History

Fact Explanation
Asymptomatic Many are asymptomatic during the early stages of the disease. [1]
History of harmful alcohol consumption Alcoholic cardiomyopathy can occur secondary to harmful use of alcohol. Dilated cardiomyopathy is a result of thiamin and other vitamin deficiencies due to alcoholism. [1,2,3]
Dyspnea [1] Patients develop dyspnea due to congestive cardiac failure and pulmonary edema. Often patients develop dyspnea with exertion. In severe heart failure patients can be dyspnoeic even at rest.
Orthopnea [1] Patients complain of dyspnea on lying down. Sometimes patients may wake up in the night with episodes of cough frothy sputum and dyspnea. All of these symptoms are due to heart failure and pulmonary edema.
Peripheral edema [1] Peripheral edema develops due to heart failure. This may be exacerbated by the presence of cirrhosis in some patients. [5]
Sudden cardiac death Patients with dilated cardiomyopathy can present with sudden cardiac death. [4]
References
  1. WEXLER RK, ELTON T, PLEISTER A, FELDMAN D. Cardiomyopathy: an overview. Am Fam Physician [online] 2009 May 1, 79(9):778-84 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20141097
  2. Alcoholic cardiomyopathy. Br Med J [online] 1972 Apr 29, 2(5808):247 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1788948
  3. KLATSKY A. L.. Alcohol and Cardiovascular Health. Integrative and Comparative Biology [online] 2004 August, 44(4):324-328 [viewed 26 June 2014] Available from: doi:10.1093/icb/44.4.324
  4. BINHAM JD, FREDLUND V. A case of dilated cardiomyopathy. Rural Remote Health [online] 2012:2143 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23121127
  5. PUNNOOSE ANN R., LYNM CASSIO, GOLUB ROBERT M.. Cirrhosis. JAMA [online] 2012 February [viewed 26 June 2014] Available from: doi:10.1001/jama.2012.82

Examination

Fact Explanation
Shifted apex beat The apex beat is shifted inferiorly and laterally due to cardiomegaly. [5,6]
Hypotension Blood pressure can be low due to reduced cardiac output in systolic dysfunction. [6,8]
Elevated Jugular venous pressure (JVP) JVP is elevated in the presence of heart failure. [7]
Tachycardia Pulse rate increases to compensate for hypotension and to maintain the cardiac output. [8]
Pulsatile liver [6] Pulsatile liver can result due to right ventricular failure. Later it may progress to cardiac cirrhosis.
Signs of heart failure Peripheral edema, diffuse pulmonary crackles, diminished first heart sound, tachycardia and gallop rhythm are clinical signs of heart failure. [2,6]
Parotid enlargement Enlarged and palpable parotid glands are seen in chronic alcoholism. [1]
Signs of chronic liver disease Alcoholism can cause cirrhosis. Once the patient develops cirrhosis they can have palmar erythema, spider nevi, jaundice and scratch marks. Abdominal examination will reveal shrunken liver, with or without splenomegaly and ascites. If the patient develops hepatic encephalopathy fetor hepaticus, hepatic flaps, altered consciousness and impaired attention can be elicited. [3,4]
References
  1. WOLFE STANLEY J., SUMMERSKILL W. H. J., DAVIDSON CHARLES S.. Parotid Swelling, Alcoholism and Cirrhosis. N Engl J Med [online] 1957 March, 256(11):491-495 [viewed 26 June 2014] Available from: doi:10.1056/NEJM195703142561103
  2. KING M, KINGERY J, CASEY B. Diagnosis and evaluation of heart failure. Am Fam Physician [online] 2012 Jun 15, 85(12):1161-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22962896
  3. SCHUPPAN D, AFDHAL NH. Liver Cirrhosis Lancet [online] 2008 Mar 8, 371(9615):838-851 [viewed 26 June 2014] Available from: doi:10.1016/S0140-6736(08)60383-9
  4. BLEIBEL W, AL-OSAIMI AM. Hepatic Encephalopathy Saudi J Gastroenterol [online] 2012, 18(5):301-309 [viewed 26 June 2014] Available from: doi:10.4103/1319-3767.101123
  5. O'NEILL T.W., SMITH M., BARRY M., GRAHAM I.M.. DIAGNOSTIC VALUE OF THE APEX BEAT. The Lancet [online] 1989 February, 333(8635):410-411 [viewed 26 June 2014] Available from: doi:10.1016/S0140-6736(89)90004-4
  6. BINHAM JD, FREDLUND V. A case of dilated cardiomyopathy. Rural Remote Health [online] 2012:2143 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23121127
  7. SCHULTZ JC, HILLIARD AA, COOPER LT JR, RIHAL CS. Diagnosis and Treatment of Viral Myocarditis Mayo Clin Proc [online] 2009 Nov, 84(11):1001-1009 [viewed 26 June 2014] Available from: doi:10.1016/S0025-6196(11)60670-8
  8. DAVIES M.R., COUSINS J.. Cardiomyopathy and anaesthesia. Continuing Education in Anaesthesia, Critical Care & Pain [online] December, 9(6):189-193 [viewed 26 June 2014] Available from: doi:10.1093/bjaceaccp/mkp032

