Transcript Iatrogenic Cardiomyopathy

Iatrogenic Heart Disease
aegrescit medendo (the remedy is worse than the disease)
Gregory L. Sheehy, M.D.
Primary Care Conference
May 10, 2006
I. Iatrogenic…a definition
Induced in a patient by a physician’s words or
actions
The American Heritage Dictionary, 2nd Ed.
OR
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An iatrogenic disorder occurs when the
deleterious effects of a therapeutic or diagnostic
regimen cause pathology…
However, the harm that a physician can do is
not limited to the imprudent use of medications
or procedures. Equally important are illconsidered or unjustified remarks.
Harrison’s Principles of Internal Medicine, 14th ed., p. 4
II. Case Report
First visit 01/02/1998 (transferring from
another clinic)
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63 year old woman who feels well but is recovering from a recent
traumatic L1 compression fracture
Other problems:
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Hypertension-145/75-Atenolol 50mg/Amlodipine 5mg
Hypertriglyceridemia-Gemfibrozil 300 mg bid
Asymptomatic diverticulosis
Asymptomatic mitral valve prolapse-no murmur noted-? Click
Vaginal hysterectomy and cholecystectomy, remote
Treatment plan:
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Medications renewed
Scheduled for complete exam in April of 1998
Patient leaving for Arizona for the remainder of the winter
Case Report, cont.
Flash forward to CPE 11/11/05, patient now 71 years
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Problem list
 Hypertension-110/70-Atenolol 50 mg/Amlodipine 5mg
 Occasional mild exertional chest pain
 Cold/numb feet-improved with brief trial off atenolol
 Hypertriglyceridemia-Gemfibrozil 600 mg bid
 Recurrent UTIs with significant episode of pyelonephritis in July 2004
 Recurrent episodes of diverticulitis (3 in all) with colonoscopy in 2003,
unremarkable except for tics
 S/p acute appendicitis with perforation/peritonitis in June 2002
 H/o mitral valve prolapse with echocardiogram in May, 1999, showing no
MVP/regurgitation
 S/p vaginal hyst and cholecystectomy, remote
At this visit, her most significant complaint is that “the cold feet and somewhat numb
sensation in her feet” is something that she is finding pretty intolerable
“The incidence of cold extremities during atenolol treatment
was 58% in one study”, Feleke et al, 1983, Micromedex
Case Report, cont.
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Treatment plan
Taper off Atenolol
 Discontinue Amlodipine
 Gradual start of Lisinopril 20mg/HCTZ 12.5 mg
 Recheck in 2 weeks
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Case Report, cont.
Return visit approximately 10 days later, 11/22/05, on
Lisinopril and HCTZ
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Problem list
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Studies
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Hypertension-100/60 in both arms
Chest pain, not severe, but clearly worse
Faster HR/palpitations/DOE-no PND
New cardiac murmur-quite loud-IV/VI pansystolic murmur with thrill all
over precordium and around to her back and very active precordium
EKG: LVH with poor R wave progression, no acute ischemic changes
Chest xray: normal
Enzymes/lytes: normal except for creatinine of 1.5, a rise
Plan
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Patient did not look acutely ill but was obviously uncomfortable
Admit for evaluation and treatment
Metoprolol 50 mg given immediately—within one hour, she started to
feel better
Endocarditis/ruptured valve leaflet/aortic dissection under consideration
III. Major Learning
Objective…Look at all of the data!
My bias failed me:
“You see only what you look for
and recognize what you know”
Echocardiogram, 5/28/99
“No significant valvular disease, specifically, there
is no mitral valve prolapse or regurgitation.
Asymmetric septal hypertrophy with no systolic
anterior motion of the mitral valve. Left
ventricular size is normal and systolic function is
hyperdynamic with an estimated ejection
fraction of 75%. There is evidence for delayed
left ventricular relaxation.”
Echocardiogram, 11/23/05
“Overall systolic function is hyperdynamic.
Moderate systolic anterior motion of the mitral
valve is noted. There is dynamic left ventricular
outflow tract obstruction at rest, with a peak
velocity of 3.5m/sec, and a peak gradient of 49
mmHg. Moderate valvular regurgitation of the
mitral valve.”
What happened?...I had
unmasked Hypertrophic
Cardiomyopathy
Why?
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Stopped beta blocker- increased heart rate
Started ACE inhibitor with a diureticdecreased preload and afterload
Follow up
Patient now on Verapamil 240 mg SR twice daily
and feels well
IV. Hypertrophic Cardiomyopathy
(HCM)
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It is an autosomal dominant genetic disease
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All first degree relatives should get tested yearly ages
12 to 18 and every 5 years from age 18 to ? (delayed
onset of hypertrophy is an issue)
Echocardiogram is the screening test of choice
Most electrocardiograms are abnormal with
LVH and often ST-T wave changes
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A “normal” ECG in HCM is unusual
HCM, cont.
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Prevalence of HCM is somewhere between 1:350 to
1:650 individuals
Many patients with HCM have no symptoms and
therefore many cases are found by screening.
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The issue is that a significant portion (25-40%) will eventually
develop symptoms
Most common symptom is dyspnea with exertion (DOE)
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Other symptoms include chest pain, presyncope/syncope, and
palpitations
Women tend to have more symptoms with advancing age
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This is possibly due to smaller LV cavity size
HCM, cont.
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Worse prognosis
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Early age at onset (i.e. < 20 years of age)
Severity of symptoms at time of diagnosis
Variable other clinical markers
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Outflow gradient > 30 mmHg
LV wall thickness >25 mm
Atrial fibrillation
Mortality rates of men=women
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The “usual” stated annual mortality rate of 3-5% is too
high…probably closer to 1%
Key Exam Findings
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A murmur that increases from a change from
sitting or squatting to the upright position
A murmur that decreases going from a standing
to sitting, squatting, or lying position
Treatment
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Medications
Beta blockers
 Verapamil
 Disopyramide
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Other
Surgical resection
 Chemical ablation
 Defibrillator
 Heart transplant
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References
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Up to Date 2006, “Hypertrophic Cardiomyopathy”
Maron BJ, Casey SA, Poliac LC, et al. Clinical course
of hypertrophic cardiomyopathy in a regional United
States cohort. JAMA 1999; 281: 650-655.
Olivetto I, Maron MS, Adabog AS, et al. Gender-related
differences in the clinical presentation and outcome of
hypertrophic cardiomyopathy. J Am Coll Cardiol 2005;
46: 480-7.