Dilated cardiomyopathy - Causes, symptoms and treatment. MF.

Causes of
Symptoms of
Diagnosis of
Treatment of
Lifestyle of
Complications and prognosis of

For correct, rhythmic contractions of the heart with adequate blood volume to be expelled to the aorta, certain conditions are necessary. First of all, the normal thickness of the heart walls and the normal size of the chambers of the heart are the atria and ventricles. There are many reasons that can disrupt biochemical processes in the cells of the myocardium, which can lead to a change in the configuration of the heart - thickening the walls of the heart and / or increasing the volume of the heart chambers. Develops a disease such as cardiomyopathy.

Cardiomyopathy is the outcome of some cardiological or systemic diseases, characterized by a violation of the functions of contraction and relaxation of the heart, and manifested by symptoms of chronic heart failure, stagnation of blood in the organs and in the heart, disturbances of the heart rhythm.

In addition to acquired as a result of certain diseases, cardiomyopathies can be congenital and idiopathic - without the established cause.

Dilated cardiomyopathy is a disease characterized by enlargement of the heart chambers with thickened or normal cardiac walls. As a result of the overflow of the blood in the heart cavities, systolic dysfunction develops - a decrease in the ventricular contraction force and a decrease in the fraction of blood discharge into the aorta below 45%( normally more than 50%).From this, the blood supply of internal organs suffers and congestive heart failure develops.

In addition to the dilatation, it is still hypertrophic( with a sharp thickening of the walls of the atria or ventricles) and restrictive( with soldering of the outer or inner cardiac shell - pericardium or endocardium to the cardiac muscle with restriction of mobility of the latter).

The prevalence of dilated cardiomyopathy ranges from 1 to 10 per 100,000 population. In newborn infants, approximately 50% of all cardiomyopathies occur and in 3% of all heart pathologies, often( 40% of all cases) require cardiac transplantation before the age of two. Among adults, as a rule, people are sick 20 - 50 years, more often men( 60%).

Causes of dilated cardiomyopathy

Only 40% of patients manage to establish the exact cause of cardiomyopathy. In other cases, the disease is considered primary, or idiopathic.

Causes of secondary dilated cardiomyopathy:

- viral infections - Coxsackie viruses, influenza, herpes simplex, cytomegalovirus, adenovirus,
- genetically caused immune disorders( defect subpopulation of T lymphocytes - natural killers), congenital heart structure at the molecular level,
-toxic myocardial damage - alcohol, narcotic substances, poisons, antitumor drugs,
- dysmetabolic disorders - hormonal disorders in the body, starvation and diets with defitsic protein, B vitamins, carnitine, selenium and other substances,
- autoimmune diseases - rheumatoid arthritis, systemic lupus erythematosus often cause autoimmune myocarditis, the outcome of which can be cardiomyopathy.

Symptoms of dilated cardiomyopathy

Sometimes signs of the disease may not appear for several months or even years, until the heart functions are compensated. As decompensation or the following symptoms immediately appear:

1. Symptoms of congestive heart failure:
- dyspnea first when walking, then at rest,
- nocturnal attacks of cardiac asthma, episodes of pulmonary edema - severe asphyxiation in prone position, obsessive cough dry or with foamy sputum pink, sometimes with streaksblood, blue coloring of the nails, tip of the nose and ears, with swelling - pronounced cyanosis of the skin of the face, lips, limbs,
- swelling of the lower extremities, intensifying towards evening and disappearing after a night's sleep,
- feeling of heaviness, moderate blunt pain in the rightof the right hypochondrium. Due to increased blood filling of the liver and dilatation of its capsules,
- increased abdominal volume due to fluid accumulation( ascites) due to cardiac cirrhosis of the liver in late stages of heart failure,
- renal dysfunction - changes in rhythm and volume of urination - rare or frequent, large orsmall portions,
- signs of a violation of the blood supply to the brain - memory impairment, attention, absent-mindedness, sudden mood swings, insomnia and other symptoms of discirculatory( in this caseve venous) encephalopathy.

Cardiac insufficiency has four stages depending on the symptoms and degree of intolerance to physical activity( I, II A, II B, III and IV stages).

2. Symptoms that are characteristic of a violation of left ventricular systolic function.
At initial reduction of the ejection fraction of the patient, weakness, fast fatigue, pallor, coldness of hands and feet, dizziness are disturbed.

With a significant decrease in cardiac output, severe weakness develops, the inability to perform minimal household activities, severe dizziness and loss of consciousness with little physical exertion.

3. Symptoms of rhythm disturbance. More than 90% occur different arrhythmias, manifested by a sense of heart failure, a sense of fading and cardiac arrest. Most often, atrial fibrillation develops, sometimes difficult to restore rhythm, so these patients form a permanent form of atrial fibrillation. It is possible to develop atrioventricular blockade, blockade of the bundle of the bundle, ventricular extrasystole and other arrhythmias.

