Eduovisual
Cardiovascular
Dilated cardiomyopathy: etiology workup and treatment
— Young/middle-aged adult with new HFrEF symptoms (dyspnea, orthopnea, fatigue, leg edema) without prior MI or longstanding HTN.
— Peripartum patient (last month of pregnancy through 5 months postpartum) with new HF.
— Patient with alcohol use disorder, chemotherapy exposure (anthracyclines, trastuzumab), chronic tachyarrhythmia (afib with RVR), or familial HF/SCD history.
— Incidentally found cardiomegaly on CXR or low EF on echo done for other reasons.
— Embolic stroke or new-onset AF/VT in a young patient.
— Insidious HFrEF (most common)
— Acute decompensated HF with cardiogenic shock (fulminant myocarditis pattern)
— Arrhythmic presentation: VT, sudden cardiac arrest, AF
— Thromboembolic: stroke, peripheral embolism from LV thrombus
Board pearl: Step 3 stems love the "32-year-old with progressive dyspnea, no CAD risk factors, EF 25%" — your reflex must be: rule out reversible/secondary causes (ischemia, tachycardia-mediated, alcohol, thyroid, peripartum, infiltrative, familial) before labeling it idiopathic DCM.
Step 3 management: Frame the encounter as (1) confirm HFrEF, (2) hunt etiology, (3) initiate GDMT, (4) risk-stratify for ICD/transplant — this sequence drives every order set.
— Exertional dyspnea, orthopnea, PND, fatigue, reduced exercise tolerance
— Lower extremity edema, abdominal distension, early satiety (RV congestion)
— Palpitations (AF, PVCs, NSVT), presyncope/syncope (VT, low CO)
— Persistent cough or wheezing ("cardiac asthma") misdiagnosed as COPD
— Unexplained weight gain or new abdominal swelling
— Cryptogenic stroke in a young patient → look for LV thrombus or AF
— Recurrent "pneumonia" not responding to antibiotics
— Alcohol: quantity/duration; ≥80 g/day × 5+ years is classic
— Drugs/toxins: cocaine, methamphetamine, anabolic steroids; anthracyclines (cumulative doxorubicin >250 mg/m²), trastuzumab, 5-FU, immune checkpoint inhibitors (myocarditis)
— Pregnancy: last trimester or up to 5 months postpartum → peripartum cardiomyopathy
— Viral prodrome: URI/GI illness within weeks → myocarditis
— Endocrine: thyroid symptoms, pheochromocytoma spells, acromegaly features
— Nutritional: thiamine (wet beriberi), selenium (Keshan), carnitine deficiency
— Autoimmune: SLE, sarcoidosis, scleroderma, eosinophilic syndromes
— Tachyarrhythmia: prolonged AF with RVR, frequent PVCs (>10–15% burden)
— HIV, Chagas (Latin American residence), Lyme (endemic exposure)
— Family history: HF before age 50, unexplained SCD, pacemaker/ICD in relatives → genetic DCM (TTN, LMNA, MYH7)
Key distinction: Peripartum cardiomyopathy is diagnosed only when HF develops in the last month of pregnancy or within 5 months postpartum and no other cause is identified — earlier-pregnancy HF suggests preexisting DCM unmasked by volume load.
Board pearl: A LMNA mutation history (relatives with conduction disease + DCM + SCD) lowers the threshold for early ICD even at EF >35%.
— Displaced, diffuse PMI (lateral and inferior to midclavicular line) — hallmark of LV dilation
— S3 gallop (volume overload, ↑ LVEDP) — high specificity for HFrEF
— S4 less common in pure DCM (vs HCM/HTN heart)
— Holosystolic murmurs of functional MR/TR at apex and LLSB, increasing with inspiration for TR
— Pulsus alternans in severe dysfunction
— Warm & dry (A): compensated — continue outpatient GDMT
— Warm & wet (B): congested, perfused — IV loop diuretics
— Cold & wet (C): congested + hypoperfused — diuretics + inotropes (dobutamine/milrinone), consider mechanical support
— Cold & dry (L): rare; cautious fluid, inotropes
CCS pearl: On a CCS case with HF exacerbation, order vitals, telemetry, daily weights, strict I/Os, BMP q12–24h immediately — and reassess perfusion/congestion at every clock advance before titrating diuretics or starting inotropes.
Board pearl: Laterally displaced PMI + S3 + elevated JVP in a young patient ≈ DCM until proven otherwise.
