Cardiomyopathy is an anatomic and pathologic diagnosis associated with muscle or electrical dysfunction of the heart. It represents a heterogeneous group of diseases that often lead to progressive heart failure and significant morbidity and mortality. The major types are dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. Symptoms are the same as those seen in heart failure and include shortness of breath, fatigue, cough, orthopnea, and edema. Diagnostic studies include BNP levels, electrocardiography, and echocardiography. Treatment is targeted at relieving heart failure symptoms and reducing mortality through pharmacotherapy, devices, and transplantation if needed.
Any diseased condition of the myocardium which leads to cardiac failure is known as cardiomyopathy. A longitudinal case study of biventricular non-compaction, treated with constitutional homeopathic medicines over four years is shared. Consideration of miasms, importance of intra-uterine history and various avenues of homeopathic prescribing in cardiac conditions are explained. Prescribing clues of the homeopathic remedy Pneumococcin are also shared.
Aortic Dissection with Hemopericardium and Thrombosed Left Common Iliac Arter...Vinod Namana
#aortic dissection #tamponade #hemopericardium #pericardial effusion #leg ischemia #type a dissection #shock #cardiogenic shock.
An aortic dissection is an uncommon serious condition, which usually presents with chest pain or upper back pain. Symptoms of aortic dissection may mimic those of other diseases, often leading to delay in diagnosis. We report an unusual case of aortic dissection with hemopericardium and thrombosed left common iliac artery presenting as acute limb ischemia. Maintaining a high index of clinical suspicion for aortic pathology could possibly lead to identification and timely management of a greater number of patients who have atypical presentations. This would be especially true for patients who have catastrophic presentations with unexplained symptoms.
Any diseased condition of the myocardium which leads to cardiac failure is known as cardiomyopathy. A longitudinal case study of biventricular non-compaction, treated with constitutional homeopathic medicines over four years is shared. Consideration of miasms, importance of intra-uterine history and various avenues of homeopathic prescribing in cardiac conditions are explained. Prescribing clues of the homeopathic remedy Pneumococcin are also shared.
Aortic Dissection with Hemopericardium and Thrombosed Left Common Iliac Arter...Vinod Namana
#aortic dissection #tamponade #hemopericardium #pericardial effusion #leg ischemia #type a dissection #shock #cardiogenic shock.
An aortic dissection is an uncommon serious condition, which usually presents with chest pain or upper back pain. Symptoms of aortic dissection may mimic those of other diseases, often leading to delay in diagnosis. We report an unusual case of aortic dissection with hemopericardium and thrombosed left common iliac artery presenting as acute limb ischemia. Maintaining a high index of clinical suspicion for aortic pathology could possibly lead to identification and timely management of a greater number of patients who have atypical presentations. This would be especially true for patients who have catastrophic presentations with unexplained symptoms.
CVD in cancer survivors.Screening of cancer survivors.Chest Radiotherapy .JACC Scientific Expert Panel
( J Am Coll Cardiol 2019;74:905–27 )manifestations of chest and mediastinal radiotherapy .
CVD in cancer survivors.Screening of cancer survivors.Chest Radiotherapy .JACC Scientific Expert Panel
( J Am Coll Cardiol 2019;74:905–27 )manifestations of chest and mediastinal radiotherapy .
A presentation I gave recently to CEO\'s of arts organisations.
It takes you through the thinking behind Techdept\'s open business plan - social media, open culture and system thinking.
This achieves greater engagement, less management bottlenecks and iterates your operational best practice: a learning organisation.
3 Ways To Cut Waste In Your Marketing Dept (Using The Web)DanKirby
This is a talk I gave June 2010 @ Green Unplugged - Communicating Sustainability...
We have found that we can use the web to better manage the marketing process - which has a range of benefits - but (importantly) helps reduce waste...
It also helps herd cats, streamline your team, and cut bullshit from your day...
Find out how, & view the presentation!
Periodontal Treatment of Medically Compromised Patients [Autosaved].pptxANIL KUMAR
The world's population is estimated to be over 7.7 billion. [1] Within this mass of humanity is a
substantial number of people who are elderly; the graying of the world's population is predicted to
produce millions of individuals with systemic medical conditions that can affect oral health and
dental treatment. The dental management of these medically compromised patients can be
problematic in terms of oral complications, dental therapy, and emergency care
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. Cardiomyopathy
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Heart failure should be managed in accordance with the 2005 American College of Cardiology/ C 14
American Heart Association guidelines.
