|Year : 2021 | Volume
| Issue : 1 | Page : 60-65
Clinical features and treatment outcomes of cardiomyopathy in Indian patients: An observational, retrospective study in tertiary care teaching institute
Anil R Jawahirani1, Deepak Jeswani2, Dilip Kshirsagar2, Rajnish M Dhediya3, Amit Y Jadhav3
1 Professor & HOD, Department of Cardiology, Datta Meghe Institute of Medical Sciences, Sawangi, Maharashtra, India
2 Department of Critical Care, CritiCare Hospital, Nagpur, Maharashtra, India
3 Medical Services, Emcure Pharmaceuticals Ltd, Pune, Maharashtra, India
|Date of Submission||28-Sep-2020|
|Date of Decision||20-Oct-2020|
|Date of Acceptance||14-Dec-2020|
|Date of Web Publication||30-Mar-2021|
Amit Y Jadhav
Emcure Pharmaceuticals Limited, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: Cardiomyopathy is defined as a heterogeneous group of diseases of the myocardium, is a transient reversible, but potentially life-threatening condition. The natural history, management pattern, and outcome of cardiomyopathy are not clear in Indian scenario. This study was conducted to investigate the clinical features, prognostic predictors, and clinical outcomes of patients with cardiomyopathy.
Materials and Methods: We retrospectively analyzed the data of 119 patients of cardiomyopathy admitted to tertiary care hospital from January 2016 to April 2019.
Results: The mean age of analyzed patients was 55.08 ± 15.75 years. During admission, symptoms such as breathlessness (63.64%) and fever (40.17%) were reported more often than other symptoms. 38.66% of patients had dilated and stress cardiomyopathy while 15.97% had ischemic cardiomyopathy. Among the independent predictors of all cause death the respiratory failure, sepsis and renal dysfunction were identified. Reduced ejection fraction in 73%, moderate-to-severe mitral regurgitation in 20%, and global hypokinesia in 68.57% patients were observed. Of total admissions, 86% of patients recovered while 14% patients resulted in death.
Conclusion: Our study shows that respiratory failure, sepsis, anemia, and renal failure are major contributing factors in poor prognosis, although most of the patients recovered from cardiomyopathy. Cardiomyopathy is the one of the important causes for heart failure with reduced ejection fraction.
Keywords: Cardiomyopathy, ejection fraction, heart failure, patients condition
|How to cite this article:|
Jawahirani AR, Jeswani D, Kshirsagar D, Dhediya RM, Jadhav AY. Clinical features and treatment outcomes of cardiomyopathy in Indian patients: An observational, retrospective study in tertiary care teaching institute. Heart India 2021;9:60-5
|How to cite this URL:|
Jawahirani AR, Jeswani D, Kshirsagar D, Dhediya RM, Jadhav AY. Clinical features and treatment outcomes of cardiomyopathy in Indian patients: An observational, retrospective study in tertiary care teaching institute. Heart India [serial online] 2021 [cited 2021 Apr 14];9:60-5. Available from: https://www.heartindia.net/text.asp?2021/9/1/60/312483
| Introduction|| |
Cardiomyopathy is a complex disease process that can affect the heart of a person of any age, but it is especially important as a cause of morbidity and mortality among the world's aging population. Cardiomyopathy is defined as a heterogeneous group of diseases of the myocardium, usually with inappropriate ventricular hypertrophy or dilatation. Cardiomyopathy often goes undiagnosed, so the numbers can vary. In 2015, the Global Burden of Disease study estimated the global prevalence of cardiomyopathy at 2.5 million cases – an increase of 27% in just 10 years.
Based on structural and functional changes, cardiomyopathy is classified as congestive cardiomyopathy, now referred to as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), and constrictive (now referred to as restrictive) cardiomyopathy (RCM). DCM is characterized by dilatation and impaired contraction of the left ventricle or both ventricles. HCM is characterized by left and/or right ventricular hypertrophy, which is usually asymmetric and involves the interventricular septum. RCM is characterized by restrictive filling and reduced diastolic volume of either or both ventricles with normal or near-normal systolic function and wall thickness. DCM reported incidence is 400,000–550,000 cases per year, with a prevalence of 4–5 million people.
