re to Blame,You Give You’re to Blame,You Give Love a Bad Name: Love a Bad Name: CHF & CHF & CardiomyopathyCardiomyopathy

Resident Rounds Resident Rounds

Nov 28/02Nov 28/02

A.F. Chad, MD, CCFPA.F. Chad, MD, CCFP

Heartbreak HotelHeartbreak Hotel

• Failure to maintain adequate Failure to maintain adequate circulation of bloodcirculation of blood

• Left versus Right sided CHFLeft versus Right sided CHF• Systolic versus Diastolic CHFSystolic versus Diastolic CHF• High versus Low Output CHFHigh versus Low Output CHF

What is Love, if not What is Love, if not Neurohormonal MechanismNeurohormonal Mechanism

• 1. Sympathetic system activation1. Sympathetic system activation• 2. Activation of the Renin-Angiotensin 2. Activation of the Renin-Angiotensin

Aldosterone system (RAAS)Aldosterone system (RAAS)• 3. Increased naturetic peptides3. Increased naturetic peptides• 4. Increased Antidiuretic hormone4. Increased Antidiuretic hormone• 5. Increased Endothelins5. Increased Endothelins

Getting in the Mood: Getting in the Mood: Sympathetic ActivationSympathetic Activation

• Causes increased cardiac output, increased Causes increased cardiac output, increased heart rate, and peripheral vasoconstrictionheart rate, and peripheral vasoconstriction

• If sustained activates the RAAS which increases If sustained activates the RAAS which increases both preload and afterloadboth preload and afterload

• Stimulation of alpha and beta receptors leads Stimulation of alpha and beta receptors leads to myocardial hypertrophy and fibroblast to myocardial hypertrophy and fibroblast hyperplasia which lead to decreased hyperplasia which lead to decreased compliancecompliance

• Increased norepinephrine levels lead to Increased norepinephrine levels lead to myocardial cell death and areas of focal myocardial cell death and areas of focal necrosis further impairing LV functionnecrosis further impairing LV function

Feeling “RAAS”NDYFeeling “RAAS”NDYYeah Baby!Yeah Baby!

• Stimulation leads to increased Stimulation leads to increased Angiotensin II which leads to :Angiotensin II which leads to :

• 1. Increased aldosterone1. Increased aldosterone• 2. Increased norepinephrine2. Increased norepinephrine• 3.Inhibition of vagal tone3.Inhibition of vagal tone

The Male Love Hormone The Male Love Hormone (Kind of): Aldosterone(Kind of): Aldosterone

• Shown to be elevated up to 20 times in Shown to be elevated up to 20 times in patients with CHFpatients with CHF

• Causes growth promoting activity in Causes growth promoting activity in nonepithelial cells nonepithelial cells

• Stimulates fibroblasts which leads to interstitial Stimulates fibroblasts which leads to interstitial and perivascular fibrosis which increases LV and perivascular fibrosis which increases LV stiffnessstiffness

• Produced in nonrenal sites such as the vessels Produced in nonrenal sites such as the vessels and heartand heart

• Up to 40% of patients will have elevated levels Up to 40% of patients will have elevated levels despite being on ACE inhibitorsdespite being on ACE inhibitors

Some like it hot & wet: Some like it hot & wet: Antidiuretic HormoneAntidiuretic Hormone

• Is elevated in severe heart failureIs elevated in severe heart failure• Higher levels have been reported in Higher levels have been reported in

patients on diureticspatients on diuretics• Can lead to hyponatremiaCan lead to hyponatremia

More than an EndothelinMore than an Endothelin

• Secreted by vascular endothelial cells Secreted by vascular endothelial cells • Potent vasoconstrictor peptide which Potent vasoconstrictor peptide which

leads to sodium retentionleads to sodium retention• Increases in proportion to the Increases in proportion to the

hemodynamic severity of heart failurehemodynamic severity of heart failure• Interest in developing endothelin Interest in developing endothelin

receptor antagonistsreceptor antagonists

Naturetic Peptides by Naturetic Peptides by NatureNature

• 3 types3 types• 1. Atrial Naturetic Peptide (ANP) – released 1. Atrial Naturetic Peptide (ANP) – released

from the atria in response to stretch. Is very from the atria in response to stretch. Is very sensitive and will be released even with sensitive and will be released even with exercise. Causes naturesis and vasodilatationexercise. Causes naturesis and vasodilatation