— Sinus tachycardia, LBBB (common, predicts CRT benefit), nonspecific intraventricular conduction delay
— Poor R-wave progression, low voltage (think infiltrative — amyloid)
— AF, frequent PVCs, NSVT, AV block (LMNA, sarcoid, Lyme, Chagas)
— Pathologic Q waves → suspect prior MI/ischemic cardiomyopathy
— LV dilation (LVEDD >5.5–6.0 cm), EF <40%, global hypokinesis
— Regional wall motion abnormalities → suggest ischemic etiology
— Functional MR/TR, LA enlargement, RV dysfunction, PASP, LV thrombus
— Diastolic parameters (E/e′, restrictive filling pattern → worse prognosis)
— BNP/NT-proBNP — supports HF, prognosticates, trends therapy
— Troponin — elevated in myocarditis, ischemia, severe HF
— CBC, CMP (Na, K, Mg, Cr, LFTs — congestive hepatopathy)
— TSH (hyper- and hypothyroidism cause DCM)
— Iron studies + ferritin + transferrin sat (hemochromatosis; >45% sat → screen)
— HIV, hepatitis C serologies
— Fasting glucose/HbA1c, lipid panel
— Urine drug screen (cocaine, meth) when history suggests
— ANA, ESR/CRP, ACE level (sarcoid — but low sens), 24-h urine metanephrines
— SPEP/UPEP + serum free light chains if >60 yo or features of amyloid
— Chagas serology in endemic-exposure patients
Step 3 management: First echo + ECG + BNP + basic labs + ischemic workup decision — do not order endomyocardial biopsy reflexively.
Board pearl: Low-voltage ECG + thick walls on echo + HFrEF or HFpEF = amyloid, not DCM — phenotype matters more than EF for diagnosis.
— Coronary angiography is gold standard, especially with CAD risk factors, angina, regional wall motion abnormalities, or age >35–40
— Coronary CTA acceptable if low-to-intermediate pretest probability
— Stress imaging less preferred — global hypokinesis limits accuracy
— Accurate EF and volumes
— Late gadolinium enhancement (LGE) patterns distinguish etiologies:
— Mid-wall striae septal LGE → idiopathic/genetic DCM (prognostic for SCD)
— Subepicardial LGE → myocarditis, sarcoid
— Subendocardial/transmural → ischemic
— Diffuse subendocardial + difficulty nulling myocardium → amyloid
— T2 mapping/edema → active myocarditis
— New HF <2 weeks with hemodynamic compromise (fulminant myocarditis, giant cell myocarditis)
— New HF 2 weeks–3 months with dilated LV + new arrhythmia, Mobitz II/3° AV block, or failure to respond to standard therapy (giant cell, sarcoid)
— Suspected eosinophilic, anthracycline, hypersensitivity myocarditis
— Suspected infiltrative disease when noninvasive testing inconclusive
— Indicated if ≥2 close relatives with DCM/SCD, conduction disease + DCM (LMNA), skeletal myopathy (dystrophinopathies), or unexplained DCM <50 yo
— Panel: TTN (titin, ~20% familial DCM), LMNA, MYH7, RBM20, SCN5A, DSP
— Cascade screening of first-degree relatives with echo + ECG every 1–3 years even if genotype negative
Key distinction: Giant cell myocarditis = rapidly progressive HF + VT/AV block in middle age → urgent EMB + immunosuppression + transplant evaluation; lymphocytic myocarditis typically supportive care.
Board pearl: Mid-wall septal LGE on CMR in DCM independently predicts SCD — strengthens ICD case.
— ACC/AHA Stage C (structural disease + symptoms) → full GDMT
— Stage D (refractory symptoms despite optimization) → advanced therapies
— NYHA class drives device timing and transplant referral
— LVEF, LV size, RV function, PASP
— NT-proBNP trajectory
— Functional capacity (6-min walk, peak VO₂)
— Renal function, serum Na (<135 = worse), iron status
— LGE burden on CMR
— Seattle Heart Failure Model / MAGGIC score for individualized risk
— Tachycardia-mediated: rate/rhythm control of AF, PVC ablation if burden >10–15%
— Alcohol: strict abstinence; partial recovery in months
— Thyrotoxicosis / hypothyroidism: treat the gland
— Hemochromatosis: phlebotomy, chelation
— Nutritional: thiamine, selenium repletion
— Peripartum: stop pregnancy support causes; bromocriptine in select cases
— Stress (Takotsubo): typically self-resolves
— Myocarditis: supportive; immunosuppression for giant cell, eosinophilic, checkpoint inhibitor, sarcoid
1. Decongest (loop diuretic) if volume overloaded
2. Initiate quadruple GDMT simultaneously or sequentially within weeks
3. Treat reversible etiology
4. Reassess EF at 3 months of optimized therapy
5. Device therapy (ICD ± CRT) if EF ≤35% persists ≥3 months on GDMT (≥40 days post-MI for ischemic)
6. Advanced HF referral for stage D
Step 3 management: Do not implant a primary-prevention ICD before 3 months of optimized GDMT in nonischemic DCM — many patients recover EF above the threshold (DANISH trial nuance: ICD benefit less clear in nonischemic, but still indicated per US guidelines for EF ≤35%, NYHA II–III).
