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Original Article JCDR Clinical and echocardiogram profile of Cardiomyopathy at tertiary care centre Virendra C. Patil1, Neeraj Desai2 and Chetan Galande2 Associate professor Department of medicine; Krishna Institute of Medical, Sciences University (KIMSU) Resident Department of medicine; Krishna Institute of Medical, Sciences University (KIMSU) 1 2 ABSTRACT Background: Cardiomyopathies represent a heterogeneous group of diseases that often lead to progressive heart failure with significant morbidity and mortality. The improved recognition or of other factor, the incidence and prevalence of heart failure due to cardiomyopathy appears to be increasing. Aims & Objectives: To study the prevalence, clinical profile and outcome of patients with cardiomyopathies and to study the echocardiographic profile. Material & methods: It is retrospective observational study of 65 patients, with age >15 years and admitted in medical ICU and ward of KIMSU, karad. This study was conducted over period of one year. All eligible subjects underwent relevant investigations including echocardiogram, Doppler study, electrocardiogram, chest radiogram and coronary angiogram. Proforma included age gender presenting complaints, past history, history of medications, clinical examination and laboratory investigations. Trans-thoracic 2-dimensional echocardiogram and Doppler study was done according to the standard protocol. Statistical analysis: Results were given as mean ± SD. Means are compared by unpaired Students t-test. Chi-square was used as appropriate. The observations and data were analyzed in the statistical package social sciences (SPSS) trial version 11. The level of significance was set at P<0.05. Results: A total of 65 patients were admitted from Jan 2010 to Dec 2012 who were diagnosed with cardiomyopathy with mean age of 58.76 years (SD±15.98). Out of the total 65 cardiomyopathy patients admitted 27 (41.53%) had Dilated cardiomyopathy (idiopathic), 15 (23.07%) patients were diagnosed with Ischemic cardiomyopathy. Total 42 (64.61%) patients had Dilated cardiomyopathy (i.e. idiopathic and ischemic dilated cardiomyopathy). A total 11 (16.92%) had Hypertrophic cardiomyopathy (HCM), 2 (3.07%) patients had Hypertrophic obstructive cardiomyopathy (HOCM) with LVOT significant gradient, 5 (7.69%) patients had Restrictive cardiomyopathy (RCMP), 4 (6.15%) had Peripartum cardiomyopathy (PPCM) and 1 (1.53%) patient had miscellaneous (alcohol induced) Cardiomyopathy. Out of 27 patients diagnosed with Dilated Cardiomyopathy (DCM), 15 (55.55%) were male patients and 12 (44.45%) were females. Out of 15 patients diagnosed with Ischemic cardiomyopathy, 7(46.66%) were males and 8(53.33%) were females. Out of 11 patients diagnosed with HCM, 9(81.81%) were males and 2(18.18%) were females. Out of 2 patients diagnosed with HOCM 1(50%) was a male patient and 1(50%) was a female patient. There were 4 female patients who were diagnosed with PPCM. A total of 5 patients were diagnosed with RCMP, out of which 1(20%) was a male patient 4(80%) patients were females. There was 1 male patient diagnosed with cardiomyopathy secondary to chronic alcohol consumption. In present study breathlessness 89.23% was most common presenting symptom and palpitations (81.53%) and cough (58.46%) were next to it with ‘p’ <0.001. Overall VPC’s (36%) were the most common ECG abnormality in patients with cardiomyopathy in present study with ‘p’ value <0.01. The LBBB (35.71%) was more frequently seen in patients with dilated cardiomyopathy with ‘p’ <0.02. The atrial flutter/ fibrillation found more commonly in patients with restrictive cardiomyopathy (80%) with ‘p’ value < 0.02. Total 74.07% of DCM, 86.67% of ischemic cardiomyopathy, 50% of PPCM, 81.82% of HCM, 100% of HOCM, RCMP and alcoholic cardiomyopathy patients had diastolic dysfunction. Idiopathic Dilated cardiomyopathy had 22% (±7.7) of lowest left ventricular ejection fraction (LVEF). Out of total 65 patients two patients with dilated cardiomyopathy succumbed with overall mortality 3.08% and case fatality rate for DCM was 4.76%. Total 96.92% patient were discharged after treatment from the hospital. Conclusion: Present study highlights significant burden of Idiopathic dilated cardiomyopathy and next to it was ischemic cardiomyopathy. A total 6 (9.23%) patients had potentially reversible cardiomyopathy like peripartum, alcoholic and myocarditis. The cardiomyopathy is