• 2. Brain Naturetic Peptide (BNP) – release from 2. Brain Naturetic Peptide (BNP) – release from the venticles in response to elevated LVEDP. the venticles in response to elevated LVEDP. Has the same effect as ANPHas the same effect as ANP

Naturetic Peptides by Naturetic Peptides by Nature cont’dNature cont’d

• 3. C-type naturetic peptide – 3. C-type naturetic peptide – limited to the vascular endothelium limited to the vascular endothelium and has limited effects on naturesis and has limited effects on naturesis and vasodilatationand vasodilatation

From the Bottom of my From the Bottom of my heart (filling my lungs)heart (filling my lungs)

• Capillary pressure (12-15mmHg)Capillary pressure (12-15mmHg)• Plasma oncotic pressure (25mmHg)Plasma oncotic pressure (25mmHg)

– Cardiac (Hi PCWP)Cardiac (Hi PCWP)– ARDSARDS– Low oncotic PLow oncotic P– Negative PNegative P– Lymphatic insufficiencyLymphatic insufficiency– OtherOther

Where does my heart go Where does my heart go now?now?

• 3.2 million in USA3.2 million in USA• 400,000 new per year400,000 new per year• 1-2% prevalence1-2% prevalence• High 5-yr mortality: 60% M, 45% WHigh 5-yr mortality: 60% M, 45% W• Median survival: 3.2 yr M, 5.4 yr WMedian survival: 3.2 yr M, 5.4 yr W• Progressive CHF vs sudden deathProgressive CHF vs sudden death

Why you Wanna Break My Why you Wanna Break My Heart?Heart?

• ISCHEMIA!!!!!!ISCHEMIA!!!!!!• Non-complianceNon-compliance• ValvularValvular• HTNHTN• CMCM• InfectiousInfectious• Thyrotoxicosis, anemiaThyrotoxicosis, anemia

To Find My HeartTo Find My Heart

• Exertional Dyspnea: most sensitive Exertional Dyspnea: most sensitive (Spec<60%)(Spec<60%)

• PND / Othopnea (sens<30%)PND / Othopnea (sens<30%)• CoughCough• EdemaEdema• AnxietyAnxiety• Non-specific stuffNon-specific stuff

Piece of My Heart?Piece of My Heart?

• COPDCOPD• AsthmaAsthma• PEPE• TamponadeTamponade• PneumoniaPneumonia• ARDSARDS

Heart and Soul: CCSHeart and Soul: CCS

• I - ordinary activity = no angina, +++ activity I - ordinary activity = no angina, +++ activity = angina= angina

• II - slight limitations, angina >2 blocks level II - slight limitations, angina >2 blocks level (+/- stress)(+/- stress)

• III - marked limitations, angina <2 blocks level III - marked limitations, angina <2 blocks level • IV - no activity w/o discomfort +/- angina at IV - no activity w/o discomfort +/- angina at

restrest• 59% Validity, 73% reproducible59% Validity, 73% reproducible

Heart and Soul: NYHAHeart and Soul: NYHA

• I - ordinary activity = no SxI - ordinary activity = no Sx• II - slight limitations, ok at rest, ordinary II - slight limitations, ok at rest, ordinary

activity = Sactivity = S• III - marked limitations, less than III - marked limitations, less than

ordinary activity = Sxordinary activity = Sx• IV - no activity w/o discomfort, Sx at restIV - no activity w/o discomfort, Sx at rest• 51% Validity, 56% reproducible51% Validity, 56% reproducible

Sea of LoveSea of Love

•Physical exam Physical exam –90% specific90% specific–20-30% sensitive20-30% sensitive

Love Shack . . . Left’s Love Shack . . . Left’s where it’s at!!!where it’s at!!!

