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Cardio > Cardiomyopathy, myocarditis & pericarditis > Flashcards

Cardiomyopathy, myocarditis & pericarditis Flashcards

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1
Q

What are the types of cardiomyopathy

A

Hypertrophic
Dilated
Restrictive
Myocarditis

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2
Q

What is dilated cardiomyopathy?

A

Chambers of the heart dilate (funnily enough)

Meaning the volume increases, but this leaves the heart walls relatively thin

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3
Q

How does heart muscle develop in dilated cardiomyopathy?

A

As the muscle walls dilate over time, new sarcomeres are added in series

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4
Q

Which chambers of the heart are affected more in DCM?

A

Ventricles

All 4 chambers of the heart can dilate though

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5
Q

What are the general causes of DCM?

A

Idiopathic

Ischaemia & valvular diseases

Arrhythmias

Genetic & familial causes

Infection, inflammatory, autoimmune, postpartum causes

Toxic damage

Injury, cell loss, scar replacement

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6
Q

What are the genetic / familial causes of DCM?

A

SCN5A gene mutations

Muscular dystrophy (Duchenne)

Haemaochromatosis

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7
Q

What toxic damage can cause DCM?

A

Chemotherapy (doxorubicin)

Cocaine

Alcohol

Exogenous chemicals

Endocrine stuff

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8
Q

What infections or diseases can cause DCM?

A

Sarcoidosis

Causes of myocarditis eg:

  • Coxsackievirus B
  • Chagas disease from south america
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9
Q

What does postpartum DCM mean?

A

= Pregnancy

DCM can occur in third trimester or just after the mother gives birth

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10
Q

What are the symptoms of DCM?

A

Progressive, slow development of:

Dyspnoea 
Orthopnoea 
PND - paroxysmal nocturnal dyspnoea 
Cough 
Ankle swelling 
Weight gain

(symptoms of heart failure)

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11
Q

If someone presents with symptoms indicating DCM, what important points should you get from the past medical history?

A

Systemic illness

Hypertension

Vascular disease

Thyroid problems

Neuromuscular disease

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12
Q

What important points for DCM should you get from the family & social history?

A

Incidence of DCM or other cardiomyopathy

Recent travel to spicy overseas places

Alcohol intake

Occupational history

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13
Q

What signs on inspection would indicate DCM?

A

SOB (tachypnoea) at rest

Elevated JVP

Poor superficial perfusion

Ankle oedema

Sacral oedema (if they’ve been lying down for a while)

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14
Q

What signs on palpation would indicate DCM?

A

Thready, narrow pulse

Irregular pulse if in AF

Displaced apex beat

Increased Cap refill

Hepatomegally

Ascites

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15
Q

When auscultating a patient, what signs would indicate DCM?

A

Mitral regurgitation murmur

S3 and S4 heart sounds

Crackles (pulmonary oedema, pleural effusions)

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16
Q

What investigations should be done for DCM?

A 
Repeat ECGs 
CXR 
CMRI 
Bloods (FBC, U+Es) 
N termial pro Brain Natriuetic Peptide
ECHO 
Coronary angiogram
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17
Q

What general measures are taken to patient care in DCM?

A

Correct anaemia

Remove exacerbating drugs eg NSAIDs

Correct any endocrine disturbance

Advise on fluid and salt intake, reduce it

Advise on managing weight to identify fluid overload

HF nurse referral

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18
Q

What drugs can be given to patients for DCM?

A

ACEI, ATII blockers, diuretics

Beta blockers

Spironolactone

Anticoagulants as required

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19
Q

What surgical management is available for DCM?

A

SCD risk assessment with ICD or CRT-D/P implant

Cardiac transplant

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20
Q

Which type of DCM has the best prognosis?

A

Postpartum DCM (pregnancy)

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21
Q

Which DCM has the worst prognosis?

A

DCM due to HIV infection

<20% survive past 10 years

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22
Q

What is the effect of Restrictive cardiomyopathy?

A

Reduced compliance of heart muscle

Reduced filling of heart means less blood pumped out

= Diastolic heart failure

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23
Q

What are the causes of RCM?

