Cardiomyopathy, Myocarditis and Pericarditis

Question 1

what is dilated cardiomyopathy?

Answer 1

Can be one but more often all chambers dilated and functionally impaired

Question 2

what is the aetiologocial background of dilated cardiomyopathy?

Answer 2

Genetic and familial DCM: SCN5A gene, muscular dystrophy

Inflammatory, infectious, autoimmune, postpartum

Toxic; drugs, exogenous chemicals, endocrine

Injury, cell loss, scar replacement

Question 3

what are symptoms of dilated cardiomyopathy?

Answer 3

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

Question 4

what would you see examining a patient with dilated cardiomyopathy?

Answer 4

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

Question 5

what are the tests you would do for dilated cardiomyopathy?

Answer 5

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

Question 6

what is restrictive and infiltrative cardiomyopathy?

Answer 6

describes the physiology of filling and myocyte relaxation capacity, the systolic function may or not be impaired

Question 7

what are the tests for restrictive and infiltrative cardiomyopathy?

Answer 7

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

Question 8

what measures would you take with restrictive and infiltrative cardiomyopathy?

Answer 8

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

Question 9

what is hypertrophic cardiomyopathy?

Answer 9

imaired relaxation is a common feature and systolic function is usually adequate albeit with some functional abnormality

Question 10

whats the prevelance of hypertrophic cardiomyopathy?

Answer 10

1:500

Question 11

whats the pathology of hypertrophic cardiomyopathy?

Answer 11

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

Question 12

what are symptoms of hypertrophic cardiomyopathy?

Answer 12

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

Question 13

what are the examination findings of hypertrophic cadiomyopathy

Answer 13

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

Question 14

what are the measures you would take with someone that has hypertrophic cardiomyopathy?

Answer 14

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

Question 15

what are specific measures for hypertrophic cardiomyopathy?

Answer 15

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

Question 16

what is myocarditis?

Answer 16

inflammation of the myocardium

Question 17

what can myocarditis impair?

Answer 17

myocardial function, conduction and generate arrhythmia

Question 18

whats the pathology of myocarditis?

Answer 18

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

Question 19

what are symptoms of myocarditis?

Answer 19

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

Question 20

what are the assessments for myocarditis?

Answer 20

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

Question 21

what are the general measures for myocarditis?

Answer 21

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

Question 22

what is the pericardium?

Answer 22

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

Question 23

what is pericarditis?

Answer 23

Inflammation of the pericardial layers with or without myocardial involvement

Question 24

what are the causes of pericarditis?

Answer 24

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

Question 25

symptoms of pericardial disease

Answer 25

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

Question 26

signs of pericardial disease

Answer 26

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

Question 27

what are the investigations of pericarditis?

Answer 27

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

Question 28

general measures of pericardial disease?

Answer 28

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

Question 29

what are the causes of constrictive pericarditis?

Answer 29

idiopathic
radiation
post surgery
autoimmune
rena failure
sarcoid

Question 30

symptoms of constrictive pericarditis

Answer 30

fatigue
shortness of breath
cough

Question 31

signs of constrictive pericarditis?

Answer 31

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

Question 32

treatment of constrictive pericarditis?

Answer 32

with careful and limited diuretics and pericardectomy

Question 33

how do you assess constructive pericarditis?

Answer 33

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