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![Management_HCM
• Enhance impaired LV diastolic function(improve filling)
Slow heart rate
Maintain normal sinus rhythm[Drugs to enhance
myocardial relaxation]
• Reduce obstruction caused by septal/MV apposition:
Avoid dehydration and vasodilators
Negative inotropic drugs (beta blockers, disopyramide)
Surgical septal myectomy
Dual chamber (atrial and ventricular) pacemaker](https://image.slidesharecdn.com/cardiomyopathymyocarditisandpericarditiscilectureoct-231003122417-bc0aefcc/75/Cardiomyopathy-Myocarditis-and-Pericarditis_C-I-lecture_Oct-ppt-27-2048.jpg)
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Cardiomyopathy, Myocarditis and Pericarditis_C I lecture_Oct.ppt
- 1. Prepared by: NigussieWondimu 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
- 2. Course Outline • Objective •Introduction • Cardiomyopathy • Types of Cardiomyopathy • Myocarditis • Pericarditis disease
- 3. Objective At the endof 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 cardiomyopathyworsens, 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 mostcommon 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
- 8. Cardiomyopathy Types • Dilated Cardiomyopathy(DCM) • Hypertrophied Cardiomyopathy(HCM) • Restrictive Cardiomyopathy • Dysrhythmia right ventricular cardiomyopathy
- 9. Dilated Cardiomyopathy • Dilationof 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
- 10. Etiology of DCM Coronary artery disease Idiopathic Hypertensive heart disease Familial/genetic • Viral/other infectious agents (HIV) • Immune/autoimmune • Alcoholic/toxic (cocaine, chemotherapeutic drugs) • Infiltrative (hemochromatosis, sarcoidosis, amyloidosis) • Post partum-;myocarditis
- 11. Dilated Cardiomyopathy Clinical Presentation •SSx 0f CHF • Chest pain (due to low coronary vascular reserve) • Mural thrombi formation • Holosystolic regurgitant murmur or gallop • Dependent edema, bibasilar rales
- 12.
- 13. Natural History ofDCM • 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 anddisposition • 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 • Abnormalcompliance 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
- 20.
- 21. Clinical Features_HCM • Symptomseverity progresses with age Dyspnea on exertion – most common initial or presenting symptom Angina-like chest pain Palpitations Syncope may also be present Sudden death
- 22. Physical Findings _HCM •JVP: Prominent “a” wave • PMI: LV heave, double apical impulse (palpable “a” wave) • Heart sounds: Loud S4 • Systolic ejection murmur at apex or lower left sternal border Murmur increased with valsalva maneuver
- 23. Dynamic murmur ofHOCM • Smaller LV volume brings septum closer to anterior MV leaflet: more obstruction and louder murmur. • Larger LV volume separates upper septum from anterior MV leaflet: less obstruction and softer murmur.
- 24. How to alterLV volume • Increase LV volume – Squatting – Passive leg lifting – Slow heart rate – IV volume infusion • Decrease LV volume – Stand (after squatting) – Valsalva maneuver – Increase heart rate – Amyl nitrate – Volume depletion
- 25. Hypertrophic Cardiomyopathy Diagnosis • EKG LVHwith “strain” pattern:30% LAE:25-50% Large septal Q waves:25% • CXR-usually normal • Echo-study of choice: disproportionate septal hypertrophy • Radionuclide ventriculogram • Contrast left ventriculogra • ECG: LVH with “strain” pattern
- 26.
- 27. Management_HCM • Enhance impairedLV diastolic function(improve filling) Slow heart rate Maintain normal sinus rhythm[Drugs to enhance myocardial relaxation] • Reduce obstruction caused by septal/MV apposition: Avoid dehydration and vasodilators Negative inotropic drugs (beta blockers, disopyramide) Surgical septal myectomy Dual chamber (atrial and ventricular) pacemaker
- 28. Admit: Withsyncopal episode B-blocker: Rx of choice for HCM Discourage vigorous exercise(not a problem for most patients) Management_HCM
- 29. • Predict riskof 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 • Oneof 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.
