Cardiomyopathies & Valvular Disorders - BMH/Tele

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Cardiomyopathies & Valvular Disorders - BMH/Tele

  1. 1. Cardiomyopathies & Valvular Disorders Telemetry Course Natalie Bermudez, RN, BSN, MS Clinical Educator for Cardiac Telemetry
  2. 2. Cardiomyopathies <ul><li>Disease of the Heart Muscle </li></ul><ul><li>FACTS: </li></ul><ul><li>Cardiomyopathy is the 2 nd most common cause of sudden death </li></ul><ul><li>** CAD is #1** </li></ul><ul><li>Prognosis for Dilated Cardiomyopathy is very poor </li></ul><ul><li>** Undiagnosed until in advanced stages ** </li></ul>
  3. 3. Cardiomyopathies <ul><li>RISK FACTORS: </li></ul><ul><li>Hypertension </li></ul><ul><li>Pregnancy </li></ul><ul><li>Viral Infections </li></ul><ul><li>ETOH Abuse </li></ul><ul><li>Males (overall) </li></ul><ul><li>African descent (both sexes) </li></ul>
  4. 4. DIAGNOSTIC EVALUATION: <ul><li>Echocardiography -> confirms dilated cardiomyopathy </li></ul><ul><li>Chest X-Ray -> reveals cardiomegaly associated with any of the cardiomyopathies </li></ul><ul><li>Cardiac Cath with possible Biopsy -> can be definitive in diagnosing hypertrophic cardiomyopathy </li></ul>
  5. 5. Cardiomyopathies <ul><li>DILATED CARDIOMYOPATHY </li></ul><ul><li>Primarily affects systolic function ** (pumping action) ** </li></ul><ul><li>Results from extensive damage to myocardial muscle fibers </li></ul><ul><li>End-result -> LV contractility ↓ </li></ul>
  6. 6. <ul><li>Poor Compensation </li></ul><ul><li>SV, EF, and CO ↓ </li></ul><ul><li>** (D/T decreased in pumping action) ** </li></ul><ul><li>Pulmonary Congestion </li></ul><ul><li>** If end-diastolic volumes increase ↑ ** </li></ul><ul><li>↑ End-Diastolic Volume is a Compensatory Response </li></ul><ul><li>** Preserves SV even though there is ↓ EF ** </li></ul>DILATED CARDIOMYOPATHY
  7. 7. <ul><li>Poor Compensation </li></ul><ul><li>Sympathetic Nervous System is stimulated </li></ul><ul><li>** Increases HR & Contractility ** </li></ul><ul><li>Kidneys are stimulated (Renin-Angiotensin) to Retain Na & H 2 O </li></ul><ul><li>** Maintain adequate CO ** </li></ul><ul><li>Vasoconstriction also Occurs </li></ul>DILATED CARDIOMYOPATHY
  8. 8. <ul><li>Poor Compensation </li></ul><ul><li>When compensatory triggers can no longer keep up to maintain adequate CO… </li></ul><ul><li>The Heart Begins to Fail!!! </li></ul>DILATED CARDIOMYOPATHY
  9. 9. <ul><li>Detrimental Dilation </li></ul><ul><li>Venous Return & Systemic Vascular Resistance Increase </li></ul><ul><li>** LV Dilation Occurs ** </li></ul><ul><li>With Time, Atria Also Dilate (Atrial Remodeling) </li></ul><ul><li>** More work required to pump blood into full ventricles ** </li></ul><ul><li>Cardiomegaly is a consequence of atrioventricular dilation </li></ul>DILATED CARDIOMYOPATHY
  10. 10. Dilated Cardiomyopathy <ul><li>STATISTICS: </li></ul><ul><li>Affects 5 to 8 of 100,000 people </li></ul><ul><li>50% of all deaths resulting from DCM occur suddenly </li></ul><ul><li>In a study conducted in 1988, 5-year mortality rate of 50% has been reported for DCM of various etiologies with EF < 50% </li></ul><ul><li>A more recent study in 2000 showed a 5-year survival rate of 75% </li></ul><ul><li>Woods et al, 2005, p. 783 </li></ul>
