Download Rajiv Gandhi University Of Health Sciences, Karnataka Bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE.
ANNEXURE- II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.
NAME OF THE
CANDIDATE AND
ADDRESS
(IN BLOCK LETTERS)
DR.KAGGALAGOUDAR.S.M
PG STUDENT IN GENERAL MEDICINE,
KARNATAKA INSTITUTE OF
MEDICAL SCIENCES,
HUBLI-580022.
2.
NAME OF THE
INSTITUTION
KARNATAKA INSTITUTE OF
MEDICAL SCIENCES, HUBLI-22.
3.
COURSE OF STUDY AND
SUBJECT
M.D. IN GENERAL MEDICINE.
4.
DATE OF ADMISSION TO
COURSE
5.
TITLE OF THE TOPIC
6.
BRIEF RESUME OF THE INTENDED WORK:
26-09-2011
“A STUDY OF CLINICAL PROFILE OF DILATED
CARDIOMYOPATHY IN CORRELATION WITH ECG
AND ECHOCARDIOGRAPHY.”
6.1 NEED FOR STUDY:
Cardiomyopathy is a primary disorder of the heart muscle that causes abnormal
myocardial performance and is not the result of disease or dysfunction of other cardiac
structures. The dominant feature is a direct involvement of the heart muscle itself. They are
distinctive because they are not the result of pericardial, valvular or congenital diseases. The
prevalence of heart failure is about 1 to 1.5% of the adult population. The mortality and
morbidity remain high (median survival of 1.7 years for men and 3.2 years for women).
Dilated cardiomyopathy is an important cause of heart failure and accounts for up to 25% of
all cases of CHF. Whether the result of improved recognition or of other factor, the incidence
and prevalence of heart failure due to cardiomyopathy appears to be increasing. The
incidence of DCM is reported to be 5 to 8 cases per 1,00,000 population per year. It occurs 3
times more frequently in males as compared to females. It is also more common in blacks.
The most widely used functional classification of cardiomyopathy recognizes
disturbances of function- dilatation, hypertrophy and restriction. Dilated cardiomyopathy is
the most common variety of cardiomyopathy.
The earlier definition of cardiomyopathy was one of a primary heart muscle disorder
of “unknown cause”. It was considered a diagnosis of exclusion. The 1980 WHO committee
reserved
the
term
cardiomyopathy
for
myocardial
diseases
of
unknown
cause.Cardiomyopathies are a heterogeneous group of diseases, but they are now classified
under a new WHO/ISFC classification system. Current diagnosis and treatment of dilated
cardiomypathies varies some what among the various types, but the cornerstone of medical
management are similar in most cases. Dilated cardiomyopathy is the most common form of
cardiomyopathy comprising over 90% of the cases. The most common dilated
cardiomyopathy is the ischemic dilated cardiomyopathy followed by idiopathic / familial,
diabetic and alcohol cardiomyopathy.
Dilated cardiomyopathy represents the final common pathway produced by a variety
of ischemic, toxic, metabolic and immunological mechanisms damaging the heart muscle.
Though the initial insult to the myocardium may vary, pathophysiology and clinical
presentation are similar in all the varieties. The most common clinical presentation is
congestive heart failure, usually left ventricular failure. The patient can also present with
symptoms secondary to arrhythmias, stroke (embolic infarction) or sudden death.
The natural history of DCM is not well established. Many patient have minimal or no
symptoms and the progression of the disease is unpredictable. The long term prognosis is not
good. Nevertheless, in symptomatic patients the course is usually one of progressive
deterioration with up to 50% of patients with heart failure succumbing within a year. The
annual mortality rate for a typical patient of DCM with heart failure is about 11 to 13
percent.1 Exact epidemiological data on dilated cardiomyopathy in India are lacking. Given
the high prevalence of chronic heart failure in the country and the increasing use of
echocardiography, the incidence of dilated cardiomyopathy is increasing. With the rapid
advancement in molecular genetics and uncovering of underlying advancement in molecular
genetics and uncovering of underlying etiologies, DCM is being recognized as a specific
diagnosis and not one of exclusion. In the US, the vast majority of the cases of HF are caused
by cardiomyopathy. Dilated cardiomyopathy is the most common indication for cardiac
transplantation in the west. In view of the high prevalence of chronic heart failure and
underlying dilated cardiomyopathy and the lack of data on DCM, this study was undertaken.
The electrocardiographic and echocardiographic profiles were also evaluated in the current
study.
6.2 REVIEW OF THE LITERATURE:
1. Sajal K. Banerjee1, Fazlur Rahman1, Mohammad Salman2, Md. Abu Siddique1, SM Mustafa
Zaman1, Khairul. Anam1, Mukhlesur Rahman1, Md. Khurshed Ahmed1, MA Rasheed3,
Nargis Akhter4, M. Faruque5, Mir Jamiluddin5, ME Hoque6, KMHS Sirajul Haque1, Md.
Harisul Hoque1 et al concluded in their study. The aim of this study was to examine clinical
profile of patients with idiopathic dilated cardiomyopathy. The age range was 18 to 65years
and 70% subjects were male. Most common symptom was dyspnea (86%) and cough (75%).
