Diseases of heart muscle and pericardial disease

Question 1

What is acute myocarditis and what are the causes?

Answer 1

Acute myocarditis is inflammation of the myocardium often associated with pericardial inflammation.
Causes:
-50% idiopathic
-Viral 
-Bacterial
-Spirochaetes
-Protozoa
-Drugs
-Toxins
-Immunological

Question 2

What are the viral causes of myocarditis?

Answer 2

enteroviruses, adenoviruses etc

Question 3

What are the bacterial causes of myocarditis

Answer 3

Staph, Strep, Clostridia, diphtheria, TB etc

Question 4

What are the spirochaetes causes of myocarditis

Answer 4

Leptospirosis, syphilis, lyme disease

Question 5

What are the protozoa causes of myocarditis

Answer 5

Chagas, toxoplasmosis

Question 6

What are the protozoa causes of myocarditis

Answer 6

Cyclophosphamide, trastuzumab, penicillin

Question 7

What are the toxin causes of myocarditis

Answer 7

cocaine, lithium, alcohol

Question 8

What are the immunological causes of myocarditis?

Answer 8

SLE, sarcoid, scleroderma

Question 9

What are the signs and symptoms of acute myocarditis?

Answer 9

ACS- like symptoms, heart failure symptoms, palpatations, tachycardia, soft S1, S4 gallop

Question 10

What tests should be done for acute myocarditis?

Answer 10

Endomyocardial biopsy is gold standard
Should have bloods: crp, esr and troponin may be raised, viral serology and tests for other causes
ECG shows st changes and t wave inversion, atrial arrhythmias, transient AV block, qt prolongation
Echo will show diastolic dysfunction and regional wall defects

Question 11

What is the treatment of acute myocarditis?

Answer 11

Supportive, treat underlying cause
Treat arrhythmias and heart failure
Avoid exercise that can precipitate arrhythmias
12-25% develop dilated cardiomyopathy

Question 12

What is dilated cardiomyopathy and how does it present?

Answer 12

It is a dilated flabby heart of unknown cause.
presentation:
-Fatigue
-dyspnoea
-pulmonary oedema
-RVF
-emboli
Signs:
-Increased pulse
_decreased BP
-increased JVP
-displaced apex
-mitral or tricuspid regurge

Question 13

What investigations should be done for dilated cardiomyopathy?

Answer 13

Bloods show raised BNP - secreted by stretched ventricular myocardium
Decreased sodium shows poor prognosis
CXR- cardiomegaly, pulmonary oedema
ECG - tachy, non specific t wave changes
echo - globally dilated and poor ejection fraction

Question 14

How is dilated cardiomyopathy treated?

Answer 14

It is treated through bed rest, diuretics, beta blockers, ACE-I, anticogulations, biventricular pacing and transplantation.
Similar to heart failure

Question 15

What is hypertrophic cardiomyopathy?

Answer 15

LV outflow obstruction from asymmetrical septal hypertrophy. Leading cause of sudden cardiac death in young.

Question 16

what is the cause of hypertrophic cardiomyopathy?

Answer 16

Autosomal dominant inheritance but 50% are sporadic, ask about family history of sudden death, may occur at any age

Question 17

What are the signs and symptoms of hypertrophic cardiomyopathy?

Answer 17

Sudden death may be first manifestation
Angina
Dyspnoea
palpitation
Jerky pulse
Systolic thrill at lower left sternal edge
Harsh ejection systolic murmur

Question 18

What tests should be done for hypertrophic cardiomyopathy?

Answer 18

ECG shoes progressive t wave inversion, deep q waves, ventricular ectopics, VT
echo- asymmetrical septal hypertrophy
Cardiac catheterisation helps assess severity

Question 19

How do you treat hypertrophic cardiomyopathy?

Answer 19

Beta blockers or verapamil for symptoms (reduce ventricular contractility)
Amiodarone for arrhythmias
Anticoagulate
Surgical intervention in severe cases and implantable defib

Question 20

What are the causes of restrictive cariomyopathy?

Answer 20

Similar to constrictive pericrditis in terms of presentation
It is caused by:
Idiopathic
Amyloidosis
Sarcoidosis
Haemochromocytosis
Scleroderma
Endomyocardial fibrosis

Question 21

What are the presentations of restrictive cardiomyopathy?

Answer 21

Features of RVF predominate
Raised JVP
Hepatomegaly
Oedema
Ascites

Question 22

How is diagnosis and treatment of restrictive cariomyopathy done?

Answer 22

Echo, MRI, cardiac catheterisation

Treat the cause

Question 23

What is a cardiac myxoma and what causes it?

Answer 23

It is a rare benign cardiac tumour

It is usually sporadic but can be familial

Question 24

What is the presentation of a cardiac myxoma?

Answer 24

Itmay mimic infective endocarditis or mitral stenosis

Tumour plop may be heard, signs vary according to posture

Question 25

What are the causes of acute pericarditis?

Answer 25

Idiopathic
Secondary to:
-Viruses - EBV, CMV etc
-bacteria - TB commonest cause
-Fungi and parasites - v rare
-autoimmune - systemic autoimmune diseases e.g. SLE, RA
-Drugs - procaine, penicillin etc
-Metabolic - uraemia, hypothyroidism
-Others - trauma, surgery, malignancy, MI

Question 26

What are the clinical features of acute pericarditis?

Answer 26

Central chest pain on inspiration or lying flat
Sitting forward typically relieves
A pericardial friction rub may be heard
fever may occur

Question 27

What tests should be done for acute pericarditis?

Answer 27

ECG classically shows saddle shaped concave ST elevation and PR depression
CXR may show cardiomegaly if pericardial effusion

Question 28

What is the treatment for acute pericarditis?

Answer 28

Nsaids or asprin with gastric protection for 1-2weeks
Colchicine 500mcg OD to reduce inflammatory mediators. Treat the cause. If autoimmune suspected can give steroids but they may increase the risk of recurrence