Quick answer
What Is Nonischemic Cardiomyopathy?
Nonischemic cardiomyopathy is a term for heart muscle that has weakened or changed shape for reasons other than coronary artery disease, such as genetic factors, inflammation, alcohol, chemotherapy drugs, or pregnancy, and it can cause heart failure.
SourcesSigns That Need Urgent Help
- Severe shortness of breath at rest
- Coughing up frothy or pink phlegm
- Fainting or nearly fainting
- A very fast heartbeat with weakness or cold sweat
- Chest pain that does not go away after a few minutes
- Cold, pale skin, or passing urine very rarely
If these signs appear, go to the nearest emergency department right away or call Heart Attack Center 1500 258.
01 / Understanding the condition
About Nonischemic Cardiomyopathy
Nonischemic cardiomyopathy is the term doctors use for a heart muscle disorder, usually with a weakened left ventricular pump, that is not caused by coronary artery disease. The term arose from a practical need: when someone is diagnosed with heart failure with a low ejection fraction, the first step is to find out whether their coronary arteries are narrowed. If they are not, or the narrowing does not sufficiently explain the weakened pump, the condition is called nonischemic, and the doctor then looks for a more specific cause.
What the Term Covers
Nonischemic cardiomyopathy is not a single disease. It includes dilated cardiomyopathy, covered on the Dilated Cardiomyopathy page, as well as non-dilated left ventricular cardiomyopathy as described in the 2023 European Society of Cardiology (ESC) guidelines, meaning scarring or a weakened pump without enlargement of the chamber. Specific causes can include genetic abnormalities, myocarditis, alcohol, chemotherapy drugs, fast heart rhythms that last a long time, pregnancy, autoimmune diseases, or buildup of substances as in infiltrative cardiomyopathy. Cardiomyopathy caused by alcohol or drugs is covered on the Toxic Cardiomyopathy page, while the form that appears around the time of giving birth is covered on the Peripartum Cardiomyopathy page.
Why the Cause Needs to Be Found
The basic treatment is the same as for heart failure in general, but some causes have specific treatments. Stopping alcohol, controlling an overly fast rhythm, or treating inflammation can clearly improve pumping function. Cardiac MRI results and genetic testing also help assess the risk of rhythm disorders. This matters because the DANISH study showed that a preventive ICD did not reduce overall deaths across all nonischemic patients, so decisions about implanting one now give more weight to each person's individual risk, for example extensive scarring or certain gene changes.
Chances of Improvement
Compared with ischemic cardiomyopathy, nonischemic cardiomyopathy more often shows improvement in ejection fraction after treatment. Even so, this improvement does not always mean a cure. In the TRED-HF study, nearly half of patients who had improved and then stopped their medicines had a relapse within six months, so medicines are usually continued. Regular follow-up with echocardiography helps your doctor assess improvement and adjust treatment with you. An overview of the cardiomyopathy family is covered on the Cardiomyopathy page.
02 / Understanding the condition
Symptoms to Recognize.
Common Symptoms
- Shortness of breath during activity or when lying flat
- Tiring easily and a reduced ability to be active
- Swelling in the ankles, legs, or abdomen
- Rapid weight gain over a few days
- Palpitations or a heartbeat that feels irregular
- Dizziness or feeling close to fainting
- Coughing or breathlessness that wakes you at night
Symptoms in Adult Women
Peripartum cardiomyopathy, one form of nonischemic cardiomyopathy, can appear from late pregnancy until several months after giving birth.
- Shortness of breath that gets worse in late pregnancy or after giving birth
- Being unable to sleep lying flat because of shortness of breath
- Leg swelling that increases after delivery
- Coughing at night or unusual palpitations
03 / Understanding the condition
What Causes This Condition?
- Genetic abnormalities in heart muscle proteins, which can run in families
- Myocarditis, an inflammation of the heart muscle after a viral infection or due to an autoimmune disease
- Excessive alcohol use or use of substances such as cocaine and methamphetamine
- Chemotherapy drugs such as anthracyclines or trastuzumab, as well as radiation to the chest area
- Heart rhythms that are too fast for a long time
- Pregnancy and the period after giving birth (peripartum cardiomyopathy)
- Buildup of abnormal substances such as amyloid or iron, as well as sarcoidosis
- Hormonal disorders such as thyroid disease, or a deficiency of certain nutrients
04 / Understanding the condition
Who Is at Higher Risk?
Genetic
A family history of cardiomyopathy, heart failure at a young age, a pacemaker or ICD implanted at a young age, or sudden cardiac arrest.
Lifestyle
Drinking too much alcohol over a long time and using substances such as cocaine or methamphetamine can damage the heart muscle.
Medical
A history of chemotherapy or chest radiation, myocarditis, autoimmune disease, thyroid disorders, diabetes, and uncontrolled fast heart rhythms.