Board pearl: 40 days post-MI, 90 days post-revascularization, 3 months post-GDMT initiation — the three waiting periods before ICD.
1. ARNI / ACEi / ARB (RAAS blockade):
— Sacubitril-valsartan preferred (PARADIGM-HF): start 49/51 mg BID → target 97/103 mg BID
— If ARNI not tolerated/affordable: ACEi (lisinopril, enalapril) or ARB (valsartan, losartan)
— Washout 36 h when switching ACEi → ARNI (angioedema risk)
— Hold for SBP <90, K >5.5, AKI; avoid in pregnancy, bilateral RAS, prior angioedema
2. Evidence-based β-blocker:
— Only three approved: carvedilol, metoprolol succinate, bisoprolol
— Start low (carvedilol 3.125 mg BID), double every 2 weeks to target
— Do not start during acute decompensation; initiate once euvolemic
3. Mineralocorticoid receptor antagonist (MRA):
— Spironolactone 12.5–25 mg → 25–50 mg daily or eplerenone
— Requires K ≤5.0 and eGFR >30; recheck K and Cr at 1 week, 1 month, then quarterly
— Watch for gynecomastia (spironolactone) → switch to eplerenone
4. SGLT2 inhibitor:
— Dapagliflozin 10 mg or empagliflozin 10 mg daily — benefit independent of diabetes (DAPA-HF, EMPEROR-Reduced)
— Hold for euglycemic DKA risk, volume depletion; mild Cr bump expected
— Loop diuretics (furosemide, torsemide, bumetanide) — symptom control, not mortality
— Hydralazine + isosorbide dinitrate — add for self-identified Black patients NYHA III–IV on GDMT (A-HeFT); alternative if ACEi/ARB/ARNI contraindicated
— Ivabradine — NYHA II–III, sinus rhythm, HR ≥70 on max β-blocker, EF ≤35%
— Vericiguat — recent worsening HF event despite GDMT
— IV iron (ferric carboxymaltose) — symptomatic HFrEF with iron deficiency (ferritin <100 or 100–300 with TSAT <20%)
— Digoxin — reduces hospitalization, not mortality; narrow therapeutic window
Step 3 management: Start all four pillars within 4–6 weeks; don't wait for sequential titration to target before adding the next class — early quadruple therapy improves outcomes.
Board pearl: Avoid non-dihydropyridine CCBs (verapamil, diltiazem), NSAIDs, thiazolidinediones, and most class I antiarrhythmics in HFrEF.
— Indications: EF ≤35%, NYHA II–III on ≥3 months optimal GDMT, expected survival >1 year with good functional status
— Ischemic: wait ≥40 days post-MI, ≥90 days post-revascularization
— Nonischemic DCM: still indicated per US guidelines (despite DANISH neutrality for all-cause mortality)
— Lower threshold: LMNA mutation, sarcoid with LV dysfunction, syncope + inducible VT, prior sustained VT/VF (secondary prevention regardless of EF)
— Class I: EF ≤35%, LBBB with QRS ≥150 ms, NYHA II–IV ambulatory, sinus rhythm, on GDMT
— Class IIa: LBBB QRS 120–149 ms; non-LBBB QRS ≥150 ms
— Greatest benefit: women, nonischemic, LBBB, wider QRS
— Convert to CRT if patient needs frequent RV pacing (>40%)
— Bridge in newly diagnosed DCM during 3-month GDMT optimization, or post-MI before 40-day mark when high arrhythmic risk
— AF ablation in HFrEF (CASTLE-AF) — improves mortality and HF hospitalization
— PVC ablation if burden >10–15% with PVC-induced cardiomyopathy
— VT ablation for recurrent ICD shocks
— Inotropes (milrinone, dobutamine) — bridge or palliative
— Mechanical circulatory support: IABP, Impella (short-term); LVAD (HeartMate 3) as bridge-to-transplant or destination therapy
— Heart transplantation — definitive; gold-standard listing requires peak VO₂ <14, INTERMACS profile, refractory symptoms; contraindications: irreversible PAH, active malignancy, severe COPD, active substance use, nonadherence
CCS pearl: For cardiogenic shock from acute DCM/myocarditis, order arterial line, central line, right heart cath, vasopressors (norepinephrine first), inotrope (dobutamine/milrinone), urgent cardiology + advanced HF consult, and consider temporary MCS before end-organ failure.