75% subjects had sinus tachycardia, 42% had ventricular ectopics and 40% had left bundle
branch block. Mean diastolic dimension was 60±9 mm, ejection fraction was 28±8%, left atrial
dimension was 40±6 mm and 36% were having mitral regurgitation. Left ventricular failure
(75%) and various type of arrhythmias (62%) were the main complications. 8% subjects were
died during hospital stay. Hence the clinical presentation of idiopathic dilated cardiomyopathy
varies from patient to patient, but most patients present later, i.e. at some point in the spectrum
of heart failure.
2. Taliercio CP, Seward JB, Driscoll DJ, Fisher LD, Gersh BJ, Tajik AJ. et al concluded in their
study Twenty-four patients (median age 2 years, range less than 1 month to 18 years) with
idiopathic dilated cardiomyopathy were identified from Mayo Clinic records from 1973 to
1982. The most common presentation was congestive heart failure (92% of patients).
Echocardiography (22 patients) generally revealed a dilated left ventricle with reduced
fractional shortening (mean 14%) and ejection fraction (mean 26%). Two-dimensional
echocardiographic evidence of left ventricular thrombus was present in 3 (23%) of 13 patients.
Median cardiac index and left ventricular end-diastolic pressure (19 patients) were 2.5
liters/min per m2 and 22 mm Hg, respectively. Myocardial biopsy in eight patients showed
nonspecific findings without active inflammation or evidence of endocardial fibroelastosis.
3. John B. O’Connell MD, FACC , Maria Rosa Costanzo-Nordin MD, Ramiah Subramanian
MB, MRC path, John A. Robinson MD, Diane E. Wallis MD, Patrick J. Scanlon MD, FACC,
Rolf M. Gunnar MD, FACC. Peripartum cardiomyopathy is defined as left ventricular dilation
and failure, first developing during the third trimester of pregnancy or in the first 6 months
postpartum. In an effort to characterize this syndrome in a middle class population, 14
consecutive patients with peripartum cardiomyopathy underwent a detailed history and
physical
examination,
right
heart
catheterization,
M-mode
and
two-dimensional
echocardiography, radionuclide ventriculography and right ventricular endomyocardial biopsy.
These patients were then observed with sequential noninvasive studies to determine prognostic
indicators. Eight (57%) of these 14 patients were primiparous and an equal number first
presented with heart failure concomitant with or immediately before the onset of labor. When
these women were compared with 55 patients with idiopathic dilated cardiomyopathy, only
mean age at onset of symptoms (28.7 ± 5.7 versus 48.2 ± 13.6 years, p < 0.001) and symptom
duration (4.1 ± 7.7 versus 19.0 ± 18.4 months, p < 0.001) differed between the groups. There
was no difference in ventricular arrhythmia, left ventricular chamber size, ejection fraction or
hemodynamic. Myocyte histologic findings were similar; however, myocarditis was identified
in 29% of patients with peripartum cardiomyopathy and in only 9% of those with idiopathic
dilated cardiomyopathy. In all patients with peripartum cardiomyopathy and myocarditis, the
myocardial biopsy was performed within 1 week of onset of symptoms. Seven (50%) of the
patients with peripartum cardiomyopathy had dramatic improvement within 6 weeks of
follow-up, and 6 (43%) died. Survivors had a higher ejection fraction (22.8 ± 11.7 versus 10.6
± 1.5%, p < 0.05) and smaller left ventricular cavity size (5.8 ± 1.2 versus 6.9 ± 0.7 cm, p <
0.05). Peripartum cardiomyopathy in a middle class population is hemody-namically
indistinguishable from idiopathic dilated cardiomyopathy but is characterized by a high
incidence of histologic myocarditis resulting in rapid, spontaneous improvement of congestive
heart failure or progressive deterioration resulting in early death.
4. PK Padhi, DK Patel, PK Mohanty, SC Sahoo, S Khan Charles P. Taliercio MD, James
B. Seward MD, FACC , David J. Driscoll MD, FACC, Lloyd D. Fisher PhD, FACC, Bernard
J. Gersh MBChB, DPhil, FACC, Abdul J. Tajik MD, FACC et al concluded in their study. The
clinical profile and course of documented cases of idiopathic dilated cardiomyopathy in
children have been poorly characterized. Twenty-four patients (median age 2 years, range < 1
month to 18 years) with idiopathic dilated cardiomyopathy were identified from Mayo Clinic
records from 1973 to 1982. The most common presentation was congestive heart failure (92%
of patients). Echocardiography (22 patients) generally revealed a dilated left ventricle with
reduced fractional shortening (mean 14%) and ejection fraction (mean 26%): Twodimensional echocardiographic evidence of left ventricular thrombus was present in 3 (23%)
of 13 patients. Median cardiac index and left ventricular end-diastolic pressure (19 patients)
were 2.5 liters/min per m2 and 22 mm Hg, respectively. Myocardial biopsy in eight patients
showed nonspecific findings without active inflammation or evidence of endocardial
fibroelastosis.