• Tachypnea / tachycardiaTachypnea / tachycardia• S3, gallupS3, gallup• DiaphoresisDiaphoresis• Crackles / wheezesCrackles / wheezes• Pulsus AlternansPulsus Alternans• PMI laterally displacedPMI laterally displaced

Love Shack . . . Right’s Love Shack . . . Right’s where it’s at!!!where it’s at!!!

• JVDJVD• EdemaEdema• Hepatomegaly / HJRHepatomegaly / HJR

Heart and Soul: KillipHeart and Soul: Killip

• I - No CHF - 5% mortalityI - No CHF - 5% mortality• II - Mild CHF (bibasilar rales and S3) II - Mild CHF (bibasilar rales and S3)

- 15-25% mortality- 15-25% mortality• III - Frank pulmonary edema - 40% III - Frank pulmonary edema - 40%

mortalitymortality• IV - Cardiogenic shock - 80% IV - Cardiogenic shock - 80%

mortalitymortality

Find My HeartFind My Heart

• CBCCBC• LytesLytes• CreatinineCreatinine• LFT’sLFT’s• TNT?TNT?• TSH?TSH?• BNP?BNP?

You Down with BNP? Yeah, You Down with BNP? Yeah, you know me! you know me!

• New polypeptide that is produced in the New polypeptide that is produced in the ventriclesventricles

• Released in proportion to LV expansion Released in proportion to LV expansion reflecting the LVEDPreflecting the LVEDP

• Levels rise with age (due to increased LV Levels rise with age (due to increased LV stiffness)stiffness)

• Levels are elevated with pulmonary disease Levels are elevated with pulmonary disease (due to increased RVEDP)(due to increased RVEDP)

• Levels are elevated in end-stage renal disease Levels are elevated in end-stage renal disease reflecting decreased excretionreflecting decreased excretion

You Down with BNP? Yeah, You Down with BNP? Yeah, you know me!you know me!

• There is a bedside test that is FDA approved, There is a bedside test that is FDA approved, but it costs $25 - $40 per test.but it costs $25 - $40 per test.

• Cut off has been determined retrospectively in Cut off has been determined retrospectively in studies studies

• Levels below 75 – 100 pg/ml correlate with Levels below 75 – 100 pg/ml correlate with fairly normal LV functionfairly normal LV function

• The higher the level the worse the LV functionThe higher the level the worse the LV function• If a patient presented with acute worsening, If a patient presented with acute worsening,

one would expect a level > 300 pg/mlone would expect a level > 300 pg/ml

You Down with BNP? Yeah, You Down with BNP? Yeah, you know me! you know me!

• This test will probably be used to also follow This test will probably be used to also follow therapy for patients. Studies have shown that therapy for patients. Studies have shown that better optimization of ACE therapy can be better optimization of ACE therapy can be instituted.instituted.

• It may reduce the need for repeat ECHO’sIt may reduce the need for repeat ECHO’s• Levels rise acutely and decline with effective Levels rise acutely and decline with effective

treatment within hours – the ½ life is 22 treatment within hours – the ½ life is 22 minutes in patients without renal diseaseminutes in patients without renal disease

You Down with BNP? Yeah, You Down with BNP? Yeah, you know me!you know me!

• The best use is in patients with multiple The best use is in patients with multiple medical problems who present with increased medical problems who present with increased dyspnea. dyspnea.

• If patients have COPD, are at risk for PE and If patients have COPD, are at risk for PE and have a history of CHF then BNP can help have a history of CHF then BNP can help separate cardiac from other causes of dyspneaseparate cardiac from other causes of dyspnea– Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander

JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA.Kazanegra R, Herrmann HC, McCullough PA. Rapid Rapid measurement of B-type natriuretic peptide in the measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. emergency diagnosis of heart failure. N Engl J Med. N Engl J Med. 2002 Jul 18;347(3):161-7.2002 Jul 18;347(3):161-7.

