cardio-met Profile picture
Mar 22 70 tweets 53 min read
1) Welcome to a new #accredited #tweetorial in our series of educational programs on #hypertrophic #cardiomyopathy #HCM. Previous programs, still available for 🆓CE/#CME, are at
Now you can earn another 0.75hr credit by following this 🧵!
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
3) This program is supported by an unrestricted educational grant from Bristol Myers-Squibb. Statement of accreditation and faculty disclosures at Credit for #physicians #nursepractitioners #physicianassociates #nurses #pharmacists from @academiccme.
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
4b) 2020 AHA/ACC Guideline for the Diagnosis & Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the @accintouch / @American_Heart Joint Committee on Clinical Practice Guidelines, from @SteveOmmen et al:
🔓 and
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:
4d) Data summary from
Hypertrophic Cardiomyopathy: New Evidence Since the 2011 American Cardiology of Cardiology Foundation and American Heart Association Guideline, from #ArianeFraiche et al:
5a) So, let's get started:
❓ How will I know when I see a patient with #HCM?
5b) Most individuals with #HCM are asymptomatic & have a normal life expectancy. Most can lead active, normal lifestyles. Individuals who present with symptoms or have a family history #FamHx of HCM may present w/ classic sx & findings which may include any of the following:
Symptoms: #presyncope, #syncope, exertional #dyspnea, activity intolerance, #palpitations, chest pain
5d) Exam findings: individuals with HCM can have a normal physical exam, or may have a notable systolic ejection murmur () that changes intensity during maneuvers that affect contractility, preload and afterload, eg:
🫀 Squatting or passive leg raise ⬇️murmur intensity
🫀 Valsalva, squat-to-stand, or walking ⬆️murmur intensity
🫀 Murmur intensity that ⬆️after a long pause
6a) ❓ What are the common ECG findings in individuals with HCM?
6b) Answer: Increased voltage with or without deep T-wave inversions in the lateral precordial leads. Some individuals with HCM, may have normal ECGs.
7a) ❓ What are important history-taking strategies for surveillance of my patients with known hypertrophic cardiomyopathy #HCM with or without known obstruction?
7b) Answer: Careful physical examination and interval assessment of symptoms remains paramount.
🫀 Symptoms may include #exertional #dyspnea, exertional #angina, exertional #syncope, or #presyncope and may vary based on loading conditions such as dehydration, heat, cold
🫀 Symptoms may be variable based on loading conditions (eg, #hydration, #bloodpressure, temperature)
🫀 #Hypertrophic cardiomyopathy can be misdiagnosed as exercise-induced #asthma, especially for young pts or those in whom coronary artery disease #CAD has been excluded.
👉Importantly, #comorbid conditions can exist in addition to #HCM and may present over time (e.g. #CAD, activity intolerance with orthopedic problems)
🫀 Functional capacity and frequency and severity of symptoms should be assessed at each visit. (e.g. ask patient to rate functional capacity 1-10 at each visit and document).
7f) Most individuals with #HCM are asymptomatic. Those who have symptoms may describe exertional dyspnea, angina, syncope or presyncope or palpitations.
Sx can vary from day to day based on the following conditions:
A. Hydration
B. Blood pressure
C. Humidity
D. All of the above
7g) It's all the above loading conditions, and others, including environmental 🌡️, can impact the frequency and severity of symptoms for individuals with hypertrophic cardiomyopathy #HCM.
8a) ❓Can hypertrophic cardiomyopathy be mis-diagnosed?
8b) Answer: Hypertrophic cardiomyopathy can be mis-diagnosed as #exercise-induced #asthma, #aortic valve #stenosis, or #anginal_equivalent particularly in patients with known or suspected #coronary_artery_disease.
9a) ❓ Which of the following represents a red flag sign or symptom that should be urgently evaluated for individuals with hypertrophic cardiomyopathy:
A. Fatigue
B. Dizziness
C. Palpitations
D. Syncope
