Dilated cardiomyopathy resident survival guide: Difference between revisions
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{{familytree | |!| | | |!| | |}} | {{familytree | |!| | | |!| | |}} | ||
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Admit to a level of care that allows for constant ECG monitoring}}</div> | {{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Admit to a level of care that allows for constant ECG monitoring}}</div> | ||
|C02=<div style="float: left; text-align: center; width: 25em;">[[ | |C02=<div style="float: left; text-align: center; width: 25em;">[[Dilated cardiomyopathy resident survival guide#Complete Diagnostic Approach|Proceed to complete diagnostic approach]]</div> }} | ||
{{familytree | |!| | | | | | |}} | {{familytree | |!| | | | | | |}} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | D01 | | | | | |D01= <div style="float: left; text-align: left; width: 45em; padding:1em;"> | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | D01 | | | | | |D01= <div style="float: left; text-align: left; width: 45em; padding:1em;"> | ||
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❑ Monitor oxygen saturation continuously<br> | ❑ Monitor oxygen saturation continuously<br> | ||
❑ If [[hypoxemia|<span style="color:white;">hypoxemia</span>]] is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without [[noninvasive ventilation|<span style="color:white;">noninvasive ventilation</span>]] <br> | ❑ If [[hypoxemia|<span style="color:white;">hypoxemia</span>]] is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without [[noninvasive ventilation|<span style="color:white;">noninvasive ventilation</span>]] <br> | ||
❑ Secure intravenous access with 18 gauge cannula <br> | ❑ Secure intravenous access with 18 gauge cannula <br> | ||
❑ Monitor fluid intake and urine output carefully to guide diuretic dose titration) <br><br> | ❑ Monitor fluid intake and urine output carefully to guide diuretic dose titration) <br><br></div>}} | ||
{{familytree | |!| | | | | | |}} | |||
{{familytree | Z01 | | | | | |Z01=<div style=" background: #FA8072">'''Assess congestion and perfusion:'''<br> | |||
'''Congestion at rest''' (dry vs. wet)<br> | |||
''"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema''<br> | ''"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema''<br> | ||
'''Low perfusion at rest''' (warm vs. cold)<br> | |||
''"Cold" suggested by narrow [[pulse pressure|<span style="color:white;">pulse pressure</span>]], [[cool extremities|<span style="color:white;">cool extremities</span>]], [[hypotension|<span style="color:white;">hypotension</span>]]'' <br> | ''"Cold" suggested by narrow [[pulse pressure|<span style="color:white;">pulse pressure</span>]], [[cool extremities|<span style="color:white;">cool extremities</span>]], [[hypotension|<span style="color:white;">hypotension</span>]]'' <br> | ||
The patient is:<br> | The patient is:<br> | ||
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❑ Warm and wet, OR <br> | ❑ Warm and wet, OR <br> | ||
❑ Cold and dry, OR <br> | ❑ Cold and dry, OR <br> | ||
❑ Cold and wet < | ❑ Cold and wet </div>}} | ||
{{familytree | |!| | | | | | |}} | |||
'''Identify precipitating factor and treat accordingly:''' <br> | {{familytree | Y01 | | | | | |Y01=<div style="float: left; text-align: left; width: 45em; padding:1em;">'''Identify precipitating factor and treat accordingly:''' <br> | ||
''Click on the precipitating factor for more details on the management'' <br> | ''Click on the precipitating factor for more details on the management'' <br> | ||
❑ [[Acute coronary syndrome|<span style="color:white;">Acute coronary syndrome</span>]] <br> | ❑ [[Acute coronary syndrome|<span style="color:white;">Acute coronary syndrome</span>]] <br> | ||
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❑ [[Anemia|<span style="color:white;">Anemia</span>]] <br> | ❑ [[Anemia|<span style="color:white;">Anemia</span>]] <br> | ||
❑ [[Thyroid|<span style="color:white;">Thyroid</span>]] abnormalities <br> | ❑ [[Thyroid|<span style="color:white;">Thyroid</span>]] abnormalities <br> | ||