Other
Pregnancy, especially over age 30, a twin pregnancy, or a pregnancy with preeclampsia, is linked to a risk of peripartum cardiomyopathy.
Groups at Higher Risk
- Cancer Survivors: Anthracyclines, trastuzumab, and chest radiation can weaken the heart muscle, sometimes years after treatment ends.
- Pregnant Women and New Mothers: Peripartum cardiomyopathy can appear from late pregnancy until several months after giving birth, and is covered on the Peripartum Cardiomyopathy page.
- Heavy Drinkers: Drinking too much alcohol over a long time can weaken the heart muscle. Pumping function often improves when alcohol is stopped.
- Relatives of People with Cardiomyopathy: Close relatives can carry the same gene change even without symptoms, so family screening is recommended.
05 / Understanding the condition
How Is It Diagnosed?
When echocardiography shows a weakened pump, the doctor first checks whether the coronary arteries are narrowed, using coronary CT or coronary angiography. If there is no narrowing, or it does not sufficiently explain the weakened pump, the condition is called nonischemic and the search for the cause continues. The doctor asks about alcohol habits, medicines including chemotherapy, past infections, pregnancy, and family history going back three generations. Cardiac MRI with contrast helps distinguish myocarditis, infiltrative disease, sarcoidosis, and genetic scar patterns. Blood tests look for thyroid disorders, iron overload, and other treatable causes. Rhythm recordings help identify rhythm disorders as either a cause or a result. In certain situations, for example suspected severe myocarditis or sarcoidosis, the doctor may consider a heart muscle biopsy. Genetic testing and family screening are recommended when the results would affect treatment.
Echocardiography
Measures the ejection fraction and chamber size and assesses the valves, as the first step when heart failure is suspected.
Coronary Angiography
Rules out narrowing of the coronary arteries as the cause, so the condition can be classified as nonischemic.
CT Coronary Angiography
An option without a catheter to rule out coronary artery disease in patients with a low to intermediate likelihood of it.
Cardiac MRI
Looks for scar tissue, inflammation, or buildup of substances that point to a particular cause and helps assess the risk of rhythm disorders.
Laboratory Tests
Blood tests for thyroid, kidney, and liver function, iron, and markers of heart strain such as NT-proBNP.
Holter Monitoring
Records the heart rhythm for 24 to 48 hours to look for ventricular rhythm disorders or fast rhythms that may be the cause.
Genetic testing from a blood sample in selected patients, for example when there is a family history or an electrical conduction disorder, to look for gene changes that affect treatment.
06 / Understanding the condition
Treatment Options.
Treatment is decided by a doctor after an assessment. The categories below can help you follow the conversation with your doctor.
Core Heart Failure Medicines
ARNI or ACE inhibitors, beta blockers, mineralocorticoid antagonists, and SGLT2 inhibitors are chosen by the doctor, with doses increased gradually.
Fluid-Removing Medicines
Diuretics are used to reduce shortness of breath and swelling caused by fluid buildup, with doses adjusted by the doctor.
Treating the Specific Cause
Stopping alcohol, controlling fast rhythms, treating inflammation or thyroid disorders, and adjusting chemotherapy together with the oncologist.
Implantable Cardioverter Defibrillator
Considered if the ejection fraction stays at 35 percent or less after at least three months of treatment, weighing age, scar tissue, and genetic factors.
Cardiac Resynchronization Therapy
For patients with a low ejection fraction and left bundle branch block or another conduction disorder, so both ventricles contract in sync.
Cardiac Rehabilitation
Supervised exercise and education to improve fitness and your ability to care for yourself at home.
Advanced Heart Failure Therapy
A left ventricular assist device (LVAD) or a heart transplant is considered for selected patients.
07 / Understanding the condition
Complications to Watch For.
Heart Failure
A weak pump causes fluid to build up in the lungs and legs, and this can worsen at any time and require a hospital stay.
Ventricular Rhythm Disorders
Scar tissue in the heart muscle can trigger ventricular tachycardia. The risk is assessed from the ejection fraction, MRI results, and genetic factors.
Atrial Fibrillation
Enlarged atria make atrial fibrillation more likely, which worsens shortness of breath and increases the risk of stroke.
Blood Clots and Stroke
Slow blood flow in a weak, enlarged ventricle can form clots that travel to the brain.
Mitral Valve Leakage
An enlarged left ventricle pulls on the mitral valve leaflets so the valve does not close tightly, adding to the heart's workload.
08 / Understanding the condition
What Can You Do?
- Limit alcohol, and stop completely if your heart's pumping function has already declined
- Avoid cocaine, methamphetamine, and similar substances
- Ask for monitoring of your heart function before and during certain chemotherapy treatments
- Get frequent or long-lasting palpitations checked so a fast rhythm does not weaken your heart
- Encourage close family members to get checked if the cause is genetic
- Take your medicines as prescribed even if you already feel better
- Weigh yourself every morning and limit salt as your doctor advises
09 / Understanding the condition
When Should You See a Doctor?
