Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S. Synonyms and keywords: Infiltrative cardiomyopathy; RCM; stiff heart; stiffening of the heart; heart stiffening; stiffened heart
Restrictive cardiomyopathy (RCMP) is a rare form among other cardiomyopathies, characterized by increased stiffness of the ventricles in the presence of normal diastolic volume and normal ventricular wall thickness. It may be classified into primary i.e EMF(endomyocardial fibrosis),Loffler’s endocarditis, Idiopathic restrictive cardiomyopathy and secondary i.e, infiltrative diseases(e.g., amyloidosis, sarcoidosis, and radiation carditis) and storage diseases (e.g., hemochromatosis, glycogen storage disorders, and Fabry’s disease). Cardiac amyloidosis is the most common cause of restrictive cardiomyopathy. Mainly due to deposition of amyloid fibrils in the extracellular space and misfolding into β-pleated sheets which are antiparallel to each other making them resistant to proteolysis, and also cause oxidative stress as a result leading to myocardial damage. Sarcoidosis characterized by noncaseating granulomas formation in various tissues including heart and hemochromatosis due to excessive accumulation of iron within the cells of various organs liver, pancreas, heart, and several endocrine glands leading to cirrhosis, diabetes, heart failure, skin pigmentation is also the common causes. Cardiac genes for desmin, α-actin, troponin I and troponin T are involved in the pathogenesis of restrictive cardiomyopathy. Restrictive cardiomyopathy should be differentiated from dilated cardiomyopathy, hypertrophic cardiomyopathy, congestive heart failure. Restrictive cardiomyopathy is very rare among all other types and accounts for approximately 5% of all cases. Its prevalence varies depending on regionality, ethnicity, age, and gender. Amyloidosis affects men and women equally. The wild-type transthyretin amyloidosis is most often found in the elderly population. Common complications of restrictive cardiomyopathy include thromboembolism, rhythm abnormalities(dysrhythmias), cardiac cirrhosis, heart failure, pulmonary hypertension. Common symptoms include dyspnea, fatigue, palpitations, syncope. Jugular venous distension is noted sometimes with Kussmaul sign and Hepatojugular reflux.S3 and S4 gallops seen. ECG shows Low QRS voltages, conduction disturbances, nonspecific ST abnormalities. Transmitral spectral Doppler often shows restrictive filling pattern and Ejection fraction (EF) is normal. The main purpose of treatment in restrictive cardiomyopathy (RCM) is to reduce symptoms by decreasing the elevated filling pressures without significantly lowering the cardiac output.Pharmacologic therapy may include Beta blockers, Amiodarone, Cardioselective [[calcium channel blockers], Diuretics, Anticoagulants for patients with atrial fibrillation, Melphalan (for antiplasma cell therapy in systemic amyloidosis), Chemotherapy (in amyloidosis). Other approaches like Pacemaker implantation and endomyocardectomy are also available.
- In 1957 for the first time Brigden coined the term ‘cardiomyopathy’ to describe group of uncommon, non-coronary myocardial diseases.
- But later in 1961 Goodwin redefined cardiomyopathies as “myocardial diseases of unknown cause”. Infact he is the one who put them into 3 seperate entities “dilated, hypertrophic and restrictive”, which we are still using today.
- In 1980 World Health Organization (WHO) and International Society and Federation of Cardiology (ISFC) combinedly published a classification which included the three subgroups proposed by Goodwin.
- There is no established system for the classification of restrictive cardiomyopathy 
- It may be classified into:
- EMF(endomyocardial fibrosis)
- Loffler’s endocarditis
- Idiopathic restrictive cardiomyopathy
- Infiltrative diseases(e.g., amyloidosis, sarcoidosis, and radiation carditis)
- Storage diseases (e.g., hemochromatosis, glycogen storage disorders, and Fabry’s disease)
- The exact pathogenesis of restrictive cardiomyopathy is not completely understood.
- Mainly characterized by impaired ventricular filling and reduced diastolic volume of one or both ventricles, with either normal or near-normal systolic function.
- Hemodynamic abnormalities constitute the main pathological aspect of restrictive cardiomyopathy.
- The primary abnormality of restrictive cardiomyopathy is impaired myocardial relaxation along with interstitial fibrosis as well as calcifications.
- Restrictive filling can been seen which is due to higher diastolic pressure.
- It is the most common cause of restrictive cardiomyopathy(RCM).
