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Cardiomyopathy Myocarditis. Michelangelo L Sabas, MD FPCP FPCC FPSCCI Interventional Cardiology The Medical City Hospital Philippine Heart Center. Cardiomyopathy. group of diseases that primarily affect the heart muscle

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Cardiomyopathy myocarditis

CardiomyopathyMyocarditis

Michelangelo L Sabas, MD FPCP FPCC FPSCCI

Interventional Cardiology

The Medical City Hospital

Philippine Heart Center


Cardiomyopathy
Cardiomyopathy

  • group of diseases that primarily affect the heart muscle

  • not the result of congenital, acquired valvular, hypertensive, coronary arterial, or pericardial abnormalities


Two fundamental forms of cardiomyopathy
Two fundamental forms of cardiomyopathy

  • a primary type, consisting of heart muscle disease predominantly involving the myocardium and/or of unknown cause

  • a secondary type, consisting of myocardial disease of known cause or associated with a systemic disease such as amyloidosis or chronic alcohol use




Cardiomyopathy myocarditis


Cardiomyopathy myocarditis


Cardiomyopathy myocarditis

  • CXR: mild to moderate cardiac silhouette enlargement systolic pressure gradient; usually of a nondilated LV cavity

  • ECG: ST segment and T wave abnormalities, LVH, abnormal Q waves

  • Echo: ASH, SAM of the MV

  • MPI: vigorous systolic function, perfusion defect

  • Cath: vigorous systolic function, dynamic LV outflow obstruction, ↑ L and R filling pressures


Cardiomyopathy myocarditis


Cardiomyopathy myocarditis

  • CXR: mild cardiac silhouette enlargement in restriction to left and/or right ventricular filling

  • ECG: low voltage, conduction defects

  • Echo: ↑ LV wall thickness, normal or mildly reduced systolic function

  • MPI: normal or mildly reduced systolic function

  • Cath: normal or mildly reduced systolic function , ↑ L and R filling pressures


Cardiomyopathy myocarditis

  • About one in three cases of CHF is due to dilated cardiomyopathy (DCM)

  • LV and/or right ventricular (RV) systolic pump function is impaired, leading to progressive cardiac dilatation (remodeling)

  • no cause is apparent in many cases

  • DCM is either familial or the end result of myocardial damage produced by a variety of known or unknown infectious, metabolic, or toxic agents

  • One-fifth to one-third of patients have familial forms of DCM


Clinical manifestations
Clinical Manifestations cardiomyopathy (DCM)

  • Chest pain

  • Syncope

  • Cardiac enlargement and findings of CHF

  • Pulse pressure is narrow and the ↑ JVP

  • S3 and S4 are common

  • MR and TR


Laboratory examinations
Laboratory Examinations cardiomyopathy (DCM)

  • CXR: enlargement of the cardiac

  • silhouette

  • ECG: ST or AF, ventricular arrhythmias,

  • LA abnormality, low voltage, diffuse

  • nonspecific ST-T-wave abnormalities,

  • and intraventricular and/or AV

  • conduction defects

  • Echo, CT imaging (CTI), and cardiac MRI show LV dilatation, with normal,

  • minimally thickened, or thinned walls,

  • and systolic dysfunction

  • BNP are usually elevated


Treatment
Treatment cardiomyopathy (DCM)

  • Standard therapy of heart

    failure with salt restriction

  • Anticoagulation

  • Antiarrhytmic agents – best

    avoided

  • Avoid: alcohol, NSAIDS, CCB’s

  • Resynchronization therapy

  • Implantable cardioverter-

    defibrillator (ICD)

  • Cardiac transplantation


Alcoholic cmp
Alcoholic CMP cardiomyopathy (DCM)

  • Consumption of large quantities of alcohol (>80 grams of ethanol/day)

  • Partially genetically determined

  • ‘Holiday heart syndrome’


Peripartum cmp
Peripartum CMP cardiomyopathy (DCM)

