When left bundle-branch block (LBBB) is accompanied by right axis deviation (RAD), the rare combination is considered to be highly suggestive of dilated or congestive cardiomyopathy. Echocardiogram shows left ventricular dilatation with normal or thinned walls and reduced ejection fraction. Cardiac catheterization and coronary angiography are often performed to exclude ischemic heart disease.Genetic testing can be important, since one study has shown that gene mutations in the TTN gene (which codes for a protein called titin) are responsible for "approximately 25% of familial cases of idiopathic dilated cardiomyopathy and 18% of sporadic cases." The results of the genetic testing can help the doctors and patients understand the underlying cause of the dilated cardiomyopathy. Genetic test results can also help guide decisions on whether a patients relatives should undergo genetic testing (to see if they have the same genetic mutation) and cardiac testing to screen for early findings of dilated cardiomyopathy.Cardiac magnetic resonance imaging (cardiac MRI) may also provide helpful diagnostic information in patients with dilated cardiomyopathy. Treatment
Medical therapy
Drug therapy can slow down progression and in some cases even improve the heart condition. Standard therapy may include salt restriction, ACE inhibitors, diuretics, and beta blockers. Anticoagulants may also be used for antithrombotic therapy. There is some evidence for the benefits of coenzyme Q10 in treating heart failure. Electrical treatment
Artificial pacemakers may be used in patients with intraventricular conduction delay, and implantable cardioverter-defibrillators in those at risk of arrhythmia.
But Threnody explains that her presence at the castle caused her father to dote on her and neglect his duties to the destruction of the kingdom; her stepmother had merely made her destructive potential literal, and forced her to confront what she was doing.The character of the evil stepmother can also be found in the genre of young adult fiction or young adult social problem novels. In Lisa Heathfields Paper Butterflies. the protagonist June suffers horrific abuse at the hands of her stepmother, a fact that she conceals from her father. Despite many examples of evil or cruel stepmothers, loving stepmothers also exist in fiction. In Kevin and Kell, Kell is portrayed as loving her stepdaughter Lindesfarne, whom her husband Kevin had adopted during his previous marriage. Likewise, Lindesfarne considers Kell her mother, and has a considerably more favorable view of her than Angelique, Kevins ex-wife and her adoptive mother, due to feeling neglected by Angelique during her childhood. The Disney film Enchanted also makes references to the "evil stepmother" belief, as the villainess is a stepmother, but her wickedness comes from her selfishness and power hungriness rather than the simple fact she is a stepmother. When a little girl tells the heroine Giselle that all stepmothers are evil, Giselle reminds her that she personally knows some wonderful women who were good stepmothers, and the fact a woman is a stepmother does not suddenly change her personality.