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The myocardium can be affected by inflammatory (infectious or immune-mediated), metabolic, infiltrative, ischemic, or primary disease processes. These disorders may be inherited and may have significant overlap (eTable 489.1). Myocardial diseases may present acutely, with signs of congestive heart failure that include tachypnea, often with rales; tachycardia; an enlarged but quiet heart; soft heart sounds that may have a tic-tac rhythm; cardiac gallops; and either no murmurs or systolic murmurs of mitral or tricuspid regurgitation. Alternatively, they may present chronically with failure to thrive, decreased exercise tolerance, and more subtle findings of heart failure. Occasionally, the predominant process may be an arrhythmia, either atrial or ventricular tachycardia/fibrillation, or heart block. These present clinically with palpitations, syncope, or sudden death. The electrocardiogram and chest x-ray are useful in confirming the presence of heart disease, but are rarely diagnostic.

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eTable 489.1. Causes of Myocardial Disease 
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In acute presentations, the chest x-ray usually shows diffuse cardiac enlargement, passive pulmonary congestion, and interstitial edema; the electrocardiogram ...

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