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Cardiomyopathy, Myocarditis and Pericardial Disease Assignment
1. Prepared by: Nigussie Wondimu ID 188/15
Submitted To: Mr. Bikila T.(Asst.Prof.)
July,2023
Fiche, Ethiopia
SALALE UNIVERSITY COLLOGE HEALTH
SCIENCE DEPARTMENT OF NURSING
Assignment: Cardiomyopathy, Myocarditis and
Pericardial Disease
3. Objective
At the end of this course students will be able to:
• Define cardiomyopathy, myocarditis & Pericarditis
disease
• List types of cardiomyopathy
• Describe etiology of cardiomyopathy, myocarditis &
Pericarditis disease
• List clinical manifestation of cardiomyopathy,
myocarditis & Pericarditis disease
4. Introduction
• cardiomyopathies as “a heterogeneous group of
diseases of the myocardium associated with
mechanical &/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
5. Introduction…
• As cardiomyopathy worsens, the heart becomes
weaker.
• It's less able to pump blood through the body and
maintain a normal electrical rhythm. This can lead to
heart failure or irregular heartbeats called
arrhythmias.
• In turn, heart failure can cause fluid to build up in the
lungs, ankles, feet, legs, or abdomen.
• The weakening of the heart also can cause other
complications, such as heart valve problems.
6. Cardiomyopathy
Definition
• cardiomyopathies as “a heterogeneous group of
diseases of the myocardium associated with
mechanical &/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
7. Cardiomyopathy...
• 3rd most common form of heart disease in U.S.
• 2nd most common cause of adolescent sudden
death(IHSS or HOCM)
• Directly affects cardiac structure and impairs
myocardial function
9. Dilated Cardiomyopathy
• Dilation of one or both ventricles
• Depressed ventricular systolic function: both
ventricles or predominantly LV. Isolated RV
cardiomyopathy is rare.
• 80% of DCM cases are idiopathic
• African Americans and males have 2.5x increased risk
• Most common age of diagnosis 20-50yrs
13. Natural History of DCM
• Congestive heart failure
• Arrhythmias (Afib, VT)
• Chest pain
• Thromboembolism
• Sudden death
14. Diagnosis of DCM
• CXR- cardiomegaly and pulmonary congestion
• ECG- LVH, Left atrial enlargement, Atrial fibrillation, Q
waves, poor R wave progression
• Echo-Biventricular enlargement and global
hypokinesis.
• Cardiac cath: contrast left ventriculogram
• Radionuclide ventriculogram: RVEF, LVEF , global
hypokinesis.
15. Diagnosis of DCM
Exclude other causes of contractile failure
(HTN, CAD, valvular disease).
Test for specific etiologies
?Percutaneous endomyocardial biopsy
16. Treatment of DCM
• Goal of Rx
• Alleviate symptoms of dyspnea
• Improve exercise tolerance
• Prevent progressive cardiac dilation
(remodeling)
• Prolong survival
17. ED care and disposition
• Admit- newly diagnosed or symptomatic
• IV lasix and digoxin-improve symptoms
• ACE inhibitors & B-Blockers-improve survival
• Antiarrhythmics: eg. Amiodarone- for complex
ventricular ectopic
• Anticoagulation can be considered
Treatment of DCM
18. Hypertrophic Cardiomyopathy (HCM)
• Synonyms
Hypertrophic Obstructive Cardiomyopathy
(HOCM)
Idiopathic Hypertrophic Sub aortic Stenosis (IHSS)
• Asymmetric LVH and/or RVH
primarily involves septum-usually without
dilation
• Dynamic systolic obstruction of LV outflow
Apposition of the bulging septum and the
anterior leaflet of mitral valve
19. Hypertrophic Cardiomyopathy
• Abnormal compliance
Impaired diastolic relaxation and filling
Normal or supernormal contractile function
• Prevalence: 1 in 500
• 50% hereditary or sporadic
Familial (autosomal dominant with variable
penetrance)
• Myofibrillar disarray
Mutations in sarcomeric contractile protein genes
• Mortality 4-6% in childhood/adolescence
21. Clinical Features_HCM
• Symptom severity progresses with age
Dyspnea on exertion
– most common initial or presenting symptom
Angina-like chest pain
Palpitations
Syncope may also be present
Sudden death
28. Admit: With syncopal episode
B-blocker: Rx of choice for HCM
Discourage vigorous exercise(not a problem for most
patients)
Management_HCM
29. • Predict risk of sudden death:
-Early age at presentation
-Positive family history
-Massive hypertrophy: LV >35 mm
-Syncope
-Non-sustained VT on Holter
-Genetic typing
• Prevent sudden death
Internal cardiac defibrillator (ICD)
Management_HCM
30. Restrictive Cardiomyopathy
• One of least common cardiomyopathies
• Abnormally stiff myocardium:
Fibrosis, infiltration, idiopathic
• Impaired diastolic function (systolic function usually
preserved)
• Decreased or normal volume of ventricles
• Wall thickness is normal
• Mostly idiopathic- sometimes familial
• Systemic disorders-amyloidosis, sarcoidosis,
hemochromatosis, scleroderma, and carcinoid.
