Cardiomyopathy, Myocarditis and Pericarditis Flashcards
<p>What are the different types of cardiomyopathy?</p>
<p>Hypertrophic</p>
<p>Dilated</p>
<p>Restrictive</p>
<p>Myocarditis</p>
<p></p>
<p>What are thedifferent types of pericardial disease?</p>
<p>Pericarditis and effusion (with or without tamponade)</p>
<p>What is dilated cardiomyopathy?</p>
<p>A condition when the heart becomes enlarged and cannot pump blood efficiently, affects other body systems such as the lungs, liver.</p>
<p>Why does dilated cardiomyopathy result in ventricular remodelling?</p>
<p>Left or right systolic pump is impairedleading to progressiveheart enlargementviaventricular hypertrophyandventricular dilation,</p>
<p>What is dilated cardiomyopathy often a cause of?</p>
<p>Congestive heart failure</p>
<p>Thrombosis in chambers is not uncommon</p>
<p>What are the possible genetic aetiological backgrounds for dilated cardiomyopathy?</p>
<p>Mutations in the SCN5A gene (a heart sodium channel gene)</p>
<p>Muscular dystrophy</p>
<p>What are the possible aetiological backgrounds for dilated cardiomyopathy? (besides genetic causes)</p>
<p>Pregnancy (post partum)</p>
<p>Chagas disease</p>
<p>Toxic insults, including drugs, chemicals and hormones (doxorubicin(Adriamycin), andcobalt are included)</p>
<p>Injury</p>
<p>Inflammatory response</p>
<p>Infection</p>
<p>Autoimmune disease</p>
<p>Chronic severe ventricular extrasystole</p>
<p>Fibrous change of the myocardium from a previousmyocardial infarction</p>
<p></p>
<p>Which chambers are affected in dilated cardiomyopathy?</p>
<p>Can be one but more often all chambers dilated and functionally impaired</p>
<p>What is the prognosis for dilated cardiomyopathy?</p>
<p>Some causes are specifically sought as they are reversible/part reversible but most are progressive and irreversible</p>
<p>What are the symptoms of dilated cardiomyopathy?</p>
<p>•Progressive, slow onset,</p>
<p>Dyspnoea</p>
<p>Fatigue</p>
<p>Orthopnoea</p>
<p>PND (paroxysmal nocturnal dyspnoea)</p>
<p>Ankle swelling</p>
<p>Weight gain of fluid overload</p>
<p>Cough.</p>
<p>What is a typical past medical history for someone with dilated cardiomyopathy?</p>
<p>Systemic illness</p>
<p>Travel</p>
<p>Hypertension</p>
<p>Vascular disease</p>
<p>Thyroid</p>
<p>Neuromuscular disease</p>
<p>What would you find on examination of someone with dilated cardiomyopathy?</p>
<p>Poor superficial perfusion</p>
<p>Thready pulse</p>
<p>Irregular pulse if in atrial fibrillation</p>
<p>SOB at rest</p>
<p>Narrow pulse pressure</p>
<p>JVP elevated</p>
<p>Displaced apex beat</p>
<p>S3 and S4 heart sounds</p>
<p>MR murmur</p>
<p>oedema (pulmonary, ankle and sacral)</p>
<p>Pleural effusions</p>
<p>Acites</p>
<p>Hepatomegaly</p>
<p>What are the relevant investigations for dilated cardiomyopathy?</p>
<p>Repeated <strong>ECG</strong> noting LBBB if present</p>
<p><strong>CXR</strong></p>
<p><strong>Basic bloods</strong></p>
<p>N terminal pro <strong>Brain Natriuretic peptide</strong></p>
<p>Basic bloods <strong>FBC</strong>, <strong>U + E</strong></p>
<p><strong>Echo</strong></p>
<p><strong>CMRI</strong> (best imaging modality)</p>
<p><strong>Coronary angiogram</strong></p>
<p>Sometimes <strong>biopsy</strong> depending on time course of cardiomyopathy</p>
<p>What is general measures in the treatmentof dilated cardiomyopathy?</p>
<p>•Correct anaemia</p>
<p>• Remove exacerbating drugs eg NSAIDs</p>
<p>• Correct any endocrine disturbance</p>
<p>• Advise on fluid and salt intake, reduce it</p>
<p>• Advise on managing weight to identify fluid overload</p>
<p>• HF nurse referral</p>
<p>What are the more specific measures in the treatment of dialted cardiomyopathy?</p>
<p><strong>ACEi</strong></p>
<p><strong>Angiotensin receptor blockers</strong></p>
<p><strong>Diuretics</strong></p>
<p><strong>Beta Blockers</strong></p>
<p><strong>Spironolactone</strong></p>
<p><strong>Anticoagulants as required</strong></p>