Cardiac resynchronization therapy should be considered in patients with New York Heart Association B 5, 14
class III or IV heart failure who remain symptomatic despite optimal pharmacologic therapy.
An implantable cardioverter-defibrillator should be placed in patients with cardiomyopathy who are B 1
at risk of sudden death.
Heart transplantation should be considered in adults with cardiomyopathy who are refractory to B 2, 3, 17, 33
maximal medical therapy.
Heart transplantation is the treatment of choice in children with idiopathic restrictive cardiomyopathy. B 9
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.
Table 1. Diagnostic and Treatment Considerations for Cardiomyopathies
Type* Signs and symptoms Diagnostic considerations Treatment considerations
Dilated Shortness of breath, ECG shows LVH Pharmacologic therapy based on the 2005
cardiomyopathy fatigue, cough, Echocardiography shows enlarged ACC/AHA heart failure guidelines (see
orthopnea, ventricular chamber, normal or Figure 1), cardiac resynchronization
paroxysmal nocturnal decreased wall thickness, systolic therapy, implantable cardioverter-
dyspnea, edema dysfunction defibrillator, surgical revascularization, left
ventricular assist device, salt restriction,
smoking cessation, cardiac rehabilitation
Hypertrophic Same as dilated ECG shows LVH, large QRS Pharmacologic therapy based on the 2005
cardiomyopathy cardiomyopathy; complex, Q-waves, and frequent ACC/AHA heart failure guidelines (see
sudden cardiac T-wave inversion Figure 1), septal myomectomy (only in
death Echocardiography shows LVH of patients with obstructive hypertrophic
unknown etiology with reduction cardiomyopathy), biventricular pacing,
in ventricular chamber volume septal alcohol ablation, implantable
cardioverter-defibrillator
Restrictive Pulmonary congestion, ECG shows LVH Chelation therapy, phlebotomy, bone
cardiomyopathy dyspnea on exertion, Echocardiography shows biatrial marrow transplantation, salt restriction,
decreased cardiac enlargement, normal or reduced implantable cardioverter-defibrillator,
output, syncope ventricular volume, normal left cardiac transplantation (in children)
ventricle wall thickness, normal
systolic function, impaired
ventricular filling
Arrhythmogenic Syncope, atypical ECG shows abnormal repolarization, Beta blockers, antiarrhythmics, catheter
right ventricular chest pain, initial small-amplitude potentials at end ablation, implantable cardioverter-
cardiomyopathy episode of ventricular of QRS complex (epsilon wave) defibrillator, cardiac transplantation
tachycardia, Echocardiography shows segmental
recurrent ventricular wall abnormalities, with or without
tachycardia wall motion abnormalities
Electrophysiology testing, cardiac
magnetic resonance imaging
*—Listed from most to least common.
ACC = American College of Cardiology; AHA = American Heart Association; ECG = electrocardiography; LVH = left ventricular hypertrophy.
Information from references 1 through 9.
May 1, 2009 ◆ Volume 79, Number 9 www.aafp.org/afp American Family Physician 779
3. Cardiomyopathy
Table 2. Causes of Cardiomyopathy
Primary Secondary
Genetic Autoimmune (systemic lupus)
Arrhythmogenic right Electrolyte imbalance Symptoms of heart failure may include
ventricular cardiomyopathy Endocrine (diabetes, hypothyroidism) shortness of breath, fatigue, cough, orthop-
Hypertrophic cardiomyopathy Endomyocardial (fibrosis) nea, paroxysmal nocturnal dyspnea, and
Mixed (genetic and nongenetic) Infiltrative (amyloidosis, Gaucher disease) edema. This presentation is common in
Dilated cardiomyopathy Inflammatory (sarcoidosis) patients with dilated cardiomyopathy.
