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R-Cradio-illness > Myocarditis and Pericarditis > Flashcards

Myocarditis and Pericarditis Flashcards

1
Q

What are the types of cardiomyopathy?

A

Hypertrophic
Dilated
Restrictive
Obliterative

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2
Q

What is hypertrophic cardiomyopathy?

A

Inappropriate ventricular hypertrophy

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3
Q

What is the distribution of hypertrophic cardiomyopathy?

A

Asymmetric septal hypertrophy
Apical hypertrophy
Generalised hypertrophy

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4
Q

What are the genetic features of hypertrophic cardiomyopathy?

A

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

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5
Q

What do genes affected by hypertrophic cardiomyopathy control?

A

Contractile porteins

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6
Q

What interaction is abnormal in beta myosin heavy chains in hypertrophic cardiomyopathy?

A

Abnormal interaction between actin and myosin filaments

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7
Q

When does hypertrophic cardiomyopathy usually manifest?

A

Early to mid teenage years

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8
Q

What is the effect of hypertrophic cardiomyopathy on ventricular contraction?

A

Normal or increased in the majority of patients

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9
Q

What is the effect of hypertrophic cardiomyopathy on systole and diastole?

A

Systole - LVOT obstruction

Diastole - reduced compliance

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10
Q

What is a common effect on relaxation in hypertrophic cardiomyopathy?

A

Impaired relaxation is a common feature

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11
Q

What is the effect of hypertrophic cardiomyopathy on systolic function?

A

Usually adequate with some functional abnormality

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12
Q

In what percentage of people with hypertrophic cardiomyopathy is the cause genetic?

A

90%

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13
Q

What is the effect of hypertrophic cardiomyopathy on diastolic function?

A

Impaired with poor capacity to fill and reduced cardiac compliance

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14
Q

What is the pathology of hypertrophic cardiomyopathy?

A

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

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15
Q

What is dilated cardiomyopathy?

A

Effectively a structural and functional description, ventricular function is impaired - usually affects the left ventricle but all 4 chambers can be dilated

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16
Q

What are the features of dilated cardiomyopathy?

A

Cardiac enlargement
Reduced contraction of one or both ventricles
Progressive and irreversible condition

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17
Q

What is the mortality of dilated cardiomyopathy?

A

25% 1 year mortality

50% 5 year mortality

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18
Q

What is the aetiology of dilated cardiomyopathy?

A

Common expression of myocardial damage, probably due to a number of different disease processes

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19
Q

What are the features of restrictive and infiltrative cardiomyopathy?

A

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

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20
Q

What are the non-infiltrative causes of cardiomyopathy?

A

Familial
Scleroderma
Diabetes
Pseudoxanthoma elastic

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21
Q

What are the infiltrative causes of cardiomyopathy?

A

Amyloid

Sarcoid

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22
Q

What are the storage diseases which cause cardiomyopathy?

A

Haemochromatosis

Fabry disease

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23
Q

What are the endomyocardial causes of cardiomyopathy?

A

Fibrosis
Carcinosis
Radiation
Drug effects

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24
Q

What is the pathology of dilated cardiomyopathy?

A

Inability to fill a ventricle which has a reduced compliance

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25
Q

When is alcohol heart disease potentially reversible?

A

In early stages with immediate and complete abstinence

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26
Q

What is myocarditis?

A

Involvement of the heart in an inflammatory process, usually caused by an infective agent

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27
Q

What infective agents cause myocarditis?

A 
Toxins
Drugs
Allergic reactions
Vasculitic disorders
Viral
Ricketsia
Bacteria
Fungi
Protozoa
Metazoan 
Spirochaetes
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28
Q

What is the clinical course of myocarditis?

A

Usually a self-limiting sub-clinical condition during the course of a viral infection
Can develop into acute and fulminating heart failure

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29
Q

What are the common pericardial diseases?

A

Acute pericarditis
Pericardial effusion
Constrictive pericarditis

30
Q

What is acute pericarditis?

A

Acute inflammation of the pericardium

31
Q

What are the causes of acute pericarditis?

A 
MI 
Infective
Neoplastic
Myxoedema
Autoimmune
Radiation
Viral
Bacterial - tuberculosis
Rheumatoid arthritis 
Systemic lupus
Scleroderma
Dressler's syndrome
32
Q

What are the types of neoplastic pericarditis?

A

Direct infiltration - lung, breast, Hodgkin’s disease

Radiation pericarditis - delayed onset, 4 months to 20 years

33
Q

What are the features of acute pericarditis?

A

Chest pain - eased by leaning forward

Friction rub

34
Q

What are the potential complications of acute pericarditis?

A

Chronic relapsing pericarditis
Pericardial effusion
Pericardial tamponade
Pericardial constriction

35
Q

What is pericardial effusion?

A

Collection of fluid in the cavity which lies between the two layers of pericardium

36
Q

What are the features of pericardial effusion?

A

Muffled heart sounds
Abnormal JVP
Well tolerated if small

37
Q

What is the management of pericardial effusion dependent on?

A

Cause

38
Q

What is pericardial tamponade?

A

Large pericardial effusion

39
Q

What are the features of pericardial tamponade?

A 
Cardiac compression, especially of the right ventricle
Reduction in cardiac output 
Medical emergency 
Tachycardia
Hypotension
Oliguria
Elevated JVP 
Pulsus paradoxus
Kussmaul sign
40
Q

What is the management of pericardial tamponade?

