©2013 MFMER | 3248567-1©2013 MFMER | 3248567-1

Contemporary HF testing //

Mexico, October 2016

Hector I. Michelena MD FASE FACCAssociate Professor of Medicine

©2013 MFMER | 3248567-2

DISCLOSURE

No Relevant Financial Relationship(s)

No Off Label Usage

©2013 MFMER | 3248567-3

CardiomyopathyHF with reduced EF

• History, physical, ECG, CxR

• Echo

• CBC (anemia, hypereosinophilia)

• Lytes, crea, BNP, Liver function,

• TSH (Hypo-hyperthyroid)

• Ferritin (hemochromatosis)

• SPEP, immunofixation, free chains (amyloid)

• Cor angio // cardiac MRI

©2013 MFMER | 3248567-4

http://www.acc.org/clinical/guidelines/failure//index.pdf.

“The single most useful

diagnostic test in the

evaluation of patients with

HF is the comprehensive 2-

dimensional echocardiogram

coupled with Doppler flow

studies….”

©2013 MFMER | 3248567-5

Dilated CardiomyopathyEtiology

• Infectious

• Viral:

• Coxsackie, adenovirus, parvovirus, HIV

• Non Viral

• Chagas, Lyme, bacterial sepsis

• Sepsis

©2013 MFMER | 3248567-6

Dilated CardiomyopathyEtiology

• Toxic

• ETOH (acute or chronic)

• Cocaine and methamphetamines

• Chemotherapy

• Anthracyclines

• Herceptin

• HER2/Neu agents

• Trastuzumab, pertuzumab

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Dilated CardiomyopathyEtiology: Specific Causes

• Tachycardia mediated

• SVT, atrial fibrillation

• Sustained VT

• Frequent/multiple VPC

• Important reversible cause of DCM

• Palpitations

• Tachycardia on ECG

• ? Holter if high suspicion

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Case 1

• 29 year old female

• History of hemolytic anemia

• G3 P1 (daughter is now 4 years old)

• Normal echocardiogram several years ago

• Now admitted with sub-acute CHF to CCU

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Case1

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Case 1

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Case 1

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Case 1

A. Ischemic cardiomyopathy

B. Iron Overload Cardiomyopathy

C. Giant cell myocarditis

D. Takotsubo Cardiomyopathy

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Case 2

• 60 year old male

• History of diabetes mellitus, HTN, ED

• Dyspnea

• CxR CM pulm congestion

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Case 2

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Case 2

A. Ischemic cardiomyopathy

B. Iron Overload Cardiomyopathy

C. Giant cell myocarditis

D. Takotsubo Cardiomyopathy

©2013 MFMER | 3248567-16

Case 2

A. Ischemic cardiomyopathy

B. Iron Overload Cardiomyopathy

C. Giant cell myocarditis

D. Takotsubo Cardiomyopathy

©2013 MFMER | 3248567-17

Iron overloadClassification

• Primary (hereditary)

• Endogenous

• Genetic - autosomal recessive

• Enhanced intestinal absorption of iron

• Secondary (transfusion/hematoligic)

• Exogenous

• Due to multiple transfusions

• Iron supply > iron excretion

• Ethanol abuse

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Iron Overload Cardiomyopathy

• Secondary Iron overload

• Thalassemia

• Sickle cell

• Myelodysplastic syndrome

• ESRD excessive iron supplementation

• Chronic transfusions

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•Multisystem

•Diabetes mellitus // Tanned skin-bronze

diabetes

•Liver disease

•Skin pigmentation

•ED

•Heart disease CHF

Hemochromatosis

Clinical Presentation

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Hemochromatosis

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Bronze diabetes

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Echo and Systemic DiseasesHemochromatosis- Pathology

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Iron Overload CardiomyopathySpectrum of Illness

Murphy et al: Cardiac Fail 16:888, 2010

Stage 1

Iron-mediated cardiovascular

injury

Stage 2

Diastolic dysfunction &

restrictive cardio-

myopathy

Stage 3

Dilated biventricular

cardio-myopathy

Diastolic HF& arrhythmia

Systolic HF& arrhythmia

AlteredEC & EP

Myocardial fibrosis

Myocardial ischemia

Anemia Apoptosis

Myocarditis

Pulmonary hypertension

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Iron Overload Cardiomyopathy

• T2* Mapping Sequence

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Iron Overload Cardiomyopathy

• T2* Mapping Sequence

Severe Iron Overload Normal

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Iron Overload Cardiomyopathy

• T2* values

• < 10 msec = severe iron overload (> 2.71 [Fe](mg/g))

• 10 to 20 msec = mild –moderate iron (1.16 – 2.71 2.71 [Fe](mg/g))

• > 20 msec = normal (<1.16 [Fe](mg/g))

• Also often see increased liver iron

©2011

MFMER |

3160621-26Carpenter et al. Circulation. 2011;123: 1519-1528.

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Iron Overload CardiomyopathyMRI

• Noninvasively quantify myocardial iron

• Shortens relaxation time (Darkens tissue)

• T2* > 20 low risk for heart failure

• T2* 10-20 msec

• Cardiac deposition of iron has likely occurred, at risk for heart failure

• T2* <10 msec high risk for heart failure

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Iron Overload Cardiomyopathy Value of Cardiac MRI and Evaluation of T2*

0.0

0.1

0.2

0.3

0 60 120 180 240 300 360

Murphy et al: Cardiac Fail 16:888, 2010

Follow-up time (days)

Pro

po

rtio

n o

f p

atie

nts

su

ffe

rin

g a

rrh

yth

mia

P<0.001

<10 ms

10-20 ms

20+ ms

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0

20

40

60

80

100

0 20 40 60 80 100

Iron Overload Cardiomyopathy Heart Failure Within 1 Year

Murphy et al: Cardiac Fail 16:888, 20101-specificity

%

Heart T2* ms

Ferritin ug/L

Liver T2* ms

10 ms

15 mg/g

2500 ug/L

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Iron Overload Cardiomyopathy Arrhythmia Within 1 Year

0

20

40

60

80

100

0 20 40 60 80 100

Murphy et al: Cardiac Fail 16:888, 2010

1-specificity

Se

nsitiv

ity (

%)

10 ms

15 mg/g

2500 ug/L

Heart T2* ms

Ferritin ug/L

Liver T2* ms

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Remember

• The iron heart is a weak heart

• Rudeness is the weak man’s imitation of strength-

• So, be kind-

• Never look down on anybody unless you’re helping them-

©2013 MFMER | 3248567-32

Questions & Discussion

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