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Cardiomyopathy and Myocarditis

Cardiomyopathy and Myocarditis. Tintinalli Chap. 59. Cardiomyopathy. Classification (2 systems) Based on Suspected Etiology Primary may be genetic, mixed (genetic or non genetic), or acquired Secondary which are accompanied by other organ system involvement

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Cardiomyopathy and Myocarditis

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  1. Cardiomyopathy and Myocarditis Tintinalli Chap. 59

  2. Cardiomyopathy • Classification (2 systems) • Based on Suspected Etiology • Primary • may be genetic, mixed (genetic or non genetic), or acquired • Secondary • which are accompanied by other organ system involvement • World Health Organization classifies on the basis of their pathologic or pathophysiologic features (more accepted system) • All are based off of echocardiography • Dilated – usually mostly Systolic dysfunction • Restrictive – usually mostly Diastolic dysfunction • Hypertrophic – usually mostly Diastolic dysfunction • Arrythmogenic right ventricular dysplasia

  3. Dilated Cardiomyopathy • Dilation of all four chambers (ventricles > atria); increased muscle mass; systolic failure • Usually presents as unexplained heart failure (prior to echo) • Signs & symptoms: • Dyspnea on exertion, fatigue, PND, dependent edema, orthopnea, palpitations • Manifestations of embolizaiton: neurologic deficits, flank pain, hematuria, pulseless cyanotic extremity • Rales, S3 & S4 gallops, narrow pulse pressure, mitral or tricuspid regurgitation (laterally displaced PMI)

  4. Dilated Cardiomyopathy • 5 to 8 cases per 100,000 population, with a prevalence of 36 per 100,000 • Causes: Huge List • 80% are usually classified as idiopathic • Ischemic is the most common identified cause • Toxins: Alcohol, cocaine, amphetamines, lead, lithium • Infectious: CMV, HIV, Varicella, Hepatitis • Endocrine: Thyroid/Growth hormone excess or deficiency • Peripartum

  5. Dilated Cardimyopathy • Diagnosis • ECG: LVH, Lt or biatrial hypertrophy, poor r wave progression, new BBB, Afib • Chest Xray: nonspecific; cardiomegaly & pulmonary vascular congestion (globular appearance) • Echocardiograpy: • ventricles & atria enlargement, • increased systolic/diastolic volumes, • EF <45%, • abnormal ventricle contraction, • valvular regurgitation

  6. Dilated Cardiomyopathy • Treatment • Treat CHF: diuretics, digitalis, vasodilators, ACE inhibitors • Anticoagulants: all with mural thrombi; evidence of pulmonary or systemic emboli; atrial fibrillation

  7. Restrictive Cardiomyopathy • Characterized by diastolic restriction of ventricular filling • Low end diastolic volume • Decreased cardiac output • Causes • Infiltrative: Amyloidosis (most common), Sarcoidosis, Scleroderma • Storage diseases: Hemochromotosis • Endomyocardial diseases: radiation, hypereosinophlic syn., carcinoid • Presentation • Similar to dilated cardiomyopathy, but more pronounced right sided heart failure & dyspnea on exertion • Physical Exam • Rales, peripheral edema, JVD, gallops, tachycardia, regurgitation murmurs, KUSSMAUL’s Sign?

  8. Restrictive Cardiomyopathy • Diagnostic Studies • ECG: chamber enlargement (atria > ventricles); low voltage; afib • Chest X ray: normal to enlarged heart with pulmonary vascular congestion • Echocardiogram: Thickened walls, markedly dilated atria, normal systolic function, mitral/tricuspid regurgitation • Catheterization—dip and plateau of LV pressure, (also with constrictive pericarditis) • Treatment • Usually diuretics and digitalis • Vasodilators can cause pronounced hypotension and may need to be avoided

  9. Hypertrophic Cardiomyopathy • Hypertrophy of the left ventricle, and occasionally of the right ventricle • Prevalence in the absence of aortic valve disease or systemic hypertension is at least 1:500 of the adult population • Interventricular septum is typically more prominently involved than the left ventricular free wall • Left ventricular volume is normal or reduced; Diastolic dysfunction usually present • 50% inherited - autosomal dominant • Most common acquired causes are HTN & Aortic Stenosis

  10. Hypertrophic Cardiomyopathy • Presentation • Dyspnea on exertion, ischemic chest pain • Palpitations, arrhythmias, syncope, pre-syncope • Sudden Death • usually due to V-tach during exercise • Physical Exam • S4 gallop • Prominent systolic ejection murmur at left sternal border that increases with valsalva, sudden standing, or exercise

  11. Hypertrophic Cardiomyopathy • Diagnosis • Chest Xray: usually normal • Echocardiogram: LVH with disproportionate septal hypertrophy; small ventricular volume • ECG: LVH & LAH; A-fib and PVC’s common * think hypertrophic cardiomyopathy in any young person whose EKG shows large septal Q waves*

  12. Hypertrophic Cardiomyopathy • Treatment • Can become unstable in a-fib due to lack of atrial kick (cardioversion & heparinization) • Long term care with Beta blockers • Amiodarone is treatment of choice for ventricular dysrhhythmias • Diuretics in the face of pulmonary congestion • Avoid agents that reduce ventricular volume (nitrates) or increase myocardial contractility (digoxin) • Antibiotic prophylaxis for dental procedures • Avoidance of competitive athletics • Anticoagulation if in a-fib

  13. Myocarditis • Definition: inflammation of the heart muscle • Multiple causes • Viruses are the most frequent pathogens, but , bacteria, fungi, protozoa, and helminths have been implicated • Most frequently identified viruses were enteroviruses (including coxsackievirus) until the 1990s, but now parvovius B19 and Human Herpes Virus 6 are more common • Autoimmune disorders such as SLE, Wegener's granulomatosis, giant cell arteritis, Kawasaki’s, and Takayasu arteritis • Drugs: PCN, sulfonamides • Toxins: Cocaine, toluene • Parasites: Chagas’, Toxoplasmosis, Trichinosis

  14. Myocarditis • Presentation • Think myocarditis in a young male with resent viral prodrome & now presents with unexplained CHF, MI with normal angiogram, new dysrhythmia/conduction defect, or symptoms of pericarditis with heart failure

  15. Myocarditis • Spectrum of presentation of myocarditis • Excessive fatigue • Chest pain • Unexplained sinus tachycardia • Acute pericarditis • S3, S4, or summation gallop • Abnormal electrocardiogram • Abnormal echocardiogram • New cardiomegaly on chest x-ray • Atrial or ventricular arrhythmia • Partial or complete heart block • New onset congestive heart failure • Atypical myocardial infarction • Cardiogenic shock

  16. Myocarditis • Diagnosis • Combination of clinical presentation and laboratory/imaging studies • ESR: elevated • Cardiac Enzymes: rise over several days as opposed to hours in AMI • Endomyocardial Biopsy: definitive diagnosis • CBC • Mild leukocytosis • Echocardiography • Dilated chambers with diffuse hypokinesis or focal wall motion defects • ECG • Low Voltage, nonspecific ST/T wave changes, any dysrhhythmia • Sinus tach most common

  17. Myocarditis • Treatment • Administer Antibiotics if suspected bacterial infection • Aspirin & IVIG if suspected Kawasaki’s • Bed Rest • CHF treated per normal protocol, but caution with digoxin • Dysrhythmias managed per normal protocol • Admit to ICU

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