❑ Systemic [[infection|<span style="color:white;">infection</span>]] <br><br> | ❑ Systemic [[infection|<span style="color:white;">infection</span>]] <br></div>}} | ||
{{familytree | |!| | | | | | |}} | |||
{{familytree | X01 | | | | | |X01=<div style=" background: #FA8072">'''Manage the patient's acute symptoms'''<br> | |||
<u>'''Chest Pain'''</u> | |||
❑ Administer [[morphine|<span style="color:white;">morphine</span>]] IV to reduce symptom severity.<br> | |||
:❑ Initial dose 4-8 mg | |||
:❑ 2-8 mg every 5 to 15 minutes, as needed<br><br> | |||
''' | '''<u>Congestiona and Volume Status</u>''' <br> | ||
'''''Diuretics''''' <br> | '''''Diuretics''''' <br> | ||
❑ Administer IV [[loop diuretics|<span style="color:white;">loop diuretics</span>]] as intermittent boluses or continuous infusion (I-B)<br> | ❑ Administer IV [[loop diuretics|<span style="color:white;">loop diuretics</span>]] as intermittent boluses or continuous infusion (I-B)<br> | ||
:❑ If patient is already on [[loop diuretics|<span style="color:white;">loop diuretics</span>]]: Rule of thumb: Administer IV dose with total daily dose = 2.5 x usual daily PO dose<br> | :❑ If patient is already on [[loop diuretics|<span style="color:white;">loop diuretics</span>]]: Rule of thumb: Administer IV dose with total daily dose = 2.5 x usual daily PO dose<br> | ||
:❑ Generally, administer IV furosemide bolus dose 40 mg IV for patients with normal renal function. | :❑ Generally, administer IV furosemide bolus dose 40 mg IV for patients with normal renal function. | ||
:❑ If patient is not already on [[loop diuretics|<span style="color:white;">loop diuretics</span>]], administer IV starting dose: | :❑ If patient is not already on [[loop diuretics|<span style="color:white;">loop diuretics</span>]], administer IV starting dose: | ||
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:❑ Evaluate adequacy of diuresis. For furosemide, adequate diuresis is defined as urine output > 1L/2hours following IV administration. | :❑ Evaluate adequacy of diuresis. For furosemide, adequate diuresis is defined as urine output > 1L/2hours following IV administration. | ||
:❑ If not adequate, increase furosemide IV dose to 80 mg. Re-evaluate diuresis adequacy in the following 2 hours post-administration. | :❑ If not adequate, increase furosemide IV dose to 80 mg. Re-evaluate diuresis adequacy in the following 2 hours post-administration. | ||
:❑ Titrate dose until adequate diuresis is achieved. Once achieved, administer the dose at a twice daily rate. | :❑ Titrate dose until adequate diuresis is achieved. Once achieved, administer the dose at a twice daily rate. | ||
:❑ Perform serial assessment of fluid input and output, [[vital signs|<span style="color:white;">vital signs</span>]], daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms <br> | :❑ Perform serial assessment of fluid input and output, [[vital signs|<span style="color:white;">vital signs</span>]], daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms <br> | ||
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:❑ Reassess diuresis adequacy several hours (2 to 9) following metolazone administration. | :❑ Reassess diuresis adequacy several hours (2 to 9) following metolazone administration. | ||
❑ Consider low dose [[dopamine|<span style="color:white;">dopamine</span>]] infusion for improved diuresis and renal blood flow (IIb-B) <br> | ❑ Consider low dose [[dopamine|<span style="color:white;">dopamine</span>]] infusion for improved diuresis and renal blood flow (IIb-B) <br> | ||
❑ Consider [[renal replacement therapy|<span style="color:white;">renal replacement therapy</span>]]/[[ultrafiltration|<span style="color:white;">ultrafiltration</span>]] in obvious volume overload (IIb-B) refractory to higher dose/combination of IV diuretics <br> | ❑ Consider [[renal replacement therapy|<span style="color:white;">renal replacement therapy</span>]]/[[ultrafiltration|<span style="color:white;">ultrafiltration</span>]] in obvious volume overload (IIb-B) refractory to higher dose/combination of IV diuretics <br><br> | ||
