CARDIOLOGY
HOCM
Young patient collapse playing sport.
PromptHOCM history questions
ResponseExertional – presyncope or syncope
Lung symptoms – dyspnoea rest and exertional, PND, orthopnea. Etc
Palpitations - atrial and vent. Dysrhythmia
Chest pain - anginal
Family hx - cardiac sudden death/known HCM
(?prior Ix/Echo)
Lung symptoms – dyspnoea rest and exertional, PND, orthopnea. Etc
Palpitations - atrial and vent. Dysrhythmia
Chest pain - anginal
Family hx - cardiac sudden death/known HCM
(?prior Ix/Echo)
PromptHOCM exam findings
ResponsePulse – sharp rising, jerky pulse
JVP – prominent a wave
Apex beat – double or triple
Auscultation – late systolic ejection murmur (left sternal edge), pansystolic murmur from MR (apex), 4th heart sound
Dynamic manoeuvres – murmur louder with Valsalva – softer with squatting (increases preload) & isometric exercise e.g. hand grip (increases afterload)
JVP – prominent a wave
Apex beat – double or triple
Auscultation – late systolic ejection murmur (left sternal edge), pansystolic murmur from MR (apex), 4th heart sound
Dynamic manoeuvres – murmur louder with Valsalva – softer with squatting (increases preload) & isometric exercise e.g. hand grip (increases afterload)
PromptECG (Describe)
ResponseLeft ventricular hypertrophy with increased precordial voltages and non-specific ST & T abnormalities
Deep, narrow (“dagger-lioke”) Q waves in lateral +/- inferior leads
Left atrial enlargement - P mitrale
Signs of WPW – short PR, delta wave
Pre-cordial T inversion
Q waves – dagger Q’s V1-5 (with narrow complex QRS)
LVH by voltage
Diffuse ST/T changes with T wave inversion chest leads V2-5
Leftward axis 1 postive 2 equiphasic 3 negative
PR interval – ok if described short (borderline – 30% assoc. with WPW)
Interpretation – 1 mark = Highly suspicious for HCM (or HOCM)
Non-specific global ST-segment depression (?c/w LVH/LMCA but age 15)
iii. aVR, V1, V2 ST segment elevation (?c/w LMCA but age 15)
iv. P-wave abnormalities (large P-waves globally/retrograde P-wave V2)
v. PR interval normal (i.e. no short PR)
vi. Sinus rhythm (i.e. no arrhythmia)
vii. Non-specific T-wave changes especially laterally (?c/w LVH)
Deep, narrow (“dagger-lioke”) Q waves in lateral +/- inferior leads
Left atrial enlargement - P mitrale
Signs of WPW – short PR, delta wave
Pre-cordial T inversion
Q waves – dagger Q’s V1-5 (with narrow complex QRS)
LVH by voltage
Diffuse ST/T changes with T wave inversion chest leads V2-5
Leftward axis 1 postive 2 equiphasic 3 negative
PR interval – ok if described short (borderline – 30% assoc. with WPW)
Interpretation – 1 mark = Highly suspicious for HCM (or HOCM)
Non-specific global ST-segment depression (?c/w LVH/LMCA but age 15)
iii. aVR, V1, V2 ST segment elevation (?c/w LMCA but age 15)
iv. P-wave abnormalities (large P-waves globally/retrograde P-wave V2)
v. PR interval normal (i.e. no short PR)
vi. Sinus rhythm (i.e. no arrhythmia)
vii. Non-specific T-wave changes especially laterally (?c/w LVH)
PromptECG (interpret)
Response
PromptInitial investigations in suspected HOCM
ResponseBedside serial ECG for dynamic changes
Bloods troponin - ischaemia (+/_ serial)
CXR cardiomegaly, pulmonary congestion
Cardiac Echo ?hypertrophy ?dynamic outflow obstruction, wall motion abnormality etc
Can have one of fbc.tft.bsl (something sensible) – alternative dx for symptoms
Bloods troponin - ischaemia (+/_ serial)
CXR cardiomegaly, pulmonary congestion
Cardiac Echo ?hypertrophy ?dynamic outflow obstruction, wall motion abnormality etc
Can have one of fbc.tft.bsl (something sensible) – alternative dx for symptoms
PromptList causes of anterior TWI
ResponseArrythmogenic RV Dysplasia
Myocardial ischaemia
Myo/pericarditis
PE
SAH
Myocardial ischaemia
Myo/pericarditis
PE
SAH
Prompt(incidentally seems to be a big theme dx of HOCM then the 16 yo DAMA’s)
ResponseCounsel patient as to ddx and possible severity/ramification e.g. sudden death
Mother/responsible guardian involvement as technically minor under 18 (but could give valid consent to treatment being over 16)
?capacity assessment - retain, understand etc.
(Other colleague involvement early e.g. expedite cardio r/v/Echo if able)
Documentation
Something sensible!
Mother/responsible guardian involvement as technically minor under 18 (but could give valid consent to treatment being over 16)
?capacity assessment - retain, understand etc.
(Other colleague involvement early e.g. expedite cardio r/v/Echo if able)
Documentation
Something sensible!
PromptList the most important complications of HOCM
Responsei. Ventricular arrhythmia
ii. Sudden death
iii. Risk to offspring (genetic transmission)
iv. Abnormal coronary arteries (ischaemia risk increased)
ii. Sudden death
iii. Risk to offspring (genetic transmission)
iv. Abnormal coronary arteries (ischaemia risk increased)
PromptList management priorities during admission for initial diagnosis of HOCM
Responsei. Telemetry/monitoring for arrhythmia*
ii. Exclusion of valvular pathology/LVOT(echo)*
iii. Parental counseling
iv. Patient counseling re sport/activity
v. Beta-blocker
vi. Consideration for electrophysiological studies
vii. Consideration for implantable defibrillator
ii. Exclusion of valvular pathology/LVOT(echo)*
iii. Parental counseling
iv. Patient counseling re sport/activity
v. Beta-blocker
vi. Consideration for electrophysiological studies
vii. Consideration for implantable defibrillator