Stress cardiomyopathy is special type of cardiomyopathy, which is defined as clinical syndrome characterized by an acute and transient (<21 days) left ventricular (LV) systolic (and diastolic) dysfunction often related to an emotional or physical stressful event, most often identified in the preceding days (1–5 days). The incidence of stress cardiomyopathy has been rising (15–30 cases per 100,000 per year) due to increased awareness and recognition. Each of these types are further subdivided by pathogenesis, such as secondary to an infection, a systemic disorder, inflammation, or an inherited disorder. In some patients, no pathogenesis could be identified, and these were termed idiopathic cardiomyopathies.
Although the life expectancy of patients with cardiomyopathy varies by etiology, the mortality rate is 20% at 1 year and 70%–80% at 8 years for most patients who develop heart failure. The most common clinical presentation in patients with cardiomyopathy is heart failure. Cardiomyopathy worsens and the heart weakens which results in clinical features such as shortness of breath, fatigue, cough, edema, and chest pain. The evaluation for underlying causes of heart failure includes a thorough history and physical examination with investigations, including B-type natriuretic peptide levels, chest radiography, electrocardiography (ECG), and echocardiography should be performed on initial presentation. The management consist of symptomatic management, administration of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a loop diuretic, spironolactone for the New York Heart Association Class III or IV heart failure, and a beta blocker. Most of the patients with stress cardiomyopathy usually present with severe chest pain, dyspnea, or both during emotional stress. The management of stress cardiomyopathy mainly consists of supportive and symptomatic treatment. In mild cases, either no treatment or a short course of limited pharmacological therapy may be sufficient. In severe cases, complicated by progressive circulatory failure, some patients need to be considered for mechanical circulatory support as a bridge to recovery.
There has been enough data for clinical profile and management of cardiomyopathy in western countries. However, clinical profile and management pattern may vary in Indian context due to difference in genetics and secondary causative factors for cardiomyopathy. In view of the paucity of relevant data in India, the present study was designed to evaluate the clinical profile and management outcome in Indian patients of cardiomyopathy.
| Materials and Methods|| |
This was a retrospective observational study conducted at Tertiary Care Teaching Institute, Nagpur, Maharashtra, India. The study was approved by the Ethics Committee of institution. Medical data of patients who visited the department of cardiology at our institute and diagnosed as patients of cardiomyopathy from January 2016 to April 2019 were retrieved and analyzed. Only the patients who had given consent for future use of medical records were identified and included in the study. The primary endpoints of this study were composite outcome, including all-cause mortality and factors contributing to it because of cardiomyopathy. Stress cardiomyopathy is defined as clinical syndrome characterized by an acute and transient (<21 days) LV systolic (and diastolic) dysfunction often related to an emotional or physical stressful event, most often identified in the preceding days (1–5 days).
Demographic details were analyzed by descriptive statistics while other data were analyzed using inferential statistics in MS Excel V.2016. Continuous variables are expressed as the mean ± standard deviation and categorical variables as numbers and percentages.
| Results|| |
The study population comprised of 119 patients with cardiomyopathy. Most of the patients belonged to the age group of 31–60 years (55.46%) and 61–90 years (53.55%). Out of 118 patients, 47.86% had hypertension (HTN) while 39.32% had type 2 diabetes mellitus (T2DM). Demographic details mentioned in [Table 1].
Patients sign and symptoms
Patients sign and symptoms associated with cardiomyopathy are mentioned in [Table 1]. Breathlessness was the most common symptom (63.64%) followed by fever (40.17), abdominal pain (15.52%, vomiting (12.93), chills with sweat (12.71%), and headache (10.26%) while pallor (62.07%) was the most common sign followed by icterus (18.97%), hepatomegaly (13.08%), and splenomegaly (12.96%) [Table 2].
In our study, dilated and stress cardiomyopathy were most common types of cardiomyopathies (38.66% each) while ischemic cardiomyopathy constitutes 15.97% of cardiomyopathies. Other less common types of cardiomyopathies were diabetic cardiomyopathy (5.04%), RCM (0.84%), and alcoholic cardiomyopathy (0.84%) [Figure 1].
|Figure 1: Data is expressed as percentage of patients (%), number of patients (n) = 119|
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Out of 118 patients, 64.41% admissions were elective or transfer however 35.59% of patients were emergency admissions. Average hospital stay was 7.14 ± 6.46 days while 4.34 ± 5.43 days of intensive care unit (ICU) stay.