Find My HeartFind My Heart

• ECGECG– IschemiaIschemia– HypertrophyHypertrophy– DysrhythmiasDysrhythmias

• CXRCXR– Cardiomegaly (lots of love)Cardiomegaly (lots of love)– Redistribution (PCWP12-18mmHg)Redistribution (PCWP12-18mmHg)– Kerley B lines(PCWP 25mmHg)Kerley B lines(PCWP 25mmHg)– Pulmonary edema (PCWP >25mmHg)Pulmonary edema (PCWP >25mmHg)

Find My Heart, Find My Heart, Find My HeartFind My Heart

• ECHOECHO– WMAWMA– EFEF– Cardiac FNCCardiac FNC– ValvesValves– TamponadeTamponade– SizeSize– DimensionsDimensions

Find My HeartFind My Heart

• Cath?Cath?– ?definitive Rx?definitive Rx

• MUGA?MUGA?– ?echo good enough?echo good enough

• Swan?Swan?– No benefit with mortalityNo benefit with mortality– ?helpful clinically?helpful clinically

• Acute emergency therapyAcute emergency therapy

• Chronic maintenance therapyChronic maintenance therapy

How do You mend a How do You mend a Broken Heart?Broken Heart?

How do You mend a How do You mend a Broken Heart?Broken Heart?

• ABCD!!!!ABCD!!!!• O2, IV’s, MonitorsO2, IV’s, Monitors• CPAP / BiPAP for Edema (more MI with CPAP / BiPAP for Edema (more MI with

BiPAP)BiPAP)– Sacchetti A. Sacchetti A. Effectiveness of BiPAP for Effectiveness of BiPAP for

congestive heart failure. congestive heart failure. J Am Coll J Am Coll Cardiol. 2001 May;37(6):1754-5.Cardiol. 2001 May;37(6):1754-5.

• Elevate head & Lower legsElevate head & Lower legs• Cheesy PoetryCheesy Poetry

How do You mend a How do You mend a Broken Heart?Broken Heart?

• What is the cause?What is the cause?• TREAT THE CAUSE!!!!!TREAT THE CAUSE!!!!!• NitratesNitrates• ACEACE• DiureticsDiuretics• MorphineMorphine• hBNPhBNP• InotropesInotropes

Sex Bomb: NitratesSex Bomb: Nitrates

• Decreases preload and afterload Decreases preload and afterload (slightly)(slightly)

• Shown to be effective in reducing Shown to be effective in reducing mortality and improving symptomsmortality and improving symptoms

• Can be given sublingual, IV, or as a Can be given sublingual, IV, or as a patchpatch

• Dose is 10mcg/min and can be titrated Dose is 10mcg/min and can be titrated up every 3 – 5 minutes until desired up every 3 – 5 minutes until desired effect. effect.

• Can cause hypotensionCan cause hypotension

Sex Bomb: NitratesSex Bomb: Nitrates

• Can switch to a patch from IV nitrates, Can switch to a patch from IV nitrates, however this switch worked only when however this switch worked only when patients were on lower doses (< 50 patients were on lower doses (< 50 mcg/ml)mcg/ml)

• Topical patches have an onset in Topical patches have an onset in decreasing PCWP at 20 – 30 minutes decreasing PCWP at 20 – 30 minutes with peak effect at 120 minutes. with peak effect at 120 minutes. Therefore, their use in an acute severe Therefore, their use in an acute severe decompensation is not warranted as first decompensation is not warranted as first line therapyline therapy

Sex Bomb: NitratesSex Bomb: Nitrates

• Sublingual NTG tabs decreased Sublingual NTG tabs decreased PCWP by 36%. Onset was 4 PCWP by 36%. Onset was 4 minutes with peak effect at 9 minutes with peak effect at 9 minutesminutes

• The spray had an onset of 1-2 The spray had an onset of 1-2 minutes with peak effect at 5 minutes with peak effect at 5 minutesminutes

Ace of the HeartAce of the Heart

• Haude M, Steffen W, Erbel R, Meyer J. Haude M, Steffen W, Erbel R, Meyer J. Sublingual administration of captopril Sublingual administration of captopril versus nitroglycerin in patients with versus nitroglycerin in patients with severe congestive heart failure. Int J severe congestive heart failure. Int J Cardiol. 1990 Jun;27(3):351-9Cardiol. 1990 Jun;27(3):351-9

