Cardiomyopathy, Myocarditis + Pericarditis Flashcards
Dilated cardiomyopathy
A structural and functional description where the ventricular function is impaired
How can dilated cardiomyopathy occur?
- Primary problem
- End result of pathological injury to myocardium
Excluding ischaemia and valvular causes, what is the aetiology of dilated cardiomyopathy?
- Genetic and familial ( SCN5A gene, Muscular dystrophy)
- Inflammatory (infectious, autoimmune, postpartum)
- Toxic (drugs, exogenous chemicals, endocrine)
- Injury (cell loss, scar replacement)
What is the pathological change in dilated cardiomyopathy?
- Can be 1 but often all chambers are dilated and therefore functionally impaired
- Thrombosis isn’t uncommon
What are the symptoms of dilated cardiomyopathy?
- Progressive and slow onset
- Dyspnoea
- Fatigue
- Orthopnoes
- PND
- Ankle swelling
- Weight gain of fluid overload
- Cough
PMH of dilated cardiomyopathy
- Systemic illness
- Travel
- HT
- Vascular disease
- Thyroid
- Neuromuscular disease
SH of dilated cardiomyopathy
- Alcohol
- Job
What would be found on examination of dilated cardiomyopathy?
- Poor superficial perfusion
- Thready pulse
- Irregular pulse if in AF
- SOB at rest
- Narrow pulse pressure
- JVP elevated +/- TR waves
- Displace apex beat
- S3 and S4
- MR murmur
- Pulmonary oedema
- Pleural effusion
- Ankle oedema
- Sacral oedema
- Ascites
- Hepatomegaly
What investigations should be carried out for dilated cardiomyopathy?
- Repeated ECG noting LBBB if present
- CXR
- N terminal pro Brain Natriuretic peptide
- Bloods
- ECHO
- CMRI
- Coronary angiogram
- Biopsy
What are the general measures in treating dilated cardiomyopathy?
- Correct anaemia
- Remove exacerbating factors
- Correct endocrine disturbances
- Advise on fluid and salt intake
- Manage weight
- HF nurse referral
What are the specific treatments for dilated cardiomyopathy?
-ACE inhibitors, ATII blockers, diuretics
-B-blockers
-Spironolactone
-Anticoagulants
-SCD risk assessment
Cardiac transplant
What is the prognosis of dilated cardiomyopathy?
Generally poor and often influenced by the causes where known
Restrictive and infiltrative cardiomyopathy.
Less common than dilated, describes the physiology of filling and myocyte relaxation capacity, the systolic function may or may not be impaired
What is the aetiology of restrictive and infiltrative cardiomyopathy?
- Non infiltrative (Familial forms of HCM, Scleroderma, Diabetic, pseudoxanthoma elasticum)
- Infiltrative (Amyloid, Sarcoid)
- Storage diseases (haemochromatosis, Fabry disease)
- Endomyocardial (Fibrosis, carcinoid, radiation, drug effects)
What is the pathology of restrictive and infiltrative cardiomyopathy?
- The inability to fill a ventricle whose wall has reduced compliance.
- relaxation of the ventricular wall us an active process that needs functioning intact myocytes
What are the investigations carried out for restrictive and infiltrative cardiomyopathy?
-Repeated ECG noting LBBB and other conduction defects
-CXR
-N terminal pro Brain Natriuretic peptide
-Blood (sarcoid, hemochromatosis)
-Auto antibodies for sclerotic CT disease
-Amyloid needs non cardiac biopsy
-Fabry: low plasma alpha galactosidase A activity
-ECHO
CMRI
-Biopsy
What are the specific treatment measures for restrictive and infiltrative cardiomyopathy?
- Limited diuretic use as low filling pressures
- B-blockers, limited ACEI use
- Anticoagulants
- SCD risk assessment
- Cardiac transplant
What is the prognosis for restrictive and infiltrative cardiomyopathy?
Poor unless reversible
What is the morphological description of hypertrophic cardiomyopathy?
Impaired relaxation is a common feature and systolic function is usually adequate albeit with some functional abnormality
Why does hypertrophic cardiomyopathy have a relatively high prevalence?
- Genetic basis
- Sarcomere gene defect
- Autosomal dominant
- Variable expression and incomplete penetrance
What is the pathology of hypertrophic cardiomyopathy?
- Myocyte hypertrophy and disarray
- Can be genarlised or segmental wall thickness
- Can be apical, septal or generalised
- Impaired relaxation so behaves in as restrictive manner
- If septal hypertrophy this coupled with mitral valve defect lead to LVOT obstruction
What are the symptoms of hypertrophic cardiomyopathy?
-Asymptomatic
-Fatigue
-Dyspnoea
-Anginal like chest pain
-Exertional pre-syncope
Syncope related to arrhythmias or LVOT obstruction
What can be found on examination of hypertrophic cardiomyopathy?