Board pearl: Peak VO₂ <14 mL/kg/min (or <12 on β-blocker) — magic number for transplant evaluation.
— Higher prevalence of HFpEF overlap, polypharmacy, frailty, orthostasis
— Start low, titrate slow but still target GDMT — undertreatment is the dominant error
— Comprehensive geriatric assessment: cognition, falls, polypharmacy, social support
— ICD benefit attenuated if life expectancy <1 year or severe comorbidity — shared decision-making essential
— Avoid digoxin if eGFR low; if used, target level 0.5–0.9 ng/mL
— Higher risk of MRA hyperkalemia → check K/Cr more often (1 week, 1 month)
— Diuretic-induced AKI and orthostatic hypotension common — daily weights and home BP logs
— HFrEF + CKD: GDMT still indicated, accepting modest Cr bumps (≤30% rise acceptable on ACEi/ARNI initiation)
— eGFR ≥20: dapagliflozin OK; eGFR ≥20: empagliflozin OK; benefits persist
— MRA: start if K ≤5.0 and eGFR ≥30; hold if K >5.5 or eGFR <30
— ARNI/ACEi/ARB: hold if Cr rises >30% or K >5.5; resume after correction
— Loop diuretics: use torsemide (better absorption) if gut edema; bumetanide if hepatic congestion
— Avoid NSAIDs absolutely; contrast caution before cath
— Iron deficiency overlap: IV iron strongly indicated
— Congestive hepatopathy from chronic RV failure → mildly elevated AST/ALT, ↑ bilirubin, ↑ INR
— Avoid hepatically metabolized drugs at high dose: sacubitril-valsartan caution in Child-Pugh B; contraindicated in Child-Pugh C
— Carvedilol undergoes hepatic metabolism — prefer bisoprolol or metoprolol succinate in severe hepatic dysfunction
— Spironolactone preferred over eplerenone for ascites management
— Diuretic resistance common — combine loop + thiazide (metolazone) with close electrolyte monitoring
Step 3 management: In the elderly DCM patient, the right answer is usually "continue GDMT at the highest tolerated dose with monitoring" — not "stop because of age."
Key distinction: A 30% Cr rise on ARNI/ACEi is expected and acceptable; >50% or K >5.5 mandates dose reduction.
— HFrEF (EF <45%) developing in the last month of pregnancy through 5 months postpartum, no other identifiable cause
— Risk factors: age >30, multiparity, multiple gestation, preeclampsia, African ancestry
— Pathogenesis: cleaved 16-kDa prolactin fragment + antiangiogenic factors → endothelial/myocyte injury
— Treatment during pregnancy: β-blockers (metoprolol, labetalol — avoid atenolol), hydralazine + nitrates (RAAS blockers teratogenic), loop diuretics with caution (placental perfusion), digoxin if needed; anticoagulate if EF <35% (LV thrombus risk)
— Postpartum: standard GDMT (ARNI, ACEi/ARB, MRA, SGLT2i, β-blocker) — compatible with breastfeeding for enalapril, captopril; ARNI not recommended while breastfeeding
— Bromocriptine (prolactin inhibition) — adjunct in select cases; requires anticoagulation
— Recovery: ~50% recover EF by 6–12 months
— Counseling: subsequent pregnancy carries 20–50% recurrence risk if EF has not normalized; contraception planning essential
— WHO Class III–IV cardiac risk — preconception counseling mandatory
— Stop ACEi/ARB/ARNI/MRA/SGLT2i before conception; switch to hydralazine/nitrates + β-blocker
— Multidisciplinary care: cardiology + MFM
— Vaginal delivery generally preferred; epidural for afterload reduction
— Annual incidence ~0.5–0.6/100,000 children
— Etiologies: myocarditis (viral), genetic (sarcomeric), neuromuscular (Duchenne, Becker — screen with annual echo starting age 10), metabolic (carnitine, Pompe, Barth syndrome), mitochondrial
— Genetic workup and family screening more central than in adults
— GDMT extrapolated from adult data; transplant outcomes excellent in pediatrics
Board pearl: Duchenne muscular dystrophy → universal cardiomyopathy by adulthood; ACEi + carvedilol prophylactically by age 10 even before LV dysfunction is detected.
Key distinction: PPCM ≠ pregnancy-unmasked preexisting DCM — timing of first HF symptoms is the discriminator.
