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Cardiovascular System > Cardiomyopathy > Flashcards

Cardiomyopathy Flashcards

1
Q

Dilated cardiomyopathy overview

A

Ventricular function is impaired, can be primary or as a result of any pathological insult to the myocardium except ischemia and valvular causes.

Can be in all or one chambers and thrombosis is common

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2
Q

Causes of dilated cardiomyopathy

A

Genetics eg SCN5A gene, muscular dystrophy

Inflammatory, infection, autoimmune, postpartum, tropical disease, haemochromatosis, sarcoid

Toxig eg drugs, exogenous chemicals, endocrinology

Injury, cell loss, scar replacement

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3
Q

Symptoms of dilated cardiomyopathy

A

Progressive, slow onset, dysphasia (can’t speak), fatigue, orthopnoea, PND, ankle swelling, weight gain of fluid overload, cough

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4
Q

Possible PMH for dilated cardiomyopathy

A

Systemic illness, travel, HT, vascular disease, thyroid, neuromuscular disease

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5
Q

Examination findings for dilated cardiomyopathy

A

Poor superficial perfusion, thready pulse, irregular if in AF, SOB at rest, narrow pulse pressure, elevated JVP, TR waves if tricuspid valve is incompetent due to expansion, displaced apex, gallop rhythm (S3 and S4), MR murmur, pulmonary oedema, pleural effusion, ankle oedema, sacral oesdema, acites, hepatomegaly

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6
Q

Investigations dilated cardiomyopathy

A

Repeated ECG noting Left Bundle Branch Block

CXR for PO, pleural effusion, cardiac shadow

N termial pro brain natriuretic peptide (screen before doing an echo)

Basic bloods FBC, U&E

Echo

cMRI

Coronary angiogram

Maybe biopsy

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7
Q

Treatment for dilated cardiomyopathy

A 
Correct anaemia
Remove exacerbating drugs eg NSAIDs
Correct endocrine disturbance
Reduce fluid and salt intake
Manage weight to identify fluid overload
HF nurse referral
ACEI, ATII blockers, diuretics
Beta blockers
Spironolactone
Anticoagulants if thrombus
SCD risk and maybe pacemaker
Transplant
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8
Q

Prognosis for dilated cardiomyopathy

A

Poor
Worst with HIV
Best is peripartum

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9
Q

Restrictive and infiltrative cardiomyopathy

A

Less common, again describes the physiology of filling and myocyte relaxation capacity, the systolic function may or not be impaired
About 50% are related to specific clinical disorders, the rest remain unknown

The pathology surrounds the inability to fill well a ventricle whose wall has reduced compliance.
Relaxation of the ventricular wall is an active process that needs functioning intact myocytes, it is not passive.

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10
Q

causes of infilrative myopaythy

A

Amyloid, Sarcoid

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11
Q

causes of non infiltrative myopathy

A

Familial, forms of HCM, Scleroderma, diabetic, pseudoxanthoma elasticum

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12
Q

causes of storage cardiomyopathy

A

Endomyocardial; Fibrosis, carcinoid, radiation, drug effects

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13
Q

basic investigations for restrictive (less compliant) and infiltrative cardiomyopathy

A

Repeated ECG noting LBBB if present and other conduction defects
CXR
N terminal pro Brain Natriuetic Peptide (indicates stretch)
Basic bloods FBC, U+E, be on the look out for sarcoid and haemachromatosis
Auto antibodies for sclerotic CT diseases
Amyloid needs non cardiac biopsy to help establish the diagnosis
Fabry; low plasma alpha galactosidase A activity
Echo
CMRI, probably best imaging modality
Biopsy more helpful but still has high false negative rate

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14
Q

specific measures for restrictive and infiltrative cardiomyopathy

A

More specific measures
Limited diuretic use as low filling pressures will cause problems
Beta blockers limited ACEI use
Anticoagulants as required
SCD risk assessment with ICD or CRT-D/P implant
Cardiac transplant
If iron overload, specific forms of amyloid or Fabrys then specific treatments are available
Endomyocardial fibrosis has little specific treatment

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15
Q

hypertrophic cardiomyopathy

A

Again impaired relaxation is a common feature and systolic function is usually adequate albeit with some functional abnormality
Myocyte hypertrophy and disarray
Can be generalised or segmental wall thickness >14mm or >12mm in primary relative
Can be apical, septal or generalised
Impaired relaxation so behaves in a restrictive manner
If septal hypertrophy this can with mitral valve defect lead to LVOT obstruction

Coronary arteries also affected with small vessel narrowing and consequent ischaemia and fibrosis, arrhythmias are common

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16
Q

symptoms of hypertrophic cardiomyopathy

A

Asymptomatic for many, fatigue, dyspnoea, anginal like chest pain, exertional pre syncope, syncope related to arrhythmias or LVOT obstruction
Breathless, palpitations, syncope, exertional symptoms, SCD

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17
Q

examination findings in hypertrophic cardiomyopathy

A

Can be none !
Notched pulse pattern
Irreg pulse if in AF or ectopy
Double impulse over apex, thrills and murmurs, often dynamic, LVOT murmur will increase with valsalve and decrease with squatting (aortic murmur due to hypertrophy of left ventricle makes it obstricted)
JVP can be raised in very restrictive filling

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18
Q

assessment for hypertrophic cardiomyopathy

A

ECG, often abnormal but a few are normal where phenotype is poorly expressed in genotype +ve individuals
Echo
CMRI
Risk stratification for SCD, may need ICD
Holters repeatedly, ETT, FH ?

