心肌病(心内科)课件

1、Dilated Cardiomyopathy DCM,GU Jun Dept. of Cardiovascular Medicine,Case A 36 year old man comes to your office complaining of three months of progressive fatigue and dyspnea on exertion. Several times in the past month he has awakened from sleep with severe breathlessness and felt a need to sit up in order to breath. He denies any chest pain. He has no past medical history of heart disease, hypertension or diabetes. His family history is negative for heart disease. He does not smoke and drinks a

2、lcohol only rarely. He takes no medications.,Physical Examination,BP 105/70mmHg, P 98 regular Lungs: rales. Heart: Enlarged heart border. S1 diminished intensity, S2 normal, S3 is present. 2/6 systolic murmur at the apex. Abdomen: Liver is enlarged and slightly tender to pressure. Extremities: Mild edema of both feet.,Dilated Cardiomyopathy, DCM,Definition,Heart muscle disorder Enlarged left ventricle or both ventricles Impaired systolic pump function Often with manifestation of heart failure or

3、 arrhythmia,Epidemiology,Annual incidence: 5-10 patients per million Male-female ratio: 2.5 : 1 Average age of incidence: 40 Higher incidence in the developing countries Annual mortality rate: 25%-45%,Etiology,Not clear Familial/genetic (20%) Viral infectious agents and autoimmune Acute viral myocarditis can progress to chronic dilated cardiomyopathy Chronic hormonal disorders Use of certain substances, especially alcohol, cocaine, antidepressants, and chemotherapy drugs,Pathology,Gross examinat

4、ion： Thinned ventricular walls Enlarged ventricles Fibrin and scar Mural thrombus Normal valves and coronary arteries,DCM Normal,Microscopic examination: Myocardial cell may be hypertrophy, denaturation, fibrosis or necrosis.,Pathology,Pathophysiology,Pump less blood for the bodys needs,Heart failure,Myocardial changes involve conduction system,Arrhythmia,Mural thrombus fall off,Embolism,Clinical Manifestation,Symptoms： No symptom in the early stage Fatigue, dyspnea, orthopnea Anorexia, edema Pa

5、lpitation, arrhythmia (Af, VT) Embolism (brain, lung, lower extremity) Sudden death (VT, embolism, bradycardia),Clinical Manifestation,Signs： Cardiac dullness extends to left and downwards Rales, pleural effusion Jugular venous distention, hepatomegaly, edema Gallop rhythm, S3, S4 Systolic murmur over the apex area (mitral insufficiency),Accessory Examination,Chest X-ray Enlargement of the heart Signs of pulmonary congestion,Accessory Examination,ECG Atrial fibrillation Conduction block ST-T cha

6、nges Low-voltage QRS Pathologic Q wave Ventricular premature or tachycardia,Accessory Examination,Accessory Examination,Echocardiography Dilated left ventricle or both ventricles Relative mitral/tricuspid insufficiency due to dilated left/right ventricle Ventricular walls not thick Poorly contractile left ventricle EF 50%,Accessory Examination,Coronary angiography: Usually normal Cardiac biopsy: Fibrosis or myocardial celluar hypertrophy, denaturation or necrosis,Exclude other heart diseases,Dil

7、ated heart Arrhythmia Heart failure,Echo:dilated& poorly contractile ventricle,Coronary/Rheu-matic/Hypertensive heart disease,Diagnosis,Specific cardiomyopathy,EXCLUDE,Diagnosis,DCM,Ischemic cardiomyopathy ICM,Age,History,Often in middle age，40 years old,Often in old age， 40 years old,Myocarditis, No history of angina,Risk factors of CHD, history of angina or myocardial infarction,Differential diagnosis,DCM,ICM,Echo,Often four chambers dilated， the weak movement of whole heart , mural thrombus i

8、n some patients,Often only left ventricle dilated, segmental movement abnormality， ventricular aneurysm in some patients,Angio- graphy,Normal,Multivessel disease,Differential diagnosis,Treatment,General treatment Decreased activity and bed rest Salt restriction Stop alcohol Nutritional support,Treatment,Treatment of heart failure Digitalis Diuretics Vasodilators ACEI (angiotensin converting enzyme inhibitors ) ARB (angiotensin receptor blockers),Treatment,Antiarrhythmic treatment Beta blockers (start with low-dose, increase dose gradually) Amiodarone Pacemaker implantation ICD (implantable cardioverter defibrillator),Treatment,CRT (Cardiac Resynchronization Therapy ) Surgery: heart transplantation,Questions,What are echocardiographic findings in DCM? How to distinguish between DCM and ICM? How to treat DCM?,

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