Restrictive cardiomyopathy Neurologic (neurofibromatosis) Although the life expectancy of patients
Acquired Nutritional (beriberi) with cardiomyopathy varies by etiology, the
Myocarditis (inflammatory Radiation mortality rate is 20 percent at one year and
cardiomyopathy) 70 to 80 percent at eight years for most
Storage (hemochromatosis)
Peripartum (or postpartum) patients who develop heart failure.12
Toxic (medications)
cardiomyopathy
Velocardiofacial syndrome Patients with hypertrophic cardiomyopa-
Stress cardiomyopathy
thy may present with heart failure, although
Information from reference 1. sudden cardiac death may be the initial pre-
sentation.17 Most patients with hypertrophic
cardiomyopathy have a propensity to develop
most likely because of the phenotypic diversity of hyper- dynamic obstruction produced by anterior motion of the
trophic cardiomyopathy, and not the consequence of mitral valve.
environmental impact or additional genetic modifiers.1 Restrictive cardiomyopathy typically leads to diastolic
Restrictive cardiomyopathy is an uncommon form heart failure from poor filling during diastole and clas-
that occurs when the ventricles become too stiff to con- sic heart failure symptoms (e.g., pulmonary congestion,
tract. This is often the result of an infiltrative process, dyspnea on exertion, decreased cardiac output) that
such as sarcoidosis, hemochromatosis, amyloidosis, progress as systolic dysfunction increases. However, syn-
and abnormalities related to desmin (a protein marker cope may occur, and sudden death is rare.4
found in sarcomeres).1,18,19 One of the familial forms In arrhythmogenic right ventricular cardiomyopa-
of restrictive cardiomyopathy has a troponin muta- thy, symptoms of heart failure are uncommon. Syncope,
tion that is the basis of restrictive and hypertrophic atypical chest pain, an initial episode of ventricular
cardiomyopathy.1 tachycardia, and recurrent ventricular tachycardia are
Arrhythmogenic right ventricular cardiomyopathy is the primary symptoms.3 In addition, the genetic defect
an autosomal dominant, inherited disorder of the muscle of arrhythmogenic right ventricular cardiomyopathy has
of the right ventricle. It may lead to syncope, ventricular cutaneous manifestations, such as Naxos disease, which
arrhythmias, heart failure (less common), or sudden is characterized by woolly (i.e., extreme curly, kinked)
death.1,2 In arrhythmogenic right ventricular cardiomy- hair and palmoplantar keratoderma.1
opathy, the myocardium is replaced by fatty and fibrous
tissue. This causes pathologic changes that lead to car- Diagnostic Evaluation
diac compromise.3 The same infiltrative process may The most common clinical presentation in patients
also affect the left ventricle.1 with cardiomyopathy is heart failure. The evaluation for
Family physicians may also encounter peripartum underlying causes of heart failure includes a thorough
(or postpartum) cardiomyopathy and alcohol-related history and physical examination with baseline chem-
cardiomyopathy.1 Peripartum cardiomyopathy is a rare istries, including B-type natriuretic peptide (BNP) lev-
dilated cardiomyopathy with onset in the third trimes- els, echocardiography, and electrocardiography (ECG);
ter of pregnancy or in the first five months postpartum. chest radiography should be performed on initial
It tends to occur in multiparous women older than
presentation.14
30 years who are obese and have had preeclampsia. Alco- In response to elevated volume and filling pressures
holism may also lead to a dilated cardiomyopathy that is associated with heart failure, the ventricles secrete BNP
potentially reversible with abstinence from alcohol use. into the bloodstream.20 This neurohormone, easily mea-
sured in plasma, has been shown to be highly sensitive
Clinical Presentation and specific in the diagnosis of heart failure in patients
Although cardiomyopathies may be asymptomatic in the with acute dyspnea.21 One study found that BNP level
early stages, most symptoms are typical of those seen in was the most accurate predictor of heart failure as the
any type of heart failure, whether systolic (reduced ejec- cause of acute dyspnea in the emergency setting.22 The
tion fraction) or diastolic (preserved ejection fraction). mean serum level of BNP was 675 ± 450 pg per mL
780 American Family Physician www.aafp.org/afp Volume 79, Number 9 ◆ May 1, 2009
4. Cardiomyopathy
(675 ± 450 ng per L) in patients with heart failure, com- is typically made by evaluating for electrical, functional,
pared with 110 ± 225 pg per mL (110 ± 225 ng per L) in and anatomic abnormalities that may have been evalu-
patients with non-heart failure etiologies. ated for previously because of a sudden arrhythmia, syn-
The Heart and Soul Study found that BNP measure- cope, or cardiac arrest.1 Alternatively, cardiac magnetic
ment is not a useful screening test in asymptomatic resonance imaging has been used in patients who have a
patients with known coronary disease.23 Conversely, the high pretest probability.