9b) Answer: #Syncope in individuals with known hypertrophic cardiomyopathy #HCM may be a marker for malignant ventricular #arrhythmia and always requires urgent evaluation. See 🔓
10a) ❓ What are the classic physical exam findings for an individual with hypertrophic cardiomyopathy with obstruction?
10b) Answer: A #systolic_murmur that changes intensity during maneuvers that effect #contractility, #preload and #afterload:
🫀 Squatting or passive leg raises ⬇️murmur intensity
🫀 #Valsalva, squat to stand or activity such as walking or bicycling 🚲, ⬆️murmur intensity
🫀 The strain phase of #Valsalva, a long pause, or the standing phase of a squat-to-stand maneuver ⬆️ murmur intensity
11a) ❓ What are other symptoms that may occur in individuals with #HCM requiring urgent or emergent evaluation and/or referral?
11b) Answer: Other Red flag 🚨signs or symptoms for individuals with #HCM necessitating urgent or emergent referral include:
🫀 Class 4⃣ #angina or #dyspnea, #syncope or #presyncope or the inability to perform activity without these symptoms.
🫀 A systolic blood pressure #SBP < 90 mmHg accompanied by any of the above symptoms
🫀 heart rate greater than 120 beats per minute accompanied by symptoms
🧠 Any acute neurologic or cognitive change
12a) ❓ What are the initial tests for an individual with a history and physical exam findings consistent with suspected #HCM?
12b) Answer: Initial tests include an #electrocardiogram (assess for #LVH) and an #echocardiogram with strain (to assess for outflow obstruction)
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).
👉Cardiac MRI may be indicated when diagnosis is uncertain.
🫀 Individuals and families with #HCM should be referred to a Center of Excellence for comprehensive care, genetic counseling, family screening and an individualized surveillance plan for the individual and family.
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?
#LVH can be related to other conditions including physiologic adaptation in elite athletes, #hypertension, #aortic valve #stenosis, & all of the following except?
a. amyloidosis
b. chronic kidney disease #CKD
c. mitral valve prolapse
d. glycogen storage dz, (e.g. Fabry Dz)
13c) Mark you response and RETURN TOMORROW for the correct answer, MORE Q&A on #HCM, and your link to 🆓CE/#CME.
👏 @SrihariNaiduMD @SABOURETCardio @pabeda1 @4hcm @EduQuintanaCVS @MagliariRafael @neallakdawala @tikuowens @DrImranSheikh
14) WELCOME BACK! @jlinderbaum is taking us methodically through foundational clinical knowledge of #hypertrophic #cardiomyopathy #HCM and YOU are earning 🆓CE/#CME.
✔️yesterday's quiz? The answer is C; all of the other options are in the #ddx for #HCM.
🫀 Now let's move on!
15a) ❓ Why would a #Holter monitor be indicated in the patient with #HCM?
15b) Answer: #Holter monitor may evaluate the incidence & presence of cardiac #arrhythmias that may occur both w/ or without patient-reported sx. Asymptomatic nonsustained #ventricular #tachycardia in individuals with #HCM is associated w/ ⬆️ risk of sudden cardiac death #SCD.
15c) Holter monitoring is typically recommended every 1-2 years to assess for nonsustained ventricular tachycardia #Vtach or asymptomatic #arrhythmias.
16a) ❓ When should #treadmill #stress_testing be considered for individuals with #hypertrophic #cardiomyopathy?
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.
16c) Exercise testing can also be used to assess for ventricular arrhythmias or hypotension w/ exercise that may indicate ⬆️risk of #SCD, & to identify the presence of a dynamic #LV #outflow obstruction (dynamic in nature, which may be absent at rest, and audible with exercise).
17a) ❓ How is #cardiac #MRI utilized in individuals with hypertrophic cardiomyopathy #HCM?
17b) Answer: #Cardiac MRI with and without #gadolinium is used for #risk_stratification and can be indicative of ⬆️risk for cardiac #arrhythmias. A cardiac MRI will assess the anatomy of the #LV & may sometimes be used in individuals with suboptimal echocardiographic images.
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.
18a) ❓What the risk markers for sudden cardiac death #SCD 🪦 in individuals with hypertrophic cardiomyopathy #HCM?
