eMedicine Specialties > Cardiology > Myocardial Disease and Cardiomyopathies

Cardiomyopathy, Dilated: Follow-up

Author: Frank E Wilklow, MD, Principal Investigator, Sub-Investigator, Cardiovascular Research Lab, Louisiana State University Health Sciences Center; Principal Investigator, Sub-Investigator, Gulf Regional Research and Education
Coauthor(s): Murat M Celebi, MD, Consulting Staff, Crescent City Cardiovascular Associates; Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital; Gary E Sander, MD, PhD, Professor, Department of Internal Medicine, Division of Cardiology, Tulane University Health Sciences Center
Contributor Information and Disclosures

Updated: Nov 19, 2008

Follow-up

Prognosis

The prognosis for patients with heart failure depends on several factors, with the etiology of disease being the primary factor. Other factors (eg, age, sex, disease severity) play important roles in determining prognosis. A higher mortality rate is associated with increased age, male sex, and severe CHF. Prognostic indices include the NYHA functional classification. Despite improved medical therapies, patients with severe heart failure have more than a 50% yearly mortality rate. Patients with mild heart failure have significantly better prognoses, especially with optimal medical therapy.

Patient Education

  • Nonpharmacologic interventions are the basis of heart failure therapy. Instruction on a sodium diet restricted to 2 g/d is very important and can often obviate the need for diuretics or reduce their dosages. Fluid restriction is complementary to a low-sodium diet. Patients should be enrolled in cardiac rehabilitation involving aerobic exercise. These nonpharmacologic therapies are paramount in the treatment of heart failure.
  • For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Congestive Heart Failure.

Miscellaneous

Medicolegal Pitfalls

  • Failure to search for an etiology for heart failure: CHF is a syndrome, not a disease.
  • Failure to place a patient on an ACE inhibitor
  • Failure to monitor digoxin levels, which may result in toxicity
  • Failure to recognize the need for advanced care
  • Failure to institute timely care to the point at which the patient is no longer a candidate for heart transplantation

Special Concerns

  • Blood pressure control: Appropriate control of blood pressure is essential to effective therapy for persons with heart failure. The systolic blood pressure must be less than 120 mm Hg (preferably <110 mm Hg). Patients taking medications should not be deemed hypotensive based solely on blood pressure measurements; instead, this determination should be made based primarily on symptoms and the effectiveness of organ perfusion.
  • The future of pharmacologic therapy in persons with heart failure
    • RAAS: The next generation of medications affecting the RAAS are the selective aldosterone receptor antagonists. Eplerenone is currently being evaluated in the treatment of heart failure.
    • Cytokine antagonists: Based on findings of TNF-alpha involvement in persons with cardiomyopathies, agents aimed at blocking TNF-alpha have been developed. Etanercept has shown benefit in animal models and short clinical trials. However, phase 3 trials were discontinued because of a lack of benefit.
    • Endothelin blockade: Endothelin-1 has deleterious hemodynamic effects on left ventricular dysfunction. Over 6 months, bosentan has been shown to increase the likelihood of improvement and decrease the likelihood of deterioration in persons with NYHA class IIIB-IV. Trials with other agents are under way.
    • Natriuretic peptides: Augmentation of natriuretic peptides can be accomplished via exogenous administration (ie, with nesiritide) or blockade of the catalytic enzyme neutral endopeptidase (ie, with omapatrilat). Administration of exogenous peptide is clinically available for the treatment of patients with salt and volume overload. These agents have demonstrated effectiveness in correcting hemodynamic derangements in patients with acutely decompensated heart failure via their vasodilatory and diuretic effects. Recent data suggest that combined blockade of ACE and neutral endopeptidase also has hemodynamic and clinical benefits.
  • Protein, stem cell, and gene therapies
    • Early animal studies using recombinant adeno-associated viral gene therapy with gene transfer of phospholamban prevented deterioration of left ventricular systolic and diastolic function in genetically predisposed animals.
    • The use of vascular endothelial growth factor may have beneficial effects in persons with ischemic cardiomyopathies. This form of gene therapy has demonstrated the benefits of reducing revascularization and improving angina and quality of life. Many formats of gene delivery are under investigation.
    • Fibroblast growth factor has also been investigated in the realm of ischemic heart disease, with mixed results 
  • Myoblast transplantation
    • This procedure involves the injection of skeletal myoblasts as an autograft into damaged myocardium (scar) at the time of bypass surgery.
    • In early investigations, this therapy has consistently resulted in improved contraction and viability of the myocardium.
    • Further investigation is needed to establish a more prominent role for myoblast transplantation in heart failure therapy. Additional studies are also being performed with other progenitor cells.
  • Embryonic stem cells hESC
    • Human embryo stem sells differentiated ex-vivo to derive cardiac myocyte stem cells and transplanted into rats who had LAD ligation have been shown to attenuate the adverse remodeling seen with extensive infarct.20
    • Autologous stem cells have been given both intramyocardial and intravenously experimentally for the treatment of congestive heart failure with varying results. Much of the early data from these trials seem to suggest that delivery mechanisms to the myocardium and the use of concomitant cytokines are equally in need of further investigation.21
 