Ace of the HeartAce of the Heart

• Captopril sublingually decreased PCWP Captopril sublingually decreased PCWP after 10 minutes with a peak effect seen after 10 minutes with a peak effect seen at 30 minutes.at 30 minutes.– Sacchetti et al showed that it decreased the Sacchetti et al showed that it decreased the

admissions to ICU – odds ration 0.29admissions to ICU – odds ration 0.29– Haude M, Steffen W, Erbel R, Tschollar W, Haude M, Steffen W, Erbel R, Tschollar W,

Belz GG, Meyer J. Belz GG, Meyer J. [Hemodynamics after [Hemodynamics after sublingual administration of captopril sublingual administration of captopril in severe heart failure. A pilot study]in severe heart failure. A pilot study] Dtsch Med Wochenschr. 1989 Jul 14;114(28-Dtsch Med Wochenschr. 1989 Jul 14;114(28-29):1095-100.29):1095-100.

IV Ace of the HeartIV Ace of the Heart

• Annane D, Bellissant E, Pussard E, Annane D, Bellissant E, Pussard E, Asmar R, Lacombe F, Lanata E, Madonna Asmar R, Lacombe F, Lanata E, Madonna O, Safar M, Giudicelli JF, Gajdos P. O, Safar M, Giudicelli JF, Gajdos P. Placebo-controlled, randomized, Placebo-controlled, randomized, double-blind study of intravenous double-blind study of intravenous enalaprilat efficacy and safety in enalaprilat efficacy and safety in acute cardiogenic pulmonary acute cardiogenic pulmonary edema. edema. Circulation. 1996 Sep Circulation. 1996 Sep 15;94(6):1316-2415;94(6):1316-24

Hot &Wet: DiureticsHot &Wet: Diuretics

• Have venodilatory properties as well as Have venodilatory properties as well as decreasing intravascular volume through decreasing intravascular volume through diuresis.diuresis.

• Causes increased plasma renin and Causes increased plasma renin and Norepinephrine levels leading to Increased SVRNorepinephrine levels leading to Increased SVR

• A study comparing high dose NTG and low A study comparing high dose NTG and low dose diuretics showed lower mortality than dose diuretics showed lower mortality than high dose diuretic and low dose NTGhigh dose diuretic and low dose NTG

Fool for Love: MorphineFool for Love: Morphine

• Causes venodilation through histamine Causes venodilation through histamine release (lasts around 10 minutes)release (lasts around 10 minutes)

• Causes sedation and respiratory Causes sedation and respiratory depressiondepression

• Sacchetti et al showed it increased ICU Sacchetti et al showed it increased ICU admissions – odds ratio 3.0admissions – odds ratio 3.0

Nesiritide (human recombinant Nesiritide (human recombinant BNP): New LoveBNP): New Love

• Increases cyclic GMP->second messenger -Increases cyclic GMP->second messenger ->dilate veins and arteries>dilate veins and arteries

• Decreases PCWP & DyspneaDecreases PCWP & Dyspnea• 2 mcg/kg IV bolus over 60 s; follow by 0.01 2 mcg/kg IV bolus over 60 s; follow by 0.01

mcg/kg/min continuous infusionmcg/kg/min continuous infusion– Elkayam U, Akhter MW, Tummala P, Khan S, Singh H. Elkayam U, Akhter MW, Tummala P, Khan S, Singh H.

Nesiritide: a new drug for the treatment of Nesiritide: a new drug for the treatment of decompensated heart failure. decompensated heart failure. J Cardiovasc J Cardiovasc Pharmacol Ther. 2002 Jul;7(3):181-94.Pharmacol Ther. 2002 Jul;7(3):181-94.