- Mainly due to deposition of amyloid fibrils in the extracellular space and misfolding into β-pleated sheets which are antiparallel to each other making them resistant to proteolysis, and also cause oxidative stress as a result leading to myocardial damage.
- Characterised by noncaseating granulomas formation in various tissues including heart.
- The usual location is basal septum, AV node, bundle of His, the ventricular free walls, and papillary muscles.
- Formation of granuloma includes 3 histological stages: edema, granulomatous infiltration, and fibrosis.
- Due to excessive accumulation of iron within the cells of various organs liver, pancreas, heart, and several endocrine glands leading to cirrhosis, diabetes, heart failure, skin pigmentation.
Genes involved in the pathogenesis of restrictive cardiomyopathy include:
- Cardiac genes for desmin, α-actin, troponin I and troponin T.
- Missense mutation (D190H) in the region of the cTnI gene (TNNI3).
- De novo mutations (R192H and K178E) in the TNNI3 gene.
- Mutations in the α-cardiac actin (ACTC), β-myosin heavy chain (β-MHC), and cTnT (TNNT2) genes have been noticed to have etiological causes of restrictive cardiomyopathy.
On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
On microscopic histopathological analysis, restrictive cardiomyopathy will show features suggestive of the cause.
- Cardiac Amyloidosis:
- On H&E stain it shows the pink color and demonstrates apple-green birefringence when viewed under polarized light.
- Consists of granulomas with macrophages and epithelioid histiocytes and lymphocytes.
- Niemann-Pick: foam cells are seen
- Mucopolysaccharidosis type II: glycosaminoglycans
- Hereditary hemochromatosis: Deposition of iron is seen
- Gaucher disease: Gaucher cells (lipid-laden macrophages) are seen
The main Causes of restrictive cardiomyopathy are enlisted below:
- Amyloidosis (AL, ATTR, SSA)
- Eosinophilic myocardial disease
- Idiopathic RCM
- Progressive systemic sclerosis (scleroderma)
- Postradiation therapy (Hodgkin's lymphoma, breast cancer etc)
- Anderson Fabry disease
- Danon's disease
- Friedreich's ataxia
- Diabetic cardiomyopathy (restrictive phenotype)
- Drug induced (anthracycline toxicity, methysergide, ergotamine, mercurial agents, etc.)
- Mucopolysaccharidoses (Hurler's cardiomyopathy)
- Myocardial oxalosis
- Wegener's granulomatosis
- Metastatic malignancies
Differentiating restrictive cardiomyopathy from Other Diseases
Restrictive cardiomyopathy should be differentiated from dilated cardiomyopathy, hypertrophic cardiomyopathy, congestive heart failure ect ,
|Type of disease||History||Physical examination||Chest X-ray||ECG||2D echo||Doppler echo||CT||MRI||Catheterization hemodynamics||Biopsy|
|Restrictive cardiomyopathy||Systemic disease (e.g., sarcoidosis, hemochromatosis).||
||Atrial dilatation||Low QRS voltages (mainly amyloidosis), conduction disturbances, nonspecific ST abnormalities||± Wall and valvular thickening, sparkling myocardium||Decreased variation in mitral and/or tricuspid inflow E velocity, increased hepatic vein inspiratory diastolic flow reversal, presence of mitral and tricuspid regurgitation||Normal pericardium||Measurement of iron overload, various types of LGE (late gadolinium enhancement)||LVEDP – RVEDP ≥ 5 mmHg
RVSP ≥ 55 mmHg
RVEDP/RVSP ≤ 0.33
|May reveal underlying cause.|
Epidemiology and Demographics
Restrictive cardiomyopathy is very rare among all other types and accounts for approximately 5% of all cases.
- Its prevalence varies depending on regionality, ethnicity, age, and gender.
- Amyloidosis: It affects men and women equally. The wild-type transthyretin amyloidosis is most often found in the elderly population.
- Sarcoidosis: More common in women than men. The highest prevalence is among black women. The highest incidence worldwide is in Japan.
- Hemochromatosis: Affects both men and women equally.
- Loffler endocarditis: More Common in tropical climates and sub-Saharan Africa.
- Any family history of restrictive cardiomyopathy
- Inherited diseases (such as hereditary hemochromatosis, Fabry disease, mutant-type [hereditary] TTR amyloidosis, etc.)
- Increased number of blood transfusions leading to secondary hemochromatosis.