A

Demands urgent drainage - pericardiocentesis, percutaneous balloon pericardiotomy, pericardial resection

41
Q

What is constrictive pericarditis?

A

Heavy fibrosis and calcification of the pericardium - becomes a rigid, non-compliant casing for the heart

42
Q

What are the features of constrictive pericarditis?

A 
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
43
Q

What might constrictive pericarditis be confused with on investigation?

A

Restrictive cardiomyopathy

44
Q

What is the treatment of constrictive pericarditis?

A

Pericardial resection

45
Q

What is the presentation of hypertrophic cardiomyopathy?

A 
Most are asymptomatic
Syncope and sudden death
Dyspnoea
Angina 
Palpitations
46
Q

What is sudden death in patients with hypertrophic cardiomyopathy normally precipitated by?

A

Competitive sport, usually due to ventricular fibrillation

47
Q

What might be seen on examination of a patient with hypertrophic cardiomyopathy?

A

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

48
Q

What are the investigations for hypertrophic cardiomyopathy?

A 
ECG
Echo
CMRI
Sudden cardiac death risk assessment 
ETT
FH
49
Q

What is the presentation of dilated cardiomyopathy?

A 
Progressive, slow onset
Fatigue 
Dyspnoea
Orthopnoea 
Ankle swelling 
Weight gain due to fluid overload
Cough 
Cardiac failure
50
Q

What might be seen on examination of a patient with dilated cardiomyopathy?

A 
Poor superficial perfusion
Thread pulse
Dyspnoea at rest
JVP elevated 
Displaced apex
Pulmonary oedema
Pleural effusions
Ascites
Hepatomegaly
51
Q

What are the investigations for dilated cardiomyopathy?

A 
Repeated ECG
CXR for oedema/effusions
Brain natriuretic peptide
FBC
U&Es
Echo
CMRI
Coronary angiogram 
Biopsy
52
Q

What are the investigations for the basic evaluation of restrictive and infiltrative cardiomyopathy?

A 
Repeated ECG
CXR
FBC
U&Es
Autoantibodies for sclerotic disease
Plasma alpha galactosidase A activity for Fabry disease
53
Q

What is the presentation of myocarditis?

A 
Mild symptoms
Chest pain 
Fever
Sweats
Chills
Dyspnoea

Adults may present with heart failure years after an initial index event of myocarditis

54
Q

What is the presentation of viral myocarditis?

A

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

55
Q

What symptoms of myocarditis might develop due to underlying ventricular arrhythmias or atrioventricular block?

A

Palpitations
Syncope
Sudden cardiac death

56
Q

What is the investigation for myocarditis?

A 
ECG - usually abnormal
Biomarkers - often elevated
Echo
CMRI 
Viral DNA PCR
Auto-antibodies
Strep antibodies
Lyme B Burgdorferi
HIV
57
Q

What is the presentation of pericarditis?

A 
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
58
Q

What are the investigations for pericarditis?

A

ECG
Echo
Troponin

59
Q

What is the presentation of pericardial effusion?

A 
Haemodynamic abnormalities
Fatigue
Dyspnoea 
Dizziness
Chest pain 
Pulsus paradoxus
JVP raised
Pulmonary oedema (rare)
60
Q

What are the investigations for pericardial effusion?

A

Echo

CXR

61
Q

What is the management of hypertrophic cardiomyopathy?

A

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

62
Q

What general measures can be taken in managing hypertrophic cardiomyopathy?

A 
Avoid heavy exercise
Avoid dehydration
Explore FH and first degree relatives
ECG/echo
Consider genetic testing
63
Q

What specific measures can be taken in managing hypertrophic cardiomyopathy?

A

Drugs to enhance relaxation - beta blockers, verapamil, disopyramide
Anticoagulation if in atrial fibrillation
Surgical septal ablation
ICD if required/indicated

64
Q

What is the management of dilated cardiomyopathy?

A

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

65
Q

What general measures can be taken in managing dilated cardiomyopathy?

A 
Correct any anaemia
Remove any exacerbating drugs e.g. NSAIDs
Correct endocrine disturbances 
Reduce salt and fluid intake 
Manage weight
66
Q

What specific measures can be taken in managing dilated cardiomyopathy?

A 
ACEIs
ATII blockers
Diuretics
Beta-blockers
Spironolactone
Anticoagulants as required 
SCD risk assessment
Cardiac transplant
67
Q

What is the prognosis of dilated cardiomyopathy?

A

Generally poor and often influenced by the cause

68
Q

What is the management of restrictive and infiltrative cardiomyopathy?

A 
Limited diuretic use as low filling pressures will cause problems 
Beta-blockers
Limited ACEI use
Anticoagulants
SCD risk assessment 
Transplant
69
Q

What general measures can be taken in managing myocarditis?

A

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

70
Q

What is the prognosis of myocarditis?

A

30% full recover
20% mortality at 1 year
56% mortality at 4 years

71
Q

What general measures can be taken in managing pericarditis?

A

Viral - conservative management
Idiopathic - colchicine and limited NSAID use
Bacterial - drainage and antibiotics, high death rate, treat aggressively

72
Q

What is the management of pericardial effusion?

A

Drainage
Send for MCS, neoplastic cells, protein and LDH
Surgical pericardial window if persistent effusion

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