Myocarditis and Pericarditis Flashcards
What are the types of cardiomyopathy?
Hypertrophic
Dilated
Restrictive
Obliterative
What is hypertrophic cardiomyopathy?
Inappropriate ventricular hypertrophy
What is the distribution of hypertrophic cardiomyopathy?
Asymmetric septal hypertrophy
Apical hypertrophy
Generalised hypertrophy
What are the genetic features of hypertrophic cardiomyopathy?
Usually autosomal dominant, familial condition
Sporadic cases
Genetic heterogeneity - over 30 different genetic variants described
Phenotypic heterogeneity - expression varies even within families who have the same genes
What do genes affected by hypertrophic cardiomyopathy control?
Contractile porteins
What interaction is abnormal in beta myosin heavy chains in hypertrophic cardiomyopathy?
Abnormal interaction between actin and myosin filaments
When does hypertrophic cardiomyopathy usually manifest?
Early to mid teenage years
What is the effect of hypertrophic cardiomyopathy on ventricular contraction?
Normal or increased in the majority of patients
What is the effect of hypertrophic cardiomyopathy on systole and diastole?
Systole - LVOT obstruction
Diastole - reduced compliance
What is a common effect on relaxation in hypertrophic cardiomyopathy?
Impaired relaxation is a common feature
What is the effect of hypertrophic cardiomyopathy on systolic function?
Usually adequate with some functional abnormality
In what percentage of people with hypertrophic cardiomyopathy is the cause genetic?
90%
What is the effect of hypertrophic cardiomyopathy on diastolic function?
Impaired with poor capacity to fill and reduced cardiac compliance
What is the pathology of hypertrophic cardiomyopathy?
Myocyte hypertrophy and disarray
Can be generalised or segmented with wall thickness
Coronary arteries are also affected with small vessel narrowing and consequent ischaemia and fibrosis
Arrhythmias common
What is dilated cardiomyopathy?
Effectively a structural and functional description, ventricular function is impaired - usually affects the left ventricle but all 4 chambers can be dilated
What are the features of dilated cardiomyopathy?
Cardiac enlargement
Reduced contraction of one or both ventricles
Progressive and irreversible condition
What is the mortality of dilated cardiomyopathy?
25% 1 year mortality
50% 5 year mortality
What is the aetiology of dilated cardiomyopathy?
Common expression of myocardial damage, probably due to a number of different disease processes
What are the features of restrictive and infiltrative cardiomyopathy?
Less common
Systolic function may or may not be impaired
About 50% related to specific clinical disorders
Non-compliant heart so fills poorly regardless of systolic function which has a profound effect on haemodynamics
What are the non-infiltrative causes of cardiomyopathy?
Familial
Scleroderma
Diabetes
Pseudoxanthoma elastic
What are the infiltrative causes of cardiomyopathy?
Amyloid
Sarcoid
What are the storage diseases which cause cardiomyopathy?
Haemochromatosis
Fabry disease
What are the endomyocardial causes of cardiomyopathy?
Fibrosis
Carcinosis
Radiation
Drug effects
What is the pathology of dilated cardiomyopathy?
Inability to fill a ventricle which has a reduced compliance
When is alcohol heart disease potentially reversible?
In early stages with immediate and complete abstinence
What is myocarditis?
Involvement of the heart in an inflammatory process, usually caused by an infective agent
What infective agents cause myocarditis?
Toxins Drugs Allergic reactions Vasculitic disorders Viral Ricketsia Bacteria Fungi Protozoa Metazoan Spirochaetes
What is the clinical course of myocarditis?
Usually a self-limiting sub-clinical condition during the course of a viral infection
Can develop into acute and fulminating heart failure
What are the common pericardial diseases?
Acute pericarditis
Pericardial effusion
Constrictive pericarditis
What is acute pericarditis?
Acute inflammation of the pericardium
What are the causes of acute pericarditis?
MI Infective Neoplastic Myxoedema Autoimmune Radiation Viral Bacterial - tuberculosis Rheumatoid arthritis Systemic lupus Scleroderma Dressler's syndrome
What are the types of neoplastic pericarditis?
Direct infiltration - lung, breast, Hodgkin’s disease
Radiation pericarditis - delayed onset, 4 months to 20 years
What are the features of acute pericarditis?
Chest pain - eased by leaning forward
Friction rub
What are the potential complications of acute pericarditis?
Chronic relapsing pericarditis
Pericardial effusion
Pericardial tamponade
Pericardial constriction
What is pericardial effusion?
Collection of fluid in the cavity which lies between the two layers of pericardium
What are the features of pericardial effusion?
Muffled heart sounds
Abnormal JVP
Well tolerated if small
What is the management of pericardial effusion dependent on?
Cause
What is pericardial tamponade?
Large pericardial effusion
What are the features of pericardial tamponade?
Cardiac compression, especially of the right ventricle Reduction in cardiac output Medical emergency Tachycardia Hypotension Oliguria Elevated JVP Pulsus paradoxus Kussmaul sign
What is the management of pericardial tamponade?
Demands urgent drainage - pericardiocentesis, percutaneous balloon pericardiotomy, pericardial resection
What is constrictive pericarditis?
Heavy fibrosis and calcification of the pericardium - becomes a rigid, non-compliant casing for the heart
What are the features of constrictive pericarditis?