6.3 AIMS AND OBJECTIVES OF THE STUDY :
1. To study the clinical profile of patients with dilated cardiomyopathy
2. To study the electrocardiographic and echocardiographic profile of these patients
7.
MATERIALS AND METHODS: Subjects admitted with symptoms and signs of heart failure
(Clinically suspected and echo-cardiography proven) in KIMS Hospital Hubli, over a period of
one year.
7.1 SOURCE OF DATA:
A total No, of patients admitted in , Department of Medicine ,Karnataka Institute of Medical
Sciences ,Hubli , during the period of December 1st 2011 to November 30th 2012 will be
taken for study considering the inclusion and exclusion criteria.
1.2 METHODS OF COLLECTION OF DATA:
 Information will be collected through a pre tested and structured Performa for each
patient.
 The study will be carried out on patients presenting with clinical features and ECG & 2D
Echocardiographic findings of Dilated cardiomyopathy.
 In all the selected patients detailed history and physical examination will be noted. Every
patient will be subjected to 12 lead ECG & Echocardiography.
SAMPLE SIZE:
A total No. of patients admitted in the Department of Medicine of Karnataka Institute of
Medical Sciences Hubli , during one year period of time that is from
December 1st 2011
to November 30th 2012 will be taken for study with considering the inclusion and exclusion
criteria.
TYPE OF STUDY: Cross sectional hospital based time bound study.
SAMPLING:
As per hospital statistics 150 patients diagnosed with Dilated cardiomyopathy were
admitted in Department of medicine, KIMS, Hubli in the year 2011. As it is a time bound
study I will be including all the patients admitted with Dilated cardiomyopathy between
December 1st 2011 to November 30th 2012
INCLUSION CRITERIA
Clinical criteria
Patients with symptoms and signs of heart failure
Echocardiography criteria
• Left ventricular ejection fraction < 45%
• Left ventricular end diastolic dimension > 3 cm / body surface area.
• Global hyokinesia.
• Dilatation of all the chambers of heart.
EXCLUSION CRITERIA
• Valvular heart disease
• Congenital heart disease
Parameters used: clinical profile, 12-lead ECG changes and 2D Echocardiography findings ,
Statistical Analysis: percentage, proportions, chi-square and correlation.
7.3
Does the study require any investigations or interventions to be conducted on patients
or
other humans or animals? (If so, please describe briefly)
Yes,
1) Routine blood investigations
2) 12 – lead ECG changes
3) 2D Echocardiography
7.4
HAS ETHICAL CLEARANCE BEEN OBTAINED FROM ETHICAL COMMITTEE
OF YOUR INSTITUTION IN CASE OF 7.3?
Yes,
Ethical clearance has been obtained from the ethical committee KIMS, Hubli.
8.
LIST OF REFERENCES:
1. Sajal k banerjee, fazlur rahman, mohammad salman, md.abu siddique et al idiopathic dilated
cardiomyopathy :clinical profile of 100 patients bangabandhu sheikh mujib medical university
,Dhaka from Jan 2004 to Dec 2009
2. Taliercio CP, Seward JB, Driscoll DJ, Fisher LD, Gersh BJ, Tajik AJ. et al , Idiopathic dilated
cardiomyopathy in the young : clinical profile and natural history ,mayo graduate school of
Medicine, Division of cardiovascular Diseases, Mayo clinic
3. Zipes D, Libby P, Bonow R, Braunwald E. A Braunwald’s heart disease - Textbook of
Cardiovascular Medicine: The cardiomyopathies. 7th Ed. Philadelphia: Elsevier Saunders; 2005.
4. Anderson KM, Kannel WB. Prevalence of congestive heart failure in Framingham Heart study
subjects. Circulation 1994; 13: S107-S112.
5. Richerdson. WHO Report on classification of cardiomyopathy.Br? Heart J. 1980 ; 44: 680-682.
6. Vijayraghavan G. API Text book of medicine. Disorders of myocardium. 7th ed Chap X.25:
490-491.
7. Singh G, Nayyar BS, Bal BS, Arora JS. Clinical profile of dilated cardiomyopathy: Indian Heart
Journal 2001; 53: 560-659.
8. Kothari S, Aajesh A, Saxena A, Juneja R. Dilated cardiomyopathy in India. Children. Indian
Heart J 2003; 55 : 147. WHO / ISFC. Task force on cardiomyopathies. Report of the WHO /
ISFC. Task force on the definition and classification of cardiomyopathies. Br. Heart journal.
9.
Signature of the candidate
10.
Remarks of the guide
RECOMMENDED
11.
Name and Designation
11.1 Guide
DR. ANAND KOPPAD
ASSOCIATE PROFESSOR,
DEPARTMENT OF MEDICINE
KIMS, HUBLI.
11.2 Signature
11.3 Co-Guide
11.4 Signature
11.5 Head of the Department
11.6 Signature
12.
12.1 Remarks of the Principal
and Chairman
12.2 Signature
DR. H. MALLIKARJUN SWAMY.
PROFESSOR AND HEAD,
DEPARTMENT OF MEDICINE
KIMS, HUBLI.