Acute treatment – Acute treatment – conclusionsconclusions

• 1. Nitrates are first line therapy and 1. Nitrates are first line therapy and should be given intravenously if the should be given intravenously if the patient is sickpatient is sick

• 2. Ace inhibitors are beneficial in acute 2. Ace inhibitors are beneficial in acute CHFCHF

• 3. Diuretics should be used in 3. Diuretics should be used in moderationmoderation

• 4. Morphine should be used with 4. Morphine should be used with extreme cautionextreme caution

Chronic TherapyChronic Therapy

• 1. Ace Inhibitors/ ARB’s1. Ace Inhibitors/ ARB’s• 2. Betablockers - 2. Betablockers - • 3. Spironolactone3. Spironolactone• 4. Diuretics4. Diuretics• 5. Digoxin5. Digoxin

Ace of the HeartAce of the Heart

• Considered first line therapy for CHF. Considered first line therapy for CHF. • Recommended for all stages of CHFRecommended for all stages of CHF• Absolute mortality reduction is around 15% at Absolute mortality reduction is around 15% at

one year for class III/IV patients with a NTT of 6 one year for class III/IV patients with a NTT of 6 (relative risk reduction is 30 – 35%) (relative risk reduction is 30 – 35%)

• The effect on mortality was dose related and The effect on mortality was dose related and the higher the dose till the target range was the higher the dose till the target range was reached ;the lower the mortalityreached ;the lower the mortality

Ace of the HeartAce of the Heart

• These results were based on the These results were based on the CONSENSUS I/II, SOLVD, AND SAVE CONSENSUS I/II, SOLVD, AND SAVE trialstrials

• Note the effect of ace inhibitors is Note the effect of ace inhibitors is reduced on patients who are on reduced on patients who are on NSAIDS as well as ASANSAIDS as well as ASA

Angiotensin Receptor Angiotensin Receptor Blockers (of love)Blockers (of love)

• Were thought to be better because angiotensin Were thought to be better because angiotensin II was still produced in patients on Ace II was still produced in patients on Ace inhibitors.inhibitors.

• These drugs block the Angiotensin II receptor.These drugs block the Angiotensin II receptor.• Also they do not produce Bradykinens which Also they do not produce Bradykinens which

Ace inhibitors do. These Bradykinens lead to Ace inhibitors do. These Bradykinens lead to S/E such as cough and angioedemaS/E such as cough and angioedema

ARB’s of loveARB’s of love

• Elite II – showed that there was no difference Elite II – showed that there was no difference between ARB’s and Ace inhibitors. Mortality between ARB’s and Ace inhibitors. Mortality was 17.7% and 15.9% respectivelywas 17.7% and 15.9% respectively

• ARB’s were better toleratedARB’s were better tolerated• They are recommended for patients who can’t They are recommended for patients who can’t

tolerate Ace inhibitorstolerate Ace inhibitors• The current research is to see whether The current research is to see whether

combined therapy will reduce mortalitycombined therapy will reduce mortality

Lip Lockers, BetablockersLip Lockers, Betablockers

• Recommended for all patients with Recommended for all patients with CHFCHF

• Shown to increase LVEF by 30%Shown to increase LVEF by 30%• Decreases mortality by 4 – 5 % Decreases mortality by 4 – 5 %

with NNT of 23with NNT of 23– MERIT-HFMERIT-HF

Spare my Heart: Spare my Heart: SpironolactoneSpironolactone

• RALES - showed 25 mg of RALES - showed 25 mg of spironolactone had a 30% relative risk spironolactone had a 30% relative risk reduction and an absolute risk reduction reduction and an absolute risk reduction of 11% with a NNT of 9of 11% with a NNT of 9

• Recommended for patients with class Recommended for patients with class III/IV CHFIII/IV CHF

• Note side effects were < 5% at this low Note side effects were < 5% at this low dose dose

Hot & Wet: DiureticsHot & Wet: Diuretics

• Help control symptoms Help control symptoms • No effect on mortalityNo effect on mortality

Love is a rose, or a Love is a rose, or a foxglove: Digoxinfoxglove: Digoxin

• No effect on mortalityNo effect on mortality• Reduced hospitalizations by 11% with a NNT of Reduced hospitalizations by 11% with a NNT of