The patient in the late stages of heart failure due to dilated cardiomyopathy looks as follows - assuming a semi-sitting position even during sleep, because it is easier to breathe. His breath is noisy, with a labored inhalation, you can hear rattling rales in the lungs from a distance because of the pronounced stagnation of blood. The face is puffy, the brushes and feet are swollen, the abdomen is enlarged in volume, sometimes the edema of subcutaneous fat is developed throughout the body - the anasarca develops. The slightest movement even within bed aggravates shortness of breath and causes discomfort.

Diagnosis of dilated cardiomyopathy

When patients see these complaints, you should consult a cardiologist or therapist. The diagnosis can be suspected on the basis of a survey and examination of the patient.

With auscultation of the heart and lungs, weakened heart sounds are heard, in most cases, arrhythmic, pathological heart sounds( gallop rhythm) are characteristic. The apical thrust is diffuse, shifted to the left and down.

Arterial pressure may be normal, elevated at the onset of the disease or more often decreased. Pulse of normal or weak filling and tension, non-rhythmic.

The laboratory methods of the study are shown:

- general clinical tests - general blood and urine tests, biochemical blood test with assessment of liver and kidney function( ALAT, ASAT, bilirubin, urea, creatinine, alkaline phosphatase, etc.),
- blood coagulation- MNO, prothrombin time and index, clotting time, etc.,
- glycemic profile( sugar curve) for people with diabetes mellitus,
- rheumatological tests( antibodies to streptolysin, streptogialuronidase, level C - reactive proteinka and others) for differential diagnostics with rheumatic heart diseases,
- determination of sodium uretic peptide in blood,
- hormonal studies - level of thyroid hormones, adrenals. Instrumental Research Methods:

- echocardiography is the most valuable non-invasive method for examining the heart muscle and heart functions. It makes it possible to distinguish cardiomyopathy from heart defects, to clarify ischemic damage to the myocardium, to determine the dimensions of the chambers and the thickness of the walls of the heart. The most important criterion that is determined by ultrasound of the heart and on which the vital prognosis depends is the fraction of cardiac output( FV).Normally, the ejection fraction in a healthy person is 55-60%, with cardiomyopathy below 45-50%, and the critical value is less than 30%.
- ECG and its modifications - daily monitoring of ECG, ECG with load( treadmill test), PEEPI - transesophageal electrophysiological study( it is not appointed by all, as it is not mandatory for dilated cardiomyopathy).
- radiography of chest organs - enlarged and enlarged shadow of heart, intensification of pulmonary pattern on pulmonary fields.

X-ray of patient with dilated heart chambers

- ultrasound of internal organs, thyroid, adrenal.
- it is possible to perform MRI of the heart, ventriculography, scintigraphy of the myocardium in diagnostically difficult cases.

Dilated cardiomyopathy must be distinguished from diffuse myocarditis, ischemic heart disease and ischemic cardiomyopathy, pericarditis, and heart defects. Therefore, if a patient is suspected of having a heart condition, the patient must consult a doctor.

Treatment of dilated cardiomyopathy

Treatment of the initial stage of heart failure begins with the correction of lifestyle and nutrition, as well as elimination of modifiable risk factors( alcohol, smoking, obesity).

Medication:

- ACE inhibitors - captopril, perindopril, ramipril, lisinopril, etc. Are indicated to all patients with systolic dysfunction. Improve survival and prognosis, reduce the number of hospitalizations. Should be appointed under the control of indicators of kidney function( urea and creatinine).Appointed for an indefinite time, perhaps for life.
- diuretics remove excess fluid from the lungs and internal organs. Appointed veroshpiron, spironolactone, furosemide, torasemide, lasix.
- cardiac glycosides are mandatory for tachyform atrial fibrillation and a reduction in the ejection fraction. Digoxin, strophanthin, and korglikon are prescribed. The dosage of the drugs should be clearly observed, as in the case of an overdose, glycoside intoxication-poisoning with these drugs develops.
- beta blockers ( metoprolol, bisoprolol and others) are prescribed to reduce heart rate, hypertension. Also improve the forecast.

These groups of drugs significantly reduce the manifestations of left ventricular dysfunction, reduce dyspnea and edema, increase the tolerance of exercise and improve the quality of life in general.

