A 73-year-old man well known to the ED with alcohol excess presented with acute pulmonary oedema requiring CPAP. His presenting ECG demonstrated sinus rhythm with a broad left bundle branch block with QRS duration of 73 ms. A subsequent coronary angiogram demonstrates the following:
A subsequent echocardiogram demonstrated a left ventricular diastolic dimension of 7 cm. There is global impairment of left ventricular systolic function with EF estimated at 30%. There was severe mitral regurgitation due to annular dilatation. He was successfully commenced on ramipril and bisoprolol.
What is the most appropriate management at this stage?
The likely diagnosis is that of alcohol-related cardiomyopathy with by-stander coronary artery disease. Triple medical therapy with ACE inhibitors, beta-blockers and spironolactone has symptomatic and prognostic benefit and should be established early with appropriate dose uptitration. Although recovery of systolic function is seen with alcohol abstinence, medical therapy should be established together with abstinence advice. The indication for device therapy should be made once medical therapy is established and a reassessment of the patient’s symptoms and left ventricular function is made. There is no strong data to support the use of formal anticoagulation in patients in sinus rhythm with dilated cardiomyopathy. The risk of concurrent alcohol use significantly reduces any benefits.
A 74-year-old patient presents to hospital with a VF arrest. She is successfully resuscitated and a subsequent ECG demonstrates a clear-cut anterior myocardial infarction with >2 mm ST elevation in leads V2–V6. Coronary angiography demonstrates a suboccluded proximal LAD, with a small unobstructed circumflex artery and a 70% stenosis in the proximal RCA. She undergoes successful coronary intervention to her proximal LAD and has an uncomplicated recovery from her infarct. Her echocardiogram demonstrates akinesia of the apex, but an overall EF estimated at 35–40%. She is established on dual anti-platelet therapy, ramipril, bisoprolol, and a statin.
What other therapy should she have?
Epleronone is indicated post infarction with an ejection fraction of less than or equal to 40%. Spironalactone is used in patients with severe impairment of left ventricular systolic impairment (<35%) with NYHA class III symptoms. An ICD is not indicated for secondary prevention in the context of an acute infarct and where the ejection fraction is >35%. CRT is indicated only in symptomatic patients with a broad QRS (>150 ms) and echo features of dyssynchrony (if QRS is 120–150 ms). Coronary intervention on the RCA would only be indicated if the patient had angina symptoms and/or there was objective evidence of ischaemia.
A 45-year-old patient with a known diagnosis of AL amyloid presents to cardiology outpatient clinic. He is under the haematologists receiving chemotherapy for myeloma.
Which one of the following statements is true when there is cardiac involvement with amyloid?
Diuretics are the mainstay of treatment for cardiac failure and fluid overload in cardiac amyloid. ACE inhibitors are used, but with caution because of hypotension. Beta-blockers are used with caution because of the frequency of conduction disease. The prognosis of AL amyloid remains very poor despite treatment of the underlying haematological disorder with chemotherapy. Cardiac transplantation is complex in these patients and is associated with poor outcomes.
A 50-year-old man with sarcoidosis is referred to the outpatient clinic from the respiratory clinic. Which one of the following features would suggest cardiac involvement?
Cardiac sarcoid is a great mimic and can have a number of presentations. Conduction disease is common, as is sustained ventricular arrhythmia. The ventricular phenotype can be dilated or hypertrophic, as well as demonstrating regional wall motion abnormality and variability in ventricular wall thickness. Pericardial effusions, constriction, and valve disease have all been recognized.
You are asked to review a 65-year-old man with known pulmonary fibrosis who has been admitted under the chest physicians with an infection. He is not responding to broad-spectrum antibiotic therapy. He is a lifelong smoker. His 12-lead ECG demonstrates first-degree AV block with complete RBBB and a normal QRS axis. His CXR is of poor quality but could be consistent with fluid overload. Echocardiography demonstrates thinning of the septum and apex with overall moderate impairment of systolic function.
Which one of the following investigations is least likely to help with the underlying diagnosis?
Exercise ECG is likely to be non-diagnostic and insensitive for underlying coronary artery disease in view of baseline changes; a cardiac catheter will be diagnostic for an ischaemic aetiology. An elevated BNP would suggest a cardiac component to the acute presentation. Serum ACE and high-resolution CT of the chest looking for sarcoid could provide a unifying diagnosis. Sarcoid should be considered in patients with chronic lung disease and conduction disease on ECG.