asymptomatic in the early stages hence early diagnosis and management is of vital importance in the form of judicious use of anticoagulant, digoxin, diuretics, ACE inhibitors and betablocker is mandatory to reduce complications, morbidity and mortality associated cardiomyopathies. Trans-thoracic echocardiogram is an important, simple and noninvasive modality of investigation which can be reproducible for the diagnosis and fallow up of most of the cardiomyopathies. Keywords: Echocardiogram, Dilated cardiomyopathy, Hypertrophic obstructive cardiomyopathy, Peripartum cardiomyopathy, Restrictive cardiomypathy Clinical and Echocardiogram Profile of Cardiomyopathy INTRODUCTION Cardiomyopathies represent a heterogeneous group of diseases that often lead to progressive heart failure with significant morbidity and mortality. The cardiomyopathies are an important and complex group of heart muscle diseases with multiple etiologies and heterogeneous phenotypic expression. Cardiomyopathy is disease of the heart muscle. It is estimated that cardiomyopathy accounts for 5–10% of the 5–6 million patients already diagnosed with heart failure in the United States. This term is intended to exclude cardiac dysfunction that results from other structural heart disease, such as coronary artery disease, primary valve disease, or severe hypertension; however, in general usage the phrase ischemic cardiomyopathy is sometimes applied to describe diffuse dysfunction occurring in the presence of multivessel coronary artery disease, and nonischemic cardiomyopathy to describe cardiomyopathy from other causes. As of 2006, cardiomyopathies are defined as “a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic.” Major types include dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. Although cardiomyopathy is asymptomatic in the early stages, symptoms are the same as those characteristically seen in any type of heart failure and may include shortness of breath, fatigue, cough, orthopnea, paroxysmal nocturnal dyspnea, and edema1–3. There is very little literature regarding cardiomyopathies from Asian countries including India. Materials & Methods It is retrospective observational study of 65 patients, with age >15 years and admitted in medical ICU and ward of KIMS, karad. This study was conducted over period of three year (Jan 2010 to Dec 2012). All eligible subjects underwent relevant investigations including echocardiogram, Doppler study, electrocardiogram, chest radiogram and coronary angiogram whenever indicated and possible. Proforma included age gender presenting complaints, past history, history of medications, clinical examination, and laboratory investigations. Transthoracic 2-dimensional echocardiogram and Doppler study was done according to the standard protocol. Aims & Objectives To study the prevalence, clinical profile and outcome of patients with cardiomyopathies and to study the echocardiographic profile. Echocardiography The echocardiographic examinations were performed in all patients according to standard techniques while the patients were lying flat or in the left lateral position by Siemens Accuson 300- X Colour Doppler ultrasound machine. The primary imaging modality used for diagnosis in all patients is transthoracic 2-dimensional and Doppler echocardiography performed by a three operators. Ejection fraction (EF) was calculated by the formula LVEF % = (LVID)2 - (LVIDS)2 . Systolic dysfunction was characterized by reduced EF <55%. Diastolic dysfunction was calculated by measuring E and A velocity across transmitral inflow velocity and tissue Doppler imaging. Diastolic dysfunction was defined as preserved left ventricle EF with (a) reduced early diastolic filling, (b) prolongation of isovolumetric relaxation, (c) increased atrial filling, the presence of which confirms diastolic dysfunction, (d) increased pre-ejection period (PEP) and shorter left ventricular ejection time (LVET) resulting in increases PEP/LVET ratio—an evidence of reduced left ventricular distensibility. Left ventricular hypertrophy (LVH) on echocardiogram defined by LVPW >12 mm and IVS >12 mm by M-mode with an LV mass ≥125 g/m2 for men and ≥110 g/m2 for women4. Echocadiographic diagnostic criteria for cardiomyopathy Dilated Cardiomyopathy labeled if enlarged left ventricle with decreased systolic function as measured by left ventricular ejection fraction characterizes dilated cardiomyopathy. Systolic failure is more marked than the frequently accompanying