A

50% idiopathic

Non infiltrative; Familial, forms of HCM, Scleroderma, diabetic, pseudoxanthoma elasticum

Infiltrative; Amyloid, Sarcoid

Storage diseases; Haemachromatosis, Fabry disease

Endomyocardial; Fibrosis, carcinoid, radiation, drug effects

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24
Q

Summarise the basic investigation for RCM

A

Repeated ECG

CXR

N termial pro Brain Natriuetic Peptide

Basic bloods (FBC, U+Es)

Auto antibodies

Fabry; low plasma alpha galactosidase A activity

Echo

CMRI

Biopsy more helpful but still has high false negative rate

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25
Which imaging method is best for identifying Cardiomyopathies?
CMRI
26
Why is taking bloods useful for identifying RCM?
Can identify Sarcoid causes and haemachromatosis
27
Why is autoantibodies a useful test for RCM?
Identifies sclerotic connective tissue diseases
28
If investigations indicate an Amyloid cause for RCM, what must be done to confirm the diagnosis?
Amyloid needs non cardiac biopsy to help establish the diagnosis
29
How is RCM pharmacologically managed?
Limited diuretic use as low filling pressures will cause problems Beta blockers limited ACEI use Anticoagulants as required
30
How is RCM surgically managed?
SCD risk assessment with ICD or CRT-D/P implant Cardiac transplant
31
What mutation is associated with hypertrophic cardiomyopathy?
Sarcomeric protein gene mutation accounts for 40-60% of cases Autosomal dominant gene but has varied expression and incomplete penetrance so often does not show Most often MYBPC3, MYH7
32
How does cardiac muscle differ in someone with HCM
Sarcomeres added in parallel Can be generalised or segmental thickness, so it may just be apical or septal areas that are fucking huge Histologically, mad disarray of cells so it doesnt look ordered n stuff
33
How can HCM cause cardiac ischaemia?
Hypertrophic muscles are heavy massive so compress the coronary arteries Reduces blood flow to areas leading to ischaemia This is why HCM is a cause of stable angina and ACS's
34
Apart from ischaemia, what other effects can HCM have on the heart?
Fibrosis Arrhythmias
35
What are the symptoms of HCM
Asymptomatic for many ``` fatigue dyspnoea anginal like chest pain Palpations exertional pre syncope syncope related to arrhythmias or LV outflow tract obstruction ```
36
What are the main examination findings for HCM
Can be none Notched pulse pattern Irreg pulse if in AF or ectopy Double impulse over apex, thrills and murmurs, often dynamic, LVOT murmur will increase with valsalve and decrease with squatting JVP can be raised in very restrictive filling
37
How do you assess HCM?
ECG ECHO CMRI Might do an ETT Could do a Holter monitor (ECG) Risk stratification for SCD, may need ICD
38
Will an ECG always show signs of HCM?
Usually yes a few are normal where phenotype is poorly expressed in genotype +ve individuals
39
How is HCM managed pharmacologically?
if symptomatic - beta blockers, verapamil, disopyrimide If in AF - anticoagulate
40
What general measures are taken to manage HCM?
Avoid heavy exercise Avoid dehydration Explore Family History and first degree relatives, ECGs and echo's may be required Consider genetic testing Regular Follow Ups to re appraise the risks and progress
41
What surgical options can be used to manage HCM?
If the disease is obstructive; surgical or alcohol septal ablation ICD if required based on risk stratification
42
Myocarditis is most commonly caused by what group of microorganisms?
Viruses
43
Describe the pathologyphysiology stuff for myocarditis
Infection causes infiltration of inflammatory cells into the myocardium Inflammation reduces cardiac function leading to Heart failure If conduction system is involved, then heart block and potential arrhythmias Myocyte degeneration or necrosis is key histological feature
44
How would a patient with myocarditis typically present?
Fairly rapid onset of: Heart failure; fatigue SOB Chest pain Fever Signs of Heart failure (ankle oedema, lung crackles etc)
45
What investigations are carried out for myocarditis?
ECG Biomarkers (bloods) ECHO CMRI Tests for specific viruses
