Hypertrophic cardiomyopathy in special clinical scenarios: Difference between revisions

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{{Hypertrophic cardiomyopathy}}
{{Hypertrophic cardiomyopathy}}


'''Editors-In-Chief:''' C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org]
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org];{{AOEIC}} {{LG}}
 
==Overview==


==Management of HCM in presence of hypotension and cardiovascular collapse==
==Management of HCM in presence of hypotension and cardiovascular collapse==
The first patient I (C. Michael Gibson, M.D.) treated as a medical student was an 18 year old woman who had HOCM. She had just entered college and had partied throughout the night. She was vomiting, developed new [[atrial fibrillation]] at a rate of 180 beats per minute. She had a [[syncopal]] episode and had a systolic blood pressure of 60 mm Hg. This young lady had sustained hemodynamic collapse as a result of volume depletion and tachycardia.
The first patient [[C. Michael Gibson, M.S., M.D.|I (C. Michael Gibson, M.D.)]] treated as a medical student was an 18 year old woman who had [[HOCM]]. She had just entered college and had partied throughout the night. She was [[vomiting]], developed new [[atrial fibrillation]] at a rate of 180 beats per minute. She had a [[syncope|syncopal episode]] and had a [[systolic blood pressure]] of 60 mm Hg. This young lady had sustained hemodynamic collapse as a result of volume depletion and [[tachycardia]].


====Precipitants of Hemodynamic Collapse====
====Precipitants of Hemodynamic Collapse====
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:*How to mix the phenylephrine: Make a solution that contains 10 mg (1 mL of 1 percent phenylephrine) of phenylephrine diluted in 500 mL of D5W. Administer at a rate of 5 to 9 mL/min (i.e. 100 to 180 drops/min assuming there are 20 drops/mL). This solution provides a phenylephrine drip of 100 to 180 µg/min.
:*How to mix the phenylephrine: Make a solution that contains 10 mg (1 mL of 1 percent phenylephrine) of phenylephrine diluted in 500 mL of D5W. Administer at a rate of 5 to 9 mL/min (i.e. 100 to 180 drops/min assuming there are 20 drops/mL). This solution provides a phenylephrine drip of 100 to 180 µg/min.
*Outside of the US, intravenous [[disopyramide]] at a dose of 50 mg over one to five minutes can be administered.
*Outside of the US, intravenous [[disopyramide]] at a dose of 50 mg over one to five minutes can be administered.
==2011 ACCF/AHA Guideline Recommendations: Asymptomatic Patients==
<ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' For patients with [[HCM]], it is recommended that comorbidities that may contribute to cardiovascular disease (e.g., [[hypertension]], [[diabetes]], [[hyperlipidemia]], [[obesity]]) be treated in compliance with relevant existing guidelines.(223) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
'''1.''' Low-intensity aerobic exercise is reasonable as part of a healthy lifestyle for patients with [[HCM]].(10,224) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''1.''' The usefulness of [[Beta blockers|beta blockade]] and [[Calcium channel blocker|calcium channel blockers]] to alter clinical outcome is not well established for the management of asymptomatic patients with [[HCM]] with or without obstruction.(10) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (HARM)===
'''1.''' Septal reduction therapy should not be performed for asymptomatic adult and pediatric patients with HCM with normal effort tolerance regardless of the severity of obstruction.(9,10) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''2.''' In patients with [[HCM]] with resting or provocable outflow tract obstruction, regardless of symptom status, pure [[vasodilators]] and [[diuretics|high-dose diuretics]] are potentially harmful.(3,9) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}
==Guideline Resources==
[http://content.onlinejacc.org/cgi/reprint/58/25/e212.pdf 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy] <ref name="pmid22075468">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=2703–38 |year=2011 |month=December |pmid=22075468 |doi=10.1016/j.jacc.2011.10.825 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)04383-X |accessdate=2011-12-19}}</ref><ref name="pmid22075469">{{cite journal |author=Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW |title=2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=25 |pages=e212–60 |year=2011 |month=December |pmid=22075469 |doi=10.1016/j.jacc.2011.06.011 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02275-3 |accessdate=2011-12-19}}</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Emergency medicine]]
[[Category:Cardiomyopathy]]
[[Category:Intensive care medicine]]
[[Category:Cardiology]]
[[Category:Cardiology]]