- Prior anthracycline use in childhood, exposure to other toxic agents.
- Eosinophilic syndrome or chronic parasitic infection
- Exposure to any radiation to the chest.
Natural History, Complications, and Prognosis
- The symptoms of (disease name) usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.
- The symptoms of (disease name) typically develop ___ years after exposure to ___.
- If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
- Common complications of restrictive cardiomyopathy include:
- Rhythm abnormalities(dysrhythmias)
- Cardiac cirrhosis
- Heart failure
- Pulmonary hypertension
- Restrictive cardiomyopathy (RCM) has the worst prognosis among all types of cardiomyopathies.
- Prognosis is generally poor, and the 2/5-year mortality rate of patients is approximately 50% and 70%, respectively.
- There is an estimated 2-5 year survival rate after diagnosis.
Diagnostic Study of Choice
History and Symptoms
- The majority of patients with [disease name] are asymptomatic.
- The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
- Symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
Patients with [disease name]] may have a positive history of:
- [History finding 1]
- [History finding 2]
- [History finding 3]
Common symptoms of include:
- Limited exercise capacity
Less Common Symptoms
Less common symptoms of restrictive cardiomyopathy include
Physical examination of patients with restrictive cardiomyopathy is usually abnormal with characteristic findings in cardiovascular and pulmonary systems.
Appearance of the Patient
- Patients with restrictive cardiomyopathy usually appear normal.
They are usually with in normal limitis.
- Skin examination of patients with restrictive cardiomyopathy is usually normal except in hemochromatosis which may show classic bronze skin
- HEENT examination of patients with restrictive cardiomyopathy is usually normal.
- Jugular venous distension is noted sometimes with kussmaul sign
- Hepatojugular reflux
- Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
- Back examination of patients with restrictive cardiomyopathy is usually normal.
- Genitourinary examination of patients with restrictive cardiomyopathy is usually normal.
- Neuromuscular examination of patients with restrictive cardiomyopathy is usually normal.
- Peripheral edema of the lower extremities
- The laboratory findings depends on the cause of the cardiomyopathy.
- Hematocrit, serum electrolytes, blood urea nitrogen (BUN), creatinine, 24 hr urine total protein, and liver function should be assessed.
- Arterial blood gas (ABG) should be checked for possibility of hypoxia.
- Serum brain natriuretic peptide (BNP) or N-terminal pro-b-type natriuretic peptide (NT-proBNP) and troponin T are indicative of the heart failure.
- Other Specific lab findings will depend upon the cause (angiotensin converting enzyme (ACE) in sarcoidosis, complete blood count (CBC) with peripheral smear helping to establish eosinophilia in hypereosinophilic syndromes, serum iron concentrations, total iron-binding capacity and ferritin levels in hemocromatosis, immunoglobulin free light κ, λ chain testing, and serum and urine immunofixation in amyloidosis, etc.
Shown below is an example of restrictive cardiomyopathy with low voltage and flipped anterior T waves.
A chest X-ray may show atrial dilatation most of the times.
Echocardiography and Ultrasound
Echocardiography may be helpful in the diagnosis of restrictive cardiomyopathy. Findings on an echocardiography suggestive of restrictive cardiomyopathy include:
- Normal or increased wall thickness
- Transmitral spectral Doppler often shows restrictive filling pattern.
- Marked left or biatrial dilatation usually as a consequence of chronically elevated filling pressures.
- Ejection fraction (EF) is normal or near normal.
- The main purpose of echo is the differential diagnosis between constrictive pericarditis(CP) and resrictive cardiomyopathy(RCM).
- Both present as heart failure with normal-sized ventricles and preserved EF, dilated atria, and doppler findings of increased filling pressure often seen in restrictive cardiomyopathy.
- Magnetic Resonance imaging and late gadolinium enhancement (LGE) is very helpful in providing information about anatomic structures, perfusion, ventricular function, as well as tissue characterization.
- Late gadolinium enhancement (LGE) depending on the pattern of scar formation can help the doctor in establishing the diagnosis to specific subtypes of restrictive cardiomyopathy(RCM).
- MRI can also quantify the myocardial iron load in patients with haemochromatosis or thalassemia who receive transfusions.
Other Imaging Findings
- Radionuclide imaging using single-photon emission computed tomography (SPECT), or positron emission tomography (PET), is also used for the diagnostic work-up of amyloidosis.
