3. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
EKG
• NSR
• LVH with QRS widening and ST segment
strain
• Abnormal EKG- No comparison EKG
available
4. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Cardiology
Frank Meissner, MD, FACP, FACC, FCCP
5. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Nutritional Cardiac Diseases
6. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Protein-Calorie Malnultrition
• Vacuolar degeneration of myofibrils
• Esp in conducting tissue
• Sudden death common, possibly from
arrythmia
• During recovery findings of CHF often seen
• Malnourished children sensitive to digoxin,
use diuretic only
7. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Beriberi Heart Disease
• Thiamine deficiency 2° ingesting highly
milled rice as staple food
• Also occurs in chronic alcoholism
• Peripheral vasodilatation - high output state
• Reduced renal blood flow with retention of
Na+ & water
• Increased blood volume & biventricular
failure
8. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Beriberi - diagnostic criteria
• Hx/O Thiamine Deficiency
• Exclusion of other causes of heart disease
• High output failure
• Evidence of peripheral neuritis or pellagra
• Rapid response to therapeutic trial of
Thiamine
9. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Beriberi- treatment
• Thiamine hydrochloride 100 mg IV QD X 5
days
• Oral thiamine 50 mg qd X 1-2 weeks
• Bed rest
• ± diuretics
10. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Non-infectious
Myocardiopathic Diseases
11. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive
Cardiomyopathy- Epidemiology
• Worldwide distribution
• High prevalence rates among blacks in
tropical/subtropical Africa
• Nigeria - 30-40% CV disease 2° idiopathic
cardiomyopathy
12. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive
Cardiomyopathy- Epidemiology
• Nigeria - 2nd most common cause of
cardiac death after RVD
• Southern Africa - 60%
• Postmortem study of East Africans - most
common fatal heart disease
13. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive
Cardiomyopathy- Etiology
• Multifactorial disease - ETOH, HTN,
Malnutrition, viral myocarditis
• West African study 40% had chronic ETOH
use + malnutrition
• Grp B Coxsackieviruses implicated if
febrile illness concurrent with CHF
14. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive
Cardiomyopathy- Pathology
• Low output failure
• Heart grossly enlarged - 500-600 gms
• Trabeculae carneae are smoothed out
• Thrombus often seen in apical region
• Mitral/tricuspid rings dilated without
evidence of intrinsic valvular disease
• Often present with 1° or more often 2° HTN
15. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Idiopathic Congestive
Cardiomyopathy-
Clinical Findings• Fatigue
• Dyspnea
• Cardiomegaly
• Diffuse Cardiac Impulse
• Gallop Rhythm
• Murmurs of MR/TR
16. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Epidemiology
• Uganda, Kenya, Zambia (E. Africa);
Nigeria, Ghana, Ivory Coast (W. Africa)
• Brazil, Columbia, Venezuela, Mexico (S. &
Cntrl America)
• Kerala & Haryana (India)
17. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Epidemiology
• In Uganda - as common a cause of cardiac
failure as RHD
• Uganda - seen in 25% of cardiac necropsies
• More common in poorer socioeconomic
conditions
• In endemic areas 50% occur in persons < 15
yrs of age
18. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Etiology
• Tropical environment
• Familial occurrence
• Circulating autoimmune heart antibodies
• Deposition of immune complexes in heart
• Elevated malaria antibody titers
• Tropical spleenomegaly
19. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Pathology
• Fibrosis of mural endocardium
• Thrombus deposition followed by fibrotic
organization
• Early in disease embolization may occur
• Usual extends to the mitral and tricuspid
valve apparatus
20. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Pathology
• Valvular regurgitation can often occur
• Restriction of cardiac filling/cardiac output
• R-ventricle infundibulum hypertrophied and
dilated
• Severe R-sided failure symptoms can be
seen (ascites/hepatomegaly)
• L-ventricular involvement results in MR &
PAH
21. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Clinical Findings
• May manifest in first several months in life
• Usually recognized in advanced stages
• Symptoms advance rapidly
• Process is usually biventricular
• High venous pressure causes exopthalmos,
periorbital facial edema, jaundice
22. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Clinical Findings
• Ascites almost always seen, but peripheral
edema rare
• Pericarditis present approx 40% cases -
aggravates restrictive cardiomyopathy
• Peripheral cyanosis and clubbing common
2° low cardiac output
• Cachexia, protein-losing enteropathy,
cardiac cirrhosis with hepatic failure -
terminal events
23. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Tropical Endomyocardial
Fibrosis- Clinical Findings
• Hyperdynamic RV outflow - L upper
parasternum
• Murmur of TR + R-sided S3
• Early peaking systolic MR murmur
• Late opening snap (MV) + L-sided S3 often
heard
• Early peaking systolic MR murmur +
opening snap unique to LV endomyocardial
fibrosis
25. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Acute Pericarditis
• Fibrinous
– Friction rub in acute rheumatic pericarditis
– Viral pericarditis - grp B coxsackie virus
• Serous
– Childhood/adult pericardial TB
– Endemic areas for endomyocardial fibrosis,
childhood effusion implys this Dx
26. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Acute Pericarditis
• Suppurative
– Common in tropics - most commonly S.
pneumoniae 2° pneumonia or S. aureus 2° osteo
– Syndrome of cough + dyspnea + toxemia +
friction rub + increasing heart size
– Mortality > 35% even with prompt Dx/Rx
• Amebic Pericarditis
– Rare complication of liver abscess
– Rupture into pericardial sac
– “Anchovy paste” pus
28. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever -
Epidemiology
• 0.05% of Strep infections lead to RF in
developed world
• 0.3 - 3% Strep infections lead to RF in third
world
29. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever- Etiology
• Nonsuppurative immunologic complication
of ß-hemolytic Strep
• Only URI give rise to RF, unlike, GN 2°
skin or URI infections
30. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever- Pathology
• Endocardium, myocardium, pericardium,
synovial joint linings, lungs, or pleura
• Characteristiclesion is perivascular
granulomatous reaction/vasculitis
• MV involved 75-80% cases
• AoV involved 30%
• TV &/or PV < 5% cases
• Healing complete or progressive valvular
disease over years and decades
31. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever-
Clinical Findings
• 1-4 wks post URI
• Revised Jones Criteria - 2 major or 1 major
& 2 minor criteria
32. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Major
• Carditis
• Polyarthritis
• Syndenham’s chorea
• Erythema marginatum
• Subcutaneous nodules
33. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Carditis
• Cardiac enlargement
• Pericardial friction rub
• Mitral or aortic vavlvular diastolic murmurs
• Prolonged PR interval
• Changing quality of heart sounds
• Tachycardia out of proportion to fever
34. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Minor
• Hx/o previous RF or RVD
• Fever
• Polyarthralgia
• Nonspecific evidence of inflammation
(increased sed rate, leukocytosis)
• Prolonged P-R interval
• Evidence of antecedent ß-hemolytic strp
infection, i.e., increased ASO, recent scarlet
fever
35. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Rheumatic Fever-
Treatment
• Bed rest
• ASA
• Rheumatic Fever- Prognosis
36. US Hospital, ZagrebUS Hospital, ZagrebUS Hospital, Zagreb
Infectious
Myocardiopathic
Diseases