32. Clinical Features_RCM
• Symptoms of CHF-dyspnea, orthopnea, pedal
edema- rarely chest pain
• Exam- rales, increased JVP, Kussmaul’s sign, S3 or S4
gallop,, hepatomegaly, pedal edema or ascites
33. Diagnosis_RCM
• CXR-signs of CHF without cardiomegaly
• EKG-nonspecific changes most likely
Conduction disturbances and low-voltage QRS
complexes: with amyloidosis or sarcoidosis
• Cardiac catheterization:
Restricted filling pattern during diastole
• RV biopsy
34. Differential Diagnosis: RCM
• Diastolic left ventricular dysfunction(due to ischemic
or hypertensive heart disease)
• Constrictive pericarditis
Need to differentiate RCM from constrictive
pericarditis (surgical treatment)
35. Treatment_RCM
Admission: based on severity of Sxs and availability
of prompt follow up
Symptom directed-diuretics and ACE inhibitors
Corticosteroids for sarcoidosis
Chelation therapy for hematochromatosis
36. Dysrhythmogenic Right Ventricular
Cardiomyopathy(DRVC)
• Most rare form of cardiomyopathy
• Progressive replacement of RV myocardium with
fibro fatty tissue
• Typical presentation of sudden death in young or
middle aged patient
• Exam usually normal
• EKG- RBBB may be present
• Echo-necessary for diagnosis
37. Myocarditis
• Is inflammation of myocardium
• Can be result of systemic disorder or infectious agent
• Viral-Coxsackie B, echovirus, influenza, parainfluenza,
Epstein-Bar, and HIV
• Bacterial-C. Diphtheria, N. meningitides, M.
pneumonia, and beta-hemolytic strep
• Frequently accompanied with pericarditis
38. Clinical Feature_ Myocarditis
• 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
39. Diagnosis and Differential_Myocarditis
• EKG-nonspecific changes, av block, prolonged QRS
suration, or ST elevation(with pericarditis)
• CXR-Normal
• Cardiac Enzymes- may be elevated
• Differentail-ischemia or infarct, valvular disease, and
sepsis
41. Pericardial disease
• May be primary and acute
or
• Chronic
- Constrictive
- Effusive
- Or constrictive-effusive
42. Acute Pericarditis
• Loose visceral and dense parietal pericardium
surround heart
• Pericardial space may contain up to 50ml normally
• Etiologies: viral, bacterial, fungal, malignancy, drugs,
radiation, connective tissue disorder, uremia,
myxedema, post-MI, or idiopathic
43. Clinical Features_Acute Pericarditis
• Sudden or gradual onset of sharp or stabbing pain
Radiation to back, neck, Lt shoulder or arm: most
common
Radiation to Lt trapezial ridge: distinguishing
Pain more severe with lying supine and relieved with
sitting
• Low grade fever, dyspnea and dysphagia
• Transient, intermittent friction rub
44. 9/98 medslides.com 44
ECG features_Acute Pericarditis
• ST-segment elevation
– leads I, II, aVL, and V3-V6
– lead aVR usually shows ST depression
• ST concave upward
– ST in AMI concave downward like a “dome”
• PR segment depression (early stage)
• T-wave inversion
– occurs after the ST returns to baseline
46. Investigations_Acute Pericarditis
• CXR-normal and can help r/o other disease
• Other tests-CBC, BUN and Cr, streptococcal serology,
viral serologies, ANA/anti-DNA abs, thyroid function,
ESR, Cardiac Enzymes
47. Treatment_Acute Pericarditis
• Idiopathic or presumed viral etiology: outpatient
