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1、DilatedCardiomyopathyDCMGUJunDept.ofCardiovascularMedicine CaseCase AA 3636 yearyear oldold manman comescomes toto youryour officeofficecomplainingcomplaining ofof threethree monthsmonths ofof progressiveprogressivefatiguefatigue andand dyspneadyspnea onon exertion.exertion.SeveralSeveraltimestimes
2、inin thethe pastpast monthmonth hehe hashas awakenedawakenedfromfrom sleepsleep withwith severesevere breathlessnessbreathlessness andandfeltfelt a a needneed toto sitsit upup inin orderordertoto breath.breath.HeHedeniesanychestpain.deniesanychestpain.HeHe hashas nono pastpast medicalmedical history
3、history ofof heartheartdisease,disease,hypertensionhypertensionorordiabetes.diabetes.HisHisfamilyfamilyhistoryhistoryisisnegativenegativeforforheartheartdisease.disease.HeHedoesdoesnotnotsmokesmokeandanddrinksdrinksalcoholalcoholonlyonlyrarely.rarely.HeHetakesnomedications.takesnomedications.Physica
4、lExaminationPhysicalExamination BP105/70mmHg,P98regularBP105/70mmHg,P98regular Lungs:rales.Lungs:rales.Heart:Enlargedheartborder.Heart:Enlargedheartborder.SS1 1diminishedintensity,Sdiminishedintensity,S2 2normal,Snormal,S3 3isispresent.present.2/6systolicmurmurattheapex.2/6systolicmurmurattheapex.Ab
5、domen:LiverisenlargedandslightlytenderAbdomen:Liverisenlargedandslightlytendertopressure.topressure.Extremities:Mildedemaofbothfeet.Extremities:Mildedemaofbothfeet.DilatedCardiomyopathy,DCMDefinitionn nHeartmuscledisordern nEnlargedleftventricleorbothventriclesn nImpairedsystolicpumpfunctionn nOften
6、withmanifestationofheartfailureorarrhythmiaEpidemiologyn nAnnualincidence:5-10patientspermillionn nMale-femaleratio:2.5:1n nAverageageofincidence:40n nHigherincidenceinthedevelopingcountriesn nAnnualmortalityrate:25%-45%Etiologyn nNotclearn nFamilial/genetic(20%)n nViralinfectiousagentsandautoimmune
7、n nAcuteviralmyocarditiscanprogresstochronicdilatedcardiomyopathyn nChronichormonaldisordersn nUseofcertainsubstances,especiallyalcohol,cocaine,antidepressants,andchemotherapydrugsPathologyn nGrossexamination：ThinnedventricularwallsEnlargedventriclesFibrinandscarMuralthrombus Normalvalvesandcoronary
8、arteries DCMNormaln nMicroscopicexamination:Myocardial cell may be hypertrophy,denaturation,fibrosis or necrosis.PathologyPathophysiologyPumplessbloodforthebloodforthebodysneedsbodysneedsHeartfailureMyocardialchangesinvolveconductionsystemArrhythmiaMuralthrombusfalloffEmbolismClinicalManifestation n
9、 nSymptoms：NosymptomintheearlystageFatigue,dyspnea,orthopneaAnorexia,edemaPalpitation,arrhythmia(Af,VT)Embolism(brain,lung,lowerextremity)Suddendeath(VT,embolism,bradycardia)ClinicalManifestation n nSigns：CardiacdullnessextendstoleftanddownwardsRales,pleuraleffusionJugularvenousdistention,hepatomega
10、ly,edemaGalloprhythm,S3,S4Systolicmurmurovertheapexarea(mitralinsufficiency)AccessoryExaminationn nChestX-rayEnlargementoftheheartSignsofpulmonarycongestionAccessoryExaminationn nECGAtrialfibrillationConductionblockST-TchangesLow-voltageQRSPathologicQwaveVentricularprematureortachycardiaAccessoryExa
11、minationAccessoryExaminationn nEchocardiographyDilatedleftventricleorbothventriclesRelativemitral/tricuspidinsufficiencyduetodilatedleft/rightventricleVentricularwallsnotthickPoorlycontractileleftventricleEF50%AccessoryExaminationn nCoronaryangiography:Usuallynormaln nCardiacbiopsy:Fibrosisormyocard
12、ialcelluarhypertrophy,denaturationornecrosisExcludeotherheartdiseasesDilatedheartArrhythmiaHeartfailureEcho:dilated&poorlycontractileventricleCoronary/Rheu-matic/HypertensiveheartdiseaseDiagnosisSpecificcardiomyopathy EXCLUDEDiagnosisDCMIschemiccardiomyopathyICMAgeHistoryOfteninmiddleage，40yearsoldM
13、yocarditis,NohistoryofanginaRiskfactorsofCHD,historyofanginaormyocardialinfarctionDifferentialdiagnosisDCMICMEchoOftenfourchambersdilated，theweakmovementofwholeheart,muralthrombusinsomepatientsOftenonlyleftventricledilated,segmentalmovementabnormality，ventricularaneurysminsomepatients Angio-graphyNo
14、rmalMultivesseldiseaseDifferentialdiagnosisTreatmentn nGeneraltreatmentDecreasedactivityandbedrestSaltrestrictionStopalcoholNutritionalsupportTreatmentn nTreatmentofheartfailureDigitalisDiureticsVasodilatorsACEI(angiotensinconvertingenzymeinhibitors)ARB(angiotensinreceptorblockers)Treatmentn nAntiar
15、rhythmictreatmentBetablockers(startwithlow-dose,increasedosegradually)AmiodaronePacemakerimplantationICD(implantablecardioverterdefibrillator)Treatmentn nCRT(CardiacResynchronizationTherapy)n nSurgery:hearttransplantationQuestionsn nWhatareechocardiographicfindingsinDCM?n nHowtodistinguishbetweenDCMandICM?n nHowtotreatDCM?