Heart failure was reported in 90 patients (75.63%), around two-third of patients (73%) had heart failure with reduce ejection fraction (HFrEF) while heart failure with preserved ejection fraction (HFpEF) and heart failure with mid-range ejection fraction (HFmrEF) was seen in 10% and 17% of patients, respectively [Figure 2].
|Figure 2: Data is expressed as percentage of patients (%), number of Patients (n) analyzed = 90, Heart failure with reduced left ventricular ejection fraction: < 40% ejection fraction; Heart failure with mid-range left ventricular ejection fraction: 40%–49% ejection fraction; Heart failure with preserved left ventricular ejection fraction: >50% ejection fraction|
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Two-dimensional (2D) echo findings of 90 patients were analyzed, however 63.91% had mild mitral regurgitation (MR) and 20% were with moderate-to-severe MR, 68.57% patients had the global hypokinesia and 15.71% patients had only anterior 2/3, apex, distal and lateral wall hypokinesia. This indicates that there is the involvement of LV dysfunction and cardiac muscle hypokinesia in the development of cardiac myopathy. 36.13% of patients developed mild-to-severe degree of pulmonary HTN the reason behind it may be valvular involvement and diastolic dysfunction.
In the patients with cardiomyopathy, 76% of patients experienced hypoxia because of acute respiratory distress due to acute lung injury and decreased air entry. 47.06% patients had leukocytosis; the reason behind it may be due to septic shock and pulmonary infections. Deranged renal and hepatic function were seen in 40% and 29.315% of patients, respectively.
In 3.45% of patient's hemoglobinuria was seen, this may be one of the reasons for severe anemia (18.10% patients). Thrombocytopenia and leukopenia were seen in 34.51% and 7.83% patients, respectively [Table 3]. The above-mentioned complications have many interconnecting reasons as well mechanisms in cardiomyopathy patients due to the involvement of multi-organ systems.
On examination, it was found that the patients had tachycardia and tachypnea with reduced oxygen saturation. Average Glasgow Coma Score was 13.93 ± 2.49 while average Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 15.95 ± 7.38 [Table 4].
Central nervous system
Most of the patients (67.24%) were conscious and well oriented, while drowsy and comatose condition was observed in 10% and 2.59% of patients, respectively.
Most of the patients had intact (70.69%) and patent airway (20.69%). In 30.70% patients, bilateral air entry decreased along with basal crept, while 8.77% shown to have bilateral rhonchi [Table 5].
Intensive care unit parameters
ICU parameters of 116 patients were observed where we found 71.55% were on O2, out of which 30.43% were on ventilator this suggests that the majority of patients have respiratory failure and developed complications such as UTI (4.39%), fever (36.52%), and hypotension (33.91%) which may be due to the indwelling urinary catheter and reduced ejection fraction, respectively.
Among included patient's biochemical investigations were carried out at baseline. It was observed that total leukocyte count was raised 13973.87 ± 10252.39 suggestive of underlying infection in the patients. Serum urea 67.71 ± 58.31 and creatinine 2.54 ± 3.44 values were increased due the renal involvement while that of serum glutamic-oxaloacetic transaminase 179.56 ± 440.02, serum glutamic-pyruvic transaminase 178.77 ± 407.0, and alkaline phosphatase 179.22 ± 228.90 levels were also dramatically augmented this is suggestive of liver cell injury. Hemoglobin value of 10.41 ± 2.49 g/dl indicates prevalence of anemia which might aggravate heart failure in patients with cardiomyopathy.
Out of 119 patients, 115 patients' final outcome was analyzed. Eighty-six percent patients recovered and were discharged from the hospital while in 14% patients' fatality was seen [Figure 3].
|Figure 3: Data expressed as percentage of patients (%), Number of patients analyzed (n) = 115|
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| Discussion|| |
In this study, we presented a comprehensive retrospective analysis of clinical features and management outcome of patients suffering from cardiomyopathy at a tertiary care center. This disease mostly affects men, who represent 53% of all patients diagnosed in our study. In previous literature, cardiomyopathy, especially HCM was reported to be male predominant, with men comprising approximately 60% of HCM cohorts. Higher proportion of patients with HTN (47.86%), T2DM (39.82%), and HFrEF (73%) in our study could be the reason for higher proportion of cardiomyopathy in male patients compared to female patients. In India, the diagnosis of heart disease is often missed out in women of low education level and a lower socioeconomic status and those with little access to medical care. This could be additional reason for lesser number of women diagnosed with cardiomyopathy in our study.
