Cardiomyopathy, Myocarditis and Pericarditis Flashcards
what is dilated cardiomyopathy?
Can be one but more often all chambers dilated and functionally impaired
what is the aetiologocial background of dilated cardiomyopathy?
Genetic and familial DCM: SCN5A gene, muscular dystrophy
Inflammatory, infectious, autoimmune, postpartum
Toxic; drugs, exogenous chemicals, endocrine
Injury, cell loss, scar replacement
what are symptoms of dilated cardiomyopathy?
Progressive, slow onset, dyspnoea, fatigue, orthopnoea, PND, ankle swelling, weight gain of fluid overload, cough.
PMH; systemic illness, travel, HT, vascular disease, thyroid, neuromuscular disease
FH ?
SH alcohol, job
what would you see examining a patient with dilated cardiomyopathy?
Poor superficial perfusion, thready pulse, irreg if in AF, SOB at rest, narrow pulse pressure, JVP elevated+/- TR waves, displaced apex, S3 and S4, MR murmur often, pulmonary oedema, pleural effusions, ankle oedema, sacral oedema, acites, hepatomegally
what are the tests you would do for dilated cardiomyopathy?
Repeated ECG noting LBBB if present CXR N termial pro Brain Natriuetic Peptide Basic bloods FBC, U+E Echo CMRI, probably best imaging modality Coronary angiogram
what is restrictive and infiltrative cardiomyopathy?
describes the physiology of filling and myocyte relaxation capacity, the systolic function may or not be impaired
what are the tests for restrictive and infiltrative cardiomyopathy?
Repeated ECG noting LBBB if present and other conduction defects
CXR
N termial pro Brain Natriuetic Peptide
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
what measures would you take with restrictive and infiltrative cardiomyopathy?
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
what is hypertrophic cardiomyopathy?
imaired relaxation is a common feature and systolic function is usually adequate albeit with some functional abnormality
whats the prevelance of hypertrophic cardiomyopathy?
1:500
whats the pathology of hypertrophic cardiomyopathy?
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
what are symptoms of hypertrophic cardiomyopathy?
Asymptomatic for many, fatigue, dyspnoea, anginal like chest pain, exertional pre syncope, syncope related to arrhythmias or LVOT obstruction
what are the examination findings of hypertrophic cadiomyopathy
Examination findings
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
JVP can be raised in very restrictive filling
what are the measures you would take with someone that has hypertrophic cardiomyopathy?
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
what are specific measures for hypertrophic cardiomyopathy?
Drugs to try and enhance relaxation, variable results but often if symptomatic, beta blockers, verapamil, disopyrimide
If in AF anticoagulate
Obstructive form; surgical or alcohol septal ablation
ICD if required based on risk stratification
what is myocarditis?
inflammation of the myocardium
what can myocarditis impair?
myocardial function, conduction and generate arrhythmia
whats the pathology of myocarditis?
Infiltration of inflammatory cells into the myocardial layers, reduced function and heart failure, heart block as conduction system is involved and arrhythmias
what are symptoms of myocarditis?
Heart failure with fatigue, SOB, CP in only 26%
Shorter course of a few weeks
May not have fever
Signs of HF
what are the assessments for myocarditis?
ECG usually abnormal Biomarkers often elevated but not falling in 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
what are the general measures for myocarditis?
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
what is the pericardium?
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
what is pericarditis?
Inflammation of the pericardial layers with or without myocardial involvement
what are the causes of pericarditis?
bacterial, post MI, perforation, dissection of proximal aorta, neoplasia
symptoms of pericardial disease
Usually 1-2/52 duration, chest pain with pleuritic features and postual features, sitting forward usually improves it lying back makes it worse
Fever
signs of pericardial disease
Temp up
, pericardial rub LSE
, look for JVP as if an effusion is present and substantial or haemodynamically relevant then it will be raised,
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
what are the investigations of pericarditis?
ECG and echo, troponin may be raised if myocardial involvement too
general measures of pericardial disease?
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
what are the causes of constrictive pericarditis?
idiopathic radiation post surgery autoimmune rena failure sarcoid
symptoms of constrictive pericarditis
fatigue
shortness of breath
cough
signs of constrictive pericarditis?
Signs more of right heart failure with oedema, ascites, high JVP, jaundice, hepatomegally, AF, TR, pleural effusion, pericardial knock
treatment of constrictive pericarditis?
with careful and limited diuretics and pericardectomy
how do you assess constructive pericarditis?
echo and right heart cath to differentiate from restrictive cardiomyopathy which can be very difficult
