Danielle Craft (Buehler) Pharmacology for Technicians I December 2, 2013 Dilated Cardiomyopathy

A fire fighter trainee was involved in training consisting of maneuvering through a maze while wearing SCBA gear in June 2011. The trainee was removed from one of the tunnels because his gear was stuck in the tunnel. His oxygen tank was low and he was nauseated and having trouble with his breathing. Later, he attempted to pass through the tunnel again and was found not breathing. He was transported to the hospital and received life support treatment, but he died shortly after that. His autopsy revealed that he had the disease known as dilated cardiomyopathy. The mixture of the strenuous physical training and dilated cardiomuopathy caused the mans sudden death. The etiology of dilated cardiomyopathy is from various causes and there is a variety of drug treatments for the disease. The cardiac muscle (heart muscle) is found in the walls of the heart. This carrdiac muscle is known as the myocardium. The heart is divided into the upper right and left atriums and the lower right and left ventricles where blood circulates through the heart (Zelman, p.112). Impairment or functional diseases of the myocardium is known as cadiomyopathy and can be divided into three forms of myocardial impairment. The most common myocardial impairment is dilated cardiomyopathy. Dilation of the ventricle and dysfunction in contraction of the heart are characteristics of dilated cadiomyopathy (Zelman, p.127). The symptoms of this disease include shortness of breath, orthopnea, weakness, fatigue, ascites, and peripheral edema (Zelman, p.140).These symptoms of the disease are similar to the symptoms of congestive heart failure . Dilated cardiomyopathy occurs in any age group and can be diagnosed through an echocardiography, EKG, and a physical examination. There are currently no known preventions for dilated cardiomyopathy (Zelman, p.140). According to the article for the Niosh

investigation for the fire fighter safety, dilated cadiomyopathy is an impairment of one or both ventricles and cardiac enlargement, arrhythmias, and emboli. Different degrees of interstitial fibrosis are also noted in this disease. The death of the fire fighter trainee was caused by dilated cardiomyopathy, which accounts for 60% of the different forms cardiomyopathy (Niosh, p.1). The ventricles begin to deteriorate causing more signs and symptoms (such as shortness of breath, swelling, weakness, and exhaustion) of congestive heart failure. These symptoms, however, were not noticed in the fire fighter trainee and the family history did not consist of the disease. Because the etiology of this disease is not always understood in many cases, dilated cardiomyopathy can also be considered idiopathic for some cases. Genetics have been linked to the cause of this disease, and these inherited factors are associated with the idiopathic dilated cardiomyopathy (Niosh, p.1). A dilated myocardium causes the walls of the heart to become thinner which causes an enlargement of the chambers of the heart. The initial beginning of the disease is noted in the right ventricle which spreads to the atria as the disease progresses and causes the heart to contract incorrectly. This causes poor circulation because the heart is unable to pump the blood correctly. Other names for dilated cardiomyopathy are known as alcoholic cardiomyopathy, congestive cardiomuopathy, diabetic cardiomyopathy, familial dialated cardiomyopathy, idiopathic cardiomyopathy, ischemic cardiomyopathy ( term used if heart attack or coronary heart disease is the cause ), peripatum cardiomyopathy, peripatum cardiomiopathy ( before or after pregnancy), or primary cardiomyopathy (American Heart Association). The causes of dilated cardiomyopathy (other than idiopathic dilated cardiomyopathy) are linked to alcohol abuse, cocaine abuse, cancer treatment drugs, long durations tachycardia, autoimmune illnesses, genetics, infections of the heart (viral or bacterial), leaky heart valves, exposure to lead, exposure to arsenic, or exposure to mercury (Chen, p.1). Amphetamines and cancer treatment drugs such as doxorubicin and daunorubicin have been known to cause dilated cardiomyopathy (American Heart Association). Poorly controlled high blood pressure is a common cause of the disease which causes an

enlarged, weakened myocardium. Although dilated cariomyopathy can affect any individual of any age, it is found to be more common in adult men. Other symptoms of dilated cardiomyopathy are lung crackles, heart murmur, bulging neck veins, enlarged heart or enlarged liver. Symptoms can also include chest pain after exercise, cough, weakness, fatigue, tachycardia, or loss of appetite. Tests such as antinuclear antibody (to detect autoimmune problems), iron tests, and antibody testing for Lyme disease and HIV are used to determine the cause of dilated cardiomyopathy. Other tests to determine the structural function or heart enlargement can be determined through the use of echocardiograms (heart ultrasounds), stress tests, chest x-rays, coronary angiograms, MRI, CT scan, and nuclear heart scans (Chen, p.1). Procdures may be needed to treat the disease such as pacemakers, a defibrillator (to recognize life-threatening rhythms), or valve replacement or valve repair. Dilated cardiomyopathy can also be misdiagnosed as asthma in children because chronic coughing and wheezing is active during physical activities (American Heart Association). Dilated cardiomyopathy can also be caused by viral infection that affects the myocardium. Based on the severity of the different symptoms of dilated cardiomyopathy, age and health, the treatment for cardiomyopathy varies. Calcium channel blockers are used to slow heart rate and anticoagulants are used to thin the blood to prevent blood clots dilated cardiomyopathy (American Heart Association). Other classes of drugs such as diuretics, inotropic agents, ACE inhibitors, beta-blockers, and anticoagulation drugs are some of the drugs used to treat dilated cardiomyopathy. Diuretics have been used to reduce fluid around the lungs which causes strain on the heart. Furosemide is one diuretic used. Inotropic agents aid in the contraction of the heart and are used intravenously. One example is Dobutamine (No brand names available) and it is given intravenously and increases blood pressure. This helps to provide stronger heart contractions that will cause more blood to circulate, but side effects are arrhythmias, tachycardia, and artery constriction. Pregnancy may interact 3

