Myocardial Diseases mi


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Myocardial Diseases mi

  1. 1. Myocardial diseases By Dr. Osman Bukhari
  2. 2. <ul><li>1- Myocarditis </li></ul><ul><li>2- Cardiomyopathy </li></ul>
  3. 3. <ul><li>Myocarditis </li></ul><ul><li>This is acute inflammation of the myocardium due to diff causes which are diff to establish during routine clinical practice. </li></ul><ul><li>1- Infective :- </li></ul><ul><li>a- Viruses ++++ (Cox, Echo, Adeno, HIV and others.) </li></ul><ul><li>b- Bacteria (Rh fever, Diphtheria,) </li></ul><ul><li>c- Spirochaetal (Lyme, Leptospirosis) </li></ul>
  4. 4. <ul><li>d- Parasitic ( Chagas , Toxoplasmosis ) </li></ul><ul><li>e- Rickettsial f- Chlamydial </li></ul><ul><li>g- Fungal </li></ul><ul><li>2- Non infective :- </li></ul><ul><li>a- Toxic b- Radiation </li></ul><ul><li>c- Autoimmune d-Drugs (Antibiotics by hypersensitivity, CQ & Emetine by direct action ) </li></ul>
  5. 5. <ul><li>Clinical picture:- </li></ul><ul><li>- Usually acute onset, but may be gradual </li></ul><ul><li>- There may be a history of recent febrile or upper respiratory illness. </li></ul><ul><li>- Pleural- pericardial chest pain is common </li></ul><ul><li>- Tachycardia, low pulse volume, hypoten, soft HS, S3, gallop, signs of HF </li></ul><ul><li>- Pericardial rub </li></ul><ul><li>- Subclinical , presenting later with CM </li></ul><ul><li>- Sudden death </li></ul>
  6. 6. <ul><li>Investigations :- </li></ul><ul><li>- CXR : Cardiomegaly </li></ul><ul><li>- ECG : ST & T wave abn, arrhythmias. HT block with diph, Chagas & Lyme. </li></ul><ul><li>- Increased cardiac enzymes in active disease </li></ul><ul><li>- Echo </li></ul><ul><li>- Endomyovardial biopsy in specialized units </li></ul><ul><li>- Serology for viruses </li></ul>
  7. 7. <ul><li>Treatment :- </li></ul><ul><li>- Bed rest </li></ul><ul><li>- TR of z cause </li></ul><ul><li>- Management of HF & arrhythmias </li></ul><ul><li>- Steroids ? </li></ul><ul><li>Prognosis: depends on z aetiology & is usually good with remission in most cases. Few run fatal course . Chronic CM may ensue </li></ul>
  8. 8. <ul><li>Cardiomyopathies (CM) </li></ul><ul><li>CM are a group of cardiac muscle diseases not due to HT, IHD, Valvular or cong heart disease. Many cases are idiopathic (Pry) but some have specific causes. </li></ul>
  9. 9. <ul><li>Cardiomyopathies are classified according to the clinical presentation to: 1- Dilated CM 2- Hypertrophic CM 3- Restrictive CM 4- Arrhythmogenic RV CM </li></ul>
  10. 10. <ul><li>Dilated cardiomyopathy </li></ul><ul><li>DCM is characterized by dilatation and impaired systolic function of the LV and/ or RV in the absence of HT, valvular or IHD </li></ul><ul><li>Causes:- </li></ul><ul><li>1- Idiopathic DCM ( primary) diagnosed by exclusion of 2ndry causes. In 25 % it is familial. 2- Secondary DCM </li></ul><ul><li>a- Post infective </li></ul>
  11. 11. <ul><li>b- Alcohol </li></ul><ul><li>c- Conn. tissue dis. d- Autoimmune </li></ul><ul><li>e- Endocrine (DM, acromegaly, myxoedema, thyrotoxicosis) </li></ul><ul><li>f- Amyloidosis g- Haemochromatosis </li></ul><ul><li>h- Thiamine & Se deficiency i- Glycogen storage dis. j- Neuromuscular disorders ( Friedrieck’s ataxia, dystrophia myotonica & Duch) </li></ul>
  12. 12. <ul><li>k- Small vessel coronary dis . </li></ul><ul><li>l- Drugs ( Doxorubicin, daunorubicin, cocaine, cyclophosphamide ) </li></ul><ul><li>m- Post partum CM n- Radiation </li></ul><ul><li>o- SS dis. P- Sarcoidosis </li></ul>
