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Cardio > Cardiomyopathy, myocarditis & pericarditis > Flashcards

Cardiomyopathy, myocarditis & pericarditis Flashcards

1
Q

What are the types of cardiomyopathy

A

Hypertrophic
Dilated
Restrictive
Myocarditis

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2
Q

What is dilated cardiomyopathy?

A

Chambers of the heart dilate (funnily enough)

Meaning the volume increases, but this leaves the heart walls relatively thin

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3
Q

How does heart muscle develop in dilated cardiomyopathy?

A

As the muscle walls dilate over time, new sarcomeres are added in series

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4
Q

Which chambers of the heart are affected more in DCM?

A

Ventricles

All 4 chambers of the heart can dilate though

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5
Q

What are the general causes of DCM?

A

Idiopathic

Ischaemia & valvular diseases

Arrhythmias

Genetic & familial causes

Infection, inflammatory, autoimmune, postpartum causes

Toxic damage

Injury, cell loss, scar replacement

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6
Q

What are the genetic / familial causes of DCM?

A

SCN5A gene mutations

Muscular dystrophy (Duchenne)

Haemaochromatosis

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7
Q

What toxic damage can cause DCM?

A

Chemotherapy (doxorubicin)

Cocaine

Alcohol

Exogenous chemicals

Endocrine stuff

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8
Q

What infections or diseases can cause DCM?

A

Sarcoidosis

Causes of myocarditis eg:

  • Coxsackievirus B
  • Chagas disease from south america
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9
Q

What does postpartum DCM mean?

A

= Pregnancy

DCM can occur in third trimester or just after the mother gives birth

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10
Q

What are the symptoms of DCM?

A

Progressive, slow development of:

Dyspnoea 
Orthopnoea 
PND - paroxysmal nocturnal dyspnoea 
Cough 
Ankle swelling 
Weight gain

(symptoms of heart failure)

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11
Q

If someone presents with symptoms indicating DCM, what important points should you get from the past medical history?

A

Systemic illness

Hypertension

Vascular disease

Thyroid problems

Neuromuscular disease

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12
Q

What important points for DCM should you get from the family & social history?

A

Incidence of DCM or other cardiomyopathy

Recent travel to spicy overseas places

Alcohol intake

Occupational history

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13
Q

What signs on inspection would indicate DCM?

A

SOB (tachypnoea) at rest

Elevated JVP

Poor superficial perfusion

Ankle oedema

Sacral oedema (if they’ve been lying down for a while)

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14
Q

What signs on palpation would indicate DCM?

A

Thready, narrow pulse

Irregular pulse if in AF

Displaced apex beat

Increased Cap refill

Hepatomegally

Ascites

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15
Q

When auscultating a patient, what signs would indicate DCM?

A

Mitral regurgitation murmur

S3 and S4 heart sounds

Crackles (pulmonary oedema, pleural effusions)

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16
Q

What investigations should be done for DCM?

A 
Repeat ECGs 
CXR 
CMRI 
Bloods (FBC, U+Es) 
N termial pro Brain Natriuetic Peptide
ECHO 
Coronary angiogram
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17
Q

What general measures are taken to patient care in DCM?

A

Correct anaemia

Remove exacerbating drugs eg NSAIDs

Correct any endocrine disturbance

Advise on fluid and salt intake, reduce it

Advise on managing weight to identify fluid overload

HF nurse referral

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18
Q

What drugs can be given to patients for DCM?

A

ACEI, ATII blockers, diuretics

Beta blockers

Spironolactone

Anticoagulants as required

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19
Q

What surgical management is available for DCM?

A

SCD risk assessment with ICD or CRT-D/P implant

Cardiac transplant

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20
Q

Which type of DCM has the best prognosis?

A

Postpartum DCM (pregnancy)

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21
Q

Which DCM has the worst prognosis?

A

DCM due to HIV infection

<20% survive past 10 years

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22
Q

What is the effect of Restrictive cardiomyopathy?

A

Reduced compliance of heart muscle

Reduced filling of heart means less blood pumped out

= Diastolic heart failure

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23
Q

What are the causes of RCM?