See a cardiologist if the following complaints appear or get worse. If you have already been diagnosed, tell your care team when your complaints change from usual. Severe shortness of breath at rest or fainting needs emergency room care right away.
- Shortness of breath with light activity or when lying down
- Leg swelling or rapid weight gain
- Palpitations, dizziness, or nearly fainting
- Shortness of breath or swelling in late pregnancy or after giving birth
- Currently receiving or having had chemotherapy, with new shortness of breath or fatigue
- Close family members with cardiomyopathy or sudden cardiac arrest at a young age
Don't Wait in an Emergency.
If symptoms are severe or come on suddenly, go to the nearest emergency department right away or call Heart Attack Center 1500 258, rather than waiting for an appointment.
10 / Common questions
Questions You May Have.
Frequently asked questions about nonischemic cardiomyopathy.
What is the difference between nonischemic cardiomyopathy and dilated cardiomyopathy?
Nonischemic cardiomyopathy is a broader term for any weakening of the heart muscle that is not caused by coronary artery disease. Dilated cardiomyopathy is one of its forms, in which the left ventricle is enlarged and its pumping is weakened. Other forms include non-dilated left ventricular cardiomyopathy and cardiomyopathy from specific causes, such as inflammation or buildup of substances. Doctors try to determine the form and cause because they can affect treatment.
Can my heart function return to normal?
In a fair number of nonischemic patients, the ejection fraction improves after several months of treatment, especially when the cause can be removed, such as alcohol or an overly fast rhythm. This is called heart failure with improved ejection fraction. However, the heart muscle often remains vulnerable. In the TRED-HF study, nearly half of patients who stopped their medicines had a relapse within six months, so medicines are usually continued.
Will I definitely need an ICD?
Not always. The DANISH study showed that in nonischemic patients as a whole, a preventive ICD did not reduce total deaths, although it did reduce sudden cardiac death. For this reason, doctors weigh age, the ejection fraction after treatment, scar tissue on MRI, and genetic factors. The assessment is usually done after at least three months of treatment, because some patients improve and no longer need one.
Why do I need a cardiac MRI?
A cardiac MRI can show scar tissue, inflammation, and buildup of substances in the heart muscle that are not visible on echocardiography. The pattern of findings helps the doctor narrow down the cause, for example myocarditis, sarcoidosis, amyloidosis, or a genetic disorder. The extent of scarring also helps assess the risk of rhythm disorders and the chance of pumping function improving, which is useful when deciding on treatment.
Does chemotherapy always damage the heart?
No. Only some cancer drugs can affect the heart, and not every patient who receives them develops problems. The risk is assessed before treatment, and heart function is then monitored during and after treatment. If heart function declines, the cardiologist and oncologist can adjust the treatment plan together. This topic is covered on the Cancer Therapy-Related Heart Disease page.
Can I drink alcohol occasionally?
If you have nonischemic cardiomyopathy, doctors generally advise not drinking alcohol, especially if alcohol is suspected to play a role or your pumping function is still low. Alcohol can weaken the heart muscle, trigger atrial fibrillation, and interact with medicines. In alcohol-related cardiomyopathy, stopping completely often improves heart function. Tell your doctor if you need help to stop.
Sources and Medical Review
Translated from the Indonesian edition medically reviewed by dr. Sri Diniharini, Sp.JP(K).
Sources as cited in the Indonesian edition.
- Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J. 2023;44(37):3503-626.
- McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-726.
- Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-1032.
- Køber L, Thune JJ, Nielsen JC, Haarbo J, Videbæk L, Korup E, et al. Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. N Engl J Med. 2016;375(13):1221-30.
- Halliday BP, Wassall R, Lota AS, Khalique Z, Gregson J, Newsome S, et al. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial. Lancet. 2019;393(10166):61-73.
- Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, et al. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation. 2016;134(23):e579-646.
- Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J. 2022;43(41):4229-361.
Doctors Who Treat This Condition
dr. Siska S. Danny, Sp.JP(K)
Interventional Cardiology
Coronary Intervention Procedures
Clinical focusPCI for Acute Coronary Syndrome · Primary Coronary Intervention
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Dr. dr. Dicky A. Hanafy, Sp.JP(K)
Arrhythmia and Electrophysiology
Arrhythmia and Device Center +1 center
Clinical focusElectrophysiology and Arrhythmia Ablation · Pacemaker and ICD Implantation
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dr. Sri Diniharini, Sp.JP(K)
Echocardiography & Cardiovascular Imaging
Cardiovascular Diagnostic Center +1 center
Clinical focusAdvanced Echocardiography · Transesophageal Echocardiography
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