More on Cardiomyopathy, Dilated

Overview: Cardiomyopathy, Dilated
Differential Diagnoses & Workup: Cardiomyopathy, Dilated
Treatment & Medication: Cardiomyopathy, Dilated
Follow-up: Cardiomyopathy, Dilated
References
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References

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Further Reading

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Keywords

congestive cardiomyopathy, heart failure, congestive heart failure, CHF, dilated cardiomyopathy, DCM, cardiac failure, cardiomyopathies, viral DCM, familial DCM, dilated cardiomyopathy, dilatated cardiomyopathy, viral dilated cardiomyopathy, familial dilated cardiomyopathy, toxic DCM, toxic dilated cardiomyopathy, granulomatous dilated cardiomyopathy, granulomatous DCM, collagen vascular disease DCM, collagen vascular disease dilated cardiomyopathy, carnitine DCM, carnitine dilated cardiomyopathy, carnitine deficiency, tachycardia-induced DCM, tachycardia-induced dilated cardiomyopathy, doxorubicin-induced DCM, doxorubicin-induced dilated cardiomyopathy, sarcoidosis, end-stage heart disease, end stage heart disease, end-stage cardiac disease, end stage cardiac disease

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Contributor Information and Disclosures

Author

Frank E Wilklow, MD, Principal Investigator, Sub-Investigator, Cardiovascular Research Lab, Louisiana State University Health Sciences Center; Principal Investigator, Sub-Investigator, Gulf Regional Research and Education
Frank E Wilklow, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Murat M Celebi, MD, Consulting Staff, Crescent City Cardiovascular Associates
Murat M Celebi, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society, Louisiana State Medical Society, and Orleans Parish Medical Society
Disclosure: Nothing to disclose.

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Gary E Sander, MD, PhD, Professor, Department of Internal Medicine, Division of Cardiology, Tulane University Health Sciences Center
Gary E Sander, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Hypertension, Heart Failure Society of America, Louisiana State Medical Society, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Medical Editor

Robert E Fowles, MD, Clinical Professor of Medicine, University of Utah College of Medicine; Consulting Staff, Intermountain Medical Center and LDS Hospital; Director and Consulting Staff, Department of Cardiology, Salt Lake Clinic
Robert E Fowles, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald J Oudiz, MD, FACP, FACC, Associate Professor of Medicine, Division of Cardiology, The David Geffen School of Medicine at UCLA; Director, Liu Center for Pulmonary Hypertension, LA Biomedical Research Institute at Harbor-UCLA Medical Center
Ronald J Oudiz, MD, FACP, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC, Sidney W and Marilyn S Lassen Professor of Cardiovascular Medicine, Chief, Section of Cardiology, Director, Cardiovascular Center of Excellence, Tulane University; Professor of Physiology, Chair, Department of Medicine, Tulane University School of Medicine
Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Diabetes Association, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Medical Association, American Society for Clinical Investigation, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Endocrine Society, European Society of Cardiology, Louisiana State Medical Society, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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