Myocarditis Flashcards
What are the 3 structural types of cardiomyopathies
Dilated (most common- systolic dysfunction) hypertrophic restrictive (diastolic dysfunction)
What is the leading cause of congestive HF
idiopathic dilated CM
What is dilated CM
LV enlarges (w/o hypertrophy) and can’t expel blood (reduced EF)
What happens to compensate for systolic dysfunction
HR and/or SV increase
CO=HRxSV, and CO is reduced in dilated CM
What causes dilated CM
**Idiopathic
also tons of others; genetics, myocarditis, etc.
What are the ABCD PIG for Dilated Cardiomyopathy
Alcohol Beriberi Coxsackie/Chagas Drugs (cocaine, chemo) Pregnancy Idiopathic/infection Genetic
What is Ischemic CM the most common cause of
HF due to systolic dysfunction
also causes Dilated CM
What happens in ischemic CM
LVEF <35-40% from CAD, often after MI
How do you treat Ischemic CM
ASA, high intensity statin, BB, Ace
Loop if fluid overloaded
What is Hypertensive CM
Concentric LVH that progresses to LV dilation
Usually causes systolic HF (but can rarely cause diastolic)
What is alcoholic cardiomyopathy
excess alcohol causes myocardial dysfunction
>90g (7-8 drinks) per day for 5 years (less for women)
What’s a characteristic ECG finding for alcoholic CM
Prolonged QTc (cause ventricular arrhythmia) Hypo-Mg and K prolong QT even more
What is peripartum CM
Development of HF late in pregnancy (36 wks) or 5 mo. postpartum
Wean therapy only after LVEF >50% for 6 mo.
Requires heart transplant
10% mortality in 2 years
What are RF for peripartum CM
age african descent cocaine pre-eclampsia multiple fetuses
What is Takotsubo CM
Stress CM, broken heart syndrome
Transient ballooning of LV during systole
Associated with physical and emotional stress
WITHOUT CAD present (If present, probably not takotsubo)
How do Takotsubo patients present
Like MI (substernal CP)
7x elevated Troponin
ST elevation
decreased LVEF (ballooning)
How do you treat Takotsubo
recovery in 1-4 weeks!
BB if at risk for recurrence
What are dilated CM patients usually misdiagnosed as
Viral URI in young adults (viral myocarditis)
What are key points that indicate Dilate CM in History
insomnia (sleeping sitting up) SOB,Cough, PND, orthopnea Hx Breast cancer alcohol or drug use Fix sudden cardiac death
What would you see on dilated CM PE
cariogenic shock, tachypnea L/RHF symptoms Hypoxia (clubbing, cyanosis) Heaves, shifted PMI (Kerley B lines on CXR)
What CMP finding in dilated CM indicates poor prognosis
Hyponatremia
How do you treat dilated CM
Same as HF; ACE (great if EF <35%) ARB BB (great if HFrEF and LVEF <40%) aldosterone antagonist (reduce M&M in Class III-IV HF)
What is sacubitril-Valsartan
Drug that reduces M&M in HFrEF patients
What are the positive functions of the drugs used to treat Dilated CM
ACE: decrease preload and after load
BB: reduce HR and decreased afterload
What are surgical options for dilated CM
LVAD
CRT (LVEF <35%)
AICD (LVEF <30-35%)
Heart transplant
What is hypertrophic CM
Unexplained LV hypertrophy >15 mm (w/o dilation) with high incidence of sudden cardiac death
AKA: IHSS and ASH
What causes hypertrophic CM
Familial HCM
structural abn
subendocardial ischemia
What is the pathophysiology of HCM
higher systolic outflow= more severe disease
Increased ventricular filling pressure
Mitral Regurgitation
What are the two types of HCM
Obstructive (due to systolic anterior motion of mitral valve obstructing flow)
Non-obstructive
What happens when you increase LVOTO (L ventricular outflow tract obstruction)
decrease preload
decrease after load
increased inotropy (contraction)
–Achieved by standing quickly or valsalva
How do you decrease LVOTO
supine with legs up
this increases chamber size and decreases inotropy
What makes HCM related to sudden cardiac death
increased risk for ventricular and supra ventricular arrhythmias
What are risk factors for sudden cardiac death in HCM
Hx syncope FHx LV wall >30 mm abn BP with exercise <30 y/o
How do HCM patients usually present
asymptomatic (until VTach)
-Fatigue, dyspnea, angina, palpitations, syncope, PMN/orthopnea, dizziness
What will you see on PE for HCM
Double apical impulse (S3 gallop)
S4
Systolic ejection crescendo/decrescendo murmur at apex/LSB (increased with low preload/afterload aka valsalva)
How do you diagnose and treat HCM
TEE to diagnose
Risk stratify, restrict physical activity, avoid volume depletion
What is pharmacologic treatment for HCM
Arrhythmias: BB (- inotropy but not vasodilator)
HCM and AFib: Anticoagulation!
