2) Our expert author is JA Linderbaum MS, ARNP, FACC, FPCNA @jlinderbaum, Associate Professor of Medicine, @MayoClinic, CV #NursePractitioner, Assoc. Medical Editor #AskMayoExpert.#FOAMed #MedEd @MedTweetorials #CardioTwitter @transformingHC @TNPJ_Journal #cardiology pic.twitter.com/JMGdK0M6lv
— cardio-met (@cardiomet_CE) March 22, 2023
4a) This #tweetorial will follow a Q&A format and will address multiple foundational issues about the diagnosis, staging, and management of #HCM. @jlinderbaum will provide guideline supported comments #guidelines
— cardio-met (@cardiomet_CE) March 22, 2023
4c) 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: EXECUTIVE SUMMARY: A Report of the @ACCinTouch / @American_HeartJoint Committee on Clinical Practice Guidelines, from @SteveOmmen et al:
— cardio-met (@cardiomet_CE) March 22, 2023
🔓https://t.co/KPqpDzQpLa
5a) So, let’s get started:
— cardio-met (@cardiomet_CE) March 22, 2023
❓ How will I know when I see a patient with #HCM? pic.twitter.com/ggNr4z0vlI
5c)
— cardio-met (@cardiomet_CE) March 22, 2023
Symptoms: #presyncope, #syncope, exertional #dyspnea, activity intolerance, #palpitations, chest pain
5e)
— cardio-met (@cardiomet_CE) March 22, 2023
🫀 Squatting or passive leg raise ⬇️murmur intensity
🫀 Valsalva, squat-to-stand, or walking ⬆️murmur intensity
🫀 Murmur intensity that ⬆️after a long pause
6b) Answer: Increased voltage with or without deep T-wave inversions in the lateral precordial leads. Some individuals with HCM, may have normal ECGs. pic.twitter.com/MZpSCUpFUj
— cardio-met (@cardiomet_CE) March 22, 2023
7b) Answer: Careful physical examination and interval assessment of symptoms remains paramount.
— cardio-met (@cardiomet_CE) March 22, 2023
🫀 Symptoms may include #exertional #dyspnea, exertional #angina, exertional #syncope, or #presyncope and may vary based on loading conditions such as dehydration, heat, cold
7d)
— cardio-met (@cardiomet_CE) March 22, 2023
👉Importantly, #comorbid conditions can exist in addition to #HCM and may present over time (e.g. #CAD, activity intolerance with orthopedic problems)
7f) Most individuals with #HCM are asymptomatic. Those who have symptoms may describe exertional dyspnea, angina, syncope or presyncope or palpitations.
— cardio-met (@cardiomet_CE) March 22, 2023
Sx can vary from day to day based on the following conditions:
A. Hydration
B. Blood pressure
C. Humidity
D. All of the above
8a) ❓Can hypertrophic cardiomyopathy be mis-diagnosed? pic.twitter.com/x5kkbF4wW4
— cardio-met (@cardiomet_CE) March 22, 2023
9a) ❓ Which of the following represents a red flag sign or symptom that should be urgently evaluated for individuals with hypertrophic cardiomyopathy:
— cardio-met (@cardiomet_CE) March 22, 2023
A. Fatigue
B. Dizziness
C. Palpitations
D. Syncope
10a) ❓ What are the classic physical exam findings for an individual with hypertrophic cardiomyopathy with obstruction? pic.twitter.com/KlqR4X9uMK
— cardio-met (@cardiomet_CE) March 22, 2023
10c)
— cardio-met (@cardiomet_CE) March 22, 2023
🫀 The strain phase of #Valsalva, a long pause, or the standing phase of a squat-to-stand maneuver ⬆️ murmur intensity pic.twitter.com/YEJD6WPnmR
11b) Answer: Other Red flag 🚨signs or symptoms for individuals with #HCM necessitating urgent or emergent referral include:
— cardio-met (@cardiomet_CE) March 22, 2023
🫀 Class 4⃣ #angina or #dyspnea, #syncope or #presyncope or the inability to perform activity without these symptoms.
12a) ❓ What are the initial tests for an individual with a history and physical exam findings consistent with suspected #HCM? pic.twitter.com/b5a00VyaO6
— cardio-met (@cardiomet_CE) March 22, 2023
12c) 👉Importantly, ECG findings can be normal in up to 5% of ppl with #HCM. If low voltage pattern is noted, other considerations should be investigated (infiltrative or dilated #cardiomyopathy).
— cardio-met (@cardiomet_CE) March 22, 2023
👉Cardiac MRI may be indicated when diagnosis is uncertain.
13a) #HCM may sometimes be a diagnosis of exclusion, particularly in younger individuals with left ventricular hypertrophy. What are other conditions that may contribute to #LVH?
— cardio-met (@cardiomet_CE) March 22, 2023
13c) Mark you response and RETURN TOMORROW for the correct answer, MORE Q&A on #HCM, and your link to 🆓CE/#CME.
