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Heart surgeon, thoracic surgeon

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Treatment of dilated cardiomyopathy

Alexey Portnov, medical expert
Last reviewed: 18.10.2021

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The main goals of treatment of dilated cardiomyopathy: correction of chronic heart failure, the timely appointment of anticoagulants and disaggregants for the prevention and treatment of thromboembolic complications in the case of atrial fibrillation, the treatment of arrhythmias, including life threatening, improving the quality of life, increasing the life expectancy of the patient.

Patients with dilated cardiomyopathy should be hospitalized when:

the newly discovered signs of heart failure to clarify its genesis (including DCMC);
complication of the course of DCM with the appearance of life-threatening rhythm disturbances;
progressing heart failure, inability to perform treatment on an outpatient basis;
the emergence of acute coronary insufficiency, acute left ventricular failure (cardiac asthma, pulmonary edema);
adherence to complications of CHF: pneumonia, rhythm disturbances, systemic embolisms, etc .;
symptomatic hypotension, syncope.

In case of signs of dilated cardiomyopathy, the patient should be recommended not to take alcohol, smoking, and normalize body weight, to limit consumption of table salt (especially in case of edematous syndrome). Appropriate physical activities appropriate to the patient's condition are also recommended. In the case of development of ventricular extrasystole, it is necessary to exclude provoking factors (coffee, alcohol, smoking, late withdrawal to sleep).

Medicinal treatment of dilated cardiomyopathy

Given that heart failure is the leading clinical syndrome in dilated cardiomyopathy, the use of ACE inhibitors and diuretics should be the basis of treatment. ACE inhibitors not only increase the left ventricular ejection fraction, increase the patients' tolerance to physical exertion and in some cases improve the functional class of circulatory insufficiency, but also improve the life expectancy, reduce mortality, and increase survival in patients with low ejection fraction. Therefore, ACE inhibitors are first-line drugs in the treatment of patients with CHF. The purpose of these agents is shown at all stages of symptomatic heart failure associated with systolic dysfunction of the myocardium.

According to some reports, beta-blockers improve the prognosis and general condition of the patient. It is recommended to start treatment with small doses. Preparations from the group of beta adrenoblockers, acting on the hyperactivation of the sympathoadrenal system, have shown the ability to improve hemodynamics and the course of heart failure, provide protective effect on cardiomyocytes, reduce tachycardia and prevent rhythm disturbances.

Treatment of heart failure should be carried out in accordance with the National Recommendations for the diagnosis and treatment of CHF.

Malignant ventricular arrhythmias are the leading cause of sudden cardiac death in patients with dilated cardiomyopathy. However, in patients with far-reaching form of the disease, up to 50% of cases of cardiac arrest may be bradyarrhythmias, pulmonary artery embolism and other vessels, electromechanical dissociation. The Working Group on the Study of Sudden Death in the European Society of Cardiology (2001) recommended the use of the following markers of sudden death in dilated cardiomyopathy:

sustained ventricular tachycardia (grade I evidence);
syncopal states (I class of evidence);
reduction of left ventricular ejection fraction (IIa class of evidence);
unstable ventricular tachycardia (IIB class of evidence);
induction of ventricular tachycardia with electrophysiologists in the sand study (grade III evidence).

With sinus tachycardia, symptomatic treatment is carried out with beta-blockers or verapamil, starting with minimal doses.

Patients with ventricular extrasystole have an increased risk of sudden death, but antiarrhythmic drugs do not improve the prognosis in asymptomatic cases with a diagnosis of "DCM" or in the presence of only a palpitation. In the case of symptoms of left ventricular failure, beta-blockers are added to treatment. When ventricular extrasystoles of high grades use amiodarone, sotalol, antiarrhythmic drugs Ia class.

In the presence of ventricular tachycardia and hemodynamically significant disorders (syncope, presyncopal conditions, arterial hypotension), an unfavorable prognosis of the disease should be assumed. It is recommended to prescribe amiodarone treatment, which reduces mortality by 10-19% in patients at high risk of sudden death, and we also need to consider the need for implantation of a cardioverter or defibrillator. In patients with persistent ventricular tachycardia and dilated cardiomyopathy, if cardiac transplantation is not possible, the main method of treatment is cardioverter implantation or defibrillator.

The choice of a method for arresting paroxysms of ventricular tachycardia is determined by the state of hemodynamics: if it is unstable, a synchronized cardioversion is performed (discharge power is 200 J). For stable hemodynamics, intravenous lidocaine (bolus + continuous infusion) is recommended. In the absence of effect resort to the introduction of amiodarone or procainamide. If the ventricular tachycardia persists, then a synchronized cardioversion is performed (discharge power 50-100 J).

With atrial fibrillation, treatment tactics depend on its form (paroxysmal, persistent, constant). Thus, with the development of paroxysmal atrial fibrillation and the presence of a frequent ventricular rhythm, signs of heart failure that do not respond quickly to pharmacological agents, immediate electrical cardioversion is shown. Medication or electrical cardioversion for rapid recovery of sinus rhythm is indicated in patients with a newly discovered episode of atrial fibrillation. In patients with cardiomegaly, i.e. DCM, the restoration of sinus rhythm with a constant form of atrial fibrillation is contraindicated. With ineffectiveness of drug or electrical cardioversion, the frequency of ventricular contractions in combination with antithrombotic treatment is monitored [shown in the case of atrial fibrillation and left ventricular dysfunction (presence of chronic heart failure, left ventricular ejection fraction 35%)], To control heart rate with a constant form of atrial fibrillation, cardiac combination is more effective glycosides and beta-address blockers.

Surgical treatment of dilated cardiomyopathy

Surgical treatment of dilated cardiomyopathy (cardiac transplantation, cardiomyoplasty, application of an artificial left ventricle) is indicated with ineffective drug, but it is rarely performed, mainly in young and middle-aged patients.

Heart transplantation is indicated with progressively increasing heart failure and if DCM has developed in a patient younger than 60 years.

The main alternative to heart transplantation today is the use of ancillary circulation devices, which have been called artificial heart ventricles.

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