diastolic dysfunction, (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 in absence of valvular heart disease and congenital heart disease.) Hypertrophic cardiomyopathy was labeled by features of marked left ventricular hypertrophy in the absence of other causes, such as hypertension or valve disease without LVOT obstructive gradient. Hypertrophic obstructive cardiomyopathy was labeled by features of marked left ventricular hypertrophy in the absence of other causes, such as hypertension or valve disease with LVOT obstructive gradient. Restrictive Cardiomyopathy was labeled if abnormal diastolic function, with mildly decreased contractility and ejection fraction (usually >30–50%). Both atria are enlarged, sometimes massively. Peripartum cardiomyopathy was labeled if features of dilated cardiomyopathy with onset in the third tri- Corresponding address: Dr. Virendra. C. Patil MD. Medicine (Associate Professor), Department of medicine, KIMSU, Karad E-mail: [email protected] DOI: 10.5530/jcdr.2014.1.6 Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 mester of pregnancy or in the first five months postpartum. Alcohol associated cardiomyopathy was labeled if features of dilated cardiomyopathy in patient with chronic alcoholic with potentially reversible with abstinence from alcohol use. All above criteria excluded the valvular, congenital and hepertensive heart disease1–4. 35 Clinical and Echocardiogram Profile of Cardiomyopathy Statistical analysis All patients presented with features suggestive of cardiomyopathy were treated according to the standard protocol. All patients were Results were given as mean ± SD. Means are compared by unpaired Students t-test. Chi-square was used as appropriate. The observations and data were analyzed in the statistical package social sciences (SPSS) trial version 11. The level of significance was set at P<0.05. clinically assessed regularly and monitored. In pharmacotherapy anticoagulant, digoxin, diuretics, ACE inhibitors, inotopic agents, antiarrhythmic agents and betablockers were used judiciously to reduce complications, morbidity and mortality associated cardiomyopathies. The regular monitoring of vital organ dysfunction, Results drug side effects and electrolyte imbalance was done. In patient with Complete 3rd degree AV block temporary pacemaking was A total of 65 patients were admitted from Jan 2010 to Dec 2012 with diagnosis of cardiomyopathy with mean age of 58.76 years (SD±15.98). Out of 65 patients 34(52.30%) were males with mean age of 62.41 years (SD±12.76) and 31(47.70%) were females with mean age of 54.77 years (SD±18.28). There was no significant statistical difference amongst gender. The total average duration of stay was 6.98 days (SD±3.962) with average hospital stay among males were 7.02 days (SD±4.427) and of females were 6.93 days (SD±3.453). (Table 1) done. Treatment is targeted at relieving the symptoms of heart failure and reducing rates of heart failure. Whenever it was indicated the implantable cardioverter-defibrillators, cardiac resynchronization therapy, and heart transplantation was advised to get it done at higher centre. Recommended lifestyle changes include restricting alcohol consumption, losing weight, exercising, quitting smoking, and eating a low-sodium diet2,3. Table 1 Gender distribution in cardiomyopathy patients Variables Mean age (n=65) SD Mean duration of stay (days) SD Male (n=34) 62.41 ±12.76 7.03 ±4.427 Females (n=31) 54.77 ±18.28 6.93 ±3.453 Total 58.76 ±15.98 6.98 ±3.962 Prevalence of patient with cardiomyopathy: Out of the total 65 cardiomyopathy patients admitted 27 (41.53%) had Dilated cardiomyopathy (idiopathic) of which one patient had myocarditis probably viral with complete heart block (CHB) which was reversible over period of six weeks (figure 1 and 2). Total 15 (23.07%) patients were diagnosed with Ischemic Cardiomyopathy. Total 42 (64.61%) patients had Dilated cardiomyopathy (i.e. idiopathic and ischemic dilated cardiomyopathy (Figure 4). A total 11 (16.92%) had Hypertrophic cardiomyopathy (HCM), 2 (3.07%) patients had Hypertrophic Obstructive Cardiomyopathy (HOCM) (Figure 3). Total 5 (7.69%) patients had Restrictive cardiomyopathy (RCMP) of which one patient had thalasemia with history of recurrent blood transfusions who had multiform and multifocal VPC’s (Figure 3). Total 4 (6.15%) patients had peripartum cardiomyopathy (PPCM) and 1 (1.53%) patient had miscellaneous (alcohol induced) Cardiomyopathy. In present