Restrictive cardiomyopathy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S.[2] 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.

Historical Perspective




Cardiac Amyloidosis

  • 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[9][10][11][12]:

Gross Pathology

On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Left side of the heart from a 3-year-old castrated male domestic short-haired catwith the endomyocardial form of restrictive cardiomyopathy (RCM), showing extensiveendocardial fibrosis involving substantial portions of the left ventricular cavity, Affiliation: Laboratory of Veterinary Clinical Oncology, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu, Tokyo 183-8509, Japan.

Microscopic Pathology

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.
  • Sarcoidosis:
    • 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:[13][14]

Differentiating restrictive cardiomyopathy from Other Diseases

Restrictive cardiomyopathy should be differentiated from dilated cardiomyopathy, hypertrophic cardiomyopathy, congestive heart failure ect [14],[13]

Differentiating restrictive cardiomyopathy from Other Diseases
Type of disease History Physical examination Chest X-ray ECG 2D echo Doppler echo CT MRI Catheterization hemodynamics Biopsy
Restrictive cardiomyopathy[14][9][13] 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


May reveal underlying cause.
Constrictive pericarditis[15][16][16]
  • Thickened pericardium
  • LVEDP – RVEDP < 5 mmHg
  • RVSP < 55 mmHg
  • RVEDP/RVSP > 0.33
  • Inspiratory decrease in RAP < 5 mmHg
  • Systolic area index > 1.1 (Ref CP in the modern era)
  • Left ventricular height of rapid filling wave > 7 mmHg
  • Normal myocardium
Hypertrophic cardiomyopathy(HCM)[17][18]
Dilated Cardiomyopathy[19][20][21][22]
  • LV dilation with diffuse hypokinetic walls

Epidemiology and Demographics


Restrictive cardiomyopathy is very rare among all other types and accounts for approximately 5% of all cases.[23][24]


  • 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.

Risk Factors

  • Any family history of restrictive cardiomyopathy[25][26]
  • 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

Natural History

  • 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:
    • Thromboembolism
    • 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

Common symptoms of include:

  • Dyspnea
  • Fatigue
  • Limited exercise capacity
  • Palpitations
  • Syncope

Less Common Symptoms

Less common symptoms of restrictive cardiomyopathy include

  • Angina

Physical Examination

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.

Vital Signs

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.



  • Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
  • Rhonchi




  • 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

Laboratory Findings


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:

CT scan


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.[31][32][33][34]
  • 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


Medical Therapy


Primary Prevention

Secondary Prevention


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