Professional Documents
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Cardiomyopathy
Abdullah Saadah
Hala Al Khateeb
18 / 02 / 2010
Cardiomyopathy
Some notes before you begin:
The recorder isnt for the whole lecture; the last four topics are not covered.
Cardiomyopathy is the 3rd most common form of heart disease in U.S. and the 2nd most
common cause of adolescent sudden death in the forms of (Idiopathic hypertrophic
subaortic stenosis (IHSS) or Hypertrophic obstructive Cardiomyopathy (HOCM).It
directly affects the cardiac structure and impairs the myocardial function.
Dilated Cardiomyopathy:
In which we have dilation and compensatory hypertrophy of the myocardium, this causes
depressed systolic function and pump failure with low cardiac output.
African Americans and males have 2.5 times increased risk. And the most common age of
diagnosis 20-50yrs.
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Clinical Presentation:
Typical Signs and symptoms of congestive heart failure (CHF); dyspnea on exertion,
orthopnea and PND (paroxysmal nocturnal dyspnea), lower limb edema, hepatic
congestion.
Chest pain can occur due to low perfusion and low coronary vascular reserve;
because of the dilation of the myocardium, the coronary tree covers larger area to
supply, which causes less blood supply to that area and chest pain.
Because of the low cardiac output and because of the dilation, stagnation of the
blood in the left ventricle will occur and Mural thrombi can form, this may cause
peripheral vascular disease, renal shutdown or even CVA.
Holosystolic regurgitant murmur or gallop may
be present because of the dilation there is
stretching of the mitral valve of the papillary
muscles of the chorda tympani and the cups of
the mitral valve will not close well during systole,
this is called functional mitral valve disease and
has no treatment.
bibasilar rales:
Abnormal breath sounds (crackles)
heard on auscultation only in the
bases of the lungs. They indicate
inflammation, fluid, or infection in
the air sacs of the lung.
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Diagnosis:
We mainly do the diagnosis depending on the clinical picture; clinically the pt. with dilated
cardiomyopathy shows stigmata of CHF.
Chest X ray : we will find enlarged heartcardiomegaly, biventricular enlargement,
increase in the pulmonary vascular marking with congestion(cephalization) and upward
diversion of the pulmonary vessels in the upper lobes indicating pulmonary edema,
hilar engorgement and increase in the hilar marking
failure.
ECG
1) LVH
2) Left atrial enlargement determined by the negativity of the P wave in lead I
increases and in lead II shows sudden P wave.
3) Q waves,
4) poor R wave progression in lead (I-III),
5) Any type of arrhythmia can occur but especially atrial fibrillation and
sometimes sinus tachycardia; with the enlargement of the heart the action
potential travel longer distance because when the myocytes get enlarged the
conductance system doesnt enlarge with them and thats why part of the action
potential will be conducted through the myocardial muscle itself, and this action
potential will be transmitted slower and causes slow beat, on the ECG shows
wider QRS than normal, the wider the QRS in the patient with dilated
cardiomyopathy the worse the prognosis.
Echo-Confirms the diagnosis and shows: dilation of the left ventricle, decreased
ejection fraction that may reach 30, enlargement in the right ventricle can be
seen later on and thats because the rise in the left ventricular systolic pressure
causes increase in the left atrial pressure which causes left atrial enlargement and
causes pulmonary edema or pulmonary hypertension, then right atrial pressure
increases and finally the right ventricle pressure will increase causing right ventricle
enlargement and failure, and as a consequence of the right ventricle failure we will
have congestion in the systemic circulation manifested by ascites and lower limb
edema.
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Differential diagnosis:
Acute MI: Clinically dilated cardiomyopathy comes with the stigmata of congestive
heart failure and the cardiac echo shows that the left ventricle is enlarged, so it is
hardly to differentiate between ischemic cardiomyopathy and dilated
cardiomyopathy, so if the patient came with the history of coronary artery disease
then it is ischemic cardiomyopathy while if he came with dilated cardiomyopathy it
is usually idiopathic.
Restrictive Pericarditis it differs from dilated cardiomyopathy by the echo; in the
echo Restrictive Pericarditis shows small ventricle compared to the dilated
cardiomyopathy where it shows large left ventricle also the thickness of the
myocardium is more in Restrictive Pericarditis than that it is in the dilated
cardiomyopathy.
