Cardiomyopathies Faculty of Medicine University of Brawija Malang Definition A heart muscle disease, often of unknown cause Cardiomyopathy Greek kardia heart + myo muscle

patheia suffering/disease 1980 WHO: heart muscle disease of unknown cause 1995 WHO/Task force: diseases of the myocardium associated with cardiac dysfunction Classification

etiology gross anatomy histology genetics biochemistry

immunology hemodynamics functional prognosis treatment WHO Classification Unknown cause (primary)

Dilated Hypertrophic Restrictive unclassified Specific heart muscle disease (secondary)

Infective Metabolic Systemic disease Heredofamilial Sensitivity Toxic

Br Heart J 1980; 44:672-673 Functional Classification Dilatated (congestive, DCM, IDC) ventricular enlargement and syst dysfunction Hypertrophic (IHSS, HCM, HOCM) inappropriate myocardial hypertrophy in the absence of HTN (hypertension) or aortic stenosis Restrictive (infiltrative)

abnormal filling and diastolic function Cardiomyopathies Ischemic Idiopathic Dilated HF-Dilated Konstam MA. J Card Failure. 2003. Hypertrophic CM

Hypertensive HF-Non Dilated Characteristics of the three types of cardiomyopathy Types LV wall LV cavity

Systolic Diastolic Prognosis contrac-tility Compli-ance 10 year survival rate Dilated Cardiomyopathy Thin Large

Normal to * 30-40% Hypertro-phic Thick Cardiomyopathy Small

70% Restrictive Cardiomyopathy Normal Normal to

50% (idiopathic type) Normal to Contractility or compliance may be normal early in the disease state but may become abnormal subsequently General approach to a patient with Cardiomyopathy

Define the problem: 1. Failure? due to a low cardiac output state (Dilated CM) or obstruction to LV filling (restrictive CM) 2. Arrhythmia? due to supraventricular or ventricular arrhythmias. 3. Syncope?- due to obstruction in LV outflow tract (HOCM) and/or arrhythmias especially slow rates. Dilated Cardiomyopathy

Dilated Cardiomyopathy The heart is dilated and has impaired function The coronary arteries are normal. Idiopathic Dilated Cardiomyopathy Observed Survival of 104 Patients 120 104 100

80 72 60 56 51 45

40 37 35 31 24 20

19 16 0 0 1 2 3

4 5 6 Years Am J Cardiol 1981; 47:525 7

8 9 10 Incidence and Prognosis 3-10 cases per 100,000 20,000 new cases per year in the U.S.A. death from progressive pump failure 1-year 2-year

5-year 25% 35-40% 40-80% stabilization observed in 20-50% of patient complete recovery is rare Features for Diagnosis of Dilated Cardiomypathy Signs and symptoms of systolic heart

failure Echocardiography shows dilated LV with global hypokinesia Normal coronary artery by angiography Presence of predisposing factors such as alcoholism, malnutrition etc Etiologic classification of the Dilated Cardiomyopathy I. II.

Idiopathic Inflammatory A. Infectious A. B. C. D. B.

Viral Bacterial Mycobacterial Others: Parasitic, Rickettsial, Fungal Non-infectious A. B. C. D. Peripartal cardiomyopathy

Autoimmune disease Hypersensitivity reaction Tranplantation rejection Etiologic classification of the Dilated Cardiomyopathy III. Toxic agents A. Alcohol B. Methamphetamines/ Cocaine C. Chemotherapeutic agents (Doxorubicin) D. Cigarette smoking E. Elemental compounds

D. Cathecolamines Etiologic classification of the Dilated Cardiomyopathy IV. Metabolic A. Malnutrition B. Endocrinologic: Thyrotoxicosis C. Electrolyte abnormalities D. Cigarette smoking E. Elemental compounds F. Cathecolamines

Etiologic classification of the Dilated Cardiomyopathy V. Familial cardiomyopathy A. Neuromyopathic 1. Progressive muscular dystrophy 2. Myotonic muscular dystrophy 3. Friedrichs ataxia B. Hereditary dilated Cardiomyopathy Clinical features Progressive biventricular heart failure leads to symptoms

Fatigue Paroxysmal nocturnal dyspnea, orthopnea, dyspnea Peripheral edema Ascites Clinical history History of specific exposure to etiologic agents (e.g alcohol, methamphetamine) Symptoms of left sided failure, then right sided heart failure Chest pain may be present in the absence

of ischemic heart disease Physical examination Similar to those of congestive heart failure Dilated heart, distended neck veins with functional MR murmur due mitral annular dilatation History and Physical Examination Symptoms of heart failure pulmonary congestion (left HF)

dyspnea (rest, exertional, nocturnal), orthpnea systemic congestion (right HF) edema, nausea, abdominal pain, nocturia low cardiac output fatigue and weakness hypotension, tachycardia, tachypnea, JVD (jugular venous distention) Clinical features Other complications secondary to the progressive dilatation of the ventricles

include: Mural thrombi with systemic or pulmonary embolization Dilatation of the tricuspid and mitral valve rings leading to functional valve regurgitation Atrial fibrillation and other arrhythmias Ventricular tachyarrhythmias and sudden death Diagnostic tests 1. ECG: non-specific changes; may show LVH, occasionally LBBB 2. Chest X-ray: multichamber dilatation with congestive

features 3. Echocardiography: multichamber dilatation, LV wall motion abnormalities usually global hypokinesia 4. Coronary angiography: normal coronary arteries 5. Angiography indicated only to rule out ischemic heart disease (ischemic cardiomyopathy) Echocardiography Evaluation of dilated ventricles Evaluation of regurgitant valves Evaluation of thrombus