Early filling of heart is normal Later filling is abruptly halted when the heart comes up against the rigid pericardium Venous congestion Oedema Ascites Liver congestion Kussmaul sign JVP rises on inspiration
What might constrictive pericarditis be confused with on investigation?
Restrictive cardiomyopathy
What is the treatment of constrictive pericarditis?
Pericardial resection
What is the presentation of hypertrophic cardiomyopathy?
Most are asymptomatic Syncope and sudden death Dyspnoea Angina Palpitations
What is sudden death in patients with hypertrophic cardiomyopathy normally precipitated by?
Competitive sport, usually due to ventricular fibrillation
What might be seen on examination of a patient with hypertrophic cardiomyopathy?
May be no findings
Notched pulse pattern
Irregular pulse pattern if in AF or ectopy
Double pulse over apex
Thrills and murmurs
LVOT murmur will increase with Valsalva manoeuvre and decrease with squatting
What are the investigations for hypertrophic cardiomyopathy?
ECG Echo CMRI Sudden cardiac death risk assessment ETT FH
What is the presentation of dilated cardiomyopathy?
Progressive, slow onset Fatigue Dyspnoea Orthopnoea Ankle swelling Weight gain due to fluid overload Cough Cardiac failure
What might be seen on examination of a patient with dilated cardiomyopathy?
Poor superficial perfusion Thread pulse Dyspnoea at rest JVP elevated Displaced apex Pulmonary oedema Pleural effusions Ascites Hepatomegaly
What are the investigations for dilated cardiomyopathy?
Repeated ECG CXR for oedema/effusions Brain natriuretic peptide FBC U&Es Echo CMRI Coronary angiogram Biopsy
What are the investigations for the basic evaluation of restrictive and infiltrative cardiomyopathy?
Repeated ECG CXR FBC U&Es Autoantibodies for sclerotic disease Plasma alpha galactosidase A activity for Fabry disease
What is the presentation of myocarditis?
Mild symptoms Chest pain Fever Sweats Chills Dyspnoea
Adults may present with heart failure years after an initial index event of myocarditis
What is the presentation of viral myocarditis?
History of recent (within 1-2 weeks) flu-like syndrome of fevers, arthralgia and malaise
or
History of pharyngitis, tonsillitis or upper respiratory tract infection
What symptoms of myocarditis might develop due to underlying ventricular arrhythmias or atrioventricular block?
Palpitations
Syncope
Sudden cardiac death
What is the investigation for myocarditis?
ECG - usually abnormal Biomarkers - often elevated Echo CMRI Viral DNA PCR Auto-antibodies Strep antibodies Lyme B Burgdorferi HIV
What is the presentation of pericarditis?
Usually 1-2 week duration Chest pain with pleuritic and postural features Relieved by sitting forwards and exacerbated by lying back Fever High temperature Pericardial rub JVP raised Hypotension
What are the investigations for pericarditis?
ECG
Echo
Troponin
What is the presentation of pericardial effusion?
Haemodynamic abnormalities Fatigue Dyspnoea Dizziness Chest pain Pulsus paradoxus JVP raised Pulmonary oedema (rare)
What are the investigations for pericardial effusion?
Echo
CXR
What is the management of hypertrophic cardiomyopathy?
Reduce risk of sudden death with screening
Family history - syncope, ventricular tachycardia, exercise hypotension
ICD for high risk cases
Symptomatic treatments - drugs, surgical resection, septal ablation
What general measures can be taken in managing hypertrophic cardiomyopathy?
Avoid heavy exercise Avoid dehydration Explore FH and first degree relatives ECG/echo Consider genetic testing
What specific measures can be taken in managing hypertrophic cardiomyopathy?
Drugs to enhance relaxation - beta blockers, verapamil, disopyramide
Anticoagulation if in atrial fibrillation
Surgical septal ablation
ICD if required/indicated
What is the management of dilated cardiomyopathy?
Cause is usually unknown so specific treatment is unavailable
Medical treatment can be given for heart failure and arrhythmia if present
Thrombi-Embolism prophylaxis
Device management with implantable defibrillator or cardiac resynchronisation therapy
What general measures can be taken in managing dilated cardiomyopathy?
Correct any anaemia Remove any exacerbating drugs e.g. NSAIDs Correct endocrine disturbances Reduce salt and fluid intake Manage weight
What specific measures can be taken in managing dilated cardiomyopathy?
ACEIs ATII blockers Diuretics Beta-blockers Spironolactone Anticoagulants as required SCD risk assessment Cardiac transplant
What is the prognosis of dilated cardiomyopathy?
Generally poor and often influenced by the cause
What is the management of restrictive and infiltrative cardiomyopathy?
Limited diuretic use as low filling pressures will cause problems Beta-blockers Limited ACEI use Anticoagulants SCD risk assessment Transplant
What general measures can be taken in managing myocarditis?
Supportive treatment of heart failure and support for brady/tachy-cardia arrhythmias
Immunotherapy if indicated by specific diagnosis
Stop possible causative drugs or toxic agent exposure
What is the prognosis of myocarditis?
30% full recover
20% mortality at 1 year
56% mortality at 4 years
What general measures can be taken in managing pericarditis?
Viral - conservative management
Idiopathic - colchicine and limited NSAID use
Bacterial - drainage and antibiotics, high death rate, treat aggressively
What is the management of pericardial effusion?
Drainage
Send for MCS, neoplastic cells, protein and LDH
Surgical pericardial window if persistent effusion