study Idiopathic dilated cardiomyopathy was the most common cardiomyopathy (‘p’ < 0.05). (Table 2) Mean and standard deviation of patient with cardiomyopathy: Out of 27 patients diagnosed with Dilated 36 Cardiomyopathy, 15 (55.55%) were male patients with mean age of 61.46 years (SD ±13.61) and 12 (44.45%) were females with mean age of 53.42 years (SD ±13.47). Out of 15 patients diagnosed with Ischemic Cardiomyopathy, 7(46.66%) were males with mean age of 70.28 years(SD ±12.89) and 8(53.33%) were females with mean age of 66.25 years(SD ±11.46). Out of 11 patients diagnosed with Hypertrophic cardiomyopathy (HCM), 9(81.81%) were males with mean age of 49.33 years (SD ±8.139) and 2(18.18%) were females with mean age of 60 years (SD ±7.071). Out of 2 patients diagnosed with Hypertrophic obstructive cardiomyopathy (HOCM)1(50%) was a male patient and 1(50%) was a female patient with mean age 35 years. There were 4 female patients who were diagnosed with PPCM with mean age of 27.5 years (SD ±6.24). A total of 5 patients were diagnosed with RCMP, out of which 1(20%) was a male patient who’s age was 60 years while 4(80%) patients were females with mean age of 59.25 years (SD ±30.192). There was 1 35 year old male patient diagnosed with cardiomyopathy secondary to chronic alcohol consumption. (Table 2) Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 Clinical and Echocardiogram Profile of Cardiomyopathy Table 2 Gender distribution, mean and standard deviation of patients with cardiomyopathy. Variables Total (n) Mean age SD Male 15 61.46 ±13.61 Female 12 53.42 ±13.47 Male 7 70.28 ±12.89 Female 8 66.25 ±11.46 Male 9 49.33 ±8.139 Female 2 60 ±7.071 Hypertrophic obstructive (HOCM) [M:1; F:1] 2 35 ± 6.5 4 27.5 ±6.244 Male 1 60 Female 4 59.25 ±30.192 1 50 Dilated Cardiomyopathy Ischemic Cardiomyopathy Hypertrophic cardiomyopathy Peripartum cardiomyopathy Female Restrictive cardiomyopathy Alcoholic cardiomyopathy Male Figure 1: Echocardiogram and Doppler study of Dilated cardiomyopathy & myocarditis with MR &TR Figure 2: Echocardiogram and Doppler study of Dilated cardiomyopathy, myocarditis and PPCM with MR & TR Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 Figure 3: Echocardiogram and Doppler study of HOCM with MR and SAM and LVOT gradient with restrictive cardiomyopathy with biatrial enlagement ad TR Figure 4: Echocardiogram and Doppler study of Isch- emic dilated cardiomyopathy showing MR & TR 37 Clinical and Echocardiogram Profile of Cardiomyopathy Clinical presentation of patients with cardiomyopathy: Total 40 (95.23%) patient with DCM, 6(54.54%) with HCM, 2 (100%), with HOCM, 5(100%) with restrictive cardiomyopathy, 4(100%) with peripartum cardiomyopathy and 1(100%) with alcoholic cardiomyopathy had breathlessness at the time of admission. A total 58(89.23%) of patients had breathlessness as a presenting complaint at the time of admission the hospital. Total 1 (2.38%) patient with DCM, 1(20%) with restrictive cardiomyopathy, 2(50%) with PPCM had hemoptysis at the time of admission. A total 4(6.15%) of patients had hemoptysis as a presenting complaint at the time of admission the hospital. Total 37 (88.09%) patient with DCM, 5(45.45%) with HCM, 2 (100%), with HOCM, 4(80%) with restrictive cardiomyopathy, 4(100%) with peripartum cardiomyopathy and 1(100%) with alcoholic cardiomyopathy had palpitations at the time of admission. A total 53(81.53%) of patients had palpitations as a presenting complaint at the time of admission the hospital. Total 29 (69.04%) patient with DCM, 2(18.18%) with HCM, 2(40%) with restrictive cardiomyopathy, 4(100%) with PPCM and 1(100%) with alcoholic cardiomyopathy had cough at the time of admission. A total 58(89.23%) of patients had cough as a presenting complaint at the time of admission the hospital. Total 21 (50%) patient with DCM, 1(9.09%) with HCM, 5(100%) with RCMP, 2(50%) with PPCM and 1(100%) with alcoholic cardiomyopathy had pedal edema at the time of admission. A total 30(46.15%) of patients had pedal edema as a presenting complaint at the time of admission the hospital. Total 15 (35.71%) patient with DCM, 1(9.09%) with HCM, 1 (50%) with HOCM and 1(20%) with restrictive cardiomyopathy, had chest pain at the time of admission. A total 18(27.69%) of patients had chest pain as a presenting complaint at the time of admission the hospital. Total 3 (7.14%) patient with DCM, 2(18.18%) with HCM, 1 (50%) with HOCM and 1(25%) with PPCM had syncope at the time of admission. A total 