- Can be nothing
- Notched pulse pattern
- Irregular pulse if in AF or ectopy
- Double impulse over apex
- Thrills and murmurs
- LVOT murmur will increase with Valsalva and decrease with squatting
- JVP will be raised in very restrictive filling
What are the investigations for hypertrophic cardiomyopathy?
- ECG (often abnormal but can be normal)
- ECHO
- CMRI
- Risk stratification for SCD, may need ICD
- Holters repeatedly
What are the general treatment measures for hypertrophic cardiomyopathy
- Avoid heavy exercise
- Avoid dehydration
- Explore FH
- Consider genetic testing
- Regular FU to re appraise the risks and progress
What are the specific treatment measures for hypertrophic cardiomyopathy?
- B-blockers
- Verapamil
- Disopyrimide
- Anticoagulation for AF
- Surgery or alcohol septal ablation if obstructive
- ICD
Myocarditis
Acute or chronic inflammation of the myocardium
What can myocarditis be in association with?
Pericarditis
What can myocarditis lead to?
- Impaired myocardial function, conduction and generate arrhythmia
- Can take on dilated cardiomyopathy appearance
Aetiology of myocarditis
Long list but is often unknown
What is the most common form of myocarditis?
Viral
What is 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 the symptoms of myocarditis?
- Heart failure
- Fatigue
- SOB
- CP
- Fever
What investigations are carried out for myocarditis?
- ECG (usually abnormal)
- Biomarkers
- ECHO
- CMRI
- Biopsy
- Viral DNA PCR
- Auto antibodies
- Strep antibodies
- Lyme B burdoferi
- HIV
- Bloods
What are the general measures for treatment of myocarditis?
- Supportive with treatment of heart failure and support for brady and tachy arrhythmias
- Immunotherapy if biopsy or other test points to specific diagnosis
- Stop possible drugs or toxic agent exposure
What is the prognosis of myocarditis?
- 30% recover fully
- 20% mortality at 1 year
- 56% mortality by 4 years
Pericardium
A reflected lining over the epicardium and the 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
Aetiology of pericarditis
Long list:
- Viral
- Idiopathic
- Bacterial
- Post MI
- Perforation
- Dissection of proximal aorta
- Neoplasia
What are the symptoms of pericarditis?
- Chest pain with pleuritic and postural features (sitting forward improves, lying down makes it worse)
- Fever
Duration of symptoms of pericarditis
1-2 weeks
Signs of pericarditis
- High fever
- Pericardial rub
- Raised JVP
- Hypotensive
- Muffled heart sounds
What investigations should be performed for pericarditis?
- ECG
- ECHO
- Troponin
What would suggest pericarditis with effusion?
Muffled heart sounds with raised JVP
What would suggest a bacterial cause of pericarditis?
High fever with no effusion
What may the ECG of pericarditis look like?
Widespread ST changes and PR depression
What are the general treatment measures for pericarditis?
- Viral is conservative
- Idiopathic gets colchicine and limited use of NSAIDs
- Bacterial must be drained and antimicrobials (high death rate)
What can occur with pericardial effusion?
Tamponade
What are the causes o pericardial effusion?
Often the same as pericarditis
What are the symptoms of pericardial effusion with tamponade?
- Overt
- Fatigue
- SOB
- Dizzy
- Hypotensive
- Chest pain
What are the signs of pericardial effusion with tamponade?
- Overt
- Pulsus paradoxus
- JVP raised
- Hypotensive
- Pleural rub
- Muffled heart sounds
- Pulmonary oedema is rare
What is the investigation for pericardial effusion with tamponade?
- Urgent ECHO
- CXR
What is the main treatment for pericardial effusion with tamponade?
Drainage
After drainage, what should happen to the fluid from a pericardial effusion?
Send for MCS, neoplastic cells, protein and LDH (most are exudates)
What is the treatment for persistent effusion?
Surgical pericardial window to allow flow to abdomen
What may be seen on an ECG with pericardial disease?
Electrical altermans in a large effusion
What is the prevalence of constrictive pericarditis?
Rare
What are the causes of constrictive pericarditis?
- Idiopathic
- Radiation
- Post surgery
- Autoimmune
- Renal failure
- Sarcoid
What is the pathology of constrictive pericarditis?
- Fatigue
- SOB
- Cough
What are the signs of constrictive pericarditis
- Signs of right heart failure
- Oedema
- Ascites
- Raised JVP
- Jaundice
- Hepatomegaly
- AF
- TR
- Pleural effusion
- Pericardial knock
How is constrictive pericarditis investigated?
- ECHO
- Right heart cath (to differentiate from restrictive cardiomyopathy)
Treatment for constrictive pericarditis
Careful and limited diuretics and pericardectomy