Normal echo Management Search and treat any underlying cause ( e.g stop alcohol) Treat heart failure (diuretics, ACE-inhibitor, nitrates/hydralazine combination) Treat any arrhythmias Prevention of sudden death with placement of implantable cardioverter defibrillator (ICD) is not recommended Anticoagulate with warfarin to prevent mural thrombi

If cardiac failure does not respond to the above steps if suitable candidate cardiac transplantation Predicting Prognosis in IDC Predictive Possible Not Predictive Clinical factors symptoms

peripartum duration family history viral illness Hemodynamics LVEF Cardiac index atrial pressure Dysarrhythmia LV cond delay complex VPC atrial fibrillation

Histology myofibril volume Neuroendocrine hyponatremia plasma norepinephrine atrial natriuretic factor alcoholism age LV size

AV block simple VPC other findings VPC: ventricular premature contraction Clinical Indications for Endomyocardial Biopsy Definite monitoring of cardiac allograft rejection

monitoring of anthracycline cardiotoxicity Possible detection and monitoring of myocarditis diagnosis of secondary cardiomyopathies differentiation between restrictive and constrictive heart disease ypertrophic cardiomyopat Types of hypertrophic cardiomyopathy

1. Obstructive type. Synonym: idiopatthic hypertrophic subaortic stenosis 2. Non obstructive type Features for diagnosis Dyspne or syncope May have a family history of hypertrophic cardiomyopathy in 50% of cases Characteristic systolic ejection murmur at the left sternal area which increases with valsalva maneuver (in obstructive type)

Features for diagnosis (continued) Marked hypertrophy of the left ventricle involving the interventricular septum and the LV outflow tract in the absence of other causes of hypertrophy Echocardiography shows interventricular septum to posterior LV wall ratio > 1.3:1. Hypertrophic obstructive cardiomyopathy Characterized by asymmetrical hypertrophy of the cardiac septum the cardiac septum is hypertrophied

compared to the free wall of the left ventricle. The most common cause of heart-related sudden death in those under 30 years old. HOCM is inherited as an autosomally dominant trait with equal sex incidence The genetic abnormality is the subject of much current research, and it seems that different genes may be involved in different families Hypertrophic obstructive cardiomyopathy The myocytes of the left ventricle are

abnormally thick when examined microscopically left ventricular filling more difficult than normal and grossly disordered Pathophysiology Systole dynamic outflow tract gradient Diastole impaired diastolic filling, filling pressure

Myocardial ischemia muscle mass, filling pressure, O2 demand vasodilator reserve, capillary density abnormal intramural coronary arteries systolic compression of arteries 65% 35% 10% Natural History annual mortality 3% in referral centers probably closer to 1% for all patients risk of SCD higher in children may be as high as 6% per year majority have progressive hypertrophy clinical deterioration usually is slow progression to DCM occurs in 10-15% Risk Factors for SCD (sudden

cardiac death) Young age (<30 years) Malignant family history of sudden death

Gene mutations prone to SCD (ex. Arg403Gln) Aborted sudden cardiac death Sustained VT or SVT Recurrent syncope in the young Nonsustained VT (Holter Monitoring) Brady arrhythmias (occult conduction disease) Br Heart J 1994; 72:S13 Clinical features Symptoms usually begins in the third and fourth decades of life. Four main symptoms:

Angina due to the increased oxygen demands of the hypertrophied muscle Palpitations- atrial fibrillations and/or ventricular arrhythmias Syncope and sudden death due to LVOT obstruction by the hypertrophied septum or to ventricular arrhythmia Orthopnea/paroxysmal nocturnal dyspnea/dyspnea due to high end diastolic pressure pulmonary edema Clinical features The signs to watch for are:

Jerky peripheral pulse Double apical beat (bisferiens pulse) Prominent a wave in jugular Systolic thrill Systolic murmur Diagnosis and investigations Electrocardiography

Continuous ambulatory electrocardiography (Holter) Echocardiography Electrocardiography The EKG is usually abnormal T wave and ST segment abnormalities LVH (Left ventricular hypertrophy) Holter Ventricular arrhythmias