7(10.76%) of patients had chest pain as a presenting complaint at the time of admission the hospital. In present study breathlessness 89.23% was most common presenting symptom and palpitations (81.53%) and cough (58.46%) were next to it with ‘p’ <0.001. (Table 3) Table 3 Clinical presentation at the time of admission: Variable Total DCM HCM HOCM RCM PPCM ACM Total (n=42) % (n=11) % (n=2) % (n=5) % (n=4) % (n=1) % Breathlessness 40 95.23 6 54.54 2 100 5 100 4 100 1 100 58 89.23 Hemoptysis 1 2.38 0 0 0 0 1 20 2 50 0 0 4 6.15 Pedal edema 21 50 1 9.09 0 0 5 100 2 50 1 100 30 46.15 Palpitations 37 88.09 5 45.45 2 100 4 80 4 100 1 100 53 81.53 Syncope 3 7.14 2 18.18 1 50 0 0 1 25 0 0 7 10.76 Cough 29 69.04 2 18.18 0 0 2 40 4 100 1 100 38 58.46 Chest pain 15 35.71 1 9.09 1 50 1 20 0 0 0 0 18 27.69 Electrocardiogram findings in patients with cardiomyopathy: Overall VPC’s (36%) were the most common ECG abnormality in patients with cardiomyopathy in present study with ‘p’ value <0.01. The LBBB (35.71%) was more frequently seen in patients with dilated cardiomyopathy with ‘p’ <0.02. The ‘QS’ pattern in chest leads was more frequently seen in patients with 38 % Ischemic cardiomyopathy (73.33%) with ‘p’ value< 0.001. Low voltage and poor ‘r’ wave progression was found more frequently in PPCM (100%) with ‘p’ value < 0.001. The atrial flutter/ fibrillation found more commonly in patients with restrictive cardiomyopathy (80%) with ‘p’ value < 0.02. [Table 4] Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 Clinical and Echocardiogram Profile of Cardiomyopathy Table 4 Electrocardiogram findings in patients with cardiomyopathy DCM (n=42) HCM (n=11) HOCM (n=2) RCM (n=5) PPCM (n=4) ACM (n=1) Total % AVNRT 2 0 0 0 0 1 3 4.61 Atrial / flutter fibrillation 1 1 0 4 0 0 6 9.23 LBBB 15 1 0 0 0 0 16 24.61 RBBB 1 0 0 1 1 0 3 4.61 VPC’s 15 5 1 1 2 0 24 36.92 ST- depression 3 9 0 0 0 0 12 18.46 CHB 1 0 0 0 0 0 1 1.53 I deg. AV block 1 0 0 0 1 0 2 3.07 II deg AV block 1 0 0 0 0 0 1 1.53 LAHB 3 1 1 1 0 0 6 9.23 LPHB 1 1 0 0 0 0 2 3.076 Low voltage & poor ‘r’ wave progression 4 0 0 3 4 1 12 18.46 QS pattern 11 0 0 0 0 0 11 16.92 LVH with strain pattern 0 10 2 0 0 0 12 18.46 Total 59 28 4 10 8 2 111 ‘p’< 0.02 Variable Echocardiographic findings in patients with cardiomyopathy: Total 74.07% of DCM, 86.67% of ischemic cardiomyopathy, 50% of PPCM, 81.82% of HCM, 100% of HOCM, RCMP and alcoholic cardiomyopathy patients had diastolic dysfunction. Idiopathic Dilated cardiomyopathy had 22% (±7.7), Ischemic cardiomyopathy had 26% (±9.5), HCM had, 65% (±12.5), HOCM had 68 %( ±11.3), RCMP had 58% (±7.9), PPCM had 21 %( ±8.7) and alcoholic cardiomyopathy had 32% left ventricular ejection fraction (LVEF) (Figure 1). Total 19% patients with DCM and 13% with ischemic cardiomyopathy had clot in left ventricle. Total 37.03% with DCM, 40% with Ischemic cardiomyopathy, 9.09% with HCM, 40% with RCMP, 50% with PPCM had LV echo-contrast on echocardiogram. Total 74.07% with DCM, 73.33% with Ischemic cardiomyopathy, 27.27% with HCM and 100% with HOCM, RCM, PPCM and alcoholic cardiomyopathy had mitral incompetence/ regurgitation. Total 55.55% with DCM, 46.66% with Ischemic cardiomyopathy, 18.18% with HCM and 100% with RCM, PPCM and alcoholic cardiomyopathy and 50% with HOCM had tricuspid incompetence/ regurgitation. The mean of pulmonary artery pressure inpatient with DCM was 52(±7.8), 48(±5.7) with ischemic cardiomyopathy, 30(±5.8) with HCM, 19(±7.9) with HOCM, 38(±6.4) with RCM, 37(±3.8) with PPCM and 35 with alcoholic cardiomyopathy. The mean of PAP was significantly high in patient with DCM with ‘p’ < 0.001. (Table 5) (Figure 1–4) One patient had myocarditis causing LV systolic dysfunction (LVEF:28%) with moderate MR & TR probably viral with complete heart block (CHB) which was reversible over period of six weeks and was treated with temporary pacemaker and treatment of CCF. (Figure 5) Table 5 Echocardiographic findings in patients with cardiomyopathy Types of cardiomyopathy Total (n=65) % LVEF % DD % PAP Clot % Echocontrast % MR % TR % DCM 27 41.53 22 (±7.7) 20 74.07 52(±7.8) 5 19 10 37.03 20 74.07 15 55.55 IDCM 15 23.07 26(±9.5) 13 86.67 48(±5.7) 2 13 6 40 11 73.33 7 46.66 HCM 11 16.92 65(±12.5) 9 81.82 30(±5.8) 0 0 1 9.09 3 27.27 2 18.18 HOCM 2 3.07 68(±11.3) 2 100 19(±7.9) 0 0 0 0 2 100 1 50 RCMP 5 7.69 58(±7.9) 5 100 38(±6.4) 0 0 2 40 5 100 5 100 PPCM 4 6.15 21(±8.7) 2 50 37(±3.8) 0 0 2 50 4 100 4 100 ALCOHOLIC 1 1.53 32 1 100 35 0 0 0 0 1 100 1 100 