'''<u>Maintenance of Diuresis</u>'''<br> | |||
' | ❑ Consider continuous infusion of furosemide following bolus administration. Infusion dose and rate vary according to the patient's creatinine clearance: | ||
❑ | :❑ CrCl > 75 ml/min: Administer furosemide infusion 100 mg loading dose with an initial infusion rate of 10 mg/hour. Maximum daily infusion rate is 240-360 mg/hour in non-elderly adults (170 mg/hour in elderly). | ||
: | :❑ CrCl= 25-75 ml/min: Administer furosemide infusion 100-200 mg loading dose with an initial infusion rate of 10-20 mg/hour. Maximum daily infusion rate is 240-360 mg/hour in non-elderly adults (170 mg/hour in elderly). | ||
:❑ CrCl < 25 ml/min: Administer furosemide infusion 200 mg loading dose with an initial infusion rate of 20-40 mg/hour. Maximum daily infusion rate is 240-360 mg/hour in non-elderly adults (170 mg/hour in elderly). | |||
❑ Monitor urine output to achieve goal urine output > 100 mL/hour.<br><br> | |||
''' | '''<u>Administer Venodilators</u>'''<br> | ||
❑ [[ | ❑ Consider administration of IV [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]], [[nitroprusside|<span style="color:white;">nitroprusside</span>]], or [[nesiritide|<span style="color:white;">nesiritide</span>]] as add-on to diuretics to relieve [[dyspnea|<span style="color:white;">dyspnes</span>]] (IIb-A)<br> | ||
:''Do not administer [[vasodilator|<span style="color:white;">vesodilators</span>]] among patients with [[hypotension|<span style="color:white;">hypotension</span>]].''<br><br> | |||
''' | '''<u>Manage Low Perfusion</u>'''<br> | ||
❑ Consider [[Right heart catheterization|<span style="color:white;"> | ❑ Administer [[Inotrope|<span style="color:white;">inotropic agents</span>]] (click here for details). | ||
:''If the patient is total body and intravascular volume overloaded in normotensive, then [[diuresis|<span style="color:white;">diuresis</span>]] alone should be undertaken. If the patient is volume overloaded but [[hypotensive|<span style="color:white;">hypotensive</span>]], then [[inotrope|<span style="color:white;">inotropes</span>]] must be administered in addition to [[diuretics|<span style="color:white;">diuretics</span>]].''<br><br> | |||
'''<u>Invasive Hemodynamic Monitoring</u>'''<br> | |||
❑ Consider [[Right heart catheterization|<span style="color:white;">pulmonary artery catheterization</span>]] in case of failure to respond to medical therapy, [[respiratory distress|<span style="color:white;">respiratory distress</span>]], [[shock|<span style="color:white;">shock</span>]], uncertainty regarding volume status, or increase in [[creatinine|<span style="color:white;">creatinine</span>]]; assess the following parameters:<br> | |||
:❑ [[PCWP|<span style="color:white;">PCWP</span>]] | :❑ [[PCWP|<span style="color:white;">PCWP</span>]] | ||
:❑ [[Cardiac output|<span style="color:white;">Cardiac output</span>]] | :❑ [[Cardiac output|<span style="color:white;">Cardiac output</span>]] | ||
:❑ [[Systemic vascular resistance|<span style="color:white;">Systemic vascular resistance</span>]] | :❑ [[Systemic vascular resistance|<span style="color:white;">Systemic vascular resistance</span>]]<br><br> | ||
'''<u>Management of Hyponatremia</u>''' <br> | |||
❑ Water restriction <br> | |||
:❑ <2 L/day if Na is < 130 meq/L | |||
:❑ < 1 L/day or more if the Na is < 125 meq/L </div>}} | |||
''' | {{familytree | |!| | | | | | |}} | ||
{{familytree | V01 | | | | | |V01=<div style=" background: #FA8072">'''Hospital Care'''<br> | |||
'''<u>Thromboprophylaxis</u>'''<br> | |||
❑ [[Anticoagulation|<span style="color:white;">Anticoagulation</span>]] in the absence of contraindications (I-B)<br><br> | ❑ [[Anticoagulation|<span style="color:white;">Anticoagulation</span>]] in the absence of contraindications (I-B)<br><br> | ||
'''Chronic | '''<u>Hold Home Administered Chronic Medical Therapy</u>'''<br> | ||