Acute valvular disruption usually causes acute re-compensation and acute heart
failure; it is usually easy by echo to differentiate between vulular disruption that
is functional rather than organic.
Sepsis
Any form of hypotension that results in low cardiac output state can come in the
differential of dilated cardiomyopathy.
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B-BLOCKERS are imp in cardiomyopathies in general and also imp to patients with
heart failure, B-blocker tend to decrease the tendency for complex arrhythmia
and the risk for sudden death. But only some types of b-blocker are indicated in
de-compensated heart failure (Bisoprolol, Metoprolol, and Carvedilol)
Anticoagulation may be considered usually in pts with dilated cardiomyopathy,
there is a rule that if the ejection fraction is less than 30 administer
anticoagulation therapy, but you should consider every patient as a separate case
and consider what other conditions the patient.
Warfarin is an anti coagulation drug but with a low therapeutic index which means that
the therapeutic dose is little less than the toxic dose, usually warfarin is indicated for
whom with an ejection fraction less than 30 or who are susceptible to mural thrombi
formation.
Hypertrophic Cardiomyopathy:
Sometimes its called idiopathic hypertrophic
subaortic stenosis (IHSS) in which the hyper trophy
happens in the outflow tract, hypertrophy can
happen in different parts of the left ventricle but
the most famous type is Usually in the out flow
tract, sometimes there is septal (posterior wall)
hypertrophy and sometimes there is apical
IHSS:
symptoms.
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dilate.
action.
Clinical Features
Sometimes its difficult to differentiate on the clinical examination between congestive
heart failure due to dilated cardiomyopathy or due to HOCM with diastolic dysfunction;
but mainly in diastolic heart failure and HCM we find LVF symptoms like pulmonary
edema, more right sided problems happen in dilated cardiomyopathy, the progression of
HOCM to RVF may begin at later stages, after 10-15 yrs while in dilated cardiomyopathy
it may happen after 2 yrs.
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Examination:
Fourth heart sound (S4) is a marker for
diastolic dysfunction; it is a marker of
increased end diastolic pressure.
Hyperdynamic apical impulse because of the
hypertrophied left ventricle compared to
weak apical pulse seen in dilated
cardiomyopathy.
Precordial lift because of the LVH.
Systolic ejection murmurs at the apex we
hear mitral regurg, and at the lower
left sternal border we hear late
systolic murmur which is a marker
for obstruction.
Murmur increased with valsalva
maneuver; when you take a deep
breath the venous return will
decrease, in case of HOCM when
This is v. imp
Anything the contractility will the obstruction,
the pressure and it will the severity of murmurs.
Anything the preload will the obstruction, the
pressure and it will the severity of the murmurs.
anything the after-load the obstruction, the
pressure and it will the severity of the murmurs.
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Diagnosis
EKG-LVH in 30%,
Left atrial enlargement In 25-50% this appears as prominent P wave in lead I and
camel hump shaped P wave in lead II
Large septal Q waves-25%
Sometimes in apical hypertrophy we will have significant T wave inversion in lead
v1-v6.
CXR-usually normal and may show left ventricular hypertrophy and the apex is
elevated from the diaphragm.
Echo-study is the diagnostic choice-demonstrates disproportionate septal
hypertrophy of the posterior wall or the anterior wall, in some cases you may see
mitral valve regurgitation , and in cases of obstruction u may see systolic anterior
portion of the septum and mitral leaflet forming obstruction in the anterior
portion and this is characteristic for HOCM.
Restrictive Cardiomyopathy
Type of
dysfunction
Dilated
cardiomyopathy
systolic
HCM
diastolic
Restrictive
cardiomyopathy
Large atria.
Clinical Features
Symptoms of CHF and right sided HF (pulmonary edema, dyspnea, orthopnea,,PND,
lower limb edema and rarely chest pain
Exam-may have S3the marker of heart failure
or S4 gallop the marker of diastolic dysfunction,
rales, jvd, Kussmauls sign(jvd with inspiration),
hepatomegaly, pedal edema or ascites .
Shows more diastolic dysfunction rather than systolic
dysfunction, its a problem in filling the ventricles, not
emptying them.
Diagnosis
It is a medical diagnosis
Constrictive pericarditis
Restrictive cardiomyopathy
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Differential Diagnosis
Constrictive pericarditis.
Diastolic left ventricular dysfunction(due to ischemic or hypertensive heart
disease) any form of diastolic dysfunction can be in the differential of restrictive
cardiomyopathy
Its v imp to differentiate between restrictive cardiomyopathy from constrictive
pericarditis which needs surgical treatment while the one earlier needs treatment
of the underlying cause and treat the symptoms.
Any patient that comes to you with heart failure and normal ejection fraction and
small right and left ventricles and bi atrial enlargement it means restrictive
cardiomyopathy.
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Echo-necessary for diagnosis but in most patients its normal; I shows nothing but
right ventricular dilation
The definite diagnostic test for this is cardiac MRI but we dont have it in Jordan it
shows that the right ventricle is dilated and shows abnormal texture of the right
ventricle.
Myocarditis
Inflammation of myocardium
Clinical Feature
Most of the symptoms are related the pathological features of Coxsackie B virus
Fever, tachycardia out of proportion to fever, myalgias, headache,rigors
Chest pain due to coexisting pericarditis
Pericardial friction rub
Severe cases may have CHF symptoms in the mild cases we may see left ventricular
failure symptoms
The only complication in a very small percentage of cases(510%) happens when myocarditis progress into dilated
cardiomyopathy, but most of the cases regain full recovery.
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Acute Pericarditis
Loose visceral pericardium and
dense parietal pericardium
surround heart
Pericardial space may contain up
to 50ml normally
Etiologies of acute pericarditisviral, bacterial, fungal, malignancy,
drugs, radiation, connective tissue
disorder, uremia, myxedema,
post-MI, or idiopathic
Clinical Features
Most common-sudden or gradual
onset of sharp or stabbing pain
with radiation to back, neck, L
shoulder or arm
Radiation to L trapezial ridge is
distinguishing
Pain more severe with lying supine and relieved with sitting
Low grade fever, dyspnea and dysphagia
Transient, intermittent friction rub
Diagnosis
EKG-changes in four stages
1) ST elevation in I, V5 and V6, PR depression in II, aVF and V4-V6
2) ST segment normalizes, T wave decreases
3) Inverted T waves in leads with previous ST elevation
4) Return to normal ECG
In I, V5, or V6 ST:Twave ratio >0.25 most likely acute pericarditis
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Etiology-metastatic malignancy,
uremia, hemorrhage(overanticoagulation), bacterial or
tubercular disorders, chronic
pericarditis, SLE, post radiation,
myxedema
Clinical Features
Dyspnea and decreased exercise tolerance-wt loss, pedal edema, ascites
Tachycardia, Narrow pulse pressure
Pulsus paradoxus
JVD, Muffled heart sounds, Hypotension
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Constrictive Pericarditis
Occurs when fibrous thickening and loss
of elasticity interfere with diastolic
filling
Cardiac trauma, pericardiotomy,
Clinical Features
Sxs gradually develop-mimics
Diagnosis
EKG-not very helpful-may show low voltage QRS and inverted T waves
CXR-pericardial calcifications seen in 50% on lateral view(not diagnostic)
ECHO, CT, MRI are diagnostic
Differential Diagnosis
Consider acute pericarditis, myocarditis, exacerbation of chronic ventricular dysfunction,
or systemic process resulting in decreased cardiac performance (sepsis)
B. MVA
C.
Overdose
D. Hypertrophic cardiomyopathy
Which of the following is not useful in cadiac tamponade?
A. IV fluids
B. Pericardiocentesis
C.
Bedside ultrasound
D. Diuretics
E. Ekg
Which of the following is not found on the EKG of acute pericarditis?
A. ST elevation and PR depression
B. Normal EKG
C.
Inverted Twave
D. Electrical Alternans
Which is not a sign or symptom of acute pericarditis?
A. Sharp stabbing chest pain with radiation to back, neck or L shoulder
B. Oslers Nodes
C.
Friction Rub
Hypertrophied
D. Restrictive
E. Dysrhythmic Right Ventricular
THE END
DONE BY HALA AL KHATEEB
S.A.RH
THX sawa for the recorder and happy anniversary
www.sawa2006.com
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