Total 65 100 Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 39 Clinical and Echocardiogram Profile of Cardiomyopathy Discussion We compared our results with various other studies from India and abroad. The dilated cardiomyopathy in adults is most commonly caused by CAD (ischemic cardiomyopathy) and hypertension1. In our study patients 41.53% had DCM (idiopathic) and 15 (23.07%) patients had Ischemic cardiomyopathy. Total 64.61% patients had DCM (i.e. idiopathic and ischemic dilated cardiomyopathy. B. Ushasree, et al5 studied one hundred seven DCM patients and 105 healthy individuals, they reported that, epidemiological factors like gender, age at onset and vegetarian diet in conjunction with sarcomere gene mutations may play a role in the disease expression. Pacheco OE et al6 studied 91 new patients with the diagnosis of dilated cardiomyopathy. Ischemic cardiomyopathy was identified as the most common cause of dilated cardiomyopathy, representing 37% of the patient and an idiopathic etiology was found in 22% of the patients. Similarly in our study 23.07% patients had Ischemic cardiomyopathy. Non ischemic dilated cardiomyopathy (NIDCM) is a disorder of myocardium. It has varying etiologies. Albeit the varying etiologies of this heart muscle disorder, it presents with symptoms of heart failure, and rarely as sudden cardiac death (SCD). Manifestations of this disorder are in many ways similar to its counterpart, ischemic dilated cardiomyopathy (IDCM). A proportion of patients with NIDCM carries a grave prognosis and is prone to sudden cardiac death from sustained ventricular arrhythmias7. In present study the VPC’s (36%) were the most common ECG abnormality in patients with cardiomyopathy in present study with ‘p’ value <0.01. The LBBB (35.71%) was more frequently seen in patients with dilated cardiomyopathy with ‘p’ <0.02. The ‘QS’ pattern in chest leads was more frequently seen in patients with Ischemic cardiomyopathy (73.33%) with ‘p’ value< 0.001. Taliercio CP, et al8 concluded in their study 24 patients with idiopathic dilated cardiomyopathy 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. These finding are comparable with our study. M B Cod et al9 reported 45 new cases of idiopathic dilated cardiomyopathy (DCM) and 19 new cases of hypertrophic Figure 5: Chest radiogram (cardiomegaly and bilateral pleral effusion) before and after treatment in patient with myocarditis with electrocardiogram showing pacemaker rhythum with temporary pacemaker for III degree AV block (CHB). Outcome of patients with cardiomyopathy: Out of two patients who succumbed one was male and one was female. Out of total 65 patients two patients with dilated cardiomyopathy succumbed with overall mortality 3.08% and case fatality rate for DCM was 4.76%. Total 96.92% patient were discharged after treatment from the hospital. (Table 6) Table 6 Outcome in cardiomyopathy patients Variables Total (n=65) % Discharged 63 96.92 Death 2 3.08 2 (n=42) 4.76%(case fatality rate) Death due to DCM 40 Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 Clinical and Echocardiogram Profile of Cardiomyopathy cardiomyopathy (HCM) with overall age- and sex-adjusted incidence rates were 6.0/100,000 and 2.5/100,000 person-years, respectively. These findings are comparable with our study in which 27 (41.53%) had DCM (idiopathic), 15 (23.07%) had Ischemic cardiomyopathy, 11 (16.92%) had HCM and 2 (3.07%) patients had HOCM. Ntusi, Ntobeko B A et al10 in their retrospective study of familial and idiopathic DCM of Eighty patients with idiopathic DCM and 40 familial cases reported that, ECG T-wave inversion was significantly more frequent in familial DCM (87.5%) than in idiopathic cases (68.8%) (‘p’=0.014), whereas idiopathic patients had a higher prevalence of pathological Q waves (32.5%) than familial cases (12.5%) (p=0.028). In our study the LBBB (35.71%) was more frequently seen in patients with dilated cardiomyopathy with ‘p’ <0.02. The ‘QS’ pattern in chest leads was more frequently seen in patients with Ischemic cardiomyopathy (73.33%) with ‘p’ value< 0.001. Ntobeko B A Ntusi, et al11 in their study of 109 unrelated patients with DCM, 29 (26.6%) had familial disease. Their mean age of onset of cardiomyopathy (28.01 (standard deviation (SD) 15.33) years) was significantly younger than that for non-familial cases (39.1 (SD 12.6) years) (p=0.001). Male predominance was present (72.4%). Similarly in present study 34(52.30%) were males slightly more