What is the best course of action for a patient with known dilated cardiomyopathy (cardiomyopathy) presenting to the emergency room (ER) with right-sided body weakness and dizziness?

Emergency Management of Dilated Cardiomyopathy with Acute Neurological Deficit

This patient requires immediate neuroimaging (CT or MRI brain) to diagnose a presumed cardioembolic stroke, followed by urgent anticoagulation if hemorrhage is excluded, as dilated cardiomyopathy carries a high thromboembolic risk and right-sided weakness indicates left hemispheric ischemia. 1

Immediate Diagnostic Priorities

Urgent Neurological Assessment

• Obtain emergent non-contrast CT head to exclude hemorrhagic stroke before any anticoagulation decisions 2
• If CT is negative and ischemic stroke is confirmed, proceed with MRI brain with diffusion-weighted imaging to define infarct territory and timing 2
• The combination of known dilated cardiomyopathy with acute focal neurological deficits (right-sided weakness) strongly suggests cardioembolic stroke from left ventricular mural thrombus 1

Cardiac Imaging to Identify Thrombus Source

• Perform urgent transthoracic echocardiography with contrast to assess for intracardiac thrombus, which is common in dilated cardiomyopathy and the likely embolic source 2
• If transthoracic echo is non-diagnostic, proceed to transesophageal echocardiography to definitively exclude left atrial appendage or left ventricular thrombus 2
• Assess left ventricular ejection fraction, as severe LV dysfunction (LVEF <30%) significantly increases thromboembolic risk 2

Rhythm Assessment

• Obtain 12-lead ECG immediately to evaluate for atrial fibrillation, which is common in dilated cardiomyopathy and dramatically increases stroke risk 2, 3
• Initiate continuous cardiac telemetry monitoring, as paroxysmal atrial fibrillation may be the precipitating arrhythmia 3
• Atrial fibrillation in the setting of dilated cardiomyopathy carries an adverse prognosis and requires aggressive anticoagulation 3

Acute Stroke Management

Thrombolytic Therapy Considerations

• If patient presents within 4.5 hours of symptom onset and hemorrhage is excluded, consider IV thrombolysis per standard acute ischemic stroke protocols 4
• However, exercise extreme caution as the presence of severe cardiomyopathy with potential intracardiac thrombus may increase bleeding risk
• Mechanical thrombectomy should be considered for large vessel occlusion if within appropriate time window 4

Anticoagulation Strategy

• Once hemorrhagic stroke is definitively excluded, initiate therapeutic anticoagulation given the high recurrent embolic risk in dilated cardiomyopathy 1
• Direct oral anticoagulants (DOACs) are first-line for stroke prevention in this population 4
• Vitamin K antagonists (warfarin) are second-line if DOACs are contraindicated 4
• The risk of embolism in dilated cardiomyopathy is sufficiently high that moderate-intensity anticoagulation is advisable in most cases 1

Concurrent Heart Failure Management

Optimize Hemodynamics

• Assess volume status carefully, as both pulmonary edema and hypotension can complicate acute stroke management 5
• If pulmonary congestion is present, administer IV loop diuretics cautiously to avoid hypotension that could worsen cerebral perfusion 5
• Monitor blood pressure meticulously—permissive hypertension may be appropriate in acute ischemic stroke, but severe hypertension requires careful reduction 4

Initiate or Optimize Guideline-Directed Medical Therapy

• Begin quadruple therapy with ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors once patient is stabilized, as this reduces mortality by up to 73% 6, 4
• Start with low doses given acute stroke and titrate gradually with close monitoring 4, 5
• Beta-blockers should be initiated cautiously in the acute stroke period to avoid excessive bradycardia or hypotension 5

Arrhythmia Management

If Atrial Fibrillation is Present

• Rate control with beta-blockers is preferred over calcium channel blockers in the setting of reduced ejection fraction 4
• Target ventricular rate of 60-100 beats per minute at rest 2
• Anticoagulation is mandatory and should be continued indefinitely 4

Assess for Ventricular Arrhythmias

• Dilated cardiomyopathy patients face significant burden of ventricular arrhythmias, which typically occur late in disease course 3
• Evaluate for non-sustained ventricular tachycardia on telemetry, as this may indicate need for ICD evaluation after recovery 6, 3
• Sustained monomorphic ventricular tachycardia is the most common sustained ventricular arrhythmia in DCM 3

Risk Stratification and Prognosis

Poor Prognostic Indicators to Assess

• Severe LV and RV enlargement and dysfunction portend worse outcomes 6, 4
• Persistent S3 gallop or right-sided heart failure indicates advanced disease 4
• Moderate to severe mitral regurgitation should be quantified as it is a key prognostic marker 2, 4
• Elevated BNP levels and serum sodium <137 mmol/L are adverse prognostic markers 4

Device Therapy Evaluation

• ICD implantation should be considered if LVEF remains <50% after 3 months of optimal medical therapy, for primary prevention of sudden cardiac death 6, 4
• Cardiac resynchronization therapy (CRT) should be evaluated if left bundle branch block is present on ECG 6, 4
• These decisions should be deferred until after acute stroke recovery and neurological prognosis is clarified 4

Critical Pitfalls to Avoid

Anticoagulation Timing

• Do not delay neuroimaging to rule out hemorrhage before making anticoagulation decisions 2
• Avoid excessive anticoagulation intensity that increases bleeding risk, but recognize that undertreatment leaves patient at high recurrent stroke risk 1

Medication Interactions

• Monitor for digoxin toxicity if patient is on digoxin, especially with concurrent diuretic use and electrolyte abnormalities 4
• Avoid negative inotropic agents (verapamil, diltiazem) as they can worsen systolic dysfunction 6
• Amiodarone should NOT be used to treat asymptomatic non-sustained VT, but may be considered for recurrent symptomatic arrhythmias 4

Blood Pressure Management

• Avoid aggressive blood pressure reduction in acute ischemic stroke, as this may worsen cerebral perfusion 4
• Conversely, avoid permissive hypertension if hemorrhagic transformation risk is high 4

Disposition and Follow-up

Inpatient Management

• Admit to stroke unit or neurological ICU with cardiac monitoring capability 4
• Multidisciplinary team should include neurology, cardiology, and cardiac electrophysiology 2
• Serial neurological examinations to detect early deterioration or hemorrhagic transformation 4

Long-term Anticoagulation

• Lifelong anticoagulation is indicated given the persistent thromboembolic risk from dilated cardiomyopathy 1
• Regular monitoring of anticoagulation intensity and bleeding complications 4
• Patient education regarding signs of recurrent stroke or bleeding 4

Advanced Therapies

• If patient fails to improve despite optimal medical therapy, assess for heart transplantation or mechanical circulatory support candidacy 6, 4
• Continuous-flow left ventricular assist device may be considered as bridge to transplantation in appropriate candidates 4