Echocardiography The most useful investigation Characteristic echocardiography findings: Increased mass of the left ventricle with asymmetric hypertrophy of the septum Abnormal systolic anterior motion of the anterior leaflet of the mitral valve Calcification of the mitral valve Left ventricular outflow tract obstruction Prognosis Children who are diagnosed at less than 14 years

of age poor prognosis and high incidence of sudden death; 71% are asymptomatic Adults : better prognosis but have a higher mortality rate than general population Progressive cardiac failure with cardiac dilatation Management Drug management Avoid vasodilators because it worsen the gradient obstruction. HOCM patient should not receive nitrates

Avoid drugs for systolic heart failure (3 Ds): Digoxin, Ace-inhibitors (vaso-Dilators) and Diuretics are contra-indicated for the obstructive type of hypertrophic cardiomyopathy Beta-blockers are used, negative inotropic effect acts to decrease the contractility of the hypertrophied septum and reduce the outflow tract obstruction Management Drug management Anti-arrhythmia is given for ventricular and atrial arrhythmias.

ICD (implantable cardioverter defibrillator) should be placed for any patient at risk for sudden death Management Dual chamber pacing This reduces the outflow tract gradient by pacing the RV apex and therefore altering the pattern of septal motion Surgery Only used when all other treatments have failed Myomectomy on the abnormal septum

Occluding the septal artery (new catheter technique to infarct the septum) Injecting a small amount of alcohol Recommendations for Athletic Activity Avoid most competitive sports (whether or not symptoms and/or outflow gradient are present) Low-risk older patients (>30 yrs) may participate in athletic activity if all of the following are absent

Recommendations for Athletic Activity Low-risk older patients (>30 yrs) may participate in athletic activity if all of the following are absent

ventricular tachycardia on Holter monitoring family history of sudden death due to HCM history of syncope or episode of impaired consciousness severe hemodynamic abnormalities, gradient 50 mmHg exercise induced hypotension moderate or severe mitral regurgitation enlarged left atrium (50 mm) paroxysmal atrial fibrillation abnormal myocardial perfusion Restrictive cardiomyopath

Restrictive Cardiomyopathy Least common in developed countries Much more common in third world countries in Africa and South East Asia due to increased fibrosis of the endocardium secondary to infection The ventricular walls are excessively stiff and impede ventricular filling increased end diastolic pressure. The systolic function on the ventricle is often normal Possible causes of restrictive cardiomyopathy

I. Infiltrative diseases A. Amyloidosis B. Hemochromatosis C. Sarcoidosis D. Glycogen storage disease (in pediatric age group) I. Endocardial Obliterative disease A. Endomyocardial B. Fibrosis With eosinophilia (Loefflers syndrome) With eosinophilia

Possible causes of restrictive cardiomyopathy III. Interstitial disease A. Idiopathic B. Familial C. Radiation-induced D. Chronic allograft rejection Clinical features of restrictive cardiomyopathy Most commonly present as right sided heart

failure symptoms Dyspnea, paroxysmal nocturnal dyspnea, and fatigue due to poor cardiac output Peripheral edema and ascites Elevated jugular venous pressure with a positive Kussmauls sign (increase in jugular venous pressure during inspiration) Up to one-third of patients: thromboembolic complications or conduction disturbances Pathophysiology Diastolic dysfunction in diastolic heart failure:

increasing stiffness of the myocardium causes severe diastolic non-compliance of both ventricles. Thus, LV and RV filling pressure are above normal causing pulmonary congestion and right-sided failure As the disease progresses, systolic function is also compromised Restriction vs Constriction History can provide important clues Constrictive pericarditis history of TB, trauma, pericarditis, collagen

vascular disorders Restrictive cardiomyopathy amyloidosis, hemochromatosis Mixed mediastinal radiation, cardiac surgery Diagnostic tests 1. ECG: non specific changes, QRS voltages may be low because of the infiltrative process

2. Chest X-ray: may show dilated left atrium and right atrium; pulmonary venous congestion, pleural effusion Diagnostic tests 3. Echocardiography: May show LV hypertrophy and RV hypertrophy but with no dilatation of the ventricles. Both atria are frequently dilated due to increase stiffness in the ventricles. Doppler signs of diastolic dysfunction suggestive of reduced

ventricular compliance Diagnostic tests 4. Cardiac catheterization: frequently not necessary 5. Cardiac biopsy: Low yield but may be useful in selected diseases with specific treatment (e.g hemochromatosis, sarcoidosis) Low voltage ECGs with LV hypertrophy by echocardiography is suggestive of restrictive cardiomyopathy Management

Presentation is similar to that of constrictive pericarditis. Often a history of pericarditis, TB, radiation or surgery will favor constrictive pericarditis. The condition usually progresses towards death relatively quickly Most patients do not survive 10 years after diagnosis. Treatment No satisfactory medical therapy Drug therapy must be used with caution

diuretics for extremely high filling prssures vasodilators may decrease filling pressure Ace-inhibitors and calcium channel blockers are of uncertain benefit. ? Calcium channel blockers to improve diastolic compliance digitalis and other inotropic agents are not indicated Prognosis Poor prognosis for patients with amyloidosis Generally declining to zero survival at 4

years. For idiopathic restrictive cardiomyopathy, 10 year survival is about 50%

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