Heart Outcomes Prevention Evaluation Study found that
BNP measurement provides the best clinical prediction The Athlete’s Heart
in the secondary prevention population.24 In the ambu- Athletes, especially those who follow intense training regi-
latory setting, BNP levels may be useful in distinguishing mens, may develop changes in cardiac structure as a normal
patients who need urgent evaluation for possible acutely physiologic response. Such changes may include eccen-
decompensated heart failure from those who are short of tric cardiac hypertrophy with a resultant increase in left
breath for other reasons. ventricular volume, and mass or concentric hypertrophy
Echocardiography is another key diagnostic modality with increased ventricular wall thickness, but no change
for patients with suspected cardiomyopathy. In dilated in cavity size.25 Although these changes are not considered
cardiomyopathy, echocardiography typically demon- to be pathologic in athletes, underlying conditions (most
strates an enlarged ventricular chamber with normal or notably hypertrophic cardiomyopathy) that place them at
decreased wall thickness and systolic dysfunction.1 The risk of sudden death may be present. To guide physicians
ECG will show left ventricular hypertrophy. In patients who treat athletes, the AHA issued recommendations
with familial idiopathic dilated cardiomyopathy, the for preparticipation cardiovascular screening (Table 3).26
American College of Cardiology (ACC)/AHA heart fail-
ure guidelines recommend screening asymptomatic first-
degree relatives with echocardiography and ECG, as well Table 3. American Heart Association Screening
as possible referral to a cardiovascular genetics center.14 Questions for Preparticipation Cardiovascular
In patients with hypertrophic cardiomyopathy, echo- Evaluation in Athletes
cardiography reveals left ventricular hypertrophy of
unknown etiology with a reduction in ventricular cham- Is there a personal history of exertional chest pain or
discomfort?
ber volume.1 The ECG also demonstrates left ventricular
Is there a personal history of unexplained syncope or near
hypertrophy, as well as a large QRS complex, Q-waves syncope?
with no history of CAD, and frequent T-wave inver- Is there a personal history of dyspnea or fatigue with exercise?
sion. A harsh murmur heard at the left sternal edge that Is there a personal history of heart murmur?
increases with Valsalva maneuver and the standing posi- Is there a personal history of elevated blood pressure?
tion is often heard on auscultation. The ACC and the Is there a family history of premature cardiac death before
European Society of Cardiology recommend that first- 50 years of age?
degree relatives and other family members of patients Is there a family history of disabling heart disease before
with hypertrophic cardiomyopathy receive a history 50 years of age?
and physical examination, ECG, and echocardiography Is there a family history of conditions known to increase
annually between 12 and 18 years of age.17 cardiac risk (e.g., dilated or hypertrophic cardiomyopathy)?
In patients with restrictive cardiomyopathy, echocar- Evaluate for heart murmur.
diography tends to show biatrial enlargement with a nor- Evaluate for femoral pulses.
mal or reduced ventricular volume, normal left ventricle Evaluate for physical features suggestive of Marfan syndrome.
wall thickness, normal systolic function, and impaired Obtain blood pressure.
ventricular filling.1 The ECG typically reveals decreased
A positive answer on questioning or an abnormal finding should
note :
voltage despite signs of left ventricular hypertrophy. prompt evaluation for a possible underlying cardiac condition.
Diagnostic evaluation for arrhythmogenic right ven- Adapted from Maron BJ, Thompson PD, Ackerman MJ, et al. Rec-
tricular cardiomyopathy differs from the other forms ommendations and considerations related to preparticipation screen-
of cardiomyopathy. Echocardiography typically reveals ing for cardiovascular abnormalities in competitive athletes: 2007
update: a scientific statement from the American Heart Association
global or segmental wall abnormalities with or without Council on Nutrition, Physical Activity, and Metabolism: endorsed
wall motion abnormalities.1 The ECG shows abnormal by the American College of Cardiology Foundation. Circulation.
repolarization and small-amplitude potentials at the 2007;115(12):1646.