— Stepwise decline in EF, NYHA class advancement, refractory congestion
— Cardiorenal syndrome (types 1 and 2): rising Cr, diuretic resistance, hyponatremia
— Cardiac cachexia (BMI loss, sarcopenia) — independent mortality predictor
— Atrial fibrillation — 25–40% of DCM patients; worsens HF and stroke risk; rhythm control (ablation) superior in HFrEF (CASTLE-AF)
— Ventricular tachycardia / VF — leading cause of SCD in DCM
— Conduction disease — LBBB common; AV block strongly suggests LMNA, sarcoid, Lyme, Chagas, amyloid
— Bradyarrhythmias requiring pacing
— LV thrombus from akinetic chambers, low-flow state
— Stroke, peripheral/visceral embolism
— Anticoagulate if LV thrombus on imaging, AF, or prior embolic event — warfarin or DOAC (warfarin preferred for LV thrombus per most data, though DOACs increasingly used)
— Routine anticoagulation for sinus rhythm + low EF alone not recommended (WARCEF: warfarin vs aspirin — no net benefit)
— Functional MR (annular dilation, papillary muscle displacement) — class IIa transcatheter edge-to-edge repair (TEER/MitraClip) for severe symptomatic functional MR despite GDMT (COAPT)
— Functional TR worsens RV failure
— Congestive hepatopathy, cardiac cirrhosis
— Type 1/2 cardiorenal syndrome
Step 3 management: New LV thrombus on echo in DCM → start anticoagulation (warfarin INR 2–3 or DOAC) for at least 3 months, then repeat imaging to confirm resolution before stopping.
Board pearl: DCM + new AV block in a middle-aged patient = think cardiac sarcoidosis until proven otherwise — order CMR + FDG-PET.
— New HFrEF diagnosis with symptomatic decompensation
— Volume overload requiring IV diuresis
— Worsening renal function on outpatient regimen
— Concerning symptoms: chest pain, syncope, sustained arrhythmia
— Hyponatremia (Na <130), severe hyperkalemia, AKI
— Inability to perform ADLs or unsafe outpatient environment
— Any new HFrEF with arrhythmia history or LBBB
— Need for IV diuretic with electrolyte instability
— GDMT initiation/titration with hemodynamic borderline
— Cardiogenic shock (cold + wet): SBP <90, lactate >2, oliguria, altered mentation
— Need for vasopressors, inotropes, or mechanical circulatory support
— Sustained VT/VF, electrical storm
— Acute fulminant myocarditis
— Respiratory failure requiring NIV/intubation
— Cardiology: every new HFrEF, EF ≤40%
— Advanced HF / transplant: Stage D, peak VO₂ <14, inotrope-dependent, recurrent admissions, severe RV dysfunction, LMNA/desmin mutations
— Electrophysiology: VT, AV block, CRT/ICD candidacy, AF for ablation
— Interventional cardiology: suspected ischemic etiology, TEER for functional MR
— Cardiothoracic surgery: LVAD candidates, severe valve disease
— Inotropes, NYHA III–IV / NT-proBNP persistently elevated, End-organ dysfunction, EF ≤35%, Defibrillator shocks, Hospitalizations >1/yr, Edema despite escalating diuretics, Low SBP, high HR, Prognostic medication intolerance
CCS pearl: When advancing the CCS clock in acute decompensated HF, recheck BMP every 12–24 h during active diuresis, daily weights, telemetry, and avoid abrupt cessation of β-blocker unless cardiogenic shock — instead, reduce dose.
Board pearl: Three consults always pair on Step 3 advanced HF: cardiology + advanced HF/transplant + palliative care when prognosis worsens.
— Asymmetric septal hypertrophy, preserved or hyperdynamic EF, LVOT obstruction with dynamic murmur (↑ with Valsalva)
— SCD in young athletes; family history
— Treatment: β-blockers, disopyramide, mavacamten, septal reduction
— Normal LV size, normal/near-normal EF, severe diastolic dysfunction, biatrial enlargement
— Causes: amyloid (AL, ATTR), sarcoid, hemochromatosis, endomyocardial fibrosis
— Amyloid clues: low voltage ECG + thick walls, apical sparing on strain, abnormal pyrophosphate scan (ATTR), monoclonal gammopathy (AL)
— RV dilation/dysfunction, fibrofatty replacement, epsilon waves, TWI V1–V3, VT with LBBB morphology
— Desmosomal protein mutations; SCD in young athletes
— Prominent trabeculations, deep recesses; may present as DCM phenotype
— Associated with thromboembolism, arrhythmia
— Apical ballooning post emotional/physical stress, postmenopausal women, mimics STEMI but clean coronaries; typically resolves in weeks
— Supportive care; avoid inotropes if LVOT obstruction
— Persistent SVT/AF/atrial flutter or PVC burden >10–15%
— Reversible with rate/rhythm control or PVC ablation — EF recovery in weeks to months
— Already detailed — temporal definition is key
— TTN, LMNA, MYH7, RBM20, SCN5A, DSP
— LMNA + conduction disease → early ICD
Key distinction: DCM = dilated chamber, low EF, eccentric remodeling; HCM = thick wall, preserved/high EF, concentric/asymmetric; Restrictive = normal size, normal EF, stiff ventricle, biatrial enlargement.
