Cardiomyopathy and Myocarditis

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Cardiomyopathy and Myocarditis

• Tintinalli Chap. 59

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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

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Dilated Cardiomyopathy

• Dilation of all four chambers (ventricles gt
  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)

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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

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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 lt45,
• abnormal ventricle contraction,
• valvular regurgitation

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Dilated Cardiomyopathy

• Treatment
• Treat CHF diuretics, digitalis, vasodilators,
  ACE inhibitors
• Anticoagulants all with mural thrombi evidence
  of pulmonary or systemic emboli atrial
  fibrillation

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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, KUSSMAULs
  Sign?

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Restrictive Cardiomyopathy

• Diagnostic Studies
• ECG chamber enlargement (atria gt 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
• Catheterizationdip 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

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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 1500 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

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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

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Hypertrophic Cardiomyopathy

• Diagnosis
• Chest Xray usually normal
• Echocardiogram LVH with disproportionate septal
  hypertrophy small ventricular volume
• ECG LVH LAH A-fib and PVCs common
• think hypertrophic cardiomyopathy in any young
  person whose EKG shows large septal Q waves

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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

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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, Kawasakis,
  and Takayasu arteritis
• Drugs PCN, sulfonamides
• Toxins Cocaine, toluene
• Parasites Chagas, Toxoplasmosis, Trichinosis

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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

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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

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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

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Myocarditis

• Treatment
• Administer Antibiotics if suspected bacterial
  infection
• Aspirin IVIG if suspected Kawasakis
• Bed Rest
• CHF treated per normal protocol, but caution with
  digoxin
• Dysrhythmias managed per normal protocol
• Admit to ICU