<p>Risk of sudden cardiac death is reduced with <strong>implantable cardioversion devices</strong> (small defibrillators) or <strong>Cariac resynchronisation therapy defibrillators</strong> (these devicesresynchronizes the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently, they also have the function of a defibrillator)</p>
<p><strong>Cardiac Transplant</strong></p>
<p>What is restrictive cardiomyopathy?</p>
<p>Whenthe walls of the heart are rigidand the heart is restricted from stretching and filling with blood properly.</p>
<p>What are the non infilatrative forms of restrictive cardiomyopathy?</p>
<p>Familial</p>
<p>Forms of hypertrophic cardiomyopathy</p>
<p>Scleroderma (a chronic hardening and contraction of the skin and connective tissue, either locally or throughout the body - autoimmune disease)</p>
<p>Diabetic pseudoxanthoma elasticum (degeneration of elastic fibres within the body)</p>
<p>What are the infiltrative forms of restrictive cardiomyopathy?</p>
<p>Amyloidosis and sarcoidosis</p>
<p>What are the storage disease associated with restrictiva cardiomyopathy?</p>
<p><strong>Haemachromatosis</strong> (a hereditary disorder in which iron salts are deposited in the tissues, leading to liver damage, diabetes mellitus, and bronze discoloration of the skin.)</p>
<p><strong>Fabry disease</strong> (a rare genetic lysosomal storagedisease - alpha-galactosidase A deficiency)</p>
<p>What are theEndomyocardial conditions asoociated withRestrictivecardiomyopathy?</p>
<p>Fibrosis, carcinoid, radiation, drug effects</p>
<p>Why is the process of relaxation of the ventricular walls described as active rather than passive?</p>
<p>It needs functioning intact myocytes</p>
<p>What are the relevant investigations for restrictive cardiomyopathy?</p>
<div>•Repeated ECG noting LBBB if present and other conduction defects</div>
<div>• CXR</div>
<div>• N termial pro Brain Natriuetic Peptide</div>
<div>• Basic bloods FBC, U+E, be on the look out for sarcoid and haemachromatosis</div>
<div>• Auto antibodies for sclerotic CT diseases</div>
<div>• Amyloid needs non cardiac biopsy to help establish the diagnosis</div>
<div>• Fabry; low plasma alpha galactosidase A activity</div>
<div>• Echo</div>
<div>• CMRI, probably best imaging modality</div>
<p>Biopsy more helpful but still has high false negative rate</p>
<p>What is meant by amyloidosis?</p>
<p>Amyloidosisis a rare and serious disease caused by accumulation ofproteinsin the form of abnormal, insoluble fibres, known asamyloidfibrils, within theextracellular spacein the tissues of the body</p>
<p>What are the general measures for restrictive cardiomyopathy?</p>
<p>•Limited diuretic use as low filling pressures will cause problems</p>
<p>• Beta blockers limited ACEI use</p>
<p>• Anticoagulants as required</p>
<p>• SCD risk assessment with ICD or CRT-D/P implant</p>
<p>• Cardiac transplant</p>
<p>If iron overload, specific forms of amyloid or Fabrys then specific treatments are available</p>
<p>Endomyocardial fibrosis has little specific treatment</p>
<p><u>Prognosis</u></p>
<p>Unless reversible then poor prognosis</p>
<p>Define hypertrophic cardiomyopathy</p>
<p>Hypertrophic cardiomyopathy(HCM) is a disease in which a portion of themyocardium(heart muscle) ishypertrophic(enlarged) without any obvious cause, creating functional impairment of the heart.</p>
<p>Theleft ventricle(one of your heart's four chambers) is almost always affected, and in some people the muscle of the right ventricle also thickens.</p>
<p>What gene is responsible for hypertrophic cardiomyopathy?</p>
<p>Sarcomere gene</p>
<p>What is the inheritance pattern for hypertrophic cardiomyopathy?</p>
<p>Autosomal dominant but with variable expression and incomplete penetrance</p>
<p></p>
<p>50% chance of inheriting the gene but how it is expressed is not known until time passes</p>
<p>Where are the possible places that hypertrophy can occur in the heart?</p>
<p>Apical, septal or generalised</p>
<p>Why does cardiac hypertrophy often present in a restrictive manner?</p>
<p>Because there is impaired relaxation</p>