❑ Chronic [[ACE inhibitor|<span style="color:white;">ACE inhibitor</span>]]: Hold if patient is hemodynamically unstable <br> | ❑ Chronic [[ACE inhibitor|<span style="color:white;">ACE inhibitor</span>]]: Hold if patient is hemodynamically unstable <br> | ||
❑ Chronic [[beta blocker|<span style="color:white;">beta blocker</span>]]: | ❑ Chronic [[beta blocker|<span style="color:white;">beta blocker</span>]]: | ||
: Hold if patient is hemodynamically unstable and/or in need or [[inotrope|<span style="color:white;">inotropes</span>]] | :❑ Hold if patient is hemodynamically unstable and/or in need or [[inotrope|<span style="color:white;">inotropes</span>]] | ||
: Decrease dose by ≥ half if patient is in moderate [[heart failure|<span style="color:white;">heart failure</span>]] | :❑ Decrease dose by ≥ half if patient is in moderate [[heart failure|<span style="color:white;">heart failure</span>]] | ||
❑ DO NOT INITIATE | ❑ DO NOT INITIATE ACEI/ARBs during an acute decompensation<br> | ||
❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate | ❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate beta blockers at a low dose in stable patients following optimization of volume status and D/C of IV diuretics and inotropes (I-B) <br><br> | ||
'''Monitor | '''<u>Monitor Laboratory Tests</u>''' <br> | ||
❑ [[BUN|<span style="color:white;">BUN</span>]] <br> | ❑ [[BUN|<span style="color:white;">BUN</span>]] daily <br> | ||
❑ [[Creatinine|<span style="color:white;">Creatinine</span>]] <br> | ❑ [[Creatinine|<span style="color:white;">Creatinine</span>]] daily <br> | ||
❑ [[ | ❑ [[Creatinine|<span style="color:white;">Creatinine</span>]] daily</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 19:09, 19 May 2015
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Steven Bellm, M.D. [2]
Dilated cardiomyopathy resident survival guide Microchapters |
---|
Overview |
Causes |
Diagnosis |
Do's |
Dont's |
Overview
Dilated cardiomyopathy (DCM) relates to a group of heterogeneous myocardial disorders and is characterized by dilatation and impaired contraction and systolic function of the left or both ventricles. Atrial and/or ventricular arrhythmias can occcur, and there is a risk for sudden death. [1] The weight of the heart assessed by the MRI and echocardiogram is increased but the maximal thicknesses of the left ventricular free wall and septum are usually normal as a result of the abnormally dilated chambers.[2] Dilated cardiomyopathy is treated the same way that congestive heart failure is.
Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.[3]
- Life-threatening causes:
- Common causes:
- Idiopathic
- Myocarditis
- Ischemic heart disease
- Infiltrative disease
- Peripartum cardiomyopathy
- Hypertension
- Human immunodeficiency virus (HIV) infection
- Connective tissue disease
- Substance abuse
- Doxorubicin
- Other
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients with signs and symptoms of severe acute decompensated heart failure who require immediate intervention.[4]
Boxes in red signify that an urgent management is needed.
Abbreviations:
BU: Blood urea nitrogen;
COPD: Chronic obstructive pulmonary disease;
D5W: 5% dextrose solution in water ;
HF: Heart failure;
IV: Intravenous;
MAP: Mean arterial pressure;
Na: Sodium;
NSAID: Non steroidal anti-inflammatory drug;
SBP: Systolic blood pressure;
S3: Third heart sound;
Identify cardinal findings that increase the pretest probability of acute decompensated heart failure ❑ Dyspnea | |||||||||||||||||
Does the patient have any of the following findings that require hospitalization and urgent management? ❑ Severe decompendated HF:
❑ Dyspnea at rest manifested by tachypnea or oxygen saturation <90%
| |||||||||||||||||
Yes | No | ||||||||||||||||
Admit to a level of care that allows for constant ECG monitoring | |||||||||||||||||
Initial stabilization: | |||||||||||||||||
Assess congestion and perfusion:
| |||||||||||||||||
Identify precipitating factor and treat accordingly: Click on the precipitating factor for more details on the management
❑ COPD | |||||||||||||||||
Manage the patient's acute symptoms Chest Pain
❑ Administer morphine IV to reduce symptom severity.
