Importance of the Subject icon

Importance of the Subject




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Importance of the Subject.


Diagnosing of myocardial diseases (MD) is made difficult by the heterogeneity in definitions and diagnostic criteria, selection bias in populations studied, and geographic variation. Many epidemiological and clinical

studies simply classify patients as having MD if heart failure is present but there is no clinical or electrocardiographic evidence of coronary disease. In addition, there are clear differences in population characteristics between community-based studies versus analyses of populations from referral centres. Finally, there appears to be geographic variation in the prevalence of specific aetiologies of MD. Estimates of the prevalence of MD range from 2–15% in community or hospital settings, and up to 50% in large clinical trials.

Although the causes of MD are many and varied, they generally culminate in a final common pathway of myocardial injury leading to ventricular dysfunction and clinical heart failure. In many cases of MD a specific aetiology is never identified.

^

Key Objective (educational purpose):


To be able to differentiate MD, to determine it’s management.


Specific Goals


Prior-to Practice Level of Knowledge and Skills


1. To identify and determine a leading syndrome.

1. To take a history from a patient, including cardiovascular symptoms. To estimate symptoms of the cardiovascular system function disorders. (Covered by the course of Propedeutics).

2. To take an individual diagnostic search (approach) and assess the diagnosis.


2.To appreciate the clinical, instrumental and lab outcomes (Covered by course of Propedeutics).

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1
. To differentiate MD and other heart diseases. To determine the clinical course and form of the disease according to classification.


3. To know the typical clinical features of basic cardiovascular diseases. Recognize the syndromes in heart diseases (Covered by course of Faculty Therapy).

4. To base principals of patient treatment in routine and emergency situations.

4. To use main methods of drug treatment in MD.















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Determination (checking up) Prior - to Practice Level of Knowledge and Skills

Q 1.


A 25-year-old man has an early systolic murmur over the apex. The second sound on a.pulmonalis is loud.

For what valvular heart disease this is like ?

A.Mitral stenosis

B.Aortic regurgitation;

C.Tricuspid stenosis;

D.Mitral regurgitation;

E. Tricuspid regurgitation

Q 2.


A patient has an early diastolic murmur at the left sternal edge maximal in the left fourth intercostal space. What valvular heart syndrom this is like for ?

A.Mitral stenosis

B.Aortic regurgitation;

C.Mitral regurgitation;

D.Tricuspid stenosis;

E.Aortic stenosis;

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Q 3.


A 50-year-old woman complains of especially intense pain in heart region during 30 min, inspiratory dyspnoe, elavated body temperature up to 39°С. Physical: Puls is 80 per minute. Auscultation reveals increased intensity of the heart sounds, dry rales in the lungs. Choose the characteristic of myicarditis.

А. Pain in heart.

B.Duration of pain.

C. Body temperature up to 39°С.

D. Inspiratory dyspnoe.

E.Heart pain.

Q 4.


A man 30 y.o. has a decreased intensity of the first sound on apex and an apical pansystolic murmur, radiating to the left axilla. What is the most probable diagnosis ?

A. Cardiac neurosis;

B. Mitral regurgitation;

C. Infective endocarditis

D. Pericarditis;

E. Mitral stenosis


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Q5.


A girl, 16 y.o., complains of piersing apical pain, expiratory dyspnoe, headache. Physical examination reveals borders of relative cardiac dulness: the right —1 cm laterally of the right edge of the sternum, the left — 1,5 сm medially of left medioclavicular line, the upper – 3 rib. Choose the characteristic of myocarditis.

A. Heart pain;

B. Headache;

C. change location right heart border;

D. change location left heart border;

E. change location upper heart border.

Q6.


Adolescent 18 y.o. has a soft apical systolic murmur. What is the most probable diagnosis ?

