心肌病(心內(nèi)科)課件

DilatedCardiomyopathy

DCMGUJunDept.of

CardiovascularMedicine

Case

A36yearoldmancomestoyourofficecomplainingofthreemonthsofprogressivefatigueanddyspneaonexertion.Severaltimesinthepastmonthhehasawakenedfromsleepwithseverebreathlessnessandfeltaneedtositupinordertobreath.Hedeniesanychestpain.Hehasnopastmedicalhistoryofheartdisease,hypertensionordiabetes.Hisfamilyhistoryisnegativeforheartdisease.Hedoesnotsmokeanddrinksalcoholonlyrarely.Hetakesnomedications.PhysicalExaminationBP105/70mmHg,P98regularLungs:rales.Heart:Enlargedheartborder. S1diminishedintensity,S2normal,S3ispresent. 2/6systolicmurmurattheapex.Abdomen:Liverisenlargedandslightlytender topressure.Extremities:Mildedemaofbothfeet.DilatedCardiomyopathy,DCMDefinitionHeartmuscledisorderEnlargedleftventricleorbothventriclesImpairedsystolic

pumpfunctionOftenwithmanifestationofheartfailureorarrhythmiaEpidemiologyAnnualincidence:5-10patientspermillionMale-femaleratio:2.5:1Averageageofincidence:40HigherincidenceinthedevelopingcountriesAnnualmortalityrate:25%-45%EtiologyNotclearFamilial/genetic(20%)

ViralinfectiousagentsandautoimmuneAcuteviral

myocarditis

canprogresstochronicdilatedcardiomyopathyChronichormonaldisordersUseofcertainsubstances,especiallyalcohol,cocaine,antidepressants,andchemotherapydrugsPathologyGrossexamination：

ThinnedventricularwallsEnlargedventriclesFibrinandscarMuralthrombus

Normalvalvesandcoronaryarteries

DCMNormalMicroscopicexamination:

Myocardialcellmaybehypertrophy,

denaturation,fibrosisornecrosis.PathologyPathophysiologyPumplessbloodforthebody'sneeds

HeartfailureMyocardialchangesinvolveconductionsystemArrhythmiaMuralthrombusfalloffEmbolismClinicalManifestation

Symptoms：

NosymptomintheearlystageFatigue,dyspnea,orthopnea

Anorexia,edemaPalpitation,arrhythmia(Af,VT)Embolism(brain,lung,lowerextremity)Suddendeath(VT,embolism,bradycardia)ClinicalManifestation

Signs：

Cardiacdullnessextendstoleftanddownwards

Rales,pleuraleffusionJugularvenousdistention,hepatomegaly,edemaGalloprhythm,S3,S4Systolicmurmurovertheapexarea(mitralinsufficiency)AccessoryExaminationChestX-rayEnlargementoftheheartSignsofpulmonarycongestionAccessoryExaminationECG

AtrialfibrillationConductionblockST-TchangesLow-voltageQRSPathologicQwaveVentricularprematureortachycardiaAccessoryExaminationAccessoryExaminationEchocardiographyDilatedleftventricleorbothventriclesRelativemitral/tricuspidinsufficiencyduetodilatedleft/rightventricleVentricularwallsnotthickPoorlycontractileleftventricleEF<50%AccessoryExaminationCoronaryangiography:UsuallynormalCardiacbiopsy:Fibrosisormyocardialcelluarhypertrophy,denaturationornecrosisExcludeotherheartdiseases

DilatedheartArrhythmiaHeartfailure

Echo:dilated&poorlycontractileventricleCoronary/Rheu-matic/HypertensiveheartdiseaseDiagnosisSpecificcardiomyopathy

EXCLUDEDiagnosisDCMIschemiccardiomyopathyICMAgeHistoryOfteninmiddleage，<40yearsoldOfteninoldage，>40yearsoldMyocarditis,Nohistoryofangina

RiskfactorsofCHD,historyofanginaormyocardialinfarctionDifferentialdiagnosisDCMICMEchoOftenfourchambersdilated，theweakmovementofwholeheart,muralthrombusinsomepatientsOftenonlyleftventricledilated,segmentalmovementabnormality，ventricularaneurysminsomepatients

Angio-graphyNormalMultivesseldiseaseDifferentialdiagnosisTreatmentGeneraltreatmentDecreasedactivityandbedrestSaltrestrictionStopalcoholNutritionalsupportTreatmentTreatmentofheartfailureDigitalisDiureticsVasodilatorsACEI(angiotensinconvertingenzymeinhibitors)ARB(angiotensin

receptorblockers)TreatmentAntiarrhythmictreatmentBetablockers(startwithlow-dose,increasedosegradually)Amiodarone

PacemakerimplantationICD