Cardiomyopathy, Myocarditis and Pericarditis Flashcards
Dilated Cardiomyopathy
condition in which the heart becomes enlarged and cannot pump blood effectively.
Genetic causes of dilated cardiomyopathy
SCN5A gene, muscular dystrophy
Other causes of dilated cardiomyopathy (3)
- Inflammatory, infectious, autoimmune, postpartum
- Toxic; drugs, exogenous chemicals, endocrine
- Injury, cell loss, scar replacement
What chambers can dilated cardiomyopathy effect
All 4 chambers and thrombosis is not uncommon
Describe the nature of the symptoms of dilated cardiomyopathy
Progressive and irreversible
Symptoms of dilated cardiomyopathy (9)
- Progressive
- Slow onset
- Dyspnoea
- Fatigue
- Orthopnoea
- PND
- Ankle swelling
- Weight gain of fluid overload
- Cough
PMH of dilated cardiomyopathy (6)
- Systemic illness
- Travel
- HT
- Vascular disease
- Thyroid
- NM disease
Social History (2)
- Alcohol
* Occupation
Examination of dilated cardiomyopathy pulse (6)
- Poor superficial perfusion
- Thready pulse
- AF- irregular pulse
- SOB at rest
- Narrow pulse pressure
- JVP elevated -/+ TR waves
Examination of cardiomyopathy (9)
- Displaced Apex
- S3 S4
- MR murmur often
- Pulmonary oedema
- Pleural effusions
- Ankle oedema
- Sacral oedema
- Ascites
- Hepatomegaly
Basic Evaluation of Dilated Cardiomyopathy (8)
- Repeated ECG noting LBBB (Left bundle branch block)
- CXR
- NBNP
- Basic bloods FBC, U+E
- ECHO
- CMRI- best imaging modality
- Coronary angiogram
- Biopsy depending on time course of cardiomyopathy
General Treatment of Dilated Cardiomyopathy (5)
- Correct anaemia- occurs but aetiology unknown
- Removed exacerbating drugs e.g. NSAIDs
- Correct any endocrine disturbances
- Advise on fluid and salt intake (reduce it)
- Advise on managing weight to identify fluid overload
Specific Treatment for cardiomyopathy (6)
- ACEI, ATII blockers, diuretics
- Beta blockers
- Spironalactone- diuretic drug
- Anticoagulants (thrombus in chambers)
- SCD risk- ICD or CRT-D/P implant
- Cardiac transplant
Prognosis of cardiacmyopathy (2)
- Generally poor and often influenced by the causes where known
- HIV has a very low proportion of survival
Restrictive Cardiomyopathy
restrictive filling of the ventricles. In this disease the contractile function (squeeze) of the heart and wall thicknesses are usually normal, but the relaxation or filling phase of the heart is very abnormal
Infiltrative Cardiacmyopathy
Infiltrative cardiomyopathies (CM) represent a group of acquired and inherited diseases characterized by the deposition of abnormal biological substances within the heart that ultimately lead to cardiac dysfunction.
Non-infiltrative (4)
- Familial
- Scleroderma
- Diabetic
- Pseudoxanthoma elasticum
Infiltrative (2)
Amyloid
Sarcoid
Storage disease cardiomyopathy
- Haemochromatosis
* Fabry disease
Endomyocardial (4)
- Fibrosis
- Carcinoid
- Radiation
- Drug effects
Pathology of restrictive and infiltrative (2)
- 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
Basic evaluation of infiltrative and restrictive cardiomyopathy (9)
- Repeat ECH noting LBBB
- CXR
- NBNP
- Basic bloods FBC, U+E, be on the look out for sarcoid and haemochromatosis
- 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- best imagine modality
Specific Treatment (5)
- Limited diuretic use as low filling pressure will cause problems
- Beta blockers limited ACEI use
- Anticoagulants as required
- SCD risk assessment with ICD or CRT-D/P implant
- Cardiac transplant
Prognosis of infiltrative and restrictive cardiomyopathy
Unless reversible prognosis is poor
Hypertrophic Cardiomyopathy
• Impaired relaxation is a common feature and systolic function is usually adequate albeit with some functional abnormality
Epidemiology of hypertrophic cardiomyopathy
Very common
1:500
Pathology of Hypertrophic Cardiomyopathy (4)
- Myocyte hypertrophy and disarray
- Can be generalised or segmental
- Can be apical, septal or generalised
- Impaired relaxation so behaves in a restrictive manner