A. Functional murmur;

B. Mitral regurgitation;

C. Pericarditis

D. Infective endocarditis;

E. Mitral stenosis.


Q 7

A male, aged 55 years, heavy smoker, complaints dyspnoe, acute pain in the heart region assiciated with walk of 500 m distance and abated by nitroglycerin. He feels palpitation constantly, too. Physical examination reveals dry rales in the lungs, heart rate 78 beat/min, blood pressure 160/85 mmHg. Choose the characteristic of myocarditis.

А. Dyspnoe.

B. Palpitation.

C. Age 55 y.o..

D. Blood pressure 160/85 mmHg.

E. Dry rales in the lungs


Q
4
8

A 17 y.o. adolescent complains of small boring pain in the region of the apex. And gives (The patient) gave two weeks history of respiratory infection. Physical examination reveals borders of relative cardiac dulness: the right —1 cm laterally of the right edge of the sternum, the left — 1,5 sm medially of left medioclavicular line, the upper – 3 rib. What is the most probable diagnosis ?

A.Pericarditis;

B.Cardiomyopathy;

C.Rheumatic fever;

D.Infective endocarditis

E.Myocarditis


Literature

Recommended reading to correct Prior-to Practice Level of Knowledge and Skills:

1.D.Rubinstein, D.Wayne. Lecture Notes on Clinical Medicine. Blackwell Scientific Publications. 1994, 417 p..

2. Audrey H Wu cardiomyopathy Management of patients with non-ischaemic. Heart. 2007;93;403-408

3. Celia M Oakley. GENERAL CARDIOLOGY: Myocarditis, pericarditis and other pericardial diseases.

4. M J Davies. CARDIOMYOPATHY: The cardiomyopathies: an overview. Heart. 2000;83;469-474

5. Robert Fagard. Athlete’s heart. Heart. 2003;89;1455-1461

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IV. Subject Material.


To achieve the aims of education you have to learn the Theory Topics on the subject:

- Clinical, laboratory and Imaging Methods of Diagnostics for MD.

- Differential Diagnosis of Классификация MD.

-Aetiology and Pathophysiology of MD.

- Manegment of MD.


You can use the references:

1.Mason JW. Myocarditis. Adv Intern Med 1999;44:293-310


2. Lecture materials

3. Appendix 1

4. Appendix 2

5. Appendix 3

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Appendix1
^

Key points of the subject: ''Myocardial diseases''.


1.Complaints, anamnesis.

Dispnoea;

Palpitation

Cardialgia;

Orthopnoea.


2. Physical.

Circulatory insufficiency;

Displacement of the heart borders to the left and to the right;

Decreased intensity of the heart sounds;

Apical systolic murmur;

Gallop rhythm;

Arrhythmias.
^

3. Preliminary diagnosis.

4.1.Electrocardiography.


Miocarditis: Sinus tachycardia, ST elevation, inverted Т. Fascicular blocks or atrioventricular conduction disturbances. First, second or third degree heart block. Extra beats, atrial fibrillation.

Hypertrophyc cardiomyopathy: Ventricular Hypertrophy. Fascicular blocks or atrioventricular conduction disturbances. Pathological Q. RV6/Rmax>3. The S-T segments show variable combinations of ST elevation (with upward concavity to convexity) and upright, diphasic, or inverted T waves.60

Dilated cardiomyopathy:

The ECG in patients with DC may be remarkably normal, but abnormalities ranging from isolated T wave changes to septal Q waves. Sinus tachycardia and supraventricular arrhythmias are common, in particular atrial fibrillation. Prolongation of atrioventricular (AV) conduction, and bundle branch block may be observed.

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4.2. X - ray examination

The chest x ray may be normal, show cardiac enlargement, pulmonary venous congestion or pleural effusions

4.3.Echocardiography.



Miocarditis

ECHO may reveal segmental or generalised wall motion abnormalities or a pericardial effusion.

Hypertrophyc cardiomyopathy: Left ventricular wall thickness exceeds 16 mm.

