HF, constrictive pericarditis, cardiomyopathy, myocarditis

Question 1

Define cardiomyopathy

Answer 1

A group of diseases in which the myocardium becomes structurally and functionally abnormal

…in the ABSENCE of coronary artery disease, valvular disease and congenital heart disease

Question 2

What are the 3 layers of the heart?

Answer 2

epicardium = outer protective 
myocardium = muscular 
endocardium = thin inner layer

Question 3

Primary versus secondary cardiomyopathy

Answer 3

1 = abnormality confined to the myocardium
2 = myopathy is part of a systemic disease

Question 4

What are the 3 types of cardiomyopathy?

Answer 4

DILATED – ventricle dilated, thin walls, reduced ventricular pressure

HYPERTROPHIC – muscle hypertrophies inwards, more rigid, obstruction etc.

RESTRICTIVE – basically the same amount of muscle but it’s rigid and doesn’t pump as well as normal

Question 5

Symptoms of cardiomyopathy

Answer 5

Symptoms of HF:

• SOB on exertion
• Fainting
• Fatigue

Sudden death often 1st presentation

Family history (sudden, unexplained death at young age)

Question 6

Signs of cardiomyopathy

Answer 6

Signs of HF:

• Respiratory crackles
• Murmurs
• S3 = Early ventricular filling- due to ventricular dilation (dilated CM)
• S4 = Atrial contraction- due to stiff, low compliant ventricle (hypertrophic CM)

Question 7

What investigations are done for cardiomyopathy?

Answer 7

GOLD STANDARD = ECHO
- visualise the structure, observe ventricular function

No single diagnostic test for all types:

• BNP
• CXR
• ECG
• cardiac catheterisation
• stress test

Question 8

Which law applies to the pathophysiology of dilated cardiomyopathy?

Answer 8

law of Laplace: increased radius leads to reduced ventricular pressure

Ventricles enlarge and become dilated.
Walls thin and weaken -> can’t contract effectively

Question 9

RF for dilated cardiomyopathy

Answer 9

ALCOHOL
post-viral (myocarditis from viral infection can damage)
haemochromatosis
genetic

Question 10

Signs of dilated cardiomyopathy

Answer 10

DISPLACED APEX BEAT
Signs and symptoms of HF
TR/MR murmur- end diastolic
S3- due to rapid ventricular filling

Question 11

On echo and x-ray, what findings would indicate dilated cardiomyopathy?

Answer 11

echo = dilated ventricle
xray = globular, enlarged heart

Question 12

State 3 ways in which hypertrophic cardiomyopathy can cause problems

Answer 12

1. Increased stiffness/rigidity of the muscle affects pumping.
2. Thickened muscle disrupts electrical conduction and causes arrhythmia.
3. Hypertrophic Obstructive Cardiomyopathy (HOCM) = thickened ventricle obstructs cardiac outflow

Question 13

RF for hypertrophic cardiomyopathy

Answer 13

50% is familial (autosomal dominant)

Question 14

How does hypertrophic cardiomyopathy present?

Answer 14

Usually ASYMPTOMATIC
Sudden cardiac death is often the 1st presentation

Angina, dyspnoea on exertion, palpitations, syncope

Question 15

Signs of hypertrophic cardiomyopathy

Answer 15

EJECTION SYSTOLIC MURMUR- dilated ventricles obstruct outflow

Jerky carotid pulse

Double apex beat but NOT DISPLACED ! (muscle grows inwards)

S4- due to ventricle non-compliance

Question 16

How do heart sounds differ in dilated versus hypertrophic cardiomyopathy?

Answer 16

DILATED = S3 (Ken-tuc-ky)

• during passive ventricular filling (early disatolic)
• due to very compliant LV (ventricle wall vibration)

HYPERTROPHIC = S4 (Ten-es-see)

• during active ventricular filling (late diastolic)
• due to non-complaint LV (forceful atrial contraction)

Question 17

State 2 signs of LVH on ECG

Answer 17

V1 + V2 = deep S

V5 + V6 = tall R (>7 large squares)

Question 18

Signs of hypertrophic cardiomyopathy on ECG

Answer 18

Q waves
Left axis deviation
signs of LVH: deep S (V1/2) and tall R (V5/6)

Question 19

Explain the pathophysiology of restrictive cardiomyopathy

Answer 19

1. Ventricles become abnormally rigid and lose flexibility.
2. Impaired ventricular filling during diastole.
3. Reduced preload -> reduced CO + backing up of blood

Question 20

Causes of restrictive cardiomyopathy

Answer 20

INFILTRATIVE -OSIS DISEASES:
sarcoidosis
amyloidosis
haemochromatosis

Familial
Idiopathic

Question 21

Signs and symptoms of restrictive cardiomyopathy

Answer 21

usually ASYMPTOMATIC

signs of RIGHT HEART FAILURE:

• raised JVP
• S3
• ascites and oedema
• hepatomegaly
• Kussmaul’s sign = paradoxical rise in JVP during inspiration

Question 22

What is Kussmaul’s sign and what does it indicate?