- 31. Pathophysiology_RCM • Impaired biventricularfilling • Elevated right and left atrial pressures
- 32. Clinical Features_RCM • Symptomsof 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 ofCHF 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: basedon 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 inflammationof 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
- 40. Treatment_Myocarditis • Supportive care •Blood cultures • Antibiotics for bacterial cause • Watch for signs of progressive heart failure
- 41. Pericardial disease • Maybe primary and acute or • Chronic - Constrictive - Effusive - Or constrictive-effusive
- 42. Acute Pericarditis • Loosevisceral 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 ECGfeatures_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
- 45.
- 46. Investigations_Acute Pericarditis • CXR-normaland 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 • Idiopathicor 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
- 49. Clinical Features _CardiacTamponade • Dyspnea and decreased exercise tolerance, wt loss, pedal edema, ascites • Tachycardia, Narrow pulse pressure • Pulsus paradoxus • JVD, Muffled heart sounds, Hypotension:-Triad
- 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 • Occurswhen 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’sgradually 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 notvery 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
- 55. DDx_Constrictive Pericarditis • RestrictiveCMP • Acute pericarditis • Myocarditis
- 56. Treatment_Constrictive Pericarditis • Supportivecare • Symptomatic patients: admission and pericardiectomy
- 57. Pericardial effusion • IsPresence 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 • Treatmentdirected 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 offluid: 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 acomponent 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
- 61. ETIOLOGY… • Dialysis, Ch.Renal failure • Hypothyroidism (myxedema), ovarian hyper stimulation synd. • Drugs: procainamide, isoniazid, hydralazine, anticoagulants. • HEMORRHAGIC PERICARDIAL EFFUSION: • Malignancy (26%) • Trans-catheter interventions and/or pacemaker insertion (18%)
- 62. ETIOLOGY… • HEMORRHAGIC PERICARDIALEFFUSION: • Malignancy (26%) • Trans-catheter interventions and/or pacemaker insertion (18%) • Post-pericardiotomy syndrome (13%) • Complication of MI (free wall rupture, thrombolysis) (11%) • Idiopathic (10%) •
- 63. ETIOLOGY… • Uremic (7%) •Aortic dissection (4%) • Trauma (3%) • Other (8%)
- 64. CLINICAL- SYMPTOMS • CVS:chest pain, pericardial pain (relieved by sitting), light headedness, syncope, palpitations • RESP: cough, dyspnea, hoarsness • GI: hiccoughs • NEUR: anxiety, confusion
- 65. CLINICAL- SIGNS • CVS:BECK’striad of tamponade (hypotension, muffled heart sounds, jugular venous distension), pulsus paradoxus, pericardial friction rub, tachycardia, hepatojugular reflux. • RESP: tachypnea, decreased breath sounds, Ewart sign • GI: hepato-splenomegaly • EXTREMITIES: weakened peripheral pulses, edema, cyanosis.
- 66. DIAGNOSIS • Suspect when: •All cases of acute pericarditis • Unexplained persistent fever +- source. Purulent per. • New radiographic cardiomegaly without pul. Congestion. • Isolated left pleural effusion • Hemodynamic deterioration after MI, cardiac surgery, invasive cardiac procedures.
- 67. TREATMENT • CONSIDER: underlyingdisease, hemodynamic significance, presence of tamponade. • Underlying disease: infectious, malignant, uremic peric. MI, collagen vascular disease. • Cardiac tamponade: volume resuscitation (RA pressure 10-12mmHg). • Pericardial fluid drainage: percutaneous/ pericadiectomy.
- 68. Summary: Cardiomyopathy WHO Classification anatomy& physiology of the LV 1. Dilated • Enlarged • Systolic dysfunction 2. Hypertrophic • Thickened • Diastolic dysfunction 3. Restrictive • Myocardial stiffness • Diastolic dysfunction 4. Arrhythmogenic RV dysplasia • Fibrofatty replacement
- 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 allyour medications exactly as prescribed. • getting prompt treatment • following your treatment plan and • getting ongoing medical care as needed
- 71.