9 to prevent 1 hospitalization per year9 to prevent 1 hospitalization per year• Used as 4th line agent after ace inhibitors, beta Used as 4th line agent after ace inhibitors, beta

blockers, spironolactone.blockers, spironolactone.– Jaeschke R, Oxman AD, Guyatt GH: Jaeschke R, Oxman AD, Guyatt GH: To what extent To what extent

do congestive heart failure patients in sinus do congestive heart failure patients in sinus rhythm benefit from digoxin therapy? A rhythm benefit from digoxin therapy? A systematic overview and meta-analysis.systematic overview and meta-analysis. Am J Am J Med 1990 Mar; 88(3): 279-86Med 1990 Mar; 88(3): 279-86

Broken HeartBroken Heart

• Steroids?Steroids?– Increase mortalityIncrease mortality

• CCB?CCB?– Dyhidropyridines BADDyhidropyridines BAD– ?Central acting in diastolic dysfnc?Central acting in diastolic dysfnc

Greatest Love of All: Greatest Love of All: Dilated CMDilated CM

• Most common CMMost common CM• Difficult to find #’s as similar RxDifficult to find #’s as similar Rx

I’ll Make Love to You: I’ll Make Love to You: Dilated CMDilated CM

• 30% idiopathic30% idiopathic• X-linked (dystrophin gene)X-linked (dystrophin gene)• BoozeBooze• Heavy MetalHeavy Metal• DrugsDrugs• Infectious (viral, Chagas)Infectious (viral, Chagas)• Post partumPost partum• Collagen vascular diseaseCollagen vascular disease• Glycogen storage diseaseGlycogen storage disease• Thiamine, PO4, zinc deficiencyThiamine, PO4, zinc deficiency• AmyloidosisAmyloidosis• Neuromuscular disordersNeuromuscular disorders

Stop Dragging My Heart Stop Dragging My Heart Around: Dilated CMAround: Dilated CM

• Biopsy helpful for etiologyBiopsy helpful for etiology• Rx same as other CHFRx same as other CHF• MDC (Metoprolol in Dilated CM) MDC (Metoprolol in Dilated CM)

– 34% reduction in primary endpoints (death, 34% reduction in primary endpoints (death, Tx)Tx)

• Multicenter Myocarditis Treatment Trial:Multicenter Myocarditis Treatment Trial:– no benefit of corticosteroids and no benefit of corticosteroids and

azathioprine for Rx of biopsy-proven azathioprine for Rx of biopsy-proven inflammation in dilated CMinflammation in dilated CM

Endless Love: Endless Love: HCMHCM

• Inappropriate hypertrophy w/o stimulusInappropriate hypertrophy w/o stimulus• Usually asymmetricUsually asymmetric• IVS usually affectedIVS usually affected• 4% mortality per year (sudden death)4% mortality per year (sudden death)

Quit Playin’ Games With Quit Playin’ Games With My Heart: HCMMy Heart: HCM

• 50% familial (AD, 6 genes, 4 50% familial (AD, 6 genes, 4 chromosomes)chromosomes)

• Abn Ca++ kineticsAbn Ca++ kinetics• Abn sympathetic stimAbn sympathetic stim• Abn CoronariesAbn Coronaries• Subendocardial ischemiaSubendocardial ischemia• Structural abnStructural abn

Tearin’ Up my Heart: Tearin’ Up my Heart: HCMHCM

• 0.05% of outpt echo0.05% of outpt echo• 25% 1st relatives of HCM25% 1st relatives of HCM• Usually 3rd decade, but anytimeUsually 3rd decade, but anytime• M>FM>F• HOCM vs HCMHOCM vs HCM

– SAMSAM

Sunshine of my Love: Sunshine of my Love: HCMHCM

• Sudden DeathSudden Death• DysrhythmiaDysrhythmia• CHFCHF• Presyncope / SyncopePresyncope / Syncope• AnginaAngina

Why Can’t This be Love?: Why Can’t This be Love?: HCMHCM

• CHF SxCHF Sx• JVD - big “a” waveJVD - big “a” wave• Double impulse pulseDouble impulse pulse• PMI increased & lateralPMI increased & lateral• SEM / HSMSEM / HSM• Split S2Split S2

