Hypertrophic cardiomyopathy: Difference between revisions
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==Background== | ==Background== | ||
*Genetically-linked (AD) hypertrophy of cardiac muscle - can but does not always cause outflow obstruction | *Genetically-linked (AD) hypertrophy of cardiac muscle - can but does not always cause outflow obstruction | ||
*Abnormal LV diastolic function due to decreased compliance | *Abnormal LV diastolic function due to decreased compliance | ||
*Historically, obstructive forms known as: | *Historically, obstructive forms known as: | ||
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**Asymmetric septal hypertrophy (ASH) | **Asymmetric septal hypertrophy (ASH) | ||
*Yamaguchi syndrome, an atypical HCOM, in which only 1% are non-Japanese | *Yamaguchi syndrome, an atypical HCOM, in which only 1% are non-Japanese | ||
File:Hypertrophic_cardiomyopathy.png| | [[File:Hypertrophic_cardiomyopathy.png|thumb|HOCM]] | ||
==Clinical Features== | |||
==Differential Diagnosis== | |||
{{Cardiomyopathy DDX}} | |||
{{Chest Pain DDX}} | |||
==Diagnosis== | ==Diagnosis== | ||
*Sx: Syncope or sudden death most common | *Sx: Syncope or sudden death most common | ||
**Also exertional dyspnea, chest pain, syncope, | **Also exertional dyspnea, chest pain, syncope, dizziness, palpitations, or [[CHF]] | ||
*Systolic murmur that increases w/ maneuvers that decrease preload (e.g. valsalva, transitioning from squatting to standing, etc.). | *Systolic murmur that increases w/ maneuvers that decrease preload (e.g. valsalva, transitioning from squatting to standing, etc.). | ||
*EKG | *EKG | ||
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**Or, high voltage/LVH, deep narrow Q waves in 1, avL, V5, V6 = "daggers of death" | **Or, high voltage/LVH, deep narrow Q waves in 1, avL, V5, V6 = "daggers of death" | ||
==Work-Up== | ===Work-Up=== | ||
*[[EKG]] | |||
**May show signs of: | |||
***LVH | |||
***"Needle-like" Q waves | |||
*CXR | |||
*ECHO | |||
== | ==Management== | ||
*Definitive treatment is myomectomy | |||
Definitive | |||
===Decompensated=== | ===Decompensated=== | ||
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**Avoid disopyramide alone w/o BB or CCB | **Avoid disopyramide alone w/o BB or CCB | ||
**'''Avoid positive inotropic vasopressors''' (dopamine, dobutamine, norepi, epi) | **'''Avoid positive inotropic vasopressors''' (dopamine, dobutamine, norepi, epi) | ||
==Disposition== | |||
*Admit | |||
==See Also== | ==See Also== | ||
*[[Cardiomyopathy]] | *[[Cardiomyopathy]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Cards]] | [[Category:Cards]] |
Revision as of 00:23, 22 February 2016
Background
- Genetically-linked (AD) hypertrophy of cardiac muscle - can but does not always cause outflow obstruction
- Abnormal LV diastolic function due to decreased compliance
- Historically, obstructive forms known as:
- Idiopathic hypertrophic subaortic stenosis (IHSS)
- Asymmetric septal hypertrophy (ASH)
- Yamaguchi syndrome, an atypical HCOM, in which only 1% are non-Japanese
Clinical Features
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
Diagnosis
- Sx: Syncope or sudden death most common
- Also exertional dyspnea, chest pain, syncope, dizziness, 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
Management
- Definitive treatment is myomectomy
Decompensated
- Consider primary insult, which usually is preload issue (fluid depletion, bleed, etc.)
- 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, max dose range depending on source
- Start at 100 mcg/min (~1.5 mcg/kg/min for average adult)
- Range usually 0.5 - 6.0 mcg/kg/min, with efficacy minimal beyond 6 mcg/kg/min)[1]
- Max phenylephrine infusion before other pressors
- Fix acid-base disorder as acidosis may prevent pressor efficacy
- Consider maxing vasopressin next
- Pressor effects more preserved in hypoxia and acidosis[2]
- Preferred over pressors with beta agonism
- Push dose pressor while waiting for IV drip:
- Place 1mL of 10mg/mL phenylephrine in 100mL NS
- Final concentration 100mcg/mL
- Use 1-2mL q2-5min (100-200mcg) in 10mL syringe
- Onset 1min; duration 20min
- Phenylephrine, max dose range depending on source
- Preserve preload
Pharmacologic Management
- Per Amer Coll of Cardiology 2011 recommendations[3]
- 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)
Disposition
- Admit
See Also
References
- ↑ Global RPH in reference to Micromedex. 12/2014. http://www.globalrph.com/phenylephrine_dilution.htm
- ↑ Overgaard CB and Dzavik V. Contemporary Reviews in Cardiovascular Medicine: Inotropes and Vasopressors - Review of Physiology and Clinical Use in Cardiovascular Disease. Circulation. 2008; 118: 1047-1056.
- ↑ American College of Cardiology. 2011. http://content.onlinejacc.org/article.aspx?articleid=1147838