end of the QRS complex (epsilon wave). The diagnosis
May 1, 2009 ◆ Volume 79, Number 9 www.aafp.org/afp American Family Physician 781
5. Cardiomyopathy
Stages of Heart Failure and Treatment
At risk of heart failure Heart failure
Stage A Stage B Stage C Stage D
At high risk of heart failure, but Structural heart disease, Structural heart disease Refractory heart failure
without structural heart disease but without signs or with prior or current requiring specialized
or symptoms of heart failure symptoms of heart failure symptoms of heart failure interventions
For example, For example, For example, For example:
patients with: Structural patients with: Development patients with: Refractory Patients who have
Hypertension heart Previous myocardial of heart Known structural symptoms marked symptoms at
Atherosclerotic disease disease infarction failure heart disease of heart rest despite maximal
Left ventricle symptoms and failure at medical therapy,
Diabetes
remodeling, including rest such as those who
Obesity Shortness of breath
left ventricular are recurrently
and fatigue,
Metabolic syndrome hypertrophy and low hospitalized or
reduced exercise
or ejection fraction cannot be safely
tolerance
Patient using discharged from
Asymptomatic valvular
cardiotoxins the hospital
disease
without specialized
Patients with
interventions
family history of Therapy
cardiomyopathy Goals
Therapy
All measures under Stages
Goals A and B Therapy
All measures under Dietary salt restriction Goals
Therapy Stage A
Drugs for routine use Appropriate measures
Goals Drugs
Diuretics for fluid retention under Stages A, B, and C
Treat hypertension, lipid ACE inhibitor or ARB in
disorders ACE inhibitors Decision based on
appropriate patients appropriate level of care
Encourage smoking Beta blockers
Beta blockers in Options
cessation, regular exercise appropriate patients Drugs in selected patients
Discourage alcohol intake, Aldosterone antagonist Compassionate end-of-life
Devices in selected patients care/hospice
illicit drug use ARBs
Implantable cardioverter- Extraordinary measures:
Control metabolic syndrome defibrillators Digitalis
heart transplantation,
Drugs Hydralazine or nitrates chronic inotropes,
ACE inhibitor or ARB in Devices in selected patients permanent mechanical
appropriate patients support, experimental
Biventricular pacing
for vascular disease or surgery or drugs
diabetes Implantable cardioverter-
defibrillators
Figure 1. American College of Cardiology/American Heart Association heart failure guidelines. (ACE = angiotensin-
converting enzyme; ARB = angiotensin receptor blocker.)
Adapted from Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the
adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the
2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the
International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society [published correction appears in Circulation. 2006;113(13):
e682-e683]. Circulation. 2005;112(12):1830.
A positive answer on questioning or an abnormal find- Treatment
ing should prompt evaluation for a possible underlying
Treatment for dilated cardiomyopathy is directed at the
cardiac condition. underlying disease. Most patients have heart failure;
Routine ECG, echocardiography, and stress testing therefore, treatment should follow the ACC/AHA heart
are not recommended as part of the preparticipation failure guidelines (Figure 1).14 Lifestyle changes should
physical examination.27 However, a recent controver- include reduced alcohol consumption, weight loss,
sial AHA scientific statement advises physicians to exercise, smoking cessation, and a low-sodium diet.14
consider ECG in all children who take medications for Treatment includes administration of an angiotensin-
attention-deficit/hyperactivity disorder, regardless of converting enzyme inhibitor or angiotensin receptor
athletic participation.28 blocker, a loop diuretic, spironolactone (Aldactone) for
782 American Family Physician www.aafp.org/afp Volume 79, Number 9 ◆ May 1, 2009
6. Cardiomyopathy
New York Heart Association (NYHA) class III or IV The treatment of restrictive cardiomyopathy is dif-
heart failure, and a beta blocker. Metoprolol (Lopressor), ficult because the underlying processes usually do not
carvedilol (Coreg), and bisoprolol (Zebeta) are the only respond to intervention. Therapies directed at specific
beta blockers with proven benefit in heart failure, accord- forms of this condition include chelation therapy, phle-
ing to randomized controlled trials.14,29-31 botomy, bone marrow transplantation, salt restriction,
The African American Heart Failure Trial demon- and implantable cardioverter-defibrillator placement.8
strated a significant reduction in hospitalizations and In children, restrictive cardiomyopathy is primar-
an increase in quality of life with the use of isosorbide ily idiopathic, and transplantation is the treatment
dinitrate/hydralazine (Bidil).32 Salt restriction, smoking of choice. This is often required within four years of
cessation, and a cardiac rehabilitation program, if indi- diagnosis.9
cated, are also important. Diastolic heart failure is typi- Pharmacologic treatment of patients with arrhyth-
cally treated with the same medical regimen as systolic mogenic right ventricular cardiomyopathy is directed at
heart failure. arrhythmia suppression and involves beta blockers, such
Cardiac resynchronization therapy is a nonpharmaco- as sotalol (Betapace), with or without amiodarone (Cor-
logic option in appropriate patients who have evidence darone).2 Nonpharmacologic options include catheter
of dyssynchrony and who have NYHA class III or IV ablation, implantable cardioverter-defibrillator place-
heart failure and continued symptoms despite maxi- ment, and cardiac transplantation in patients refractory
mal medical therapy.5,14 An implantable cardioverter- to rhythm control interventions.2,3
defibrillator may be needed for primary or secondary
prevention in patients at high risk of sudden death.1
The Authors
Referral to an electrophysiologist is needed for final
determination of eligibility for resynchronization or RANDY WEXLER, MD, MPH, FAAFP, is an assistant professor of clini-
placement of an implantable cardioverter-defibrillator.5 cal family medicine at The Ohio State University College of Medicine in
Columbus. He received his medical degree from Wright State University
The Surgical Treatment for Ischemic Heart Failure School of Medicine, Dayton, Ohio, and his master of public health degree
Trial found that in patients with heart failure caused from The Ohio State University. He completed a family practice residency
by CAD, surgical revascularization with surgical ven- at Mount Carmel Medical Center in Columbus.