A

50% idiopathic

Non infiltrative; Familial, forms of HCM, Scleroderma, diabetic, pseudoxanthoma elasticum

Infiltrative; Amyloid, Sarcoid

Storage diseases; Haemachromatosis, Fabry disease

Endomyocardial; Fibrosis, carcinoid, radiation, drug effects

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24
Q

Summarise the basic investigation for RCM

A

Repeated ECG

CXR

N termial pro Brain Natriuetic Peptide

Basic bloods (FBC, U+Es)

Auto antibodies

Fabry; low plasma alpha galactosidase A activity

Echo

CMRI

Biopsy more helpful but still has high false negative rate

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25
Q

Which imaging method is best for identifying Cardiomyopathies?

A

CMRI

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26
Q

Why is taking bloods useful for identifying RCM?

A

Can identify Sarcoid causes and haemachromatosis

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27
Q

Why is autoantibodies a useful test for RCM?

A

Identifies sclerotic connective tissue diseases

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28
Q

If investigations indicate an Amyloid cause for RCM, what must be done to confirm the diagnosis?

A

Amyloid needs non cardiac biopsy to help establish the diagnosis

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29
Q

How is RCM pharmacologically managed?

A

Limited diuretic use as low filling pressures will cause problems

Beta blockers limited ACEI use

Anticoagulants as required

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30
Q

How is RCM surgically managed?

A

SCD risk assessment with ICD or CRT-D/P implant

Cardiac transplant

31
Q

What mutation is associated with hypertrophic cardiomyopathy?

A

Sarcomeric protein gene mutation accounts for 40-60% of cases

Autosomal dominant gene but has varied expression and incomplete penetrance so often does not show

Most often MYBPC3, MYH7

32
Q

How does cardiac muscle differ in someone with HCM

A

Sarcomeres added in parallel

Can be generalised or segmental thickness, so it may just be apical or septal areas that are fucking huge

Histologically, mad disarray of cells so it doesnt look ordered n stuff

33
Q

How can HCM cause cardiac ischaemia?

A

Hypertrophic muscles are heavy massive so compress the coronary arteries

Reduces blood flow to areas leading to ischaemia

This is why HCM is a cause of stable angina and ACS’s

34
Q

Apart from ischaemia, what other effects can HCM have on the heart?

A

Fibrosis

Arrhythmias

35
Q

What are the symptoms of HCM

A

Asymptomatic for many

fatigue
dyspnoea
anginal like chest pain
Palpations 
exertional pre syncope
syncope related to arrhythmias or LV outflow tract obstruction
36
Q

What are the main examination findings for HCM

A

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

37
Q

How do you assess HCM?

A

ECG

ECHO

CMRI

Might do an ETT

Could do a Holter monitor (ECG)

Risk stratification for SCD, may need ICD

38
Q

Will an ECG always show signs of HCM?

A

Usually yes

a few are normal where phenotype is poorly expressed in genotype +ve individuals

39
Q

How is HCM managed pharmacologically?

A

if symptomatic - beta blockers, verapamil, disopyrimide

If in AF - anticoagulate

40
Q

What general measures are taken to manage HCM?

A

Avoid heavy exercise

Avoid dehydration

Explore Family History and first degree relatives, ECGs and echo’s may be required

Consider genetic testing

Regular Follow Ups to re appraise the risks and progress

41
Q

What surgical options can be used to manage HCM?

A

If the disease is obstructive; surgical or alcohol septal ablation

ICD if required based on risk stratification

42
Q

Myocarditis is most commonly caused by what group of microorganisms?

A

Viruses

43
Q

Describe the pathologyphysiology stuff for myocarditis

A

Infection causes infiltration of inflammatory cells into the myocardium

Inflammation reduces cardiac function leading to Heart failure

If conduction system is involved, then heart block and potential arrhythmias

Myocyte degeneration or necrosis is key histological feature

44
Q

How would a patient with myocarditis typically present?

A

Fairly rapid onset of:

Heart failure;
fatigue
SOB

Chest pain
Fever

Signs of Heart failure (ankle oedema, lung crackles etc)

45
Q

What investigations are carried out for myocarditis?

A

ECG
Biomarkers (bloods)
ECHO
CMRI

Tests for specific viruses

46
Q

Why is a blood test useful for myocarditis?