<p>What is the complication associated with septal hypertrophy?</p>
<p>With mitral valve defect can lead to Left ventriculr outflow tract obstruction</p>
<p></p>
<p>LVOTis nearly indistinguishable from the rest of the ventricle</p>
<p>What is the effect of hypertrophiccardiomyopathy on the coronary arteries?</p>
<p>Causes small vessel narrowing and consequent ischaemia and fibrosis, arrhythmias are common</p>
<p>What are the symptoms of hypertrophic cardiomyopathy?</p>
<p>Asymptomatic for many</p>
<p>Fatigue</p>
<p>Dyspnoea</p>
<p>Anginal like chest pain</p>
<p>Exertional pre syncope</p>
<p>Syncope related to arrhythmias</p>
<p>LVOT obstruction</p>
<p>What are the examination findings for hypertrophic cardiomyopathy?</p>
<p>•Notched pulse pattern</p>
<p>• Irreg pulse if in AF or ectopy</p>
<p>• Double impulse over apex, thrills and murmurs, often dynamic, LVOT murmur will increase with valsalve and decrease with squatting</p>
<p>• JVP can be raised in very restrictive filling</p>
<p>What is the assessment for hypertrophic cardiomyopathy?</p>
<p>•ECG, often abnormal but a few are normal where phenotype is poorly expressed in genotype +ve individuals</p>
<p>• Echo</p>
<p>• CMRI</p>
<p>• Risk stratification for SCD, may need ICD</p>
<p>Exercise tolerance test</p>
<p>FH</p>
<p>What are the general measures in the treatment of hypertrophic cardiomyopathy?</p>
<p>•Avoid heavy exercise</p>
<p>• Avoid dehydration</p>
<p>• Explore FH and first degree relatives, ECGs and echoes may be required</p>
<p>• Consider genetic testing</p>
<p>What are the specific measures in the treatment of hypertrophic cardiomyopathy?</p>
<p>•Drugs to try and enhance relaxation, variable results but often if symptomatic, <strong>beta blockers, verapamil, disopyrimide</strong></p>
<p>• If in AF <strong>anticoagulate</strong></p>
<p>• Obstructive form; surgical or alcohol septal ablation</p>
<p>• <strong>ICD</strong> if required based on risk stratification</p>
<p>What is myocarditis?</p>
<p>Acute or chronic inflammation of the myocardium</p>
<p>What is restrictive myocarditis often confused for?</p>
<p>Constrictive pericarditis</p>
<p>What is the effect of cardiomyopathy?</p>
<p>Can impair myocardial function, conduction and generate arrhythmia</p>
<p>What are a few of the possible causes of myocarditis?</p>
<p>Viral - Adenovirus, Hep C, HIV</p>
<p>Bacterial - Mycobacterial Species, Chlamydiapneumoniae, Streptococcal species, treponum pallidum</p>
<p>Fungal - Aspergillus, candida</p>
<p>Toxins - anthracylines, cocaine</p>
<p>Autoimmune activation - Giant cell myocarditis, small pox vaccination</p>
<p>Protozoal - trypanosoma cruzi</p>
<p>Parasitic - Schistosomiasis, larva migrans</p>
<p>Hypersensitivity - clozapine, penicillin</p>
<p>Where are the inflammatory cells in myocarditis?</p>
<p>Infiltration of inflammatory cells into the myocardial layers</p>
<p>What is the result of myocarditis on the electrical function of the heart?</p>
<p>Can result in heart block and arrhythmias</p>
<p>What are the symptoms of myocarditis?</p>
<p><strong>Heart Failure with fatigue</strong></p>
<p><strong>SOB</strong></p>
<p><strong>Chest pain</strong> only in a quarter of patients</p>
<p>May not have fever</p>
<p><strong>Signs of Heart Failure</strong></p>
<p>What are the relevant investigations for myocarditis?</p>
<p>• ECG usually abnormal</p>
<p>• Biomarkers often elevated but not falling in a pattern consistent with MI</p>
<p>• Echo, can get RWMA</p>
<p>• CMRI can see oedema in certain images</p>
<p>• Low threshold for biopsy</p>
<p>• Viral DNA PCR</p>
<p>• Auto antibodies</p>
<p>• Step antibodies</p>
<p>• Lyme B burgdorferi</p>
<p>• HIV</p>
<p>What is the treatment for myocarditis?</p>
<p>Treatment of heart failure</p>
<p>Support for brady and tachycardia arrhytmias</p>
<div>•Immunotherpay if biopsy or other Ix point to a specific diagnosis</div>
<div>• Stop possible drugs or toxic agent exposure</div>
<p></p>
<p></p>
<p>What is prognosis for myocarditis?</p>