— cardio-met (@cardiomet_CE) March 22, 2023
👏 @SrihariNaiduMD @SABOURETCardio @pabeda1 @4hcm @EduQuintanaCVS @MagliariRafael @neallakdawala @tikuowens @DrImranSheikh pic.twitter.com/s4tCgPQFNK
15a) ❓ Why would a #Holter monitor be indicated in the patient with #HCM? pic.twitter.com/qMo058ylzG
— cardio-met (@cardiomet_CE) March 23, 2023
15c) Holter monitoring is typically recommended every 1-2 years to assess for nonsustained ventricular tachycardia #Vtach or asymptomatic #arrhythmias.
— cardio-met (@cardiomet_CE) March 23, 2023
16b) Answer: Treadmill stress testing is used to determine #risk_stratification for sudden death, to assess #exercise capacity, & to promote active lifestyle in individuals with #HCM.
— cardio-met (@cardiomet_CE) March 23, 2023
17a) ❓ How is #cardiac #MRI utilized in individuals with hypertrophic cardiomyopathy #HCM? pic.twitter.com/wMcwhHeQIM
— cardio-met (@cardiomet_CE) March 23, 2023
17c) The presence of late #gadolinium enhancements (evidence of myocardial disarray) on cardiac MRI is a risk marker for cardiac #arrhythmias and sudden cardiac events. pic.twitter.com/wHMLx4nlHA
— cardio-met (@cardiomet_CE) March 23, 2023
18b) (cont)
— cardio-met (@cardiomet_CE) March 23, 2023
🫀 Unexplained syncope, (esp within the past 6mos)
🫀 Nonsustained #VTach on exercise testing or #Holter
🫀 Extensive (>15%) #gadolinium enhancement on cardiac MRI
🫀 #LV systolic dysfunction (LVEF <50%)
🫀 Presence of an #apical #aneurysm on #echo or MRI
19b) Answer:
— cardio-met (@cardiomet_CE) March 23, 2023
🫀 #Syncope or #presyncope, especially during exercise
🫀 #Chestpain &/or or postprandial #angina equivalent
🫁 #dyspnea with activity or after being supine
🫀 #Palpitations
🫀 Fatigue or activity intolerance
20b) Answer: #Dynamic (sometimes present, variable) #LVOTO occurs in ~ 70-75% of ppl w/ #HCM. #Gradient > 30 mmHg at rest may ➡️sx.
— cardio-met (@cardiomet_CE) March 23, 2023
Gradients >/= 50 mmHg at rest or w/ provocation & associated w/ sx are considered the threshold for consideration of #septal #reduction therapies.
21b) (cont)
— cardio-met (@cardiomet_CE) March 23, 2023
🫀 #Holter monitor every 1-2 years or with change in symptoms
🫀 Echocardiogram every 1-3 years or change in clinical status
23a) ❓ What are the common 💊 used for the treatment of #HCM?
— cardio-met (@cardiomet_CE) March 23, 2023
Answer: The most common drug classes for the treatment of symptomatic HCM include (established) #beta_blockers and #CCBs, plus (emerging) cardiac myosin inhibitor (not yet in guidelines, see https://t.co/yM1CxliUVS):
23c) #Beta_blockers are usually effective with some symptom improvement in about 70% of individuals with #HCM.
— cardio-met (@cardiomet_CE) March 23, 2023
23e) 1⃣ cardiac myosin inhibitor has recently been approved by @US_FDA to date: #mavacamten. Mavacamten promotes an energy-sparing and super-relaxed state that translates as a reduction in #LVOTO & improvement of cardiac filling pressures.
— cardio-met (@cardiomet_CE) March 23, 2023
25a) ❓When should I refer to an #HCM expert?
— cardio-met (@cardiomet_CE) March 23, 2023
Answer: Patients should be referred to a HCM specialist and/or an HCM Center of Excellence at initial diagnosis and when sx persist despite medical therapy, or they are unable to tolerate medical therapy. pic.twitter.com/dWGYuXrl6I
26a) ❓ What are screening options for first-degree family relatives of pts w/ known #HCM?
— cardio-met (@cardiomet_CE) March 23, 2023
Answer:
🧬Genetic testing and/or echocardiographic surveillance should be considered for all first-degree relatives of individuals with hypertrophic cardiomyopathy. pic.twitter.com/BDi8GaxZjp
26c) … based on clinical and echocardiographic findings can help to identify patients more likely to have a positive genetic test.
— cardio-met (@cardiomet_CE) March 23, 2023
27) So congratulations! You just earned 0.75h 🆓CE/#CME! We have reviewed the current #guidelines for #HCM all right here on Twitter. Claim your credit NOW at https://t.co/VchavioDzM.
— cardio-met (@cardiomet_CE) March 23, 2023
I am @jlinderbaum of @MayoClinic, #CV #NursePractitioner. Please FOLLOW US for more programs!