  11. 11. Idiopathic Dilated Cardiomyopathy <ul><li>Has a prevalence of 0.04% and is a relatively common cause of heart failure </li></ul><ul><li>Incidence increases with age and is higher in males </li></ul><ul><li>50% of IDC cases may be familial </li></ul><ul><li>Endomyocardial biopsy provides a definitive diagnosis </li></ul><ul><li>Moser & Riegel, 2008, p. 1110 </li></ul>
  12. 12. Secondary Dilated Cardiomyopathy <ul><li>Ischemic Dilated Cardiomyopathy </li></ul><ul><li>The most common type of dilated cardiomyopathy </li></ul><ul><li>Caused by Coronary Artery Disease </li></ul><ul><li>About 15% to 45% of patients who have a myocardial infarction will develop dilatation of the left ventricle with a decrease in ejection fraction </li></ul><ul><li>Prognosis is worse for ischemic cardiomyopathy, than for non-ischemic cardiomyopathies </li></ul><ul><li>Moser & Riegel, 2008, p. 1111 </li></ul>
  13. 13. Secondary Dilated Cardiomyopathy <ul><li>Hypertensive Dilated Cardiomyopathy </li></ul><ul><li>Valvular Dilated Cardiomyopathy </li></ul><ul><li>Anthracycline Dilated Cardiomyopathy </li></ul><ul><li>(Anthracycline = Anticancer Agent) </li></ul><ul><li>Peripartum Dilated Cardiomyopathy </li></ul><ul><li>Alcohol-Related Dilated Cardiomyopathy </li></ul><ul><li>Moser & Riegel, 2008 </li></ul>
  14. 14. <ul><li>Dilated Cardiomyopathy </li></ul><ul><li>May be overlooked until LV Failure Occurs </li></ul><ul><li>SOB, orthopnea, DOE </li></ul><ul><li>PND, Dry Cough @ night, Fatigue </li></ul><ul><li>Peripheral Edema, Hepatomegaly, JVD, Weight Gain </li></ul>Signs & Symptoms
  15. 15. <ul><li>Dilated Cardiomyopathy </li></ul><ul><li>Peripheral Cyanosis </li></ul><ul><li>Tachycardia </li></ul><ul><li>Pansystolic Murmur (mitral/tricuspid insufficiency) </li></ul><ul><li>S 3 & S 4 gallops rhythms </li></ul><ul><li>Irregular Pulse (with A-Fib) </li></ul>Signs & Symptoms
  16. 16. TREATMENT <ul><li>Dilated Cardiomyopathy </li></ul><ul><li>Management of underlying cause, if known </li></ul><ul><li>ACEI (First-line), to reduce afterload </li></ul><ul><li>Diuretics with ACEI’s </li></ul><ul><li>Digoxin </li></ul><ul><li>Hydralazine/Isosorbide Dinitrate </li></ul><ul><li>Antiarrhythmics </li></ul><ul><li>Cardioversion (A-Fib to Sinus) </li></ul>
  17. 17. TREATMENT: <ul><li>Dilated Cardiomyopathy </li></ul><ul><li>Pacemaker Insertion </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Revascularization (CABG) if d/t ischemia </li></ul><ul><li>Valvular Repair/Replacement </li></ul><ul><li>Lifestyle Modifications </li></ul><ul><li>Heart Transplant </li></ul>
  18. 18. Cardiomyopathies <ul><li>HYPERTROPHIC CARDIOMYOPATHY </li></ul>Primarily Affects Diastolic Function (**filling***) Features of HCM: Asymmetrical LV Hypertrophy Hypertrophy of Intraventricular Septum (HOCM) Rapid, forceful contractions of LV Impaired Relaxation Obstruction of LV outflow
