Is it HF secondary to rheumatic heart disease???

Transcription

1 Is it HF secondary to rheumatic heart disease??? Is mitral regurg. Is complication of CHF???

2 Cardiomyopathy

3 Definition The term cardiomyopathy is purely descriptive, meaning disease of the heart muscle 2006 AHA defined 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 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, often leading to cardiovascular death or progressive heart failure-related disability.

4 Cardiomyopathy

5 Functional Classification Dilated (Congestive, DCM, IDC) Ventricular dilation, hypokinetic left ventricle, and systolic dysfunction Hypertrophic Inappropriate myocardial hypertrophy, with or without left ventricular obstruction Restrictive (Infiltrative) Abnormal ventricular filling with diastolic dysfunction Arrhthymogenic Right Ventricular Fibroadipose replacement of right ventricle

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7 Definition Primary (idiopathic) is a disease of unknown etiology that principally affects the myocardium leading to LV dilation and systolic dysfunction. Secondary causes include ischemia, alcoholic, peripartum, post-infectious, viral. Most common of the cardiomyopathies.

8 Schematic of Dilated CM Medslides.com

9 DCM - Incidence and Prognosis Prevalence is 36 per 100,000 population Highest Third most incidence common in middle cause of age heart failure Most - Blacks 2x frequent more frequent cause than whites of heart transplantation - Men 3x more frequent than women DCM accounts for approximately 10,000 deaths and 46,000 hospitalizations per year in the US Complete recovery is rare

10 Idiopathic Dilated Cardiomyopathy 120 Observed Survival of 104 Patients Am J Cardiol 1981; 47: Years

11 Clinical Manifestations Symptoms may be gradual in onset Acute presentation Misdiagnosed as viral URI in young adults Uncommon to find specific myocardial disease on endomyocardial biopsy

12 Clinical Manifestations cont. Symptoms/Signs of heart failure Pulmonary congestion (left heart failure) dyspnea (rest, exertional, nocturnal), orthopnea Systemic congestion (right heart failure) edema, nausea, abdominal pain, nocturia - Fatigue,weakness, palpitation - Syncope or pre syncope -Sudden death

13 PHYSICAL FINDING

14 Tachycardia,tachypnea,JVP may be elevated Pulmonary rales Laterally displased and difuse point of maximal impulse,left and right ventricular lift S3 ands4 gallop Hepatomegaly due to elevated venous pressures; the liver may be pulsatile with severe tricuspid regurge. Ascites, peripheral edema Muscle wasting or other sign of cardiac cachexia

15 Diagnosis

16 Lab investigation Diagnosis Electrolyte,BUN,creatinine CBC LFT Cardiac enzymes : to exclude acute or recent myocardial inj. Thyroid function test

17 Diagnosis CXR (enlarged heart, CHF) Echocardiogram (left ventricular dilation, global hypokinesis, low EF,variable Electrocardiogram (tachycardia, A-V degree block, LBBB, of mitral NSSTT and changes, /or PVC s) tricuspid regurgitation) 24-hour Holter monitor Myocardial biopsy, rare If lightheadedness, palpitation, syncope Cardiac catheterization if age >40, ischemic history, high risk profile, abnormal ECG

18 Diagnosis Investigation to exclude CT disease Family screen

19 DCM - Treatment Limited activity according to patient status. Salt restriction Fluid restriction Initiate medical therapy ACE inhibitors,arbs Diuretics, digoxin for symptomatic relief Beta blockers Anticoagulation prn (EF <30%, hx of embolic events) Implantable defibrillators

20 DMC Treatment THERAPUTIC PROCEDURES : Implantable cardioverter-defebrilator Cardiac resynochronization therapy in patient meet criteria. WHAT IS THE CRITERIA FOR CRT??? -Patient with NYHA classiii IV symptoms and intra ventricular conduction delay -patient with left ventriculare EJ 35% despite optimal treatment -LBBB with QRS>130ms

21 DCM Treatment Cont. Cardiac transplantation This disorder is the most common indication for cardiac transplantation Survival after transplant is 80% one year 70% 5 years Left Ventricular Reduction Procedures LV-reshaping

22 When to hospitalize???? Decompinsated HF AF with rapid ventriculare response Syncope Cardiac arrest HOSPITAL DISCARGE CRITERIA After medical stabilization and optimizing HF medication After successful cardiac defibrilator and/or biventriculare pace maker device.

23 FOLLOW UP Every 3 months or more depend onseverity of disease Appropriate follow up with an Electrophysiologist as needed Serial ECHO

24 COMPLICATION s Progressive heart failure Arrhythmias Sudden death Complication of device implantation: Perforation with myocardial rupture and cardiac tamponade,infection, and bleeding.

25 Myocarditis Its an inflammatory disease of the cardiac muscle. Can be focal or diffuse involve endocardium\pericardium \vavular structures Most commenly associated with viral infection but could be due to infectious disease \drugs\autoimmune

26 Symptoms Usually variable Most commonly asymptomatic Other present with: 1-chest pain 2-dysnea\fatigue\decrease exercise tolerance 3-palpitation\dizzy \syncope 4-Cardiogenic shock

27 Signs Variable finding: 1-tachycardia 2-hypotention 3-fever 4-signs of fluid over load 5-murmer of mitral or tricuspid regurge

28 ESSENTIALS FOR DIAGNOSIS New onset heart failure preceded by viral infection. Elevated ESR with acute myocarditis ECG and ECHO may show wide variety of changes Mural thrombi may be found Endomyocardial biopsy is the gold standered for diagnosis

29 Mosul College of Medicine 2013