Cardiomyopathy , HOCM In MRCP Part 1

Cardiomyopathies

Introduction

Myocardium is the main functional part of the heart. Heart failure is synonymous with failure of cardiac muscle. Myocardium may be affected by disease of muscle itself ( Primary) or due to effect of other disease process ( Secondary) or by coronary artery disease. Interestingly, as cardiac muscle is anatomically related with skeletal muscle ( striated muscle) , primary disease of skeletal muscle involves cardiac muscle also.

 Clinical types of Cardiomyopathy

Mainly as below:

  • Dilated cardiomyopathy ( Systolic heart failure)
  • Hypertrophic cardiomyopathy of multiple varieties ( Diastolic heart failure)
  • Restrictive cardiomyopathy ( Diastolic heart failure)

Of them, HOCM ( Hypertrophic Obstructive Cardiomyopathy) is the most common.

Clinical Presentation

Patient presents with symptoms of dyspnoea, angina and syncope due to outflow obstruction. Moreover there would be other-

  • Clinical features of Heart failure
  • Clinical features of Arrhythmia
  • Clinical features of primary disease / cause

 Bad prognostic feature ( risk factors of sudden cardiac death) of HOCM

Exercise induced hypotension is the most important

Investigation ( ECG, Echo, Electrophysiological Study, BNP, Electrolyte etc)

  • To diagnose heart failure ( eg Echo or cardiac MRI)
  • To identify causes of heart failure eg IHD
  • To identify complications eg renal function
  • To identify prognostic factor or co morbidities

Management

  • Management of heart failure
  • Management of Arrhythmia ( eg ICD)
  • Management of primary disease / cause

 


Heart Failure in MRCP Part 1

Category : Heart Failure , MRCP Part 1

Heart Faluire Infographics

Introduction
It means failure of pumping action of the heart. Heart failure may be Diastolic (less filling) or Systolic (less output) or both. Echocardiogram findings of Ejection Fraction (EF) indicates mostly systolic function of the heart. Normal EF does not exclude diastolic dysfunction. Symptoms (Breathlessness, Fatigability, Palpitation) of heart failure are very important.

Clinical Presentation
May be of Left or Right heart failure or both. Peripheral edema is the common presentation of right heart failure. Breathlessness is the common presentation of left heart failure.

Diagnosis
Symptoms are the main indicator of diagnosis. But subclinical heart failure can be diagnosed by investigation eg BNP (B type Natriuretic peptide) level.

Stage/ Grade of Heart Failure
Staging is very important to design treatment plan. Heart failure is categorized as Stage A, B, C, D. Treatment is mainly designed according to this staging. NYHA functional classification of heart failure well accepted one and this classification has great impact on further therapeutic decision making.

Investigation of Heart Failure
1) To diagnose heart failure: (BNP level)
2) To identify causes of heart failure eg IHD
3) To identify complications eg renal function
4) To identify prognostic factor/ aggravation factor or co morbidities

Management
Depends on stage (A, B, C, D) of heart failure. Some drugs are chosen according to NYHA functional classification. 4 groups of drug are important for mortality outcome and these drugs are introduced step by step. There are multiple drugs which act at different pathophysiologic (neurohumoral) mechanism of heart failure. General management is very important. Some patient may need CRT.

For further details see NICE guideline of Heart Failure.

DOAMSmrcp suggestion of heart failure

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Ischemic Heart Disease in MRCP Part 1

IHD in MRCP-2

Causes :
Main cause of ischemia to heart muscle is Coronary Artery Disease ( Atherosclerotic or Non Atherosclerotic eg: cocaine abuse, Prinzmetal`s angina, Syndrome X).
Other (non coronary artery) causes are Aortic valve disease, Hypertrophic left ventricle ( eg- HOCM), Anemia etc.

Clinical Presentation and Diagnosis:
Central chest pain is the cardinal symptom but may be atypically breathless (angina equivalent in diabetes or old patient). Moreover there may be additive features of complications (Heart failure/cardiogenic shock, Myocardial rupture/left ventricular aneurysm, DVT and pulmonary embolism, Pericarditis, Dysrhythmias, Mitral regurgitation, Severe depression) of IHD or other cardiac risk factors , comorbidities.

Differential diagnosis of chest pain of IHD is challenging.

Acute MI is defined by several criteria. The commonest is an increase and then a
decrease in cardiac biomarkers (eg troponin) and either: symptoms of ischaemia OR ECG changes of new ischaemia OR development of pathological Q waves OR loss of myocardium on imaging.

Investigations:
ECG, Biomarkers, CXR, Echocardiogram, Coronary angiogram, CBC, Sugar, U/E, Lipids etc

Aims (basic principles) of Investigations in Hypertension
1) To diagnose ischemia
2) To identify causes of ischemia
3) To identify complication
4) To identify associated other cardiac risk factors or co morbidities

Management:
A) Management of Stable angina
B) Management of Acute coronary syndrome (ACS)

                       Immediate management of ACS
Drug
PCI ( if possible)
Thrombolysis (if PCI not is possible and NO contraindication of thrombolysis )

                       Long term management of ACS
Management of causes of IHD
Management of complication of IHD / co morbidities
Education of the patient ( eg: driving- DVLA guideline , sexual activity etc)

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Hypertension In MRCP Part 1

Category : MRCP Part 1

Clinical Presentation
Mostly asymptomatic as the majority of cases are primary hypertension. Patient with secondary hypertension presents with the clinical features of causes of hypertension. Additionally, longstanding hypertensive patient can present with complications (Target Organ Damage) of hypertension. Few patients present with occipital headache.

Aims (basic principles) of Investigations in Hypertension
1) To diagnose: ( No Investigation is required as Hypertension is diagnosed by measuring blood pressure)
2) To identify causes of secondary hypertension
3) To identify Target Organ Damage/ complication
4) To identify associated other cardiac risk factors or co morbidities

HTN IN MRCP

Management of Hypertension
All the categories of antihypertensive medications are NOT suitable for each patient. Choosing the appropriate antihypertensive drug depends upon following factors-
a) Age
b) Race
c) Causes ( etiology) of hypertension
d) Existing Target Organ Damage / complication
e) Associated co morbidities ( eg – pregnancy etc)
f) Adverse effect of drugs

Target Blood Pressure by Treatment
In general—- less than 140/90 mm Hg
If age more than 80 years—— less than 150/90 mm Hg
If pregnant——– less than150/100 mm Hg, but if any associated Target Organ Damage- less than 140/90 mm Hg

For further information go through  NICE Guideline of Hypertension

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