Love in an Elevator : Love in an Elevator : HCMHCM

• Genetic StudiesGenetic Studies• ECGECG• Doppler EchoDoppler Echo

– LV outflow gradient >50mmHgLV outflow gradient >50mmHg– Diastolic dysfncDiastolic dysfnc– Ground glassGround glass– HOCM: septum >1.4:1 ratio to post wallHOCM: septum >1.4:1 ratio to post wall

This Year’s Love: This Year’s Love: HCMHCM

• ABCDABCD• Normal CHF / CAD RxNormal CHF / CAD Rx• MyomectomyMyomectomy• Catheter septal ablationCatheter septal ablation• MV replacementMV replacement• ICDICD• B-blockadeB-blockade• CCBCCB• Anti-arrhythmiasAnti-arrhythmias

My Love is Restricted to My Love is Restricted to YouYou

• Least common CMLeast common CM• ? Incidence ?? Incidence ?• Important (but DIFFICULT) to Important (but DIFFICULT) to

differentiate from constrictive differentiate from constrictive pericarditis as different Rx and pericarditis as different Rx and prognosisprognosis

• Poor prognosisPoor prognosis

Why My Love is Restricted Why My Love is Restricted to Youto You

• Idiopathic restrictive cardiomyopathyIdiopathic restrictive cardiomyopathy– EMFEMF– Loeffler eosinophilic endomyocardial diseaseLoeffler eosinophilic endomyocardial disease

• 2ndary restrictive cardiomyopathy2ndary restrictive cardiomyopathy– HemochromatosisHemochromatosis– AmyloidosisAmyloidosis– SclerodermaScleroderma– Carcinoid heart diseaseCarcinoid heart disease– Glycogen storage disease of the heartGlycogen storage disease of the heart

Looking For LoveLooking For Love

• Chest x-rayChest x-ray– Absence of cardiomegaly, normal cardiac Absence of cardiomegaly, normal cardiac

silhouettesilhouette– CHFCHF

• ElectrocardiogramElectrocardiogram– LBBB common, RBBB possibleLBBB common, RBBB possible– Low voltageLow voltage– Nonspecific ST-T changesNonspecific ST-T changes– Various arrhythmiasVarious arrhythmias– Chamber enlargementChamber enlargement

Radar LoveRadar Love

• EchocardiographyEchocardiography– Normal to symmetrically thickened Normal to symmetrically thickened

wallswalls– Rapid early-diastolic filling, slow late-Rapid early-diastolic filling, slow late-

diastolic fillingdiastolic filling– Normal or slightly reduced ventricular Normal or slightly reduced ventricular

volume and systolic functionvolume and systolic function

Pain is LovePain is Love

• Cardiac catheterizationCardiac catheterization– Elevated ventricular end-diastolic pressureElevated ventricular end-diastolic pressure– Dip and plateau configuration of the diastolic Dip and plateau configuration of the diastolic

portion of the ventricular pressure pulseportion of the ventricular pressure pulse– Normal to slightly decreased ejection Normal to slightly decreased ejection

fractionfraction– Prominent x and y descentProminent x and y descent

Gangsta of LoveGangsta of Love

• Endomyocardial biopsyEndomyocardial biopsy– May detect typical eosinophil infiltration in May detect typical eosinophil infiltration in

the inflammatory stagethe inflammatory stage– May detect myocardial fibrosis in later-stage May detect myocardial fibrosis in later-stage

casescases– Negative findings do not exclude diagnosisNegative findings do not exclude diagnosis

Love SpreadsLove Spreads

• Treat underlying cause if possibleTreat underlying cause if possible• Therapy similar for other causes of CHFTherapy similar for other causes of CHF• Consider anticoagulation as prone to Consider anticoagulation as prone to

thromboembolism thromboembolism

All You Need is LoveAll You Need is Love

• Thanks to Dr Arun Abbi for Thanks to Dr Arun Abbi for “lending” many of these slides“lending” many of these slides