  • Occurs during last trimester or within 6 months after delivery

  • Mortality: 10-20%

  • Avoid further pregnancies


Neuromuscular disease
Neuromuscular Disease cardiomyopathy (DCM)

  • Duchenne’s progressive muscular dystrophy

  • Myotonic dystrophy

  • Friedreich’s ataxia


Drugs
Drugs cardiomyopathy (DCM)

  • Anthracycline derivatives, ie. Doxorubicin

  • Cyclophosphamide

  • Cocaine abuse


Arrhythmogenic right ventricular cmp dysplasia
Arrhythmogenic Right Ventricular CMP / Dysplasia cardiomyopathy (DCM)

  • Familial cardiomyopathy characterized by progressive fibrofatty replacement of the right ventricle and, to a much lesser degree, of the LV myocardium

  • RV failure with jugular venous distention, hepatomegaly, and edema

  • Ventricular tachyarrhythmias

  • ECG: QRS prolongation localized to the right precordial leads and left bundle branch block–type ventricular tachycardia

  • CTI and CMRI: RV dilatation, RV aneurysm, and fatty replacement


Taka tsubo cmp
Taka-Tsubo CMP cardiomyopathy (DCM)

  • Apical ballooning syndrome

  • Abrupt onset of severe chest discomfort preceded by a very stressful emotional or physical event

  • Women >50 years

  • ST-segment elevations and/or deep T-wave inversions in the precordial leads

  • No obstruction in the epicardial coronary arteries is noted on angiography

  • Reversible within 3–7 days and do not cause long-term cardiac dysfunction or disability


Cardiomyopathy myocarditis

diasbility cardiomyopathy (DCM)


Cardiomyopathy myocarditis

  • Features: cardiomyopathy (DCM)

    • dynamic LV outflow tract

      pressure gradient

    • assymmetric LVH

  • Pathophysiologic abnormality: increased stiffness of the hypertrophied muscle (diastolic)

  • 50% of patients with HCM have a + family history = autosomal dominant


Clinical features
Clinical Features cardiomyopathy (DCM)

  • Sudden death

  • Dyspnea

  • Angina pectoris, fatigue, syncope

  • PE: double or triple apical impulse, rapidly rising carotid arterial pulse, S4, systolic murmur


Hemodynamics
Hemodynamics cardiomyopathy (DCM)

  • Pressure gradient is dynamic

  • Obstruction result from narrowing of the LV outflow tract by SAM of the MV against the hypertrophied septum

  • Basic mechanisms involved in the production and intensification of the dynamic intraventricular obstruction: (1) increased LV contractility, (2) ↓ventricular preload, and (3) ↓aortic impedance and pressure (afterload)

  • Hemodynamic features: ↑LVDP and systolic pressure gradient between the body of the LV and the subaortic region


Laboratory evaluation
Laboratory Evaluation cardiomyopathy (DCM)

  • ECG: LVH, Q waves, Arrhythmias

  • Chest x-ray: normal or cardiomegaly

  • Echocardiogram: LVH, ‘ground-glass’ appearance of the septum, SAM of the MV

  • Apical hypertrophy: rare form of HCM


Treatment1
Treatment cardiomyopathy (DCM)

  • Avoid: competitive sports / strenuous physical activity, dehydration, nifedipine

  • Caution on diuretics

  • Beta blockers for angina and syncope

  • Amiodarone

  • Verapamil, diltiazem

  • Pacemaker

  • Septal ablation, surgical myotomy /myectomy

  • Screen family members


Cardiomyopathy myocarditis

  • Hallmark: abnormal diastolic function cardiomyopathy (DCM)

  • Late stages: systolic function is also impaired.