  19. 19. <ul><li>Hypertrophied ventricles become stiff </li></ul><ul><li>Do not relax during ventricular filling </li></ul><ul><li>** aka Diastole ** </li></ul><ul><li>Ventricular filling ↓ , LV pressure ↑ </li></ul><ul><li>↑ Left Atrial & Pulmonary Venous Pressures </li></ul><ul><li>** Leads to Venous Congestion & Dyspnea ** </li></ul>HYPERTROPHIC CARDIOMYOPATHY
  20. 20. <ul><li>Compensatory response kicks in -> ↑ HR </li></ul><ul><li>** Ventricular Filling Decreases Even More ** </li></ul><ul><li>↓ Ventricular Filling Time & Obstruction of Ventricular Outflow -> ↓ CO </li></ul><ul><li>MVR occurs if papillary muscles hypertrophy and valve doesn’t close </li></ul>HYPERTROPHIC CARDIOMYOPATHY
  21. 21. HYPERTROPHIC CARDIOMYOPATHY <ul><li>STATISTICS: </li></ul><ul><li>As many as 60% to 80% of cases are inherited through autosomal dominant transmission </li></ul><ul><li>Usually goes undetected until adulthood </li></ul><ul><li>It prevalence is 1 per 500 in the general U.S. population and is higher in blacks </li></ul><ul><li>Woods et al, 2005, p. 784 </li></ul>
  22. 22. <ul><li>Hypertrophic Cardiomyopathy </li></ul><ul><li>Angina </li></ul><ul><li>Dyspnea </li></ul><ul><li>Fatigue </li></ul><ul><li>Systolic ejection murmur </li></ul><ul><li>(left sternal border & apex) </li></ul><ul><li>Pulsus biferiens </li></ul><ul><li>(peripheral pulse with a characteristic double impulse) </li></ul><ul><li>Abrupt arterial Pulse </li></ul><ul><li>Irregular Pulse (with A-fib) </li></ul>Signs & Symptoms
  23. 23. <ul><li>Hypertrophic Cardiomyopathy </li></ul><ul><li>Beta-Blockers </li></ul><ul><li>( ↓ HR, ↓ O 2 demand, improve ventricular filling) </li></ul><ul><li>Cardioversion (A-Fib to Sinus) </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Ca Channel Blockers </li></ul><ul><li>(reduce stiffness, ↑ diastolic pressures) </li></ul>TREATMENT:
  24. 24. <ul><li>Hypertrophic Cardiomyopathy </li></ul><ul><li>Ablation of AV Node (HOCM) </li></ul><ul><li>Dual Chamber Pacemaker (HOCM) </li></ul><ul><li>AICD </li></ul><ul><li>Ventricular myotomy/myectomy </li></ul><ul><li>Mitral Valve Replacement </li></ul><ul><li>Heart Transplant </li></ul>TREATMENT:
  25. 25. Cardiomyopathies <ul><li>RESTRICTIVE CARDIOMYOPATHY </li></ul>Characterized as stiffness of the ventricle ** LV Hypertrophy & Endocardial Fibrosis Thickening ** Ventricle does not relax during diastole ** Ventricular Filling Reduced ** The rigidity of the myocardium causes failure to completely contract during systole ** End-result is decreased CO **
  26. 26. <ul><li>Restrictive Cardiomyopathy </li></ul><ul><li>Chest Pain </li></ul><ul><li>Dyspnea </li></ul><ul><li>Fatigue </li></ul><ul><li>Orthopnea </li></ul><ul><li>Edema </li></ul><ul><li>Systolic murmurs </li></ul><ul><li>Pallor </li></ul><ul><li>S 3 & S 4 gallops rhythms </li></ul>Signs & Symptoms
  27. 27. <ul><li>Restrictive Cardiomyopathy </li></ul><ul><li>Management of underlying cause </li></ul><ul><li>Digoxin </li></ul><ul><li>Diuretics </li></ul><ul><li>Restricted Na Diet </li></ul><ul><li>Oral Vasodilators </li></ul>TREATMENT:
  28. 28. Valvular Disorders <ul><li>Malfunction of the Heart Valves </li></ul><ul><li>Mitral & Aortic Valve Disorders: </li></ul><ul><li>Insufficiency (Regurgitation) </li></ul><ul><li>Stenosis </li></ul><ul><li>Prolapse (Mitral Only) </li></ul>