46
Why is a blood test useful for myocarditis?
Biomarkers such as cTn, CK often elevated but not falling in a pattern consistent with MI
47
Why is an ECHO useful for myocarditis investigation?
Can identify Regional wall motion abnormalities (RWMA)
48
What specific viral tests can be done for myocarditis?
``` Viral DNA PCR Auto antibodies Step antibodies Lyme B burgdorferi HIV ```
49
What are the general measures for treating myocarditis?
Supportive treatment of heart failure Support for brady and tachy arrhythmias. Immunotherpay if biopsy or other Ix point to a specific diagnosis Stop possible drugs or toxic agent exposure
50
What is the prognosis for myocarditis?
30% recovery fully 20% mortality at 1 year 56% mortality by 4 years At 11 years those still alive are 93% transplant free
51
What is pericarditis?
Inflammation of the pericardial layers with or without myocardial involvement
52
What are the main/key causes of pericarditis?
``` Idiopathic Viral Bacterial Post MI Perforation Dissection of proximal aorta Neoplasia ```
53
What are the symptoms of pericarditis?
chest pain with pleuritic features sitting forward usually improves it lying back makes it worse Fever
54
What are the signs of pericarditis?
Pyrexia Low Blood pressure Muffled heart sounds Pericardial rub at LSE Raised JVP
55
What does pericarditis with a raised JVP indicate?
raised JVP should make you consider not just pericarditis but effusion
56
If a patient has a high fever, is generally very unwell, but has no effusion What does this indicate?
Likely bacterial pericarditis
57
What are the investigations for pericarditis?
ECG Echo Bloods (troponin)
58
Why should bloods be taken for a patient for pericarditis?
Raised cTn indicates myocardium is involved / infected as well
59
How would you identify pericarditis on an ECG?
PR depression & ST elevation
60
What are the general measures for pericarditis?
Viral is conservative Idiopathic gets colchicine and limited use of NSAIDs Bacterial must be drained even if small effusion and antimicrobials, high death rate If large effusion present and some haemodynamic effects then drain
61
What is the risk posed by pericardial effusion?
Tamponade
62
What are the symptoms of Tamponade?
Symptoms are overt fatigue SOB Dizzy with low BP Occasionally chest pain.
63
What are the signs of Tamponade?
Signs are overt as well; ``` pulsus paradoxus JVP raised low BP +/- rub +/- muffled Heart Sounds ``` Pulmoary oedema although this is very rare in pericardial effusions/tampaonade
64
What investigations should be done for pericardial effusions or tamponade?
Urgent ECHO CXR - can show large cardiac shadow ECG
65
How is pericardial effusion or tamponade treated?
Drainage is the destination treatment Persistent effusion needs a surgical pericardial window made to allow flow to abdomen Send for MCS, neoplasic cells, protein and LDH
66
What is the nature of most pericardial effusions?
Exudate Determined by sending sample for protein levels, LDH etc to be tested
67
What feature of an ECG would indicate a large pericardial effusion?
Electrical alternans | Axis of QRS alternates between beats ± wandering base line
68
Constrictive pericarditis is a rare type of pericarditis What are the causes of it?
``` idiopathic radiation post surgery autoimmune renal failure sarcoid ```
69
What is the effect of constrictive pericarditis?
impaired filling although myocardium is normal most of the time causes Diastolic heart failure
70
What are the symptoms of restrictive pericarditis?
fatigue, SOB, cough
71
What are the signs of restrictive pericarditis?
Right heart failure signs: ``` oedema ascites high JVP jaundice hepatomegally AFib Tricuspid regurgitation pleural effusion pericardial knock ```
72
How do you investigate restrictive pericarditis? What disease must you make sure to differentiate against?
Echo Right heart catheter differentiate from restrictive cardiomyopathy which can be very difficult
73
How is restrictive pericarditis treated?
Careful and limited diuretics Pericardectomy - removal of part/all of the pericardium

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