Answer 22

Kussmaul’s sign = paradoxical rise in JVP during inspiration

Indicates impaired right ventricular filling so blood backs up into the jugular vein.

Question 23

What normally happens to JVP during inspiration?

Answer 23

Normally JVP falls with inspiration

due to reduced pressure in the expandingthoracic cavity

therefore increased volume afforded to right ventricular expansion during diastole.

Question 24

Define constrictive pericarditis

Answer 24

Chronic inflammation of the pericardium with thickening and scarring
(basically chronic pericarditis with fibrosis)

Question 25

Causes of constrictive pericarditis

Answer 25

Infectious (TB, bacterial, viral)- TB commonest cause worldwide Acute pericarditis Cardiac surgery and radiation- commonest in UK Idiopathic

Question 26

signs of constrictive pericarditis

Answer 26

Similar to restrictive cardiomyopathy signs of RIGHT HEART FAILURE: - raised JVP - S3 - ascites and oedema - hepatomegaly - Kussmaul’s sign = paradoxical rise in JVP during inspiration

Question 27

investigations for constrictive pericarditis

Answer 27

CXR: pericardial calcification Echo: increased pericardial thickness – differentiate from restrictive cardiomyopathy Cardiac CT/MRI

Question 28

How can constrictive pericarditis be cured?

Answer 28

Surgical pericardial resection is the definitive treatment (pericardectomy) (unlike restrictive CM which requires transplant)

Question 29

Aston was a 33-year-old male who suddenly collapsed on stage. Although the doctors attempted “love CPR”, the patient died, and the post-mortem revealed a hypertrophic heart. What was the most likely cause of death? A. Obstructed flow of blood from the heart B. Arrhythmia C. Reduced pumping of blood due to stiff myocardium D. Stroke E. Sub-arachnoid haemorrhage

Answer 29

A. Obstructed flow of blood from the heart Likely to experience warning symptoms beforehand B. Arrhythmia Most likely cause of death from HCM, hypertrophic muscle affects electrical circuits C. Reduced pumping of blood due to stiff myocardium Likely to experience warning symptoms beforehand D. Stroke Heart issue rather than brain issue, ventricular arrhythmia (not AF) E. Sub-arachnoid haemorrhage Heart issue rather than brain issue

Question 30

Marvin presents with a 4-month history of increasing breathlessness and ankle swelling. On examination, he has ascites and Kussmaul’s sign is elicited. What would be the most useful diagnostic investigation? ``` A. Echocardiography B. ECG C. Endomyocardial biopsy D. Abdominal X-ray E. CK ```

Answer 30

A. Echocardiography Allows differentiation between restrictive cardiomyopathy and constrictive pericarditis B. ECG Non-specific signs – not the most useful C. Endomyocardial biopsy Pericardial biopsy might be useful – but highly invasive D. Abdominal X-ray Chest X-ray would be useful to look for pericardial calcifications, but these are not specific to constrictive pericarditis E. CK May be mildly elevated in both constrictive pericarditis and restrictive cardiomyopathy – not that helpful

Question 31

Define myocarditis

Answer 31

Inflammation of the myocardium | i.e. Inflammatory cardiomyopathy

Question 32

Causes of myocarditis

Answer 32

- Infectious- Coxakie B virus = most common cause in - Europe - Drugs (cocaine) - Metals - Radiation

Question 33

Signs and symptoms of myocarditis

Answer 33

Flu-like prodrome Chest pain (worse when lying down) SOB Palpitations

Question 34

Investigations myocarditis

Answer 34

ECG: non-specific ST and T wave changes Cardiac biomarkers: CK and troponin Endomyocardial biopsy: diagnostic but not routinely performed

Question 35

What is the most common complication of myocarditis?

Answer 35

dilated cardiomyopathy (why dilated cardiomyopathy can be post-viral)

Question 36

How can you differentiate between constrictive pericarditis and my myocarditis?

Answer 36

Cardiac biomarkers are not elevated in constrictive pericarditis, but they are in myocarditis because the muscle is affected