  29. 29. Valvular Disorders <ul><li>Main Problems with Valvular Disorders: </li></ul><ul><li>Atrial and Ventricular Remodeling </li></ul><ul><li>Heart Failure </li></ul>
  30. 30. Mitral Valve Insufficiency The abnormal leaking of blood through mitral valve, from the left ventricle into the left atrium May be caused by stenosis or prolapse of the mitral valve
  31. 31. <ul><li>Dysfunctions of the following valvular components can cause MVI: </li></ul><ul><li>Valve Leaflets </li></ul><ul><li>Papillary Muscles </li></ul><ul><li>Chordae Tendonae </li></ul><ul><li>Annulus (stretched </li></ul><ul><li>d/t cardiac </li></ul><ul><li>enlargement) </li></ul>Mitral Valve Insufficiency
  32. 32. Mitral Valve Stenosis Narrowing of the mitral valve; Results in impedance of blood flow to ventricles Results in decreased ventricular filling = ↓ CO Backflow to Left Atrium = Atrial Remodeling
  33. 33. MVS is very commonly caused by atherosclerotic disease which results in calcification of valves Other Causes: Congenital Heart Disease Rheumatic Heart Disease
  34. 34. Mitral Valve Prolapse Folding, inversion, and displacement of mitral valve leaflets towards the left atrium
  35. 35. Mitral Valve Prolapse <ul><li>Chordae tendonae becomes elongation </li></ul><ul><li>May cause it to rupture </li></ul><ul><li>Displacement > 2 mm above mitral annulus </li></ul>
  36. 36. Aortic Valve Insufficiency Aortic Valve fails to close completely Causes backflow of blood into ventricle May be caused by stenosis or prolapse of the aortic valve
  37. 37. Aortic Valve Insufficiency VENTRICULAR REMODELING: Eccentric Hypertrophy – (ventricular wall thickening with dilatation) Concentric Hypertrophy – (ventricular wall thickening with diminished capacity)
  38. 38. Aortic Valve Stenosis The hardening of the aortic valve or aorta itself
  39. 39. Aortic Valve Stenosis
  40. 40. AVS is very commonly caused by atherosclerotic disease which results in calcification of valves <ul><li>Other Causes: </li></ul><ul><li>Congenital aortic bicuspid valve (associated with coarctation of the aorta) </li></ul><ul><li>Rheumatic Heart Disease </li></ul>
  41. 41. References <ul><li>Donofrio, J., Haworth,K., Achaeffer, L., & Thompson, G. (2005). Cardiovascular care made incredibly easy. Ambler, PA: Lippincott Wilkins & Williams </li></ul><ul><li>Hodgson, B. B., & Kizior, R. J. (2007). Saunders nursing drug handbook. St. Louis, MS: Saunders Elsevier. </li></ul><ul><li>Moser, D. k., & Riegel, B. (2008). Cardiac nursing: A companion to braunwald’s heart disease. St. Louis, MS: Saunders Elsevier. </li></ul><ul><li>Skidmore-Roth, L. et al. (2007). Mosby’s nursing drug reference, (20 th ed.). St. Louis, MS: Mosby Elsevier. </li></ul><ul><li>Smeltzer et al. (2008). Brunner and suddarth’s textbook of medical-surgical nursing, (11 th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. </li></ul><ul><li>Woods, S. L., Sivarajan Froelicher, E. S., Underhill Motzer, S., & Bridges, E. J. (2005). Cardiac Nursing (5 th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. </li></ul>

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