A

Biomarkers such as cTn, CK often elevated but not falling in a pattern consistent with MI

47
Q

Why is an ECHO useful for myocarditis investigation?

A

Can identify Regional wall motion abnormalities (RWMA)

48
Q

What specific viral tests can be done for myocarditis?

A 
Viral DNA PCR
Auto antibodies
Step antibodies
Lyme B burgdorferi
HIV
49
Q

What are the general measures for treating myocarditis?

A

Supportive treatment of heart failure

Support for brady and tachy arrhythmias.

Immunotherpay if biopsy or other Ix point to a specific diagnosis

Stop possible drugs or toxic agent exposure

50
Q

What is the prognosis for myocarditis?

A

30% recovery fully

20% mortality at 1 year

56% mortality by 4 years

At 11 years those still alive are 93% transplant free

51
Q

What is pericarditis?

A

Inflammation of the pericardial layers with or without myocardial involvement

52
Q

What are the main/key causes of pericarditis?

A 
Idiopathic 
Viral 
Bacterial
Post MI
Perforation
Dissection of proximal aorta
Neoplasia
53
Q

What are the symptoms of pericarditis?

A

chest pain with pleuritic features

sitting forward usually improves it lying back makes it worse

Fever

54
Q

What are the signs of pericarditis?

A

Pyrexia

Low Blood pressure

Muffled heart sounds

Pericardial rub at LSE

Raised JVP

55
Q

What does pericarditis with a raised JVP indicate?

A

raised JVP should make you consider not just pericarditis but effusion

56
Q

If a patient has a high fever, is generally very unwell, but has no effusion

What does this indicate?

A

Likely bacterial pericarditis

57
Q

What are the investigations for pericarditis?

A

ECG
Echo
Bloods (troponin)

58
Q

Why should bloods be taken for a patient for pericarditis?

A

Raised cTn indicates myocardium is involved / infected as well

59
Q

How would you identify pericarditis on an ECG?

A

PR depression & ST elevation

60
Q

What are the general measures for pericarditis?

A

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

61
Q

What is the risk posed by pericardial effusion?

A

Tamponade

62
Q

What are the symptoms of Tamponade?

A

Symptoms are overt

fatigue
SOB
Dizzy with low BP
Occasionally chest pain.

63
Q

What are the signs of Tamponade?

A

Signs are overt as well;

pulsus paradoxus
JVP raised
low BP 
\+/- rub
\+/- muffled Heart Sounds

Pulmoary oedema although this is very rare in pericardial effusions/tampaonade

64
Q

What investigations should be done for pericardial effusions or tamponade?

A

Urgent ECHO

CXR - can show large cardiac shadow

ECG

65
Q

How is pericardial effusion or tamponade treated?

A

Drainage is the destination treatment

Persistent effusion needs a surgical pericardial window made to allow flow to abdomen

Send for MCS, neoplasic cells, protein and LDH

66
Q

What is the nature of most pericardial effusions?

A

Exudate

Determined by sending sample for protein levels, LDH etc to be tested

67
Q

What feature of an ECG would indicate a large pericardial effusion?

A

Electrical alternans

Axis of QRS alternates between beats ± wandering base line

68
Q

Constrictive pericarditis is a rare type of pericarditis

What are the causes of it?

A 
idiopathic
radiation
post surgery
autoimmune
renal failure
sarcoid
69
Q

What is the effect of constrictive pericarditis?

A

impaired filling although myocardium is normal most of the time

causes Diastolic heart failure

70
Q

What are the symptoms of restrictive pericarditis?

A

fatigue, SOB, cough

71
Q

What are the signs of restrictive pericarditis?

A

Right heart failure signs:

oedema
ascites
high JVP
jaundice
hepatomegally
AFib
Tricuspid regurgitation 
pleural effusion
pericardial knock
72
Q

How do you investigate restrictive pericarditis?

What disease must you make sure to differentiate against?

A

Echo
Right heart catheter

differentiate from restrictive cardiomyopathy which can be very difficult

73
Q

How is restrictive pericarditis treated?

A

Careful and limited diuretics

Pericardectomy - removal of part/all of the pericardium

Cardio (41 decks)

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