🫀 Massive hypertrophy with a wall thickness >/= 3 cm
🫀 Family history of unexplained sudden death or #SCD due to known hypertrophic cardiomyopathy
18b) (cont)
🫀 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
19a) ❓ What are the most important symptoms to assess at office visits for individuals with hypertrophic cardiomyopathy?
19b) Answer:
🫀 #Syncope or #presyncope, especially during exercise
🫀 #Chestpain &/or or postprandial #angina equivalent
🫁 #dyspnea with activity or after being supine
🫀 #Palpitations
🫀 Fatigue or activity intolerance
20a) ❓ What is the significance of a dynamic left ventricular outflow tract obstruction #LVOTO >50 mmHg?
20b) Answer: #Dynamic (sometimes present, variable) #LVOTO occurs in ~ 70-75% of ppl w/ #HCM. #Gradient > 30 mmHg at rest may ➡️sx.
Gradients >/= 50 mmHg at rest or w/ provocation & associated w/ sx are considered the threshold for consideration of #septal #reduction therapies.
21a) ❓What should be included in the annual clinical follow-up for persons with #HCM?
🩺Annual clinical exam w/ review of patient education including hydration, aerobic activity, symptom assessment and avoidance of highly strenuous exercise with loading conditions.
21b) (cont)
🫀 #Holter monitor every 1-2 years or with change in symptoms
🫀 Echocardiogram every 1-3 years or change in clinical status
22) ❓What meds should be avoided 🚫in pts with #HCM?
Answer: #Vasodilators & #diuretics should be avoided due to the potential for exacerbation in #LV outflow obstruction. These medications are generally avoided in individuals with HCM.
23a) ❓ What are the common 💊 used for the treatment of #HCM?
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
23b) #Beta_blockers are the preferred initial therapy for symptomatic, dynamic outflow obstruction. BBs ⬇️myocardial contractility & HR response to exercise, which lowers the degree dynamic obstruction. Start at low dose & titrated to a resting HR </= 60 bpm.
23c) #Beta_blockers are usually effective with some symptom improvement in about 70% of individuals with #HCM.
23d) #CCBs ⬇️contractility & HR response to exercise ➡️ degree of obstruction.
Verapamil requires caution in case of severe resting obstruction due to potential for acute hemodynamic deterioration. CCB are usually effective in ~ 60% of individuals with outflow tract obstruction.
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.
24) ❓What are additional lifestyle rec's for individuals with #HCM & #LVOTO?
🌡️Avoid environmental vasodilatation (high temperatures & humidity, hot tubs, saunas)
🫀 Avoid vasodilators, including alcohol, diuretics
🥤Consistent hydration: at least 2 L water per day
25a) ❓When should I refer to an #HCM expert?
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.
25b) Individualized tx options may be indicated:
🫀 Review & titrate 💊
🫀 SCD risk assessment
🫀 advanced management such as a septal myectomy or septal ablation
💊advanced med tx such as #disopyramide or #mavacamten
🧬Advanced genetic screening & family planning
26a) ❓ What are screening options for first-degree family relatives of pts w/ known #HCM?
🧬Genetic testing and/or echocardiographic surveillance should be considered for all first-degree relatives of individuals with hypertrophic cardiomyopathy.
26b) Genetic testing requires referral to a genetic counselor for discussion & evaluation of coverage options. Currently, the yield of genetic testing is ~ 60%, so shared decision making & careful selection of individuals for genetic testing . . .
26c) ... based on clinical and echocardiographic findings can help to identify patients more likely to have a positive genetic test.
26d) Echocardiographic surveillance is necessary when genetic testing is inconclusive/incomplete. Echo screening is rec'd annually for 1st deg relatives & competitive athletes, & every 5 years for other adults as clinically indicated based on age & physical activity status.
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
I am @jlinderbaum of @MayoClinic, #CV #NursePractitioner. Please FOLLOW US for more programs!