  • Myocardial fibrosis, hypertrophy, or infiltration due to a variety of causes is responsible


Cardiomyopathy myocarditis

Classification of Types of Restictive CMP cardiomyopathy (DCM)

Noninfiltrative   Idiopathic cardiomyopathy Familial cardiomyopathy   Hypertrophic cardiomyopathy   Scleroderma   Pseudoxanthoma elasticum   Diabetic cardiomyopathy   

Infiltrative   Amyloidosis   Sarcoidosis   Gaucher disease   Hurler disease   Fatty infiltration   

Storage Disease   Hemochromatosis   Fabry disease   Glycogen storage disease   

Endomyocardial   Endomyocardial fibrosis Hypereosinophilic syndrome   Carcinoid heart disease   Metastatic cancers   Radiation   Toxic effects of anthracycline   Drugs causing fibrous endocarditis (serotonin, methysergide, ergotamine, mercurial agents, busulfan)


Clinical features1
Clinical Features cardiomyopathy (DCM)

  • Exercise intolerance and dyspnea are usually prominent

  • Dependent edema, ascites, and an enlarged, tender, and often pulsatile liver

  • Kussmaul's sign

  • Heart sounds may be distant, and S3 and S4


Laboratory
Laboratory cardiomyopathy (DCM)

  • ECG: low-voltage, nonspecific ST-T-wave abnormalities and various arrhythmias

  • CXR: Absent pericardial calcification

  • Echo, CTI, and CMRI: symmetrically thickened LV walls and normal or slightly reduced ventricular volumes and systolic function; the atria are usually dilated

  • Doppler echo: diastolic dysfunction

  • Cath: ↓cardiac output, ↑ RV and LV end-diastolic pressures, and a dip-and-plateau configuration of the diastolic portion of the ventricular pressure pulses resembling constrictive pericarditis


Treatment2
Treatment cardiomyopathy (DCM)

  • Management depends on the etiology and usually disappointing

  • anticoagulation


Myocarditis
Myocarditis cardiomyopathy (DCM)

  • cardiac inflammation due to infection, hypersensitivity to drugs, irradiation, chemicals or physical agents


Etiology
Etiology cardiomyopathy (DCM)

  • Viral (Most Common)   Adenovirus   Coxsackie virus/ Enterovirus   Cytomegalovirus   Parvovirus B19   Hepatitis C virus   Influenza   Human immunodeficiency virus   Herpes virus   Epstein-Barr virus   Mixed infections   

  • Bacterial   Mycobacterial species   Chlamydia pneumoniae   Streptococcal species   Mycoplasma pneumoniaeTreponema pallidum

  • Fungal   Aspergillus   Candida   Coccidioides    Cryptococcus   Histoplasma


Etiology1
Etiology cardiomyopathy (DCM)

  • ProtozoalTrypanosoma cruzi

  • Parasitic   Schistosomiasis   Larva migrans   

  • Toxins   Anthracyclines   Cocaine   

  • Hypersensitivity   Clozapine   Sulfonamides    Cephalosporins   Penicillins   Tricyclic antidepressants   

  • Autoimmune Activation   Smallpox vaccination    Giant cell myocarditis   Churg-Strauss syndrome   Sjögren syndrome   Inflammatory bowel disease   Celiac disease   Sarcoidosis   Systemic lupus erythematosus   Takayasu arteritis   Wegener granulomatosis


Clinical features2
Clinical Features cardiomyopathy (DCM)

  • history of a preceding upper respiratory febrile illness or a flulike syndrome, and viral nasopharyngitis or tonsillitis

  • transient electrocardiographic ST-T-wave abnormalities, to a fulminant condition with arrhythmias, acute CHF, and early death

  • simulates an acute coronary syndrome with chest pain, ECG changes, and elevated serum levels of troponin

  • physical examination is often normal


Treatment3
Treatment cardiomyopathy (DCM)

  • Avoid exercise and strenuous activity

  • CHF management

  • Antiarrhythmics

  • Cardiac transplantation


Cardiomyopathy myocarditis

THANK YOU. cardiomyopathy (DCM)