Differential Diagnoses

Fact Explanation
Hypertrophic cardiomyopathy [1] In hypertrophic cardiomyopathy cardiac muscles are hypertrophied limiting the cardiac chamber size. [2]
Restrictive cardiomyopathy Sarcoidosis, hemochromatosis, amyloidosis are common infiltrative causes of restrictive cardiomyopathy. [1]
Arrhythmogenic right ventricular cardiomyopathy This is an autosomal dominant disease. Syncope, ventricular arrhythmias, symptoms of heart failure and sudden death are common presentations. [1]
References
  1. WEXLER RK, ELTON T, PLEISTER A, FELDMAN D. Cardiomyopathy: an overview. Am Fam Physician [online] 2009 May 1, 79(9):778-84 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20141097
  2. NISHIMURA R. A.. Hypertrophic Cardiomyopathy: A Patient Perspective. Circulation [online] 2003 November, 108(19):133e-135 [viewed 26 June 2014] Available from: doi:10.1161/​01.CIR.0000097621.97566.96

Investigations - for Diagnosis

Fact Explanation
Electrocardiography (ECG) Left ventricular hypertrophy can be present. [1]
Echocardiography Dimensions of the cardiac chambers can be measured. The ventricular wall thickness is either normal or decreased. There is demonstrable systolic dysfunction and poor contractility. [1,2]
Chest X-ray [1] Signs of heart failure that can be detected in chest X-ray include, alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusions.
B-type natriuretic peptide (BNP) levels In heart failure BNP is elevated. BNP is secreted from the dilated and pressure overloaded ventricles. This is highly sensitive in diagnosing heart failure. [1]
Thallium scintigraphy Areas of reversible ischemia can be identified with this. [2]
Cardiac catheterization Cardiac catheterization is helpful in assessing hemodynamic status, systolic and diastolic function. [2]
References
  1. WEXLER RK, ELTON T, PLEISTER A, FELDMAN D. Cardiomyopathy: an overview. Am Fam Physician [online] 2009 May 1, 79(9):778-84 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20141097
  2. MASSIN EK. Current Treatment of Dilated Cardiomyopathy Tex Heart Inst J [online] 1991, 18(1):41-49 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC324959

Investigations - Fitness for Management

Fact Explanation
Liver function test Hepatic transaminases, coagulation profile and serum bilirubin levels should be assessed as chronic alcoholism may have lead to cirrhosis. [1,2]
Renal function test Serum electrolytes and serum creatinine assess the basic renal function as hepatorenal syndrome is one of the complications of cirrhosis. [3]
References
  1. BLAKE JC, SPRENGERS D, GRECH P, MCCORMICK PA, MCINTYRE N, BURROUGHS AK. Bleeding time in patients with hepatic cirrhosis. BMJ [online] 1990 Jul 7, 301(6742):12-15 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1663385
  2. RUNYON BRUCE ALLEN. A Primer on Detecting Cirrhosis and Caring for These Patients without Causing Harm. International Journal of Hepatology [online] 2011 December, 2011:1-8 [viewed 26 June 2014] Available from: doi:10.4061/2011/801983
  3. Practice advisory for preanesthesia evaluation. An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. [viewed 26 June 2014] Available from: http://www.guideline.gov/content.aspx?id=36197

Management - General Measures

Fact Explanation
Patient education Patients should be advised to quit the consumption of alcohol. At least alcohol consumption should be cut down to safe levels (one or two drinks per day). Alcoholic cardiomyopathy is potentially reversible if the patient maintain abstinence. [1,2,3]
Dietary modifications A low salt diet and fluid restriction will minimize the risk of fluid overload. [1]
References
  1. WEXLER RK, ELTON T, PLEISTER A, FELDMAN D. Cardiomyopathy: an overview. Am Fam Physician [online] 2009 May 1, 79(9):778-84 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20141097
  2. PEARSON T. A.. Alcohol and Heart Disease. Circulation [online] 1996 December, 94(11):3023-3025 [viewed 25 June 2014] Available from: doi:10.1161/​01.CIR.94.11.3023
  3. COSTANZO S., DI CASTELNUOVO A., DONATI M. B., IACOVIELLO L., DE GAETANO G.. Cardiovascular and Overall Mortality Risk in Relation to Alcohol Consumption in Patients With Cardiovascular Disease. Circulation [online] December, 121(17):1951-1959 [viewed 26 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.109.865840

Management - Specific Treatments

Fact Explanation
Management of heart failure Drugs which are used in the management of heart failure are angiotensin converting enzyme inhibitors, diuretics and digoxin. These are considered the first line treatment options. In addition beta blockers and inotrophs can also be used. [2]
Antiarrhythmic drugs Arrhythmia is a preventable complication of cardiomyopathy. Antiarrhythmic drugs are indicated for treatment of arrhythmia. [2]
Thrombo-prophylaxis Patients with dilated cardiomyopathies are at risk of formation of thrombi and pulmonary or systemic embolization. [2] Heparin or warfarin is used for the purpose of anticoagulation.
Cardiac resynchronization therapy Patients who are symptomatic (NYHA class III or IV heart failure) even with adequate medical management and who are having cardiac dyssynchrony are eligible for cardiac resynchronization therapy. [1]
Implantable cardioverter-defibrillator This is indicated in patients with high risk of sudden cardiac death. [1,2]
Heart transplantation This is the last option of treatment. [1,2]
Left ventricular assist device Patients who are not fit enough for heart transplantation left ventricular assist device will improve the quality of life. [1]
References
  1. WEXLER RK, ELTON T, PLEISTER A, FELDMAN D. Cardiomyopathy: an overview. Am Fam Physician [online] 2009 May 1, 79(9):778-84 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20141097
  2. MASSIN EK. Current Treatment of Dilated Cardiomyopathy Tex Heart Inst J [online] 1991, 18(1):41-49 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC324959