- An increased myocardial uptake of Tc-99m pyrophosphate or Tc-99m 3,3-diphosphono-1,2-propanodicarboxylic acid helps to identify patients with familial transthyretin-related amyloidosis(ATTR) and also it can differentiate them from those with light chain amyloid(AL).
- Radionuclide imaging with 18fluorodeoxyglucose- (FDG-) PET is recently being used to assist in the diagnosis of cardiac sarcoidosis.
- Decrease in myocardial perfusion with enhanced 18FDG uptake is consistent with inflammation, while decreased perfusion with reduced 18FDG uptake is associated with scarring.
Other Diagnostic Studies
- Restrictive cardiomyopathy has no definitive treatment. But However, the ones directed at individual causes have been proven to be effective.
- The main purpose of treatment in restrictive cardiomyopathy (RCM) is to reduce symptoms by decreasing the elevated filling pressures without significantly lowering the cardiac output.
- Pharmacologic therapy may include:
- Beta blockers
- Cardioselective calcium channel blockers
- Anticoagulants for patients with atrial fibrillation
- Digoxin (use with caution)
- Melphalan (for antiplasma cell therapy in systemic amyloidosis)
- Chemotherapy (in amyloidosis)
- Corticosteroids, cytotoxic agents (eg, hydroxyurea), and interferon (in Loeffler endocarditis)
- Chelation therapy or therapeutic phlebotomy (in hemochromatosis)
- Other treatments:
- Pacemaker implantation
- Cardiac transplantation
- Novel approches (eg, RNA interference or gene silencing molecules that target abnormal protein production in familial amyloidosis)
- ↑ GOODWIN JF, GORDON H, HOLLMAN A, BISHOP MB (January 1961). "Clinical aspects of cardiomyopathy". Br Med J. 1 (5219): 69–79. doi:10.1136/bmj.1.5219.69. PMC 1952892. PMID 13707066.
- ↑ BRIGDEN W (December 1957). "Uncommon myocardial diseases: the non-coronary cardiomyopathies". Lancet. 273 (7008): 1243–9. doi:10.1016/s0140-6736(57)91537-4. PMID 13492617.
- ↑ "Report of the WHO/ISFC task force on the definition and classification of cardiomyopathies". Br Heart J. 44 (6): 672–3. December 1980. doi:10.1136/hrt.44.6.672. PMC 482464. PMID 7459150.
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- ↑ 9.0 9.1 Mogensen J, Kubo T, Duque M, Uribe W, Shaw A, Murphy R, Gimeno JR, Elliott P, McKenna WJ (January 2003). "Idiopathic restrictive cardiomyopathy is part of the clinical expression of cardiac troponin I mutations". J. Clin. Invest. 111 (2): 209–16. doi:10.1172/JCI16336. PMC 151864. PMID 12531876.
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- ↑ 13.0 13.1 13.2 Hong JA, Kim MS, Cho MS, Choi HI, Kang DH, Lee SE, Lee GY, Jeon ES, Cho JY, Kim KH, Yoo BS, Lee JY, Kim WJ, Kim KH, Chung WJ, Lee JH, Cho MC, Kim JJ (September 2017). "Clinical features of idiopathic restrictive cardiomyopathy: A retrospective multicenter cohort study over 2 decades". Medicine (Baltimore). 96 (36): e7886. doi:10.1097/MD.0000000000007886. PMC 6393124. PMID 28885342.
- ↑ 14.0 14.1 14.2 14.3 Rammos A, Meladinis V, Vovas G, Patsouras D (2017). "Restrictive Cardiomyopathies: The Importance of Noninvasive Cardiac Imaging Modalities in Diagnosis and Treatment-A Systematic Review". Radiol Res Pract. 2017: 2874902. doi:10.1155/2017/2874902. PMC 5705874. PMID 29270320.
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- ↑ 16.0 16.1 Biçer M, Özdemir B, Kan İ, Yüksel A, Tok M, Şenkaya I (November 2015). "Long-term outcomes of pericardiectomy for constrictive pericarditis". J Cardiothorac Surg. 10: 177. doi:10.1186/s13019-015-0385-8. PMC 4662820. PMID 26613929.
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- ↑ Alvarez P, Tang WW (2017). "Recent Advances in Understanding and Managing Cardiomyopathy". F1000Res. 6: 1659. doi:10.12688/f1000research.11669.1. PMC 5590086. PMID 28928965.