cardiomyopathies & valvular disorders - bmh/tele

Cardiomyopathies & Cardiomyopathies & ValvularValvular DisordersDisorders

Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MS

Telemetry Telemetry CourseCourse

Clinical Educator for Cardiac TelemetryClinical Educator for Cardiac Telemetry

CardiomyopathiesCardiomyopathiesDisease of the Heart MuscleDisease of the Heart Muscle

FACTS:FACTS:Cardiomyopathy is the 2Cardiomyopathy is the 2ndnd most most common cause of sudden deathcommon cause of sudden death

** CAD is #1**** CAD is #1**

Prognosis for Dilated Prognosis for Dilated Cardiomyopathy is very poorCardiomyopathy is very poor

** Undiagnosed until in advanced stages **** Undiagnosed until in advanced stages **

CardiomyopathiesCardiomyopathies

RISK FACTORS:RISK FACTORS:

Hypertension Hypertension

PregnancyPregnancy

Viral InfectionsViral Infections

ETOH AbuseETOH Abuse

Males (overall)Males (overall)

African descent (both sexes)African descent (both sexes)

DIAGNOSTIC DIAGNOSTIC EVALUATION:EVALUATION:

EchocardiographyEchocardiography → confirms dilated → confirms dilated cardiomyopathycardiomyopathy

Chest X-RayChest X-Ray → reveals cardiomegaly → reveals cardiomegaly associated with any of the associated with any of the

cardiomyopathiescardiomyopathies

Cardiac Cath with possible BiopsyCardiac Cath with possible Biopsy → → can be definitive in diagnosing can be definitive in diagnosