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Cardiomyopathy and Myocarditis

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Title: Cardiomyopathy and Myocarditis


1
Cardiomyopathy and Myocarditis
2
Cardiomyopathy
  • Definition diseases of the heart muscle of
    unknown etiology that produce both structural and
    functional damage to the myocardium (Rivers)
  • Definition Cardiomyopathies are a heterogeneous
    group of diseases of the myocardium associated
    with mechanical and/or electrical dysfunction
    that usually (but not invariably) exhibit
    inappropriate ventricular hypertrophy or
    dilatation and are due to a variety of causes
    that frequently are genetic. Cardiomyopathies
    either are confined to the heart or are a part of
    generalized systemic disorders, often leading to
    cardiovascular death or progressive heart
    failure-related disability. (AHA 2006)

3
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

4
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

5
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 ideopahtic
  • Ischemic is the most common identified cause
  • Toxins Alcohol, cocaine, amphetamines, lead,
    lithium
  • Infectious CMV, HIV, Varicella, Hepatitis
  • Endocrine Thyroid/Growth hormone excess or def
  • Peripartum

6
Dilated Cardiomyopathy
  • Diagnosis
  • ECG LVH, Lt or biatrial hypertrophy, poor r
    wave progression, new BBB, Afib
  • Chest Xray nonspecific cardiomegaly
    pulmonary vascular congestion
  • Echocardiograpy ventricles atria enlargement,
    increased systolic/diastolic volumes, EF lt45,
    abnormal ventricle contraction, valvular
    regurgitation

7
Dilated Cardiomyopathy
  • Treatment
  • Treat CHF diuretics, digitalis, vasodilators,
    ACE inhibitors
  • Anticoagulants all with mural thrombi evidence
    of pulmonary or systemic emboli atrial
    fibrillation

8
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,
    hyereosinophlic syn., carcinoid
  • Presentation
  • Similar to dilated cardiomyopathy, but more
    pronounced right sided heart failure dyspnea on
    extertion
  • Physical Exam
  • Rales, peripheral edema, JVD, gallops,
    tachycardia, regurgitation murmurs

9
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
  • Treatment
  • Usually diuretics and digitalis
  • Vasodilators can cause pronounced hypotension and
    may need to be avoided

10
Hypertrophic Cardiomyopathy
  • hypertrophy of the left ventricle, and
    occasionally of the right ventricle
  • prevalence of hypertrophic cardiomyopathy 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 in
    HCM, and diastolic dysfunction is usually present
  • 50 of cases are inherited via an autosomal
    dominant transmission
  • Most common acquired causes are HTN Aortic
    Stenosis

11
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

12
Hypertrophic Cardiomyopathy
  • Diagnosis
  • Chest Xray usually normal
  • Echocardiogram LVH with disproportionate septal
    hypertrophy small ventricular volume
  • ECG LVH LAH Afib and PVCs common
  • think hypertrophic cardiomyopathy in any young
    person whose EKG shows large septal Q waves

13
Hypertrophic Cardiomyopathy
  • Treatment
  • Can become unstable in afib due to lack of atrial
    kick (cardioversion heparinization)
  • Long term care with Beta blockers
  • Amiodarone is treatment of choice for ventricular
    dysrhythmias
  • 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 afib

14
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 systemic lupus
    erythematosus, Wegener's granulomatosis, giant
    cell arteritis, Kawasakis, and Takayasu
    arteritis
  • Drugs PCN, sulfonamides
  • Toxins Cocaine, toluene
  • Parasites Chagas, Toxoplasmosis, Trichinosis

15
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
  • 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
    dysrhythmia (sinus tach most common)

17
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

18
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