Dilated cardiomyopathy: Ejection fraction < 0.45 and/or a fractional shortening of < 25%, and a left ventricular end diastolic dimension of > 112% predicted value corrected for age and body surface area.

4.4.Laboratory:


Increase in creatine kinase, appearance of troponin.

Differential diagnosis — according to Differential Approach:

Dilated cardiomyopathy; Pericarditis. Miocarditis; Myocardial infarction; Hypertrophyc cardiomyopathy; Restricted cardiomyopathy; Aortic stenosis; IE; Cardiac neurosis. Angina pectoris; Trombosis of a.pulmonalis; SLE.

7


^

Appendix 3

Classification of myocardial diseases.


The cardiomyopathies, as defined by the World Health Organization (1996).




Management of patients with non-ischaemic cardiomyopathy:

1.1.Management of Miocarditis:


It is recommended that whenever myocarditis is suspected exercise should be avoided. Effective antiviral agents are unavailable and usually inappropriate.

Immunosuppressive agents would be inappropriate if the myocarditis were caused by the direct effect of persisting virus but potentially useful to suppress an ongoing autoimmune inflammatory response.

The use of steroids in an acutely ill patient therefore remains a discretionary clinical option in addition to the use of diuretics, angiotensin converting enzyme (ACE) inhibitors, adrenergic blocking agents, and spironolactone.
^

1.2.Management of cardiomyopathy.

Dilated cardiomyopathy:


Angiotensin converting enzyme inhibitors, β-blockers, natriuretic peptides, cytokine antagonists.

Heterotopic heart transplantation, partial left ventriculectomy

Hypertrophic cardiomyopathy management.


Medical treatment.


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^

Obstructive HCM:


Medical treatment: β-blockers are the first line treatment in patients with LVOT (left ventricular outflow tract) obstruction. (Verapamil is best avoided in individuals with obstruction because of possible peripheral vasodilatation and haemodynamic collapse !). Disopyramide is also effective in gradient and symptom reduction, probably. It may have a superior effect on exercise tolerance compared to β-blockers.

Non-medical treatment: Surgical septal myectomy remains the gold standard for those individuals with drug refractory symptoms and a resting gradient of > 50 mm Hg. The aim is to widen the outflow tract, eliminating systolic mitral leaflet septal contact.

Two other modalities have been developed for the treatment of LVOT obstruction: dual chamber pacing and alcohol septal ablation.
^

Non-obstructive HCM:


β-blockers, verapamil, and diltiazem.

1.3.Prognosis.


R
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ecovery from acute myocarditis often surprises and delights after life threatening illness. It is also uncertain how many will progress to dilated cardiomyopathy.
























































































^

Assignments for the check of achievement educational purpose

Item 1.


A 25 years-old-man complains of dispnoe, heart pain, associated with mild physical strain, palpitation, syncope. Physical: Resistent apex beat, an apical pansystolic murmur, heard best in the left third and fourth intercostal spaces. ECG: Pathological QV2,3,4 , RV6/Rmax>3. Which of the following is the most likely disease?

A. Cardiac neurosis;

B. Mitral stenosis

C. Dilated cardiomyopathy;

D. Mitral regurgitation;;

E. Hypertrophyc cardiomyopathy

Item 2.


A man, aged 38, complains of elavated body temperature up to 37,5 °C. He had an influenza 10 days ago. Physical: Auscultation reveals decreased intensity of the heart sounds. ECG: tachycardia, atrial extrasystole. First degree heart block. What is the most probable diagnosis?

A. Pericarditis;

B. Cardiac neurosis;

C. Miocarditis

D. ІЕ;

E. Cardiomyopathy.

Item 3.


A 40 y.o. man has not complaints. Physical: Auscultation reveals normal intensity I heart sound, an apical systolic murmur. ECG: high amplitude

RV3. Echo: Left ventricular wall thickness exceeds 20 mm. What is the most probable diagnosis ?