<div>•30% recovery fully but 20% mortality at 1 year and 56% by 4 years. At 11 years those still alive are 93% transplant free.</div>
<p>What is pericarditis?</p>
<p>INflamamtino of the pericardial layers with or without myocardial involvement</p>
<p>What are the most common causes of pericarditis?</p>
<p>Mostly idiopathic or viral (echovirus, adenovirus)</p>
<p></p>
<p>Key ones to pick up are bacterial (streptococcus, staphylococcus, lymes disease)post MI (free wall rupture), perforation, dissection of proximal aorta, neoplasia</p>
<p>What are the symptoms of pericardial disease?</p>
<p>Usually 1-2/52 duration, chest pain with pleuritic features and postual features, sitting forward usually improves it lying back makes it worse</p>
<p>Fever</p>
<p>What are the signs of pericardial disease?</p>
<p>High temperature</p>
<p>Pericardial rub</p>
<p>Raised JVP (if there is a substantial or haemodynamically relevant effusion is present)</p>
<p>Low blood pressure</p>
<p>Muffled heart sounds</p>
<p>Very unwell with a high fever and NO effusion can suggest bacterial</p>
<p>What are the investigations for pericardial disease?</p>
<p>ECG</p>
<p>ECHO</p>
<p>Troponin may be raised if myocardial involvement too</p>
<p>What are the features of pericardial disease on an ECG?</p>
<p>Diffuse ST segment elevation and PR segment depression</p>
<p>What is the general measures for pericardial disease?</p>
<p>•Viral is conservative</p>
<p>• Idiopathic gets colchicine and limited use of NSAIDs</p>
<p>• Bacterial must be drained even if small effusion and antimicrobials, high death rate</p>
<p>• If large effusion present and some haemodynamic effects then drain</p>
<p>Define tamponade</p>
<p></p>
<p>Compression of the heart by an accumulation of fluid in the pericardial sac.</p>
<p>What are the causes of pericardial effusion?</p>
<p>•Often same causes as pericarditis</p>
<p>Wat are the symptoms of pericardial effusion where tamponade is present?</p>
<p>Symptoms are overt, fatige, SOB, dizzy with low BP, occasionally chest pain.</p>
<p>Define pulsus paradoxus?</p>
<p>An abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.</p>
<p>What are the signs of pericardial disease when tamponade is present?</p>
<p>Pulsus paradoxus</p>
<p>JVP raised</p>
<p>Low blood pressure</p>
<p>Sometimes pericardial rub</p>
<p>Sometimes muffled heart sounds</p>
<p>Pulmonary oedema is very rare</p>
<p>What is the test for pericardial effusion?</p>
<p>Urgent echo</p>
<p>CXR can show large cardia shadow</p>
<p>What is the treatment for pericardial effusion?</p>
<p>Drainage</p>
<p>Persistent effusion needs a surgical pericardial window made to allow flow to abdomen</p>
<p>What are the causes of constrictive pericarditis?</p>
<p>Causes are idopathic, radiation, post surgery, autoimmune, renal failure, sarcoid.</p>
ECG of tamponade
ECHO with large effusion
<p>What is the pathology of constricitve pericarditis?</p>
<p>Pathology is that of impaired filling although myocardium is normal most of the time</p>
<p>What are the symptoms and signs ofConstricitve pericarditis</p>
<p>Symptoms of <strong>fatigue</strong>, <strong>SOB</strong>, <strong>cough</strong></p>
<p>Signs more of right heart failure with <strong>oedema</strong>, <strong>ascites</strong>, high <strong>JVP</strong>, <strong>jaundice</strong>, <strong>hepatomegally</strong>, <strong>AF</strong>, <strong>TR (tricuspid regurgitation?)</strong>, <strong>pleural effusion</strong>, <strong>pericardial</strong> <strong>knock</strong></p>
<p>What is the investigation for Constricitve pericarditis?</p>
<p>Assess with echo and right heart cath to differentiate from restrictive cardiomyopathy which can be very difficult</p>
<p>What is treatment forConstricitve pericarditis?</p>
<p>Treatment is with careful and limited diuretics and pericardectomy</p>
<p>What is pericardectomy?</p>
<p>Pericardiectomyis the surgical removal of part or most of the pericardium. This operation is most commonly done to relieve constrictive pericarditis or to remove a pericardium that is calcified and fibrous.</p>