The most vulnerable 64.70% of all affected patients are over 50 years of age. In a previous retrospective study published by Bagger et al., more than half of the cardiomyopathy patients were in the age group of 40–59 years of age. Our findings are in line with previous report. It is interesting to note that in our study, 47.86% of patients had HTN, whereas only 39.32% were diabetic. In cardiomyopathy, the association between HTN and diabetes although described in literature but it is well recognized that incidence of HTN is high in these patients. Higher prevalence of these comorbidities in older age group might contribute to higher proportion of patients of cardiomyopathy in older age group.
Although cardiomyopathies may be asymptomatic in the early stages, most symptoms are typical of those seen in any type of heart failure, whether reduced ejection fraction or preserved ejection fraction. Symptoms of heart failure may include shortness of breath, fatigue, cough, orthopnea, paroxysmal nocturnal dyspnea, and edema. This presentation is common in patients with DCM. Patients with HCM may present with heart failure, although sudden cardiac death may be the initial presentation. Dyspnea is the most common symptom, affecting 63.64% of patients in our study. The second-most common symptom in our study was fever (40%). The presence of associated infection which is supported by leukocytosis in 47.06% of patients could be the reason for common clinical presentation of fever. Both the infectious agent and development of inflammatory response to infection can lead to irreversible myocardial injury, which can lead to cardiomyopathy called as infective cardiomyopathy (IC). Because of the long-term consequences, it is important to diagnose IC quickly and start appropriate treatment. However, IC is still a diagnostic challenge. IC is often underdiagnosed because of a wide spectrum of factors causing IC-infectious, toxic, immunologic, and various clinical manifestation. Identification and causative infectious agent and appropriate treatment are very crucial for prevention of long-term consequences of IC. This subcategory of cardiomyopathy may have special interest in Indian scenario due to higher prevalence of infections in India.
Dilated and stress cardiomyopathy was the most common type found which matches the literature. The high rate of stress cardiomyopathy in our study was observed may be due to physical stress, cardiovascular medications, microvascular dysfunction, and precipitating factors such as diabetes and HTN. Raised catecholamines in hypertensive patients also contribute into the stress. Furthermore, the reduced ejection fraction was one of the major factors in cardiomyopathy patients. Hypertrophic, dilated, and RCM may each present with heart failure with reduced ejection fraction. In our study, HFrEF was reported in 73% of patients with heart failure.
2D ECG revealed abnormal left ventricle morphology, LV wall motion abnormalities such as global hypokinesia, and resulting LV systolic dysfunction. Complications such as LV outflow tract obstruction, moderate-to-severe MR, may arise due to the above-described changes. In one stress cardiomyopathy study, Citro et al. found mean LVEF in 37.5% and moderate-to-severe mitral valve regurgitation in 21.5% of cases. Our results show similar mean 31.76% LVEF and moderate-to-severe MR in 20% of cases.
Low APACHE II score and high GCS score are associated with increased recovery rate and reduced mortality rates. Our study found that hypoxia was the most common trigger followed by ARDS, sepsis, renal failure, and anemia. Ninety-one percent patients had intact and patent airway which was also major reason behind recovery rate of 86% in our study. Reduced SpO2 and tachypnea are related to dyspnea which is the major contributing factors in the development of complications along with tachycardia. In 14% patients death was final outcome. The major reason of death can be respiratory failure due to ARDS, septic shock, and renal failure. From total admissions, 64.41% were elective this may be the reason for recovery and discharge from the hospital along with proper management.
The main limitation of our study is its retrospective nature; as a result, some data were unavailable. The study had inconsistently collected data, missing data elements which resulted in reduced statistical validity. There might be detection bias and selection bias as the study was retrospective. Finally, because the mortality is low, it is difficult to establish statistically significant prognostic factors.
| Conclusion|| |
Our study showed the patients characteristics in the Indian population where the cardiovascular and respiratory system are majorly involved in cardiomyopathy patients. Reduced EF, global hypokinesia, valvular involvement, and pulmonary HTN are the major contributing factors to heart failure in cardiomyopathy patients. Renal failure, sepsis, and anemia were the bad prognostic factors in these patients.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]