2.1.3. Acquired Causes of DCM

DCM can also be acquired through mechanisms unrelated to genetic factors. Causes of DCM outside of familial inheritance include infection or ischemia, which can lead to myocarditis [47]. Viral infection can cause both damaging immune and inflammatory responses and direct viral toxicity, resulting in cardiac myocyte necrosis, fibrotic development, and ventricular dilation [48]. Enterovirus infection can also cause cardiomyopathy, and in its most severe form, sudden death. The mechanism of disease is thought to be through the virus-encoded 2A protease, which cleaves the dystrophin protein. The resulting dystrophin fragment increases risk for fibrosis and ischemic injury *in vivo* [49]. Reductions in myocardial perfusion, a known deficit caused by ischemic heart disease, is also observed in DCM patients [50]. Defects in myocardial blood flow can lead to chronic ischemic events and thus contribute to the progression of DCM [51].

## *2.2. The Role of Calcium Cycling in DCM Pathogenesis*