Symptoms of Hypertrophic Cardiomyopathy (6)
- Asymptomatic for many
- Fatigue
- Dyspnoea
- Anginal like chest pain
- Exertional pre-syncope
- Syncope related to arrhythmias or LVOT obstruction
Examination of hypertrophic cardiomyopathy
- 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
Assessment of Hypertrophic Cardiomyopathy
- ECG
- ECHO
- CMRI
- Risk stratification for SCD, may need ICD
General treatment for Hypertrophic Cardiomyopathy
- Avoid heavy exercise
- Avoid dehydration
- Explore FH and first-degree relatives
- ECGs may be required
- Consider genetic testing
- Appraise the risks and progress
Specific treatment for hypertrophic cardiomyopathy
- Drugs to try and enhance relaxation- b blockers, verapamil, disopyramide
- If AF- anticoagulant
- Obstructive form; surgical or alcohol septal ablation
- ICD is required based on risk stratification
Myocarditis (4)
- Acute or chronic inflammation of the myocardium
- Can be associated with pericarditis
- Can impair myocardial function, conduction and generate arrhythmias
- Can eventually take on the dilated cardiomyopathy appearance
Most common cause of myocarditis
Viral
Symptoms of Myocarditis
- Heart Failure
- Fatigue
- SOB
- CP in 20%
- May not have fever
- Signs of HF
Assessment for myocarditis
- ECG usually abnormal
- Biomarkers elevated but not falling in a pattern consistent with MI
- ECHO
- CMRI can pick up oedema
- Low threshold for bx
- Viral DNA PCR
- Auto-antibodies
- Strep antibodies
- Lyme B burgdorferi
- HIV
General measures for myocarditis
- Supportive with treatment of heart failure and support for brady and tachy arrhythmias
- Immunotherapy if bx points to a specific diagnosis
- Stop possible drugs or toxic agent exposure
Pericardium
is a reflected lining over the epicardium and the partial parietal pericardium that is the inner portion of the exterior sac around the heart and proximal great vessels
Pericarditis
inflammation of the pericardial layers with or without myocardial involvement
Causes of Pericarditis (5)
- Bacterial
- Post MI
- Perforation
- Dissection of proximal aorta
- Neoplasia
Symptoms of Pericarditis (3)
- Chest pain with pleuritic features
- Postual features- sitting forward improves it and lying back makes it worse
- Fever
Signs of pericarditis(6)
- Temperature
- Pericardial rub
- Raised JVP and an effusion
- Low BP
- Muffled HS
- High fever with no effusion may suggest bacterial
Investigations for Pericarditis (3)
• ECG -Widespread ST changes -PR depression • ECHO • Troponin levels may be raised if there is myocardial involvement
General Measures for pericarditis (3)
- Viral is conservative
- Idiopathic gets colchicine and limited use of NSAIDs
- Bacterial must be drained even if small effusion and antimicrobials given
- If large effusion present and some haemodynamic effects then drain
Symptoms of pericarditis (5)
Overt Fatigue SOB Dizzy Low BP Chest pain
Signs of pericarditis (7)
- Overt
- Pulsus paradoxus
- JVP raised
- Low BP
- Pericardial rub
- Muffled HS
- Pulmonary oedema is very rare
Key tests for pericarditis (5)
- Urgent ECHO
- CXR- large cardiac shadow
- Drainage is the destination treatment
- MCS, neoplastic cells, protein and LDH
- Pericardial effusion needs a surgical pericardial window made to allow flow to abdomen
Occurrence of Constrictive pericarditis
Rare
Causes of Constrictive Pericarditis (5)
- Idiopathic
- Radiation
- Post-surgery
- Autoimmune
- Renal failure
Pathology of constrictive Pericarditis (2)
- Impaired filling
* Myocardium is normal most of the time
Symptoms of constrictive Pericarditis (3)
Fatigue
SOB
Cough
Signs of constrictive Pericarditis (7)
- Right heart failure with oedema
- Ascites
- High JVP
- Jaundice
- Hepatomegally AF
- Pleural effusion
- Pericardial knock
Assessment of constrictive Pericarditis (2)
- ECHO
* Right heart catheter- to differentiate it from restrictive cardiomyopathy
Treatment of constrictive Pericarditis (2)
- Limited diuretics
* Pericardiectomy