with NSAIDs for 1-3 weeks
• Myocarditis or hemodynamic instability: admit
• Treat any identified specific causes
48. Cardiac Tamponade: Nontraumatic
• Pressure in pericardial sac exceeds normal filling
pressure in RV: restricts filling and COP
• Etiology: metastatic malignancy, uremia,
hemorrhage(over-anticoagulation), bacterial or
tubercular disorders, chronic pericarditis, SLE, post
radiation, myxedema
50. Diagnosis_ Cardiac Tamponade
• EKG-low voltage QRS with ST elevation and PR
depression possible
• Electrical Alternans-classic finding—P and R wave
beat to beat variability
• CXR-+/- enlarged cardiac silhoutte
• ECHO-diagnostic modality of choice
51. Treatment_ Cardiac Tamponade
• Admission to ICU or monitored setting
• IV Fluid Bolus: improves RV filling and improves
hemodynamics
• Pericardiocentesis-therapeutic and diagnostic
52. Constrictive Pericarditis
• Occurs when fibrous thickening and loss of elasticity
interfere with diastolic filling
• Etiology: Cardiac trauma, pericardiotomy,
intrapericardial hemmorhage, fungal or bacterial
pericarditis, uremic pericarditis
53. C/F_Constrictive Pericarditis
• Sx’s gradually develop-mimics restrictive CM-
CHF, DOE, and decreased exercise tolerance
Chest pain, orthopnea, PND uncommon
• Exam- JVD and Kussmaul’s sign,Pedal edema,
hepatomegaly, ascites.
• Pericardial “knock”: early diastolic sound at apex
54. Constrictive Pericarditis
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
57. Pericardial effusion
• Is Presence of abnormal amount and/or character of
fluid in the pericardial space
• Can be caused by LOCAL/SYSTEMIC/IDIOPATHIC
• Can be ACUTE or CHRONIC (symptoms)
• Important implications for prognosis (intrathoracic
neoplasm), diagnosis (myopercarditis) or both
(dissecting of ascentding aorta)
58. Pericardial effusion
• Treatment directed at removal of pericardial fluid and
alleviation of the underlying cause
• Spectrum of causes of effusion is similar to acute
pericarditis
• More likely than constriction following MI and
cardiac surgery
• Can coexist with acute pericarditis and chronic
constrictive disease
59. PHYSIOLOGY
• Volume of fluid: 15-50 ml.
• Essentially and ultra filtrate of plasma
• Total protein generally low. Albumin conc. HIGH.
• Contribution of pericardial fluid: end-diastolic
pressure (mostly RA,RV)ensure uniform contraction of
the myocardium
• Acute (80ml) vs. Chronic (up to 2lt).
60. ETIOLOGY
• As a component of any pericardial disorder or 2ry to
a systemic disorder:
• Acute idiopathic or viral pericaditis
• Infectious: Viral, Purulent pericarditis, Tuberculous,
HIV
• Post MI/post cardiac surgery
• Malignancy (lung, breast, hodgkin’s, mesothelioma)
• Mediastinal radiation
• Autoimmune disease
69. PREVENTION cardiomyopathy, myocarditis &
pericarditis disease
control the underlying conditions of high blood
pressure, high blood cholesterol and diabetes:
• Get regular checkups with your health care
professional.
• Follow your health care professional's advice about
lifestyle changes.
70. Prevention…
• Take all your medications exactly as prescribed.
• getting prompt treatment
• following your treatment plan and
• getting ongoing medical care as needed