  13. 13. <ul><li>Clinically:_ </li></ul><ul><li>- Symptom & signs of Lt & Rt heart failure </li></ul><ul><li>- Syncope from arrhythmias & conduction defects. </li></ul><ul><li>- Systemic or pulm embolism - Asymptomatic cardiomegaly </li></ul><ul><li>- Cardiomegaly, S3 gallop, MR & TR </li></ul><ul><li>- Sudden death </li></ul>
  14. 14. <ul><li>Investigations:- </li></ul><ul><li>- CXR : Cardiomegaly & pulm congestion </li></ul><ul><li>- Echo : Dilated ventricles with poor global systolic function </li></ul><ul><li>- ECG : Diffuse non specific ST segment & T wave changes, tachycardia, arrhythmias, conduction abn. </li></ul><ul><li>- Angiography to exclude CAD in those at risk </li></ul>
  15. 15. <ul><li>Treatment:- </li></ul><ul><li>Aim is to relieve symptoms, retard disease progression & prevent complications . </li></ul><ul><li>- Alcohol must be discontinued. </li></ul><ul><li>- TR secondary causes </li></ul><ul><li>- Conventional TR of HF . ACE- I & BB are indicated in most cases. Digoxin for AF. Severe Vt dilatation, AF & history of embolization are indications for anticoagulation </li></ul><ul><li>- Antiarrhythmic therap, permanent pacing </li></ul>
  16. 16. <ul><li>or implantable cardiovertor (defibrillators in specific cases. </li></ul><ul><li>- Cardiac transplantation for advanced dis. refractory to med. TR </li></ul><ul><li>- HF is resistant to TR and there is high risk of thromboembolism & progression to death. </li></ul>
  17. 17. <ul><li>Hypertrophic cardiomyopathy </li></ul><ul><li>1- In HCM there is variable muscle hypertrophy commonly involving IVS, unrelated to any pressure or volume overload, restricting LV filling during diastole. In 25% there is LV outflow obstruction due to combined effect of hypertrophy & SAM of za anterior Mitral valve leaflet ( HOCM) or idiopathic hypertrophic subaortic stenosis ( IHSS) . </li></ul>
  18. 18. <ul><li>2 -The abn. muscle is a focus of dangerous arrhythmias , sp VT which may convert to VF & HCM is potentially fatal & pat must avoid severe exercise which may provoke arrhythmias. </li></ul><ul><li>3-The obst. is worsened by factors that increase myocardial contractility or decreased LV filling and size </li></ul><ul><li>4- Obst. is decreased by factors that increas venous return. </li></ul><ul><li>5 - In 50 % it is familial-AD inheritance . Sporadic cases occur. Presentation in early adulthood </li></ul>
  19. 19. <ul><li>6 - HF results from stiff non compliant LV with impaired diastolic filling </li></ul><ul><li>7- MR results from SAM </li></ul><ul><li>8 - Systolic LV function is preserved till late when progressive dilatation my occur. </li></ul><ul><li>Clinically:- </li></ul><ul><li>1 - Asymptomatic </li></ul><ul><li>2- Chest pain, dyspnoea & syncope </li></ul><ul><li>3- Cardiac arrhythmias & sudden death </li></ul><ul><li>4-Jerky carotid pulse because of rapid </li></ul><ul><li>ejection. </li></ul>
  20. 20. <ul><li>5 - Double apical pulsation due to forceful atrial contraction producing T4 </li></ul><ul><li>6 - Ejection syst. murmur in za Lt sternal border due to LV outflow obst. Intensity is increased by factors that decrease LV size (e.g. Valsalva,s, amyl nitrate, standing & digoxin) by bringing up za ant. Leaflet of MV close to the septum. Situations that increase cardiac size by increasing venous return decrease za intensity of z murmur e.g. BB, lying down and squatting. </li></ul>
  21. 21. <ul><li>7 -Pansyst. murmur of MR secondary to SAM </li></ul><ul><li>8- S4 </li></ul><ul><li>9 - Sudden death sp. those who present early, FH of sudden death, history of syncope , those with VT on ambulatory ECG & abn BP response during exercise. </li></ul>