with the use of dobutamine; therefore, a doctor must be contacted if an individual may become pregnant or if the individual is pregnant while taking this drug. Herbal preparation can also interact with dobutamine. Medications such as cimetidine or methyldopa cause the side effects of dobutamine to be increased. Catechol-Omethyltransferase inhibitors or droxidopa also cause the side effects to increase. These medications should not be taken together. Blood pressure should be continuously monitored after receiving this drug. This drug should be stored at 15 degrees to 30 degrees Celsius. An Angiotensin converting enzyme inhibitor (ACE inhibitor), monopril (fosinopril), is an after load reducing agent that helps to relax the arteries and reduce the hearts strenuous task. Monopril is taken by mouth and can cause low blood pressure, kidney problems, liver problems, and lower white blood cell counts. Because monopril affects the metabolism of endogenous bradykinin, it should be carefully monitored for severe reactions. Also, if angioedema involving the face, lips, mucous membranes, tongue, glottis or extremities is noticed, a doctor should be contacted and monopril should no longer be used. ACE inhibitors can also help the heart to return to normal size which can prevent sudden deaths similar to the fire fighter trainee. Beta-blockers can slow heartbeat which will restrain the heart from overworking. An example is carvedilol ( Coreg), and it is administered by mouth and taken with food (which will provide slower absorption of the drug). Side effects include fluid retention, dizziness, fatigue, depression, and low blood pressure. Beta-blockers can also help the heart to return to normal size, however beta-blockers are not recommended for children in treating dilated cardiomyopathy. Treatment can begin as an inpatient or outpatient if the patients fluid retention has decreased. Carvedilol tablets are started as a small dose (6.25 mg) twice a day and gradually increased until 25 mg twice daily is tolerable for the patient. The drug must be received in small doses and gradually increased because some patients are not able to tolerate the targeted dose from the doctor. Discontinuation of carvedilol should be over a period of one to two weeks because abrupt discontinuation may cause damage (Drugs).

Anticoagulation medications are also used such as dipyridamole (no brand name). This is used to prevent blood clots from forming to prevent strokes; however, these drugs cause excessive bruising and excessive bleeding. Dipyridamole is also a coronary vasodilator. Dipyridamole is administered intravenously and orally and is used as an addition to warfarin, and aspirin can be used in place of dipyridamole. This is not recommended if you are pregnant, have asthma, angina, irregular heartbeat, or have severe muscle weakness. Interactions occur with drugs such theophyllines, adenosine, or anticholinesterases. Also, an individual should not drive until the individual knows what reactions will result from taking this medication. Caffeinated foods such as cola, chocolate, tea, or coffee should not be in an individuals diet while taking this medication (Drugs). Anti-arrhythmia medications are also used for individuals with ventricles that contract very poorly. Lidocaine is an example of this form of medication. The medication is used to prevent lifethreatening heart rhythms and used to control abnormal rhythms. It is a local anesthetic and is used to prevent nerves from communicating with certain areas of the body. Side effects include low blood pressure, nausea, constipation, depression, dizziness, inability to concentrate, and skin rashes (American Heart Association). Dilated cardiomyopathy is treated with a variety of drugs because of the different signs and symptoms of the disease. The severity of the disease also changes the treatment of the disease. Infections, myocarditis, metabolic disorders, genetic disorders, and immune disorders are part of the etiology of the disease; therefore, different medications and treatments are used to treat dilated cardiomyopathy.

Works Cited Niosh: Fire Fighter Fatality Investigation and Prevention Program. 2011 June. http://www.cdc.gov/NIOSH/FIRE/reports/face201108.html

Chen MD, PhD, Michael A.; Zieve, MD, David. 4 June 2012. Medline Plus: Dilated Cardiomyopathy. <http://www.nlm.nih.gov/medlineplus/ency/article/000168.htm > accessed 01 December 2013.

American Heart Association: Dilated Cardiomyopathy. <http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Dilated-CardiomyopathyDCM_UCM_444187_Article.jsp#>; <http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Prevention-and-Treatment-ofCardiomyopathy_UCM_444176_Article.jsp> accessed 01 December 2013.

Dialated Cardiomyopathy <http://www.heart.org/idc/groups/heartpublic/@wcm/@hcm/documents/downloadable/ucm_312224.pdf> journal. accessed 01 December 2013.

<http://www.drugs.com/pro/carvedilol.html>accessed 01 December 2013.