Congestiona and Volume Status
❑ Low sodium diet (<2 g daily)
❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) Maintenance of Diuresis
❑ Monitor urine output to achieve goal urine output > 100 mL/hour. Administer Venodilators
Manage Low Perfusion
Invasive Hemodynamic Monitoring Management of Hyponatremia
| |||||||||||||||||
Hospital Care Thromboprophylaxis Hold Home Administered Chronic Medical Therapy
❑ DO NOT INITIATE ACEI/ARBs during an acute decompensation Monitor Laboratory Tests | |||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[5]
Symptoms of heart failure | |||||||||||||||||||||||||||||||||||||||||||||
History and symptoms: ❑ Hints for etiology (at least 3 generations of family history, and others) | |||||||||||||||||||||||||||||||||||||||||||||
Physical examination: ❑ Vital signs:
❑ General appearance:
❑ Heart:
❑ Lungs:
❑ Abdomen:
❑ Extremities:
| |||||||||||||||||||||||||||||||||||||||||||||
Laboratory findings: ❑ Complete blood count
| |||||||||||||||||||||||||||||||||||||||||||||
Imaging and additional tests: ❑ Noninvasive imaging:
❑ Invasive imaging: Consider invasive Imaging only in specific cases.
| |||||||||||||||||||||||||||||||||||||||||||||
Examples for specific findings for dilated cardiomyopathy:
❑ Echo (dilated left and/or right ventricle, global hypokinesis with left ventricular ejection fraction under 40% | |||||||||||||||||||||||||||||||||||||||||||||
Rapidly progressive symptoms (within 1 month)? And/or new ventricular tachycardia? | |||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||
Consider endomyocardial biopsy | Treat with conventional heart failure medications | ||||||||||||||||||||||||||||||||||||||||||||
Clinical improvement after 1 week? | |||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||
Continue conventional heart failure treatment | Consider endomyocardial biopsy | ||||||||||||||||||||||||||||||||||||||||||||
Do's
- The initial diagnostic approach should aim to identify potentially reversible causes of left ventricular dysfunction. Pertinent history includes alcohol consumption, recent viral illness, coronary risk factors, and family history.
Dont's
- Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF.[5] Optimal timing of endomyocardial biopsy for patients unresponsive to medical therapy remains unclear.[3]
- Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI.[6]
References
- ↑ "Report of the WHO/ISFC task force on the definition and classification of cardiomyopathies". Br Heart J. 44 (6): 672–3. 1980. PMC 482464. PMID 7459150.
- ↑ Tazelaar HD, Billingham ME (1986). "Leukocytic infiltrates in idiopathic dilated cardiomyopathy. A source of confusion with active myocarditis". Am J Surg Pathol. 10 (6): 405–12. PMID 3521345.
- ↑ 3.0 3.1 Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL; et al. (2000). "Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy". N Engl J Med. 342 (15): 1077–84. doi:10.1056/NEJM200004133421502. PMID 10760308.
- ↑ Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH; et al. (2013). "2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 128 (16): 1810–52. doi:10.1161/CIR.0b013e31829e8807. PMID 23741057.
- ↑ 5.0 5.1 Yancy, C. W.; Jessup, M.; Bozkurt, B.; Butler, J.; Casey, D. E.; Drazner, M. H.; Fonarow, G. C.; Geraci, S. A.; Horwich, T.; Januzzi, J. L.; Johnson, M. R.; Kasper, E. K.; Levy, W. C.; Masoudi, F. A.; McBride, P. E.; McMurray, J. J. V.; Mitchell, J. E.; Peterson, P. N.; Riegel, B.; Sam, F.; Stevenson, L. W.; Tang, W. H. W.; Tsai, E. J.; Wilkoff, B. L. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 128 (16): e240–e327. doi:10.1161/CIR.0b013e31829e8776. ISSN 0009-7322.
- ↑ WRITING COMMITTEE MEMBERS. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE; et al. (2013). "2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 128 (16): e240–327. doi:10.1161/CIR.0b013e31829e8776. PMID 23741058.