  22. 22. <ul><li>Investigations: </li></ul><ul><li>1 - CXR : Usually unremarkable </li></ul><ul><li>2 - ECG: LV hypertrophy, ST-Tw changes, Q waves in inferolat. leads in up to 25 % resulting from hypertrophy of IVS 3 - Echo is diagnostic: ASH, SAM & small hyper contractile LV </li></ul><ul><li>4 - Ambulatory ECG: prognostic information </li></ul><ul><li>5 - Pedigree analysis </li></ul>
  23. 23. <ul><li>Management:- </li></ul><ul><li>Aim is to prevent sudden death & relieve angina. </li></ul><ul><li>1- Amidarone & implantable defibrillators for za arrhythmias. </li></ul><ul><li>2- Chest pain & dyspnoea are treated by BB and verapamil or disopyramide . 3 - Avoid digoxin & vasodilators as these may increase outflow obst. </li></ul><ul><li>4- In severe obst. surgical resection of muscles below Ao valve. </li></ul>
  24. 24. <ul><li>5 - Non surgical septaL alcohol injection in some. </li></ul><ul><li>6 - Screen family members by echo for early diagnosis & TR of complications </li></ul>
  25. 25. <ul><li>Restrictive CM </li></ul><ul><li>1- Characterized by impaired diastolic filling symptom & signs of HF. 2 -The contractile function of za ventricles is preserved. 3-Dilatation of za atria with thrombus formation is common. </li></ul><ul><li>4- Conditions associated with RCM include amyloidosis, sarcoidosis, Lofflers endocarditis, radiation, EMF, post surg. myocardial fibrosis, haemochromatosis, carcinoid syndrome & scleroderma . </li></ul>
  26. 26. <ul><li>5 -Idiopathic form of RCM may be familial . </li></ul><ul><li>Clinically:- </li></ul><ul><li>1 - Dyspnoea, fatigue & embolic symptoms are za presenting features. </li></ul><ul><li>2 - persistently elevated JVP, hepatomegaly, ascites & dependent edema due to restricted RV filling.- </li></ul><ul><li>3 - Kussmaul,s sign, S4 & cardiac enlargement with S3 in advanced cases . Cardiac size may remain normal. </li></ul>
  27. 27. <ul><li>4 - Should be diff from constrictive pericarditis . Normal LV function & thick pericardium suggest CP. </li></ul><ul><li>Investigations:- </li></ul><ul><li>1- CXR : Normal or slightly enlarged cardiac size with atrial enlargement and pulm congestion. </li></ul><ul><li>2- ECG: Low voltage, ST segment & T wave abn. </li></ul><ul><li>3- Echo : myocardial thickening , normal systolic EF with impaired diast. Filling. </li></ul>
  28. 28. <ul><li>4- Endomyocardial biopsy ( amyloidosis) Treatment:- </li></ul><ul><li>1- No specific TR </li></ul><ul><li>2-TR HF & embolic manifestations </li></ul><ul><li>3-TR underlying cause e. g. amyloidosis with melphalan, prednisolone +/- colchicine. Sarcoidosis with prednisolone. </li></ul><ul><li>4- Cardiac transplantation in severe cases sp idiopathic. </li></ul>
  29. 29. <ul><li>Arrhythmogenic RV CM </li></ul><ul><li>Characterized by : 1- Progressive fibro fatty replacement of RV myocardium </li></ul><ul><li>2- Familial in 50% with AD </li></ul><ul><li>3-The condition is often asymptomatic 4- Risk of vent arrhythmia & sudden </li></ul><ul><li>death++. </li></ul><ul><li>5 - RT HF or CHF later with ventricular </li></ul><ul><li>dilatation and paradoxical decrease in </li></ul><ul><li>arrhythmias. </li></ul>
  30. 30. <ul><li>6- CXR- Unremarkable except in advanced cases. </li></ul><ul><li>7- ECG- T wave inversion in V1-3,epsilon waves at z end of QRS & RBBB. </li></ul><ul><li>8- Echo – Normal early—Dilated RV later. </li></ul><ul><li>9- RV biopsy- =Fibro fatty tissue. </li></ul><ul><li>10- BB 1 st line TR for non life threatening arrhythmias. Amiodarone & sotalol for symptomatic refractory arrhythmias. </li></ul><ul><li>11- Cardiac transplantation . </li></ul>