A. Pericarditis

B. Hypertrophyc cardiomyopathy;

C. Dilated cardiomyopathy;

D. ІЕ;

E
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. Miocarditis;


Item 4.

In routine medical screening a 20 y.o. sportsman is interviewed, no complaints were revealed. Echo: symmetrical left ventricular hypertrophy. Physical: Apical systolic murmur. What is the most probable diagnosis?

A. Dilated cardiomyopathy;

B. Hypertrophyc cardiomyopathy;

C. Myocarditic cardiosclerosis

D. Miocarditis;

E. “Athlete’s heart”.


Item 5

A 60 y.o. woman, professional runner in past, is treated with diuretics and angiotensin-converting enzyme inhibitors (3 years ago high blood pressure and marked hypertrophy of left ventricular were revealed). Now BP is normal. Echocardiography: calculated mass of LV is decreased. What is the most probable diagnosis ?


A. Dilated cardiomyopathy;

B. Hypertrophyc cardiomyopathy;

C. Myocarditic cardiosclerosis

D. Miocarditis;

E. “Athlete’s heart”.

Item 6.

A 60 y.o. woman, professional runner in past, is treated with diuretics and angiotensin-converting enzyme inhibitors (3 years ago high blood pressure and marked hypertrophy of left ventricular were revealed). Now BP is normal. Echocardiography: calculated mass of LV is decreased. What is the most probable diagnosis ?


A. Atherosclerotic cardiosclerosis;

B. Angina pectoris;

C. Miocarditis

D. Hypertrophyc cardiomyopathy;

E
16
.. Dilated cardiomyopathy;

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Item 7

A 57-year-old-man complains of dyspnoe and heart pain associated with routine exercise. ECG: pathological QV2,V3,V4. Echo: Ejection fraction < 0.45. What is the most probable diagnosis ?

A. Angina pectoris;

B. Aatherosclerotic cardiosclerosis;

C. Hypertrophyc cardiomyopathy;

D. Dilated cardiomyopathy;

E. Post-infarction cardiosclerosis;


Item 8

A 30 y.o. man, diagnosis: hypertrophyc cardiomyopathy. Physical: Heart rate 100 p/m, blood pressure 110/70 mmHg. What is a most advisible medicine in this case?


A. Propranolol;

B. NItrates;

C. Amiodaron;

D.Digoxin;

E Aspirin


Appendix3

Secondary Cardiomyopathies

Infiltrative*


    Gaucher disease    Amyloidosis (primary, familial autosomal dominant, senile, secondary forms)

    Hurler’s disease

    Hunter’s disease

Storage

    Hemochromatosis

    Fabry’s disease

    Glycogen storage disease (type II, Pompe)

    Niemann-Pick disease

Toxicity

    Drugs, heavy metals, chemical agents

Endomyocardial

    Endomyocardial fibrosis

    Hypereosinophilic syndrome (Löeffler’s endocarditis)

Inflammatory (granulomatous)

    Sarcoidosis

Endocrine

    Diabetes mellitus

    Hyperthyroidism

    Hypothyroidism

    Hyperparathyroidism

    Pheochromocytoma

    Acromegaly


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Cardiofacial

Noonan syndrome

    Lentiginosis

Neuromuscular/neurological

    Neurofibromatosis

    Tuberous sclerosis

Nutritional deficiencies

    Beriberi (thiamine), pallagra, scurvy, selenium, carnitine, kwashiorkor

Autoimmune/collagen

    Systemic lupus erythematosis

    Dermatomyositis

    Rheumatoid arthritis

    Scleroderma

    Polyarteritis nodosa

Electrolyte imbalance

Consequence of cancer therapy

    Anthracyclines: doxorubicin (adriamycin), daunorubicin

    Cyclophosphamide

    Radiation



*Accumulation of abnormal substances between myocytes (ie, extracellular).

Genetic (familial) origin.

Accumulation of abnormal substances within myocytes (ie, intracellular).


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