Alcoholic cardiomyopathy: Difference between revisions
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===Physical Examination=== | ===Physical Examination=== | ||
====Appearance of the Patient==== | |||
* | The patient may have altered mental status due to chronic alcoholism. | ||
====Neck==== | |||
* [[Jugular venous distension]] may be seen in the presence of [[right heart failure]] | |||
====Extremities==== | |||
* Pedal edema | |||
* Cold extremities with decreased pulse | |||
====Lungs==== | |||
* [[Rales]] may be heard on lung exam due to pulmonary congestion. | * [[Rales]] may be heard on lung exam due to pulmonary congestion. | ||
*[[ | |||
* | ====Heart==== | ||
* Other sequelae of [[alcoholic liver disease]] may also be noted on physical examination. | =====Palpitation===== | ||
* Enlargment of the [[heart]] with a laterally displaced and diffused point of maximal impulse. | |||
=====Auscultation===== | |||
* Abnormal [[heart sound]]s, namely third [[S3]] and fourth [[S4]] sounds may be heard. | |||
* Apical [[murmur]] of [[mitral regurgitation]] and the lower parasternal murmur of [[tricuspid regurgitation]] may be present secondary to papillary muscle displacement and dysfunction. | |||
====Abdomen==== | |||
* [[Hepatomegaly]] | |||
* [[Ascites]] | |||
Other sequelae of [[alcoholic liver disease]] may also be noted on physical examination. | |||
* [[Telangiectasia]] | |||
* [[Spider angiomata]] | |||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
Revision as of 18:35, 20 June 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hardik Patel, M.D.
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Overview
Alcoholic cardiomyopathy is a disease in which the excessive use of alcohol use damages the heart muscle causing heart failure. It is characterized by constellation of findings which includes a history of excessive alcohol intake, physical signs of alcohol abuse, heart failure, and supportive findings consistent with dilated cardiomyopathy.
Pathophysiology
Alcoholic cardiomyopathy is a type of dilated cardiomyopathy. Both acute and chronic alcohol consumption, in excessive amounts, has been associated with adverse effects on the myocardium leading to nonischemic dilated cardiomyopathy. The maximum recommended dose of alcohol consumption in US men and women is 14 drinks and 7 drinks respectively. Consumption above these levels has been shown to be associated with the increased risk of alcoholic cardiomyopathy. [1]
Excessive use of alcohol has a direct toxic effect on the heart muscle cells. The heart muscle becomes weakened, subsequently dilates, and cannot pump blood efficiently. The lack of blood flow affects all parts of the body, resulting in damage to multiple tissues and organ systems. Alcohol may also simultaneously be causing direct damage to the liver.[2].
Proposed mechanisms of myocardial injury in alcoholic cardiomyopathy include:
- Ethanol induced apoptosis
- Impaired contraction of myocardium due to direct toxicity
- Inhibition of protein synthesis
- Activation of renin-angiotensin system (RAS)
- Inhibition of oxidative phosphorylation
- Fatty acid ester accumulation
- Nutritional deficiency of thiamine
- Free radical damage
Epidemiology and Demographics
Alcoholic cardiomyopathy is more prevalent in middle aged males between the ages of 35-50. However, females may be more sensitive to cardiotoxic effects of alcohol, and may develop alcoholic cardiomyopathy with lesser amounts of alcohol use, than males.
Diagnosis
History and Symptoms
The alcohol history, with attention to daily, maximal, and lifetime intake and the duration of alcohol consumption as well as the nutritional status of the patient should be inquired about.
Symptoms presented by the occurrence of alcoholic cardiomyopathy are the result of the heart failure and usually occur after the disease has progressed to an advanced stage. Therefore the symptoms have a lot in common with other forms of cardiomyopathy. Symptoms may develop acutely or insidiously.
- Anasarca or overall swelling
- Anorexia
- Arrhythmias
- Cachexia
- Cough containing mucus, or pink frothy material
- Decreased alertness or decreased concentration
- Dyspnea or shortness of breath with activity
- Fatigue
- Nocturia or a need to urinate at night
- Oliguria or decreased urine output
- Orthopnea or breathing difficulty while lying down
- Paroxysmal nocturnal dyspnea
- Palpitations
- Pedal edema
- Syncope
- Weakness
Physical Examination
Appearance of the Patient
The patient may have altered mental status due to chronic alcoholism.
Neck
- Jugular venous distension may be seen in the presence of right heart failure
Extremities
- Pedal edema
- Cold extremities with decreased pulse
Lungs
- Rales may be heard on lung exam due to pulmonary congestion.
Heart
Palpitation
- Enlargment of the heart with a laterally displaced and diffused point of maximal impulse.
Auscultation
- Abnormal heart sounds, namely third S3 and fourth S4 sounds may be heard.
- Apical murmur of mitral regurgitation and the lower parasternal murmur of tricuspid regurgitation may be present secondary to papillary muscle displacement and dysfunction.
Abdomen
Other sequelae of alcoholic liver disease may also be noted on physical examination.
Electrocardiogram
- Reduced QRS voltage may be present.
- T wave alternans may be present.
Chest X Ray
- Chest x rays usually show evidence of cardiomegaly or an enlarged heart, pulmonary congestion, and pleural effusions.
Echocardiography
- Echocardiography is the most useful initial diagnostic test in the evaluation of patients with heart failure. Because of its noninvasive nature and the ease of the test, it is the test of choice in the initial and follow-up evaluation of most forms of cardiomyopathy. It provides information not only on overall heart size and function, but also on valvular structure and function, wall motion and thickness, and pericardial disease.
Other Diagnostic Studies
- Cardiac catheterization or angiogram to rule out coronary artery blockages.
Treatment
Treatment for alcoholic cardiomyopathy involves lifestyle changes, including complete abstinence from alcohol use, a low sodium diet, and fluid restriction, as well as medications. If the heart failure is severe, the effectiveness of treatment will be limited.
Medications may include, ACE inhibitors and beta blockers which are commonly used for other forms of cardiomyopathy to reduce the strain on the heart. Diuretics can also be used to help remove the excess fluid from the body. Persons with congestive heart failure may be considered for surgical insertion of an ICD or a pacemaker which can improve the heart function. In cases where the heart failure is irreversible and worsening, a heart transplant may be considered.
Treatment will possibly prevent the heart from further deterioration, and the cardiomyopathy is largely reversible if complete abstinence from alcohol is maintained.
References
- ↑ Thun MJ, Peto R, Lopez AD; et al. (1997). "Alcohol consumption and mortality among middle-aged and elderly U.S. adults". The New England Journal of Medicine. 337 (24): 1705–14. doi:10.1056/NEJM199712113372401. PMID 9392695. Unknown parameter
|month=ignored (help) - ↑ Piano MR (2002). "Alcoholic cardiomyopathy: incidence, clinical characteristics, and pathophysiology". Chest. 121 (5): 1638–50. PMID 12006456. Unknown parameter
|month=ignored (help)