Sx despite BB: replace BB with Non-DHP CCB (Verapamil)
Disopyramide: anti arrhythmic, STRONG - inotrope (more than BB and CCB), prolongs QT, accelerates AV (use WITH BB)
What is surgical treatment for HCM
surgical septal myectomy
alcohol septal ablation
What is restrictive CM
Ventricles impaired filling WITHOUT hypertrophy or dilation (diastolic dysfunction)
Severe cases have bi-atrial enlargement
What are the causes of restrictive CM
Idiopathic Loeffler eosinophilic endomyocardial disease (#1 world wide) Amyloidosis (#1 in US) High incidence in tropics Resembles constrictive pericarditis
How dos RCM present clinically
Late stage with pronounced Sx
Exercise intolerance, SOB, fatigue, orthopnea, palpitations, syncope
What will you see on RCM PE
RHF Sx
Cardiac cachexia
amyloidosis signs (easy bruising, periorbital purpura, macroglossia)
JVD (Kussmaul’s sign)
How do you diagnose RCM
*Echo! Cardiac MRI ECG: ST depression, AFib, low voltage QRS Cardiac cath Ventricular biopsy (last resort)
What will lab findings for RCM show
eosinophilia
LFT
high NT-pro-BNP
How can you tell the difference between RCM and constrictive pericarditis
Cardiac cath
NT-pro-BNP elevated in RCM but NOT in constrictive pericarditis
How do you manage RCM
want to reduce filling pressure w/o reducing CO- BB, CCB
Diuretics (but use caution)
ACE and ARB not for amyloidosis
Anticoagulate if in AFib
-Treat underlying disease (chemo for amyloidosis) (phlebotomy for hemochromatosis)
-Pacemaker, LVAD
What is cardiac amyloidosis
deposition of amyloid fibrils systemically, infiltrating the heart
4 types with varying prognosis
What is Myocarditis
inflammation of myocardium associated with CAD
can be rapidly progressive and manifest in otherwise healthy patient
-Usually cause systolic dysfunction
What are the types of myocarditis
Fulminant myocarditis (after viral prodrome)
acute myocarditis
chronic active myocarditis (fibrosis on biopsy)
chronic persistent myocarditis (no systolic dysfunction)
What causes myocarditis
Idiopathic
**Viral in developed countries (enterovirus, coxsackie B, adenovirus, CMV, EBV)
developing countries (rheumatic carditis, chagas, HIV
What is the prognosis of Myocarditis
Fulminant myocarditis survivors: good prognosis
1/3 develop DCM
Mild Sx recover completely
Postpartum CM have 50% mortality at 1 yr
How does Myocarditis present clinically
Acute decompensating HF (**edema, S3 gallop, tachycardia)
Recent URI, flu Sx (1-2 wk)
CP (pericardial friction rub)
How do you diagnose myocarditis
Endomyocardial biopsy***
indicate in fulminant HF w/in 2 wks/new onset HF w/o treatment response
How do you treat Myocarditis
avoid strenuous activity
supportive care
If fulminate myocarditis, manage as if HF