with mean age of 62.41 years (SD±12.76) and 31(47.70%) were females with mean age of 54.77 years (SD±18.28). There was no significant statistical difference amongst gender. Haq Nawaz et al12 reported the mean age was 47.12±17.9 year with male predominance (males=34, females=16). Mean ejection fraction was 30.6±6.9%. Complications revealed on echocardiography were intracardiac thrombi (5, 10%), spontaneous echo contrast (5, 10%), pericardial effusion (6, 12%), mitral regurgitation (46, 92%), tricuspid (25, 50%), aortic (5, 10%), pulmonary (2, 4%) multi-valvular regurgitation (28, 56%), and left atrial dilatation (36, 72%). LV systolic dysfunction, cardiac thrombi, spontaneous echo contrast, mitral and tricuspid regurgitation and left atrial enlargement are important complications of dilated cardiomyopathy. Echocardiography is important tool towards identification of these complications. Phadke R S et al13 stated that, the incidence of HCM amongst the autopsied primary cardiomyopathies (N = 101) was 13.9% (n=14). Males were affected more. In present study total 11 (16.92%) had HCM, 2 (3.07%) patients had HOCM. Common presenting symptoms were exertional dyspnoea, angina and palpitations. Concentric and asymmetric hypertrophy was equally seen. Cardiac failure was the commonest cause of death. In our study 6(54.54%) with HCM, 2 (100%), with HOCM had breathlessness, 5(45.45%) with HCM, 2 (100%), with HOCM had palpitations, 2(18.18%) with HCM had cough, 1(9.09%) with HCM, had pedal edema, 1(9.09%) with HCM, 1 (50%) with HOCM, chest pain 2(18.18%) with HCM and 1 (50%) with HOCM syncope at the time of admission. Tanjore RR et al 14 studied the 127 HCM cases were divided into subtypes based on pattern of hypertrophy. They suggests that modes of inheritance other than autosomal dominant may be encountered in a subset of HCM especially in asymmetric septal hypertrophy, apical, concentric and mid cavity obstruction subsets. Hypertrophic cardiomyopathy is caused by 11 mutant genes with more than 500 individual transmutations. The most common variation Journal of Cardiovascular Disease Research Vol. 5 / Issue 1 Jan–Mar, 2014 involves the beta-myosin heavy chain and myosin-binding protein C. Not all persons with a hypertrophic cardiomyopathy genetic defect are symptomatic. High prevalence of Arginine to Glutamine Substitution at 98, 141 and 162 positions in Troponin I (TNNI3) associated with hypertrophic cardiomyopathy among Indians15. Fundamental knowledge about HCM and sarcomere biology has emerged recently16. In present study genetic study was not possible due to resources limitations. Seth S et al17 in their study of 52 patients with RCMP had heart failure with normal or near normal left ventricular size and function. Similarly in present study total 5 (7.69%) patients had (RCMP) had near normal LVEF 58% (±7.9) with bi-atrial enlagement, functional MR and TR with more prevalence of atrial flutter/ fibrillation (80%) with ‘p’ value <0.02. Total 100% of RCMP patients had diastolic dysfunction. Naser M. Ammash et al18 studied 94 patients with echocardiographic criteria of idiopathic restrictive cardiomyopathy, mainly dilated atria with nonhypertrophied, nondilated ventricles. Atrial fibrillation was noted in 74% of patients and systolic dysfunction in 16%. The endomyocardial fibrosis is the most common restrictive cardiomyopathy observed world wide. The disease occurs in its classical endemic form in the selected coastal belt in Kerala, India, affecting young people of lower socio- economic families, and attracting worldwide attention19. The Thalassemia associated with the restrictive phenotype, with restrictive left ventricular filling, pulmonary hypertension, and right heart failure. The pathophysiology of the disorder is multifactorial, with a central role of myocardial iron overload and the significant contribution of immuno inflammatory mechanisms20. In our study one female patient with age 20 years had Restrictive cardiomyopathy with Thalassemia with history of recurrent blood transfusions who had multiform and multifocal VPC’s. Jahan Ara Hasan et al21 studied 32 patients with peripartum cardiomyopathy of them total 20 (62.57%) patients presented in late post partum period. Similarly all 4 patients in present study presented in postpartum periods with features of PPCM. The main complication was congestive cardiac failure in 20 (62.57) patients and 3 maternal deaths occurred. In our study all 4 patients with PPCM were