• • •

Missing some Tweet in this thread? You can try to force a refresh

Keep Current with cardio-met

cardio-met Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!


Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @cardiomet_CE

Jan 17
1a) Welcome to a new #accredited #tweetorial, “MOA and Clinical Trial Data for Novel & Emerging Therapeutic Strategies for #HCM: Can We Target Our Therapy?"
1b) Our expert (and returning @cardiomet_ce) author is Giuseppe Galati MD, MMSc in Heart Failure, FHFA, @GiuseppeGalati_ , Consultant #Cardiologist #HeartFailure & #Cardiomyopathies
2) @GiuseppeGalati_ is in Milan 🇮🇹 This program is intended for #healthcare professionals & is accredited for 0.75h CE/#CME credit for #physicians #physicianassistants #nurses #nursepractitioners #pharmacists.
Read 46 tweets
Dec 19, 2022
1) Welcome to a new #accredited #tweetorial on #hypertrophic #cardiomyopathy #HCM. Our expert author is Ahmad Masri MD @MasriAhmadMD of @OHSUCardio where he leads the Hypertrophic Cardiomyopathy Ctr. See a previous program from him, on #Fabry disease, at…. Image
2a) This program is intended for #healthcare providers and is supported by an educational grant from Bristol-Myers Squibb. Statement of accreditation and faculty disclosures at FOLLOW US for the most timely expert education in #cardiometabolic care!
2b) #Physicians #Nurses #PhysicianAssociates #NursePractitioners #Pharmacists earn a full 1⃣ hour of 🆓CE/#CME credit from following this 🧵. For educational purposes, Twitter still works!! 😁
Read 93 tweets
Nov 22, 2022
1a) Welcome to a new #accredited #tweetorial on the management of aFXa-DOAC-associated #hemorrhage and specifically the role of coag laboratory testing in these challenging cases.
1b) Our expert author is #pharmacist Craig Beavers, PharmD @beaverspharmd CV Clinical Pharmacy Specialist @UK_COP, and Immediate Past Chair of the @ACCinTouch #ACCCVT Section
2) This 🆓program is accredited for 0.5h CE/#CME for #physicians #physicianassociates #nurses #nurespractitioners #pharmacists and is supported by a grant from AstraZeneca. See statement of accreditation and faculty disclosures at
Read 37 tweets
Oct 18, 2022
1a) Welcome to a new #accredited #tweetorial on a very challenging topic: managing #ICH in a patient taking anti-FXa #DOACs! Your expert authors are both #neurointensivists: Richard Choi, DO @rkchoi @christianacare and Casey Albin, MD @caseyalbin @EmoryNeuroCrit ImageImage
1b) #Physicians #Nurses #Pharmacists #physicianassociate #NPs earn 0.5h CE/#CME from @academiccme for following this 🧵 Image
2) This program is supported by an educational grant from AstraZeneca and is intended for #HCPs. Accreditation statement and faculty disclosures at Prior (& future) programs in this space, available for 🆓CE/#CME credit, at….
Read 52 tweets
Oct 10, 2022
1) Welcome to a new #accredited #tweetorial, Update on New HFrEF Data from ESC 2022 with a Focus on Vericiguat. Our expert author is Giuseppe Galati MD, MMSc in Heart Failure, FHFA, @GiuseppeGalati_ , Consultant #Cardiologist #HeartFailure & #Cardiomyopathies
2) @GiuseppeGalati_ is at San Raffaele Research Hospital, Milan 🇮🇹 @SanRaffaeleMI. This program is intended for #healthcare professionals & is accredited for 0.75h CE/#CME credit for #physicians #physicianassistants #nurses #nursepractitioners #pharmacists.
3) This program is supported by an educational grant from Bayer. See archived programs still open for credit at Statement of accreditation & faculty disclosures at🙏 FOLLOW US !
Read 43 tweets
Aug 1, 2022
Join us tomorrow for the launch of a new #accredited #tweetorial on the primary care management of #hyperlipidemia covering the relationship between #LDL_C & major #CV events, CV risk categories, recommended LDL-C treatment goals, & oral therapeutic options for lipid-lowering
1) Welcome to a new #tweetorial on the primary care management of #hyperlipidemia. Our returning @cardiomet_CE expert author is dedicated #SoMe education advocate Kevin Fernando, FRCGP FRCP Edin, FAcadMEd MSc Diabetes @drkevinfernando
2a) This is the next instalment of @cardiomet_CE's 10-part #tweetorial foundational series on #lipid management! It is accredited for #CME/CE and intended for #physicians #physicianassociates #nurses #nursepractitioners #pharmacists.
#FOAMed @MedTweetorials #cardiotwitter
Read 45 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!


0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy


3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us on Twitter!