Board pearl: Apical sparing ("cherry on top") on strain echo + thick walls + low voltage = cardiac amyloid, not DCM — completely different therapy (tafamidis for ATTR; chemotherapy for AL).
— Significant epicardial CAD with prior MI or chronic hibernating myocardium → global dysfunction
— Regional WMA on echo, fixed defects on stress imaging, obstructive CAD on cath
— Management adds: antiplatelets, statin (high-intensity), revascularization in selected patients (STICH: CABG benefit in EF ≤35% + multivessel CAD)
— Severe chronic AR or MR → eccentric hypertrophy → EF decline
— Severe AS → afterload mismatch → reduced EF
— Treat the valve, not just the muscle
— Long-standing uncontrolled HTN → LVH → eventual dilation with EF drop
— BP control + GDMT; reversible early
— Anthracyclines (cumulative, dose-dependent, late onset years later) — monitor with echo before/during/after; consider dexrazoxane
— Trastuzumab (HER2 inhibitor) — typically reversible
— 5-FU, capecitabine — vasospasm + cardiomyopathy
— Immune checkpoint inhibitors — fulminant myocarditis; high-dose steroids
— Cocaine, methamphetamine, anabolic steroids, alcohol
— Amyloid, sarcoid, hemochromatosis (often restrictive but can be dilated late)
— Hyper/hypothyroidism, acromegaly, pheochromocytoma, Cushing, diabetic cardiomyopathy
— Viral myocarditis (Coxsackie B, parvovirus B19, HHV-6, SARS-CoV-2, adenovirus)
— Chagas (T. cruzi) — apical aneurysm + RBBB + LAFB in Latin American immigrant
— HIV, Lyme
— Thiamine (wet beriberi), selenium (Keshan), carnitine, hypocalcemia, hypophosphatemia
— Severe anemia, thyrotoxicosis, AV fistula, Paget disease, beriberi — treat the cause; EF may be preserved or reduced
Step 3 management: Always exclude ischemic etiology (cath or CTA) before diagnosing "idiopathic" DCM in adults — it changes therapy fundamentally (revascularization, antiplatelets, statin intensification).
Board pearl: Latin American immigrant + DCM + RBBB/LAFB + apical aneurysm + GI symptoms (megacolon, megaesophagus) = Chagas disease.
— ARNI (or ACEi/ARB)
— Evidence-based β-blocker (carvedilol, metoprolol succinate, bisoprolol)
— MRA (spironolactone or eplerenone) if K ≤5.0 and eGFR ≥30
— SGLT2 inhibitor (dapagliflozin or empagliflozin) regardless of diabetes
— Loop diuretic at lowest effective dose
— Statin if ischemic etiology or ASCVD indication
— Anticoagulation if AF (CHA₂DS₂-VASc), LV thrombus, prior embolism
— Antiplatelet if ischemic CMP
— Aldactone/Eplerenone dose check, iron studies, B12
— Sodium <2–3 g/day (modest restriction; extreme restriction unhelpful)
— Fluid restriction (1.5–2 L/day) only if hyponatremic or refractory congestion
— Strict alcohol abstinence in alcoholic DCM; ≤1 drink/day others
— Tobacco cessation, illicit drug cessation; refer to programs
— Weight loss for BMI >30
— DASH/Mediterranean dietary pattern
— Annual influenza vaccine
— Pneumococcal (PCV20 or PCV15 + PPSV23 per ACIP)
— COVID-19 boosters per CDC
— RSV vaccine if age ≥60
— Tdap booster, shingles for age ≥50
— Recognize worsening HF: 2 lb overnight or 5 lb/week weight gain, increasing edema, orthopnea, PND → call clinic
— Sick-day rules: hold SGLT2i and diuretic during severe dehydration/illness; resume per provider
— Avoid NSAIDs, high-sodium OTCs, herbal supplements (licorice, ephedra)
— Class I for stable HFrEF — improves QOL, peak VO₂, hospitalizations
— Refer at discharge
Step 3 management: Schedule follow-up within 7–14 days of HF discharge — this single intervention reduces 30-day readmission (transition-of-care quality metric).
Board pearl: Quadruple GDMT + ICD/CRT eligibility check + cardiac rehab referral + 7-day follow-up = the "discharge bundle" Step 3 rewards.