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Revision as of 15:57, 12 January 2012

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Management of HCM in presence of hypotension and cardiovascular collapse

The first patient I (C. Michael Gibson, M.D.) treated as a medical student was an 18 year old woman who had HOCM. She had just entered college and had partied throughout the night. She was vomiting, developed new atrial fibrillation at a rate of 180 beats per minute. She had a syncopal episode and had a systolic blood pressure of 60 mm Hg. This young lady had sustained hemodynamic collapse as a result of volume depletion and tachycardia.

Precipitants of Hemodynamic Collapse

  • Volume depletion or dehydration which can be due to:
  • Vomiting
  • Diuretics
  • Hemorrhage
  • Reduced pre-load which can be due to:
  • Sepsis
  • Venodilators such as nitrates
  • Following epidural blockade
  • Vasodilator therapy
  • Sepsis

Physical examination Findings in Hemodynamic Collapse

A rapid, weak pulse is present in the patient who is hypotensive. The JVP is flat. A systolic murmur is present.

Echocardiographic Findings in Hemodynamic Collapse

  • A small hypercontractile left ventricle is present
  • Prolonged systolic anterior motion of the mitral valve is present
  • Mitral regurgitation with a posterior directed jet

Treatment of Hemodynamic Collapse

Initial treatment includes the following:

  • Avoid nitrates even though it appears the patient is in heart failure!
  • Avoid vasodilators again even though it appears the patient is in heart failure! Both these agents could cause further hemodynamic compromise.
  • Administer beta-blockers to slow the heart rate and fluids to raise the left ventricular filling pressures.
  • Elevate the legs to increase venous return and raise the preload

If the patient does not respond to these measures, then the following can also be administered:

  • Intravenous phenylephrine at a rate of 100 to 180 µg/min, which is then reduced to 2 to 3 mL/min (40 to 60 drops/min).
  • How to mix the phenylephrine: Make a solution that contains 10 mg (1 mL of 1 percent phenylephrine) of phenylephrine diluted in 500 mL of D5W. Administer at a rate of 5 to 9 mL/min (i.e. 100 to 180 drops/min assuming there are 20 drops/mL). This solution provides a phenylephrine drip of 100 to 180 µg/min.
  • Outside of the US, intravenous disopyramide at a dose of 50 mg over one to five minutes can be administered.

2011 ACCF/AHA Guideline Recommendations: Asymptomatic Patients

[1][2]

“

Class I

1. For patients with HCM, it is recommended that comorbidities that may contribute to cardiovascular disease (e.g., hypertension, diabetes, hyperlipidemia, obesity) be treated in compliance with relevant existing guidelines.(223) (Level of Evidence: C)

Class IIa

1. Low-intensity aerobic exercise is reasonable as part of a healthy lifestyle for patients with HCM.(10,224) (Level of Evidence: C)

Class IIb

1. The usefulness of beta blockade and calcium channel blockers to alter clinical outcome is not well established for the management of asymptomatic patients with HCM with or without obstruction.(10) (Level of Evidence: C)

Class III (HARM)

1. Septal reduction therapy should not be performed for asymptomatic adult and pediatric patients with HCM with normal effort tolerance regardless of the severity of obstruction.(9,10) (Level of Evidence: C)

2. In patients with HCM with resting or provocable outflow tract obstruction, regardless of symptom status, pure vasodilators and high-dose diuretics are potentially harmful.(3,9) (Level of Evidence: C)

”

Guideline Resources

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy [1][2]

References

  1. ↑ 1.0 1.1 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (2011). "2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): 2703–38. doi:10.1016/j.jacc.2011.10.825. PMID 22075468. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (2011). "2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): e212–60. doi:10.1016/j.jacc.2011.06.011. PMID 22075469. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)


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