Cardiomyopathy, Myocarditis & Pericarditis - Presentation & Therapy Flashcards
Briefly outline what dilated cardiomyopathy is.
3
- left ventricle becomes enlarged/weakened
- heart struggles to pump blood efficiently
- can affect the hearts relaxing and filling capabilities
What are some of the causes of dilated cardiomyopathy?
- severe IHD/CAD
- valvular disease (regurgitation)
- genetics (SCN5a gene)
- autoimmune (post-partum)
- alcoholism
- thyroid disease
What happens on a histological basis with a dilated/overstretched myocardium?
(3)
- scarring
- muscle becomes non-contractile (HF)
- thrombus can form between stretched muscle cells
What are some of the reversible causes of DCM or ones which recover well?
(3)
- post partum
- haemaochromatosis (Fe storage disease)
- lifestyle induced (e.g. alcoholism)
What is an example of an endocrine cause of DCM?
hyperthyroidism
What are the symptoms of dilated cardiomyopathy?
- SOB at rest
- fatigue
- orthopnoea
- PND
- palpitations
- syncope
- peripheral oedema
- weight gain
What information would you be looking to gather from a history with suspected DCM?
PMH: IHD/CAD, hypertension, anaemia, thyroid problems, valvular disease
Fx: Hx of CVD/DCM
Sx: smoker, alcohol, travel
What observations might be picked up on clinical examination which could suggest dilated cardiomyopathy?
(6)
- peripheral oedema
- S3/S4 (e.g. S3 gallop)
- hepatomegaly
- raised JVP
- ascites
- pleural effusion (crackles)
What investigations would you carry out for suspected dilated cardiomyopathy?
(7)
- ECG/ECHO
- Bloods
- BNP (NT-proBNP)
- CXR
- CT
- MRI
- biopsy
What blood tests might be requested and why? What can they rule out?
FBC - anaemia, infection
TFT - thyroid function
BNP - sign of HF
U+Es - renal function, fluid balance
What might a CXR reveal in patients with DCM?
4
- cardiomegaly
- hepatomegaly
- pleural effusion
- pleural oedema
What are some general measures in treatment that could tackle underlying causes of DCM?
(4)
- correct anaemia
- remove exacerbating drugs (e.g. NSAIDs)
- correct endocrine disturbances
- HF nurse referral
What would be more specific medical drug therapies to treat DCM?
Give examples.
(4)
- ACE inhibitors (e.g. ramipril)/ARB (e.g. candesartan)
- beta blocker (e.g. bisoprolol)
- diuretics (e.g. spironolactone)
- antiplatelets (e.g. aspirin, clopidogrel)
What surgical interventions could be considered in severe cases of DCM?
- ICD (implantable cardioverter defibrillator)
- pacemaker
- heart transplant
- PCI/CABP
Which type of DCM has the best prognosis? Which has the worst?
- peripartum
- DCM due to HIV infection
What are the three main types of cardiomyopathy?
- dilated
- restrictive
- hypertrophic
Briefly outline what restrictive cardiomyopathy is.
5
- least common of the three cardiomyopathies
- heart walls are rigid (but not thickened).
- heart is restricted from stretching and filling with blood properly.
- The pumping action of the heart is not usually affected, and the heart can contract to pump blood around the body.
- However, it is the filling function of the heart, where the heart muscle relaxes and the ventricles fill with blood, that is affected.
What are infiltrative cardiomyopathies?
- diverse group of cardiac diseases that are characterized by the deposition of abnormal substances within the heart tissue
- causes the ventricular walls to develop either diastolic dysfunction or, less commonly, systolic dysfunction.
Give examples of some infiltrative cardiomyopathies.
2
cardiac amyloidosis (too much amyloid protein) cardiac sarcoidosis
What are examples of non-infiltrative cardiomyopathies?
genetics
cancer treatment
diabetes
Give examples of some storage restrictive cardiomyopathies.
2
Fabry disease
Haemochromatosis (too much Fe in diet)
What is a sign of restrictive cardiomyopathy that may be picked up during an imaging investigation?
biatrial dilation
What are the symptoms of restrictive cardiomyopathies?
- HF symptoms
- SOB (fluid in lungs)
- arrhythmias/heart block
- fatigue
- weight gain
- peripheral oedema
- syncope
- palpitations
What investigations would you carry out for suspected restrictive cardiomyopathy?
- Hx/examination
- ECG (LBBB)
- CXR
- BNP (NT-proBNP)
- Bloods (FBC, U+Es - sarcoidosis, haemochromatosis, Fabry disease)
- ECHO
- cardiac MRI
- biopsy (rare)
- bone scan (amyloidosis)
- cardiac catheterisation (rare)
How is restrictive cardiomyopathy currently medically managed?