In addition,
- blood thinners( anticoagulants) are prescribed: aspirin, tromboass, acetamidol, and others. They are indicated to prevent increased blood clot formation in the bloodstream. Warfarin, or clopidogrel, or plavix is ​​used in atrial fibrillation under the control of INRs once a month( or under the control of the prothrombin index).
- nitrates - short-acting drugs( nitrospray, nitromint) can be recommended to the patient with an increase in dyspnea during walking or with concomitant angina. Intravenously in a hospital, nitroglycerin is injected to stop left ventricular failure and pulmonary edema.
- calcium channel antagonists ( nifedipine, verapamil, diltiazem) are usually prescribed to patients with other forms of cardiomyopathy instead of beta-blockers in the presence of contraindications to the latter. But with a violation of the systolic function of the left ventricle, this appointment is contraindicated, since they "relax" the heart muscle, which is already unable to properly contract. Also, nifedipine increases the heart rate, which is unacceptable with the tachyform of atrial fibrillation. However, if it is not possible to use beta-blockers, amlodipine or felodipine may be prescribed.

Surgical treatment of dilated cardiomyopathy:

- implantation of cardioverter - defibrillator in the presence of life-threatening ventricular tachyarrhythmias
- implantation of pacemaker is indicated for severe violations of intraventricular conduction, with dissociation of synchronous contractions of the atria and ventricles
- heart transplantation

Indications and contraindications for surgical treatment are determined strictly by the cardiologist and cardiac surgeon, since the tolerance of the organism to an operation on an exhausted heart is unknowna possible adverse outcome.

Lifestyle

For cardiomyopathy, the following recommendations should be followed:
- rejection of bad habits
- reduction in excess weight, but not with fasting or debilitating diets, but with the help of proper eating behavior. You should organize a diet: 4 - 6 meals a day in small portions with the predominant use of liquid dishes, products cooked in boiled form or steamed. It is necessary to exclude fried foods, spicy, salty, fatty foods and spices. Confectionery, fatty meat and poultry are confined. At the same time, it is necessary to enrich the diet with omega-3-unsaturated fatty acids contained in marine fish( salmon, mackerel, salmon, trout, caviar).Vitamin, minerals, selenium and zinc content is also useful in food. Especially rich in selenium oat flakes, tuna, buckwheat, eggs, wheat bran, peas, sunflower seeds, white mushrooms, lard.
- restriction of table salt in the diet to 3 grams per day, and with severe edematous syndrome - up to 1.5 grams per day, limiting fluid intake, including with the first dishes up to 1.5 liters per day.
- a mode of work that allows you to give enough time to rest and sleep( at least 8 hours of night sleep)
- the physical activity of patients must be present daily, but according to the degree of manifestation of heart failure. Even if the patient spends most of his time in bed due to severe shortness of breath, swelling, etc., he should still move at least within the bed and perform simple rotational movements with his head, hands and feet, and perform breathing exercises. The complex of physiotherapy exercises can be clarified by the attending physician.
- Vaccination against influenza and pneumococcus is indicated for persons with a family predisposition to myocarditis and cardiomyopathy. In the treatment of ARVI and other respiratory diseases, such persons are obliged to use recombinant interferon( viferon, geneferon, kipferon, etc.).
- correction of concomitant diseases - diabetes mellitus, hypertension, hyper- and hypothyroidism, etc.
- the focus on fruitful cooperation with the attending physician, the establishment of a positive result of treatment, the implementation of all recommendations and the constant intake of the necessary medications is the key to success in the therapy of cardiomyopathy.

Complications of dilated cardiomyopathy

Congestive heart failure and cardiac arrhythmias are often considered complications of cardiomyopathy, but in essence they are more of a clinical manifestation, as they develop in almost all patients, and the general symptoms of cardiomyopathy are the symptoms of these disorders.

To dangerous consequences include thromboembolic complications - the formation of thrombi in the heart cavity. Due to stagnation and slow movement of blood through the chambers, platelets settle on the walls of the heart and form a parietal thrombus, which can be carried by blood flow through large arteries and clog their lumen. This includes thromboembolism of the pulmonary, femoral, bryzhezhechnoy arteries, ischemic stroke. Prophylaxis is the constant intake of drugs that dilute blood.

Frequent ventricular extrasystole, ventricular tachycardia can lead to ventricular fibrillation, cause heart failure and death. Prevent the occurrence of fatal rhythm disturbances can be a constant reception of beta-blockers and cardiac glycosides.

Forecast

The prognosis for the natural course of dilated cardiomyopathy without treatment is unfavorable, because the heart completely stops performing the pumping function, which will lead to the degeneration of all organs, exhaustion and death.
With the medical treatment of the disease, the prognosis for life is favorable - a five-year survival rate is 60-80%, and a ten-year survival after heart transplant is 70-80%.

The labor forecast is determined by the stage of circulatory disturbance. At the first stage of heart failure, the patient can work, but heavy physical work, night shifts, business trips are counter-indicative. For the refusal of these types of work, the patient can provide the employer with a certificate from the attending physician, or the decision of the Ministry of Health of the Russian Federation for obtaining the III( working) group of disability. In the presence of IIA and above the stage of heart failure, the II group of disability is determined.

Doctor therapist Sazykina O.Yu.