tricular reconstruction does not lead to greater improve- TERRY ELTON, PhD, is a professor in the Davis Heart and Lung Research
ment in symptoms or exercise tolerance, or a reduction Institute and College of Pharmacy, Division of Pharmacology, at The Ohio
in death rate, compared with surgical revascularization State University. He received his doctor of philosophy degree in biochem-
istry from Washington State University in Pullman. He completed postdoc-
alone.6 Transplantation may be an option for patients if
torate training in biochemistry at Washington State University and at the
all other treatments have failed.33 If the patient is ineli- University of Alabama at Birmingham.
gible for transplantation, a left ventricular assist device
ADAM PLEISTER, MD, is a fellow in the Department of Internal Medicine,
may improve survival and quality of life.7 Division of Cardiovascular Medicine, at The Ohio State University. He
The management of hypertrophic cardiomyopathy is received his medical degree at the Medical College of Wisconsin in Mil-
focused on reducing symptoms and complications from waukee. He completed his internal medicine residency at The Ohio State
heart failure by following ACC/AHA guidelines. Because University.
many patients with hypertrophic cardiomyopathy have DAVID FELDMAN, MD, PhD, FACC, is an associate professor of medicine
diastolic dysfunction and typically need higher fill- and cardiology, and of physiology and cell biology at The Ohio State Uni-
ing pressures, diuretics should be used with caution.17 versity College of Medicine. He received his medical degree and doctor of
philosophy degree from the Medical College of Georgia in Augusta. He
If patients do not respond to drug therapy, treatment completed a cardiology fellowship at Washington University in St. Louis,
is dictated by whether the patient has nonobstructive and postdoctorate training in molecular and cell biology at Duke Univer-
hypertrophic cardiomyopathy or obstructive hypertro- sity School of Medicine in Durham, N.C.
phic cardiomyopathy. Nonobstructive end-stage disease Address correspondence to Randy Wexler, MD, MPH, FAAFP, The Ohio
that is refractive to maximal medical therapy requires State University, B0902B Cramblett Hall, 456 W. 10th Ave., Columbus,
heart transplantation17; this represents most patients OH 43210 (e-mail: randy.wexler@osumc.edu). Reprints are not avail-
able from the authors.
with hypertrophic cardiomyopathy.34
Patients with obstructive hypertrophic cardiomyopa- Author disclosure: Dr. Wexler has received research grants from Pfizer
thy may benefit from septal myomectomy, biventricu- Pharmaceuticals, Inc., and CVRx. He is also on the Data Safety Monitoring
Board for CardioMems. Dr. Feldman has served as a consultant and/or
lar pacing, or septal alcohol ablation. An implantable received honorarium from Novartis Pharmaceuticals and Glaxo-Smith
cardioverter-defibrillator may be needed in patients at Kline; he also has received research grants from Medtronic, the National
high risk of sudden death.17 Institutes of Health, and the Heart Failure Society of America.
May 1, 2009 ◆ Volume 79, Number 9 www.aafp.org/afp American Family Physician 783
7. Cardiomyopathy
Documents and the European Society of Cardiology Committee for
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784 American Family Physician www.aafp.org/afp Volume 79, Number 9 ◆ May 1, 2009