- specific treatments if underlying cause known (e.g. Fabrys, amyloidosis, haemochromatosis)
- ACE inhibitors (limited)
- beta blockers
- antiplatelets
- antiarrhythmics
- CCBs
- diuretics (although limited)
- surgery (transplant, ICD)
Why do diuretics have to be limited?
they reduce venous return/CO, and it is the filling pressure that affects this pathology.
Briefly outline what hypertrophic cardiomyopathy is.
- portion of the heart myocardium becomes thickened without an obvious cause.
- can be apical, septal or generalised.
- impaired relaxation so behaves in a restrictive manner.
- systolic function is usually ok.
What are the complications of hypertrophic cardiomyopathy?
6
- arrhythmias (AF)
- HF
- SCD
- LVOT obstruction
- Coronary artery disease/ischaemia
- fibrosis
What are the symptoms of hypertrophic cardiomyopathy?
5
- fatigue
- SOB on exertion
- syncope (arrhythmias/LVOT)
- anginal like chest pain
- peripheral oedema
What is the main cause of hypertrophic cardiomyopathy?
genetics (sarcomere gene defect)
What might be found on examination of a patient with HCM?
4
- could be none
- irregular pulse (AF)
- raised JVP
- peripheral oedema
What investigations might be carried out to come to a diagnosis of HCM?
(4)
- ECG
- Echo
- CMRI
- genetic testing
What general measures might be taken when managing HCM?
- regular follow ups
- assessment for risk of SCD, need for ICD
- avoid dehydration
- avoid heavy exercise
What would be more specific medical drug therapies to treat HCM?
(6)
- beta blockers
- diuretics (but limited)
- verapamil (CCB)
- disoprymide (anti-arrhythmic)
- antiplatelet (if in AF)
- surgery (ICD, transplant, septal myectomy)
Briefly outline what myocarditis is?
- acute/chronic inflammation of myocardium
- can be associated with pericarditis
- reduced function of myocardium
There are many causes of myocarditis, which is the most common?
viral
What are the complications of myocarditis?
arrhythmias
heart failure
heart block
What are the symptoms of myocarditis?
- fatigue
- SOB
- chest pain
- shorter courses of myocarditis may not have a fever
What investigations would be carried out to diagnose myocarditis?
What would the investigation be similar to?(1)
(6)
Similar to cardiomyopathy
- ECG (usually abnormal)
- biomarkers (but not troponin)
- Echo
- CMRI (oedema)
- viral DNA PCR
- Bloods: antibodies (HIV, Lymes)
How is myocarditis generally managed?
3
- treatment for symptoms of HF/arrhythmias
- immunotherapy
- stop possible toxic drug or exposure
What is pericarditis?
Inflammation of the pericardial layers with or without myocardial involvement.
What is the main causes of pericarditis?
viral
idiopathic
What are some key causes of pericarditis, other than viral?
5
bacterial post MI perforation dissection of proximal aorta neplasia
What are the symptoms of pericarditis?
2
- chest pain (pleuritic)
- sitting forward helps, leaning back makes it worse
- fever
What are the clinical signs of pericarditis?
5
- fever (bacterial?)
- pericardial rub (walking in snow)
- raised JVP (pericardial effusion)
- hypotensive
- muffled heart sounds (fluid insulates)
What investigations might be carried out to diagnose pericarditis?
- ECG
- Echo
What might an ECG reveal in a patient with pericarditis?
PR depression ST elevation (like an MI)
What is the treatment for pericarditis?
viral - symptomatic only
bacterial - drain, antimicrobial therapy
What might cause a pericardial effusion?
When would a pericardial be haemodynamically significant?
same causes of pericarditis
pericardial tamponade
What are the symptoms of pericardial effusion (with tamponade)?
(4)
- fatigue
- SOB
- dizzy/low BP
- chest pain
What are the signs of pericardial effusion (with tamponade)?
4
- raised JVP
- low BP
- pericardial rub
- muffled heart sounds
What changes on an ECG would indicate pericardial effusion?
QRS changes (heart is swinging in the fluid)
What are the causes of constrictive pericarditis?
6
- idiopathic
- radiation
- post-op
- autoimmune
- renal failure
- sarcoidosis
What are the symptoms/signs of constrictive pericarditis?
3
- fatigue
- SOB
- cough
signs similar to RHF:
- peripheral oedema
- raised JVP
- ascites
- hepatomegally
What is the treatment for constrictive pericarditis?
2
limited diuretics
pericardectomy
