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Dilated Cardiomyopathy Daily Report Jafer Jeelani

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r/o active myocarditis. r/o primary/secondary forms/causes of heart muscle disease ... to myocarditis and DCM. Most common cause of infectious myocarditis is ... – PowerPoint PPT presentation

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Title: Dilated Cardiomyopathy Daily Report Jafer Jeelani


1
Dilated Cardiomyopathy Daily Report Jafer
Jeelani
2
  • Dilated Cardomyopathy (DM) dilation and impaired
    contraction of one/both ventricles.
  • Diagnosis requires evidence of dilatation and
    impaired contraction of either Left or both
    ventricles
  • EFlt40 percent
  • fractional shortening less than 25 percent

3
  • Why is it important
  • Responsible for
  • 10,000 deaths annually
  • 46,000 hospitalizations annually.
  • Affects 2-3 million people in US
  • Incidence of CHF (largely dilated cardiomyopathy)
    is 400,000 cases per year.
  • Framingham study found that 5 years after initial
    presentation of CHF, 42 of women and 62 of men
    had died.

4
  • Pahophysiology
  • Cardiomegaly-LV/biventricular dilatation.
  • Decreased systolic function
  • Reduced LV contraction ability ? decreased
    cardiac output ? increased residual volumes in
    end-systole and end-diastole.

5
  • Symptoms
  • Fatigue
  • Dyspnea on exertion
  • Shortness of breath
  • Orthopnea, paroxysmal nocturnal dyspnea
  • Decreased exercise tolerance
  • Peripheral edema
  • Thromboembolic complications
  • Chest pain
  • Syncope

6
  • Physical exam
  • Tachypnea
  • Tachycardia
  • Hypertension
  • Signs of hypoxia
  • Jugular venous distension (JVD)
  • Pulmonary edema (crackles and/or wheezes)
  • S3 gallop
  • Enlarged liver or hepatojugular reflex
  • Peripheral edema
  • Hepatomegaly
  • Splenomegaly
  • Displaced PMI

7
  • Complications
  • Heart failure
  • Atrial or ventricular arrythmias
  • Sudden death

8
  • Necessary information
  • Age
  • Sex
  • Race
  • Medical history, especially the following
  • Hypertension
  • Angina
  • Coronary artery disease
  • Anemia
  • Thyroid dysfunction
  • Breast cancer
  • Medications
  • Social history (eg, tobacco, alcohol, illicit
    drug use)

9
  • Epidemiology
  • Range children to elderly
  • Most pts present b/w ages 20-60
  • Men 3x women
  • Black 3x white

10
  • Causes
  • Idiopathic 50 percent
  • Myocarditis 9 percent
  • Ischemic heart disease 7 percent
  • Infiltrative disease 5 percent
  • Peripartum cardiomyopathy 4 percent
  • Hypertension 4 percent
  • HIV infection 4 percent
  • Connective tissue disease 3 percent
  • Substance abuse 3 percent
  • Doxorubicin 1 percent
  • Other 10 percent

11
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12
  • Causes continued… w/ focused selections
  • Idiopathic Dilated Cardiomyopathy
  • considered idiopathic if
  • exclusion of 50 percent obstruction of one or
    more coronaries
  • r/o active myocarditis
  • r/o primary/secondary forms/causes of heart
    muscle disease
  • 30 of idiopathic DCM cases have a familial
    distribution.
  • Association w/ the dystrophin gene
  • Which causes X-linked dilated cardiomyopathy

13
  • Ischemia
  • overall CAD in the most common cause of
    cardiomyopathy in US but is responsible for only
    7 of cases for DCM
  • Stress-induced cardiomyopathy
  • Uncommon ST elevation ACS in absence of critical
    CAD
  • Aka transient left ventricular apical ballooning
  • takotsubo cardiomyopathy
  • broken heart syndrome
  • brought-out on by intense psychologic stress
  • occurring mostly in postmenopausal women.
  • transient left ventricular apical ballooning
  • apical ballooning is seen on left
    ventriculography or echocardiography
  • Complications
  • hemodynamic instability/cardiogenic shock.

