Cardiomyopathy, Myocarditis and Pericarditis Flashcards
Causes of dilated cardiomyopathy
Ischaemic and valvular causes Genetic and familial: SCN5A gene, muscle dystrophy Inflammatory, infections, autoimmune, postpartum Injury, cell loss, scar replacement Toxic, drugs, exogenous chemicals, endocrine Irreversible specific causes: - Alcohol - Endocrine - Tropical disease - Post partum - Haemaochromatosis (build up of iron) - Sarcoid
Types of cardiomyopathy
Dilated Cardiomyopathy
Restrictive and Infiltrative cardiomyopathy
Hypertrophic cardiomyopathy
Pathophysiology of DCM
Ventricular function is impaired
Pathophysiology of RCM+ICM
Systolic function may or may not be impaired
Ventricle has reduced compliance and so inability to fill the ventricle well
Types of ICM and RCM
- Non-infiltrative; familial, forms of HCM, scleroderma, diabetic, pseudoxanthoma, elasticum
- Infiltrative; amyloid, sarcoid
- Storage diseases: Haemochromataosis, fabry disease
- Endomyocardial; fibrosis, carcinoid, radiation, drug effects
Pathology of HCM
Myocyte hypertrophy and disarray
Can be generalised or segmental wall thickness
Can be apical, septal or generalised
Impaired relaxation and so behaves in a restrictive manner
If septal hypertrophy this can with mitral valve defect lead to LVOT obstruction
Coronary arteries also affected - small vessel narrowing and consequent ischemia and fibrosis.
Arrhythmias are common
Key causes of pericarditis
Bacterial
Post MI
Dissection of proximal aorta
Neoplasia
Symptoms of dilated cardiomyopathy
Progressive, slow onset Dyspnoea and PND Fatigue Orthopnoea Ankle swelling Weight gain of fluid overload Cough
Signs of DCM
Poor superficial perfusion Thready pulse, irregular in AF SOB at rest Narrow pulse pressure Displaced apex S3 + S4 MR murmur often Pulmonary oedema Pleural effusions Ankle oedema Sacral oedema Ascites Hepatomegaly
Investigations for DCM
Repeated ECG noting if LBBB is present CXR N terminal pro BNP Basic bloods: FBC, U and Es ECHO CMRI Coronary angiogram Sometimes biopsy depending on the course of cardiomyopathy
Investigations of RCM and ICM
Repeated ECG noting LBBB if present and other conduction defects
CXR
N terminal pro BNP
Basic bloods: FBC, U and Es, be on the lookout for sarcoid and haemachromatosis
Auto antibodies for sclerotic CT diseases
Amyloid needs non-cardiac biopsy to help establish the diagnosis
ECHO
Fabry; low plasma alpha galactosidae A activity
CMRI
Symptoms of HCM
Asymptomatic for many Fatigue Dyspnoea Palpitations Anginal like chest pain Exertional pre syncope Syncope related to arrhythmias or LVOT obstruction SCD
Signs of HCM
Can be none
Notched pulse pattern
Irregular pulse if in AF or ectopy
Double impulse over apex, thrills and murmurs, often dynamic, LVOT, murmur will increase
JVP can be raised in very restrictive filling
Investigations for HCM
ECG: often abnormal but can be normal if phenotype is poorly expressed in genotype +ve individuals
ECHO
CMRI
Risk stratification for SCD, may need ICD
Pathology of myocarditis
Infiltration of inflammatory cells into the myocardial layers, reduced function and heart failure, heart block as conduction system is involved, and arrhthymias
Symptoms of myocarditis
Heart failure with SOB, CP in only 26%
Shorter course of a few weeks
May not have fever
Signs of HF
Investigations for myocarditis
ECG usually abnormal Biomarkers often elevated but not falling into a pattern consistent with MI ECHO, can get RWMA CMRI - can see oedema in certain images Low threshold for biopsy Viral DNA PCR Auto antibodies Step antibodies Lyme B burgdorferi HIV
Types of pericardial disease
Pericarditis
Pericardial effusion
Constrictive pericarditis
Symptoms of pericarditis
Fever
Usually 1-2/52 duration
Chest pain with pleuritic and postual features
Sitting forward usually improves the chest pain and lying back makes it worse
Signs of pericarditis
Fever
Pericardial rub LSE
Look for JVP as if effusion is present or substantial haemodynamically relevant then It will be raised
Low BP
Muffled heart sounds and raised JVP should make you think effusion as well as pericarditis
High fever and very unwell despite no effusion may suggest bacterial
Investigations for pericarditis
ECG: widespread ST changes and PR depression of pericarditis
ECHO
Troponin may be raised if myocardial involvement too
Symptoms of pericardial effusion
Fatigue
SOB
Dizzy with low BP
Occasionally chest pain
Signs of pericardial effusion
Pulsus paradoxus JVP raised Low BP \+/- rub \+/- muffled heart sounds Pulmonary oedema very rare in pericardial effusions/tamponade
Investigations of pericardial effusion
Urgent ECHO
CXR can show large cardiac shadow
ECG: with electrical alternans if large effusion
Causes of constrictive pericarditis
Idiopathic Radiation Post-Surgery Autoimmune Renal failure Sarcoid
Symptoms of constrictive pericarditis
Fatigue
SOB
Cough
Signs of constrictive pericarditis
More of right heart failure with oedema Ascites High JVP Jaundice Hepatomegaly AF TR Pleural effusion Pericardial knock
Investigations for constrictive pericarditis
ECHO
Right heart catheter: to differentiate from restrictive cardiomyopathy which can be very difficult
Treatment for DCM
GENERAL MEASURES: Correct anaemia Remove exacerbating drugs e.g. NSAIDs Correct any endocrine disturbance Advise on reduction of fluid and salt intake Advise on managing weight to identify fluid overload. HF nurse referral SPECIFIC MEASURES: ACEI, ATII blockers Diuretics Spironolactone Anticoagulants as required SCD risk assessment with ICD or CRT-D/P implant Cardiac transplant
RCM + ICM treatments
GENERAL MEASURES:
MORE SPECIFIC MEASURES
limited diuretic use as low filling pressures will cause problems
Beta blockers, limited ACEI use
Anticoagulants as required
SCD assessment with ICD or CRT-D/P implant
Cardiac transplant
HCM treatments
GENERAL MEASURES
Avoid heavy exercise
Avoid dehydration
Explore FH and 1st degree relatives, ECGs and ECHOs may be required
Consider genetic testing
Regular FU to reappraise the risks and progressive
SPECIFIC MEASURES
If in AF: anticoagulate
Drugs to try and reenhance relaxation, variable results but often if symptomatic, beta blockers, verapramil, disopryimide
Obstructive forms; surgical or alcohol septal ablation
ICD if required based on risk stratification
Myocarditis treatment
GENERAL MEASURES
Supportive treatment of heart failure and support for brady and tachy arrythmias
Immunotherapy if biopsy or other Ix point to a specific diagnosis
Stop possible drugs or toxic agent exposure
Pericarditis treatment
GENERAL MEASURES
Viral is conservative
Idiopathic gets colchine 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, drain
Pericardial effusion treatment
Drainage is the destination treatment
Send for MCS, neoplastic cells, protein and LDH, most are exudates
Persistent effusion needs a surgical pericardial window made to allow flow to the abdomen
Constrictive pericarditis treatment
Careful and limited diuretics and pericardetomy