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19
Q

general measures for hypertrophic cardiomyopathy

A

Avoid heavy exercise
Avoid dehydration
Explore FH and first degree relatives, ECGs and echoes may be required
Consider genetic testing
Regular FU to re appraise the risks and progress

20
Q

specific measures for hypertrophic cardiomyopathy

A

Drugs to try and enhance relaxation, variable results but often if symptomatic, beta blockers, verapamil(CCB), disopyrimide(SCB antiarrhythmia)
If in AF anticoagulate
Obstructive form; surgical or alcohol septal ablation
ICD if required based on risk stratification

21
Q

myocarditis

A

Acute or chronic inflammation of the myocardium
Can be in association with pericarditis
Can impair myocardial function, conduction and generate arrhythmia
Long list of possible causes………
However often the cause is not found despite investigations

Can eventually take on the dilated cardiomyopathy appearance

Prevalence 8-10 pre 100000
Most common is viral

22
Q

pathology of myocarditis

A

Infiltration of inflammatory cells into the myocardial layers, reduced function and heart failure, heart block as conduction system is involved and arrhythmias

23
Q

symptoms of myocarditis

A

Heart failure with fatigue, SOB, CP in only 26%
Shorter course of a few weeks
May not have fever
Signs of HF

24
Q

assessment for myocarditis

A 
ECG usually abnormal
 Biomarkers often elevated but not falling in a pattern consistent with MI
 Echo, can get RWMA (regional wall motion abnormalities)
 CMRI can see oedema in certain images
 Low threshold for biopsy
 Viral DNA PCR
 Auto antibodies
 Step antibodies
 Lyme B burgdorferi
 HIV
25
Q

general measures for myocarditis

A

Supportive with treatment of heart failure and support for brady and tachy arrhythmias.
Immunotherpay if biopsy or other Ix point to a specific diagnosis
Stop possible drugs or toxic agent exposure

26
Q

prognosis of myocarditis

A

30% recovery fully but 20% mortality at 1 year and 56% by 4 years. At 11 years those still alive are 93% transplant free.

27
Q

pericarditis

A

Inflammation of the pericardial layers with or without myocardial involvement
Pericardium is a reflected lining over the epicardium (the viceral pericardium) and the parietal pericardium that is the inner portion of the exterior sac around the heart and proximal great vessels

28
Q

key causes of pericarditis

A

bacterial, post MI, perforation, dissection of proximal aorta, neoplasia

29
Q

symptoms of pericarditis

A

Usually 1-2/52 duration, chest pain with pleuritic features and postual features, sitting forward usually improves it lying back makes it worse
Fever

30
Q

signs of pericarditis

A

Temp up, pericardial rub LSE, look for JVP as if an effusion is present and substantial or haemodynamically relevant then it will be raised (because it squeezes the heart), low BP, muffled HS and raised JVP should make you consider not just pericarditis but effusion
High fever and very unwell despite no effusion may suggest bacterial

31
Q

investigations for pericardial disease

A

ECG and echo, troponin may be raised if myocardial involvement too

32
Q

ECG for pericardial disease

A

ECG with widespread ST elevation changes and PR depression of pericarditis

33
Q

general measures for pericarditis

A

Viral is conservative
idiopathic gets colchicine and limited use of NSAIDs
Bacterial must be drained even if small effusion and antimicrobials, high death rate
If large effusion present and some haemodynamic effects then drain

34
Q

pericardial effusion

A

May be haemodynamically significant = tamponade or not
Often same causes as pericarditis
Where tamponade is present

35
Q

symptoms of pericardial effusion

A

fatige, SOB, dizzy with low BP, occasionally chest pain.

36
Q

signs of pericardial effusion

A

pulsus paradoxus, JVP raised, low BP, +/- rub, +/- muffled HS. Pulmoary oedema is very rare in pericardial effusions/tampaonade

37
Q

investigations for pericardial effusion

A

CXR can show large cardiac shadow

MCS (urine), neoplasic cells, protein and LDH, most are exudates

38
Q

treatment for pericardial effusion

A

Drainage is the destination treatment

Persistent effusion needs a surgical pericardial window made to allow flow to abdomen

39
Q

ECG for pericardial effusion

A

electronic alternans (alternating QRS altitude)

40
Q

constrictive pericarditis

A

impaired filling although myocardium is normal most of the time

41
Q

causes of constrictive pericarditis

A

idopathic, radiation, post surgery, autoimmune, renal failure, sarcoid

42
Q

symptoms of restrictive pericarditis

A

fatigue, SOB, cough

43
Q

signs of restrictive pericarditis

A

right heart failure with oedema, ascites, high JVP, jaundice, hepatomegally, AF, TR, pleural effusion, pericardial knock

44
Q

investigations of restrictive pericarditis

A

Assess with echo and right heart cath to differentiate from restrictive cardiomyopathy which can be very difficult

45
Q

treatment of restrictive pericarditis

A

Treatment is with careful and limited diuretics and pericardectomy

Cardiovascular System (33 decks)

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