14
  • Infectious cardiomyopathy
  • variety of infections can lead to myocarditis and
    DCM
  • Most common cause of infectious myocarditis is
    viral
  • Ex Coxsackievirus, influenza virus, adenovirus,
    echovirus, cytomegalovirus, and human
    immunodeficiency virus (HIV).
  • Pathogenesis if immune response is not
    sufficient myocyte injury occurs via
  • Direct cytotoxicity
  • Persistent immune response against viral genomic
    fragments.
  • HIV infection
  • Heart disease secondary to HIV is increasing in
    frequency.
  • Mechanisms drug toxicity, secondary infections,
    myocyte damage by HIV. Autoimmune response
    induced by HIV or other viruses ex
    coxsackievirus,CMV, EBV

15
  • Chagas' disease
  • infection from Trypanosoma cruzi
  • leading cause of DCM in Central and South
    America.
  • Characterized by acute myocarditis, cardiac
    enlargement, tachycardia, and nonspecific ECG
    abnormalities including RBBB and PVCs.
  • LV apical aneurysms pathognomonic.
  • Toxic cardiomyopathy
  • Secondary to alcohol, cocaine, medications (esp.
    chemotherapeutic drugs), radiation and many
    others.

16
  • Alcohol
  • Leading cause of DCM.
  • prevalance of ACM is variable and ranges from 23
    to 40 (CHEST)
  • Direct toxicity to myocytes (oxygen free
    radicals, defects in protein synthesis)
  • Risk related to mean daily intake and duration.
  • Individual susceptibility is still a big factor
  • Occurs in 2 stages (CHEST)
  • Asymptomatic
  • Consumption of gt 90 g of alcohol a day
  • (seven to eight standard drinks per day)
  • for gt 5 years are at risk for development of
    asymptomatic ACM
  • symptomatic is anything in excess of above

17
Impact of Alcohol on survival
  • Survival curves of cardiac deaths in male
    patients with ACM and IDCM. The solid line
    indicates patients with ACM and alcohol
    abstinence, the small dashed line indicates IDCM,
    and the large dashed line indicates patients with
    ACM without abstinence.

18
Hypothetical scheme of pathogenesis of ACM
(CHEST)
19
  • Cocaine
  • relationship less well understood than between
    cocaine and coronary ischemia.
  • Mechanisms direct toxic effect, the
    cocaine-induced hyperadrenergic state, and
    infectious cardiomyopathy (parenteral abuse).
  • Abstinence leads to reversal of the myocardial
    dysfunction.
  • End-stage renal disease
  • Pts w/ ESRD on HD can develop Dilated CM via an
    uncertain mechanism.
  • Obstructive sleep apnea
  • Impairment of LV function.
  • Therapy w/ nasal CPAP can lead to significant
    improvement

20
  • Workup
  • History
  • Exam
  • Labs
  • EKG
  • CXR
  • Cardiac CATH
  • CT scan
  • Gated pool scan
  • Biopsy

21
  • Workup cont…
  • Lab Studies
  • CBC r/o anemia.
  • Chem 7 assess BUN/Creat/K
  • LFT may rise with hepatic congestion
  • Fasting glucose screen for DM
  • TFT r/o thyrotoxicosis (arrythmias) or
    hypothyroidism
  • Fe/TIBC if hemochromatosis is a risk
  • BNP -- gt indicator of failure
  • ANA possible lupus
  • Viral studies
  • Urine toxicology screen

22
  • Other studies
  • Chest x-ray
  • Cardiomegaly
  • Prominent upper lobe vessels (cephalization)
  • Kerley B lines
  • Pleural effusions
  • Bats wing pulmonary edema
  • Electrocardiogram
  • Look for arrhythmias e.g. A fib, V Tach
  • Conduction abnormalities esp. seen in pts with
    dilated cardiomyopathy BBB

23
  • Other studies cont…
  • Echocardiogram
  • EF helps distinguish systolic and diastolic HF
  • Regional wall motion abnormalities suggesting
    ischemia
  • Valvular disease
  • Pulmonary artery pressures.
  • Dilated chambers/ thin walls
  • Endomyocardial biopsy may be helpful in
    diagnosing myocarditis, connective tissue
    disorders, and amyloidosis.

24
  • Treatment
  • Lifestyle changes
  • Medical management
  • Surgical management

25
  • Lifestyle
  • Daily weighing
  • Low salt diet
  • Limit fluid intake
  • Medical
  • ASA
  • B-Blocker
  • ACE
  • Spirnolactone
  • Lasix
  • Nitrates
  • Hydralazine
  • Surgical
  • Cardiac resynchronization (CRT)
  • Biventricular pacemaker
  • Improves contraction
  • Implantable cardioverter defibrillators (ICD)
  • Those at risk for life threatening arrythmias or
    sudden death
  • CABG for CAD, correction of valvular dz.

26
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