discharged with no mortality. The incidence of PPCM was 1 case per 1374 live births. Major risk factors for the development of PCM were multiparity and advanced maternal age. Echocardiography is useful in early diagnosis and for follow-up assessment of left ventricular function. Most of the patients noticed good symptomatic improvement at time of discharge and during the follow-up with standard therapy22. The incidence of PPCM was one case per 1374 live births in an Indian study23. Similarly in our study total 4 (6.15%) patients had PPCM with mean age of 27.5 years(±6.24). total 4(100%) patients with PPCM 4 (100%) had breathlessness, 2(50%) had hemoptysis had palpitations at the time of admission. 4(100%) had cough 2(50%) had pedal edema and 1(25%) had syncope. Low voltage & poor ‘r’ wave progression on ECG was present in 4(100%) patients with ‘p’ value < 0.001. Total 2 (50%) patients had diastolic dysfunction and the mean left ventricular ejection fraction (LVEF) was 21% (±8.7). Total 2 (50%) patients had LV echocontrast on echocardiogram, 4 (100%) had mitral incompetence and the mean of pulmonary artery pressure was 37(±3.8) mmHg. All four 41 Clinical and Echocardiogram Profile of Cardiomyopathy patients with PPCM were discharged with improved LVEF with no mortality. The abstinence from alcohol has been associated with improvement in left ventricular function. Conversely, patients with ongoing alcohol abuse and dilated cardiomyopathy have a poor prognosis, with progressive biventricular failure and, ultimately, death24. Alcoholic cardiomyopathy (ACM) causes myocyte dysfunction, due to abnormalities in calcium homeostasis, and cause elevated levels of norepinephrine. Increasing doses of ethanol have been associated with a negative inotropic effect on myocytes in animal experiments25. ACM is characterized by an increase in myocardial mass, dilation of the ventricles, and wall thinning and associated with diastolic dysfunction, whereas systolic dysfunction is a common finding in symptomatic ACM patients. ACM remains an important cause of a dilated cardiomyopathy, and in latter stages can lead to heart failure26. Alcoholic cardiomyopathy represents about 3.8% of all cardiomyopathy cases and it is a result of long-term (>5 years) alcohol consumption (>90 g of alcohol per day). It occurs twice as frequently in men as in women. Alcoholism is one of the main causes of myocardial damage27. In our study one 45 years male with chronic alcoholic presented with AVNRT with CCF with LV systolic dysfunction with LVEF 30% (dilated cardiomyopathy) was improved with medical line of treatment and was discharged with improved with LV systolic dysfunction and was advised alcohol abstinence. The myocarditis is an inflammatory disease of the heart frequently resulting from viral infections and/or post-viral immune-mediated responses. It is one of the important causes of dilated cardiomyopathy worldwide28. In our study one patient had myocarditis probably viral with complete heart block (CHB) which was reversible over period of six weeks and was treated with temporary pacemaker and treatment of CCF. Conclusion Present study highlights significant burden of Idiopathic dilated cardiomyopathy and next to it was ischemic cardiomyopathy. A total 6 (9.23%) of patients had reversible cardiomyopathy like peripartum, alcoholic and myocarditis. Total two patients with dilated cardiomyopathy succumbed with overall mortality 3.08% and case fatality rate for DCM was 4.76%. Although cardiomyopathy is asymptomatic in the early stages, symptoms are the same as those characteristically seen in any type of heart failure and may include shortness of breath, fatigue, cough, orthopnea, paroxysmal nocturnal dyspnea, and edema. Finding a potentially reversible cause (alcohol induced, peripartum cardiomyopathy, hyperthyroidism, ischemic cardiomyopathy, tokotsubo cardiomyopathy and myocarditis etc.) of cardiomyopathy is equally important. Trans-thoracic echocardiogram is an important, simple and noninvasive modality of investigation which can be reproducible for the diagnosis and fallow up of most of the cardiomyopathies. Treatment is targeted at relieving the symptoms of heart failure and reducing rates of heart failure–related hospitalization and mortality. Treatment options include pharmacotherapy, implantable cardioverter-defibrillators, cardiac resynchronization therapy, and heart 42 transplantation. 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