— First post-discharge visit: 7–14 days (telehealth acceptable)
— Every 2 weeks during GDMT titration until target/max tolerated
— Every 3 months once stable; every 6 months in long-term stable patients
— Closer if NYHA III–IV, recent decompensation, advanced HF candidacy
— Symptom review, NYHA class, weight, BP, HR, orthostatics
— Volume status: JVP, lungs, edema, hepatic congestion
— Medication adherence and side effects
— Depression screen (PHQ-9)
— BMP (Na, K, Cr) at 1 week and 1 month after starting/uptitrating ACEi/ARNI/MRA; then every 3–6 months stable
— Magnesium with K
— NT-proBNP — trend at major transitions; routine serial use controversial but accepted
— Annual: TSH, CBC, iron studies, lipids, HbA1c, eGFR, LFTs
— Digoxin level if used (target 0.5–0.9 ng/mL)
— INR every 4 weeks if on warfarin (LV thrombus)
— Repeat echo at 3 months of optimized GDMT (decides ICD/CRT and prognosis)
— Repeat with any clinical change, post-revascularization, post-ICD/CRT
— CMR if etiology unresolved or for prognostic LGE assessment
— ICD/CRT interrogation every 3–6 months (remote monitoring preferred)
— Wound checks, infection surveillance
— Supervised aerobic + resistance training, 36 sessions over 12 weeks
— Improves NYHA class, hospitalization, QOL (HF-ACTION)
— Daily weights, symptom diary
— Sodium and fluid education
— Action plan for "wet" symptoms (sliding-scale diuretic protocol in select patients)
— Advance care planning when stage C–D — initiate early, not at end-of-life
— Driving restrictions after ICD shock (per AHA): private driving — 1 week after primary prevention implant, 6 months after secondary prevention/appropriate shock; commercial driving largely restricted
Step 3 management: A 7–14 day post-discharge visit + medication reconciliation + symptom and weight check = the highest-yield intervention to prevent 30-day readmission.
Board pearl: Repeat echo at 3 months of optimal GDMT — many nonischemic DCM patients recover EF above the ICD threshold and avoid device implantation.
— Initiate discussions early in Stage C, not at terminal decompensation
— Address: code status, ICD deactivation preferences, LVAD/transplant goals, hospice triggers
— ICD deactivation at end of life is ethically and legally permissible — equivalent to withdrawal of other life-sustaining therapy; document patient/surrogate consent
— Distinguish deactivation of shock therapy (allowed even when patient near death to avoid distressing shocks) from pacemaker deactivation (rarely indicated)
— Hospice can coexist with ICD if shocks deactivated
— LVAD/transplant evaluations require capacity assessment, social support, adherence history, substance use sobriety (typically ≥6 months)
— Pregnancy in known DCM — preconception counseling about maternal mortality (10–20% in severe DCM), fetal risk, contraception
— Genetic testing — counsel on implications for relatives, insurance (GINA protects health insurance/employment but not life/disability/long-term care insurance)
— Driving after ICD shock — state-dependent reporting; counsel and document
— Commercial drivers, pilots — federal restrictions with EF thresholds
— Disclose ICD/CRT to MRI facility; many modern devices are MRI-conditional
— Medication reconciliation at every transition — HF meds are high-risk for omission and duplication
— Communicate discharge plan to primary care within 48 hours
— Patient teach-back on warning signs, weight log, diuretic plan
— Beware automatic resumption of held home meds (e.g., ACEi held for AKI) without reassessment
— Verify allergies (ACEi-induced angioedema must be flagged for ARNI risk)
— Black-box warnings: ARNI/ACEi/ARB contraindicated in pregnancy; metformin caution in advanced HF
— Iodinated contrast in CKD + HF — pre-hydration, hold SGLT2i
— Health literacy assessment — HF self-care depends on it
— Transplant/LVAD candidacy must avoid bias; UNOS criteria emphasize medical urgency
— Cost of ARNI, SGLT2i, ivabradine, vericiguat — engage social work, manufacturer assistance
Step 3 management: When a hospice-bound stage D HF patient asks about their ICD, the ethically correct order is discuss goals → obtain consent → device team deactivates shock function → document in chart and notify hospice.
Board pearl: ICD deactivation ≠ physician-assisted death — it is allowed withdrawal of therapy.
— Doxorubicin (cumulative >250 mg/m²); dexrazoxane is cardioprotective
— Trastuzumab — reversible; hold and reassess
— Cocaine, methamphetamine, alcohol (>80 g/day chronic)
— Immune checkpoint inhibitors → fulminant myocarditis (steroids)
— 5-FU → vasospasm + cardiomyopathy
— Coxsackie B, parvovirus B19, HHV-6, adenovirus, SARS-CoV-2 (myocarditis)
— Chagas (T. cruzi) — apical aneurysm, RBBB+LAFB
— HIV (direct + ART-related)
— Lyme — AV block + DCM
— Diphtheria toxin
— TTN (titin) — most common familial DCM
— LMNA — DCM + conduction disease + skeletal myopathy → early ICD
— Duchenne/Becker — X-linked, dystrophin
— Barth syndrome — X-linked, tafazzin (TAZ), neutropenia, 3-methylglutaconic aciduria
— Hyper/hypothyroidism; acromegaly; pheochromocytoma; Cushing; diabetes
— Thiamine (wet beriberi); selenium (Keshan); carnitine; hypocalcemia/phosphatemia
— Apical sparing on strain → amyloid
— Mid-wall septal LGE → genetic/idiopathic DCM
— Subepicardial LGE → myocarditis/sarcoid
— Epsilon wave → ARVC
— Low voltage + thick walls → amyloid
— Apical ballooning, clean cath → Takotsubo
— PARADIGM-HF — ARNI superior to enalapril
— DAPA-HF / EMPEROR-Reduced — SGLT2i in HFrEF
— MADIT-II / SCD-HeFT — primary prevention ICD
— CASTLE-AF — AF ablation in HFrEF
— COAPT — TEER for functional MR
— STICH — CABG in ischemic HFrEF ≤35%
— A-HeFT — hydralazine/ISDN in Black patients
— DANISH — ICD in nonischemic (no all-cause mortality benefit but SCD reduced)
— EF ≤35% on GDMT × 3 months → ICD
— QRS ≥150 ms LBBB → CRT class I
— Peak VO₂ <14 → transplant evaluation
— 40 days post-MI, 90 days post-revasc, 3 months post-GDMT
Board pearl: Memorize the four pillars + four thresholds — you'll answer 70% of HFrEF Step 3 questions correctly.
— "32 yo, EF 25%, idiopathic DCM, started on GDMT 1 month ago, asks about ICD."
— Answer: continue GDMT and reassess EF at 3 months before ICD; wearable defibrillator if high-risk.
— "55 yo with AF in RVR × 1 year, new EF 25%."
— Answer: rate or rhythm control (ablation preferred per CASTLE-AF), then reassess EF — likely reversible.
— "28 yo, 2 weeks postpartum, dyspnea, EF 30%, no prior cardiac history."
— Answer: PPCM; start β-blocker, hydralazine/nitrates (or ACEi/ARNI postpartum, watch breastfeeding compatibility), MRA, diuretic; anticoagulate if EF <35%; counsel on subsequent pregnancy risk.
— "Family history of HF + SCD + pacemakers; patient with EF 38%, first-degree AV block."
— Answer: suspect LMNA; lower threshold for ICD even at EF >35%.
— "DCM patient develops new complete heart block + VT."
— Answer: CMR + FDG-PET; endomyocardial biopsy; immunosuppression; ICD.
— "Breast cancer survivor on doxorubicin + trastuzumab, new EF 35%."
— Answer: pause trastuzumab, ARNI/ACEi + β-blocker (carvedilol/enalapril proven), reassess EF in 3 months; trastuzumab usually reversible.
— "EF 30%, NYHA III, LBBB QRS 160 ms on full GDMT."
— Answer: CRT-D.
— "Multiple HF admissions, on max GDMT, intolerant to ARNI from hypotension, BUN/Cr rising, peak VO₂ 12."
— Answer: advanced HF/transplant referral; consider LVAD/transplant.
— "Stage D patient enrolling in hospice, concerned about device."
— Answer: discuss goals of care; deactivate ICD shock function with consent.
— "55 yo heavy drinker, EF 25%."
— Answer: strict abstinence + GDMT; recheck EF in 3–6 months — substantial reversibility possible.
Step 3 management: When a stem describes a reversible cause, the correct answer always pairs treat the cause + start GDMT — not one or the other.
Board pearl: "Family history of SCD + DCM + AV block" = LMNA — early ICD even if EF >35%.
Dilated cardiomyopathy is LV dilation with EF <40% not explained by ischemia or loading conditions — confirm with echo, hunt aggressively for reversible causes (ischemia, alcohol, tachycardia, peripartum, toxins, thyroid, infiltrative, genetic, infectious), initiate the four pillars of GDMT (ARNI/ACEi/ARB + evidence-based β-blocker + MRA + SGLT2 inhibitor), reassess EF at 3 months, and risk-stratify for ICD/CRT and advanced therapies including transplant or LVAD.
Step 3 management: The discharge bundle = quadruple GDMT + ICD/CRT eligibility documented + cardiac rehab referral + 7–14 day follow-up + vaccinations + advance care planning — execute this every HFrEF admission.
Board pearl: Reversible causes can normalize EF — always treat tachycardia, alcohol, thyroid, peripartum, and ischemia before committing to permanent device therapy.