Hypertrophic cardiomyopathy: Difference between revisions
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==Work-Up== | ==Work-Up== | ||
#[[EKG]] | #[[EKG]] | ||
##May show signs of: | |||
###LVH | |||
###"Needle-like" Q waves | |||
#CXR | #CXR | ||
#ECHO | #ECHO | ||
==Differential Diagnosis== | ==Differential Diagnosis== |
Revision as of 16:06, 15 January 2016
Background
- Genetically-linked (AD) hypertrophy of cardiac muscle - can but does not always cause outflow obstruction
- "HOCM"
- Abnormal LV diastolic function due to decr compliance
Diagnosis
- Sx: Syncope or sudden death most common
- Also exertional dyspnea, chest pain, syncope, dizzyness, palpitations, or CHF
- Systolic murmur that increases w/ maneuvers that decrease preload (e.g. valsalva, transitioning from squatting to standing, etc.).
- EKG
- Nonspecific/normal.
- Or, high voltage/LVH, deep narrow Q waves in 1, avL, V5, V6 = "daggers of death"
Work-Up
- EKG
- May show signs of:
- LVH
- "Needle-like" Q waves
- May show signs of:
- CXR
- ECHO
Differential Diagnosis
Cardiomyopathy
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy
- Restrictive cardiomyopathy
- Peripartum cardiomyopathy
- Takotsubo cardiomyopathy
- Arrhythmogenic right ventricular dysplasia
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Treatment
Definitive = Myomectomy
Decompensated
- If decompensated presents as hypotensive CHF
- Preserve preload
- Careful hydration
- Avoid high airway pressure if intubate
- Limit tachycardia
- Beta blockers
- Avoid vasodilators (no nitrates)
- Maintain sinus rythm (i.e. cardiovert A. fib)
- Increase afterload (hypotensive only)
- Phenylephrine
- Preserve preload
Pharmacologic Management
- Per Amer Coll of Cardiology 2011 recommendations[1]
- Class I
- BBs for angina or dyspnea in adults in HCM regardless of obstructive physiology - use with caution in sinus brady or conduction abnormality
- Titrate BB dose to symptoms, may increase BB dose to resting HR to 60 bpm
- PO verapamil titrated up to 480 mg/d if pt unresponsive or cannot tolerate BBs - caution in advanced HF, hypotension, sinus brady, high LVOT gradients
- IV phenylephrine for acute hypotension unresponsive to fluids
- Class IIa
- Reasonable to add disopyramide with BB or verapamil if unresponsive to BB or CCB alone in obstructive HCM
- Reasonable to add oral diuretics in nonobstructive HCM when symptoms persist despite BB or CCB
- Class III (harm)
- Avoid nifedipine and other dihydropyridine CCB
- Avoid digitalis
- Avoid disopyramide alone w/o BB or CCB
- Avoid positive inotropic vasopressors (dopamine, dobutamine, norepi, epi)
See Also
Source
- Tintinalli
- Adapted from ....Rosen, Mattu (lecture)
- Houston BA, Stevens GR. Hypertrophic Cardiomyopathy: A Review. Clinical Medicine Insights Cardiology. 2014;8(Suppl 1):53-65. doi:10.4137/CMC.S15717.
- ↑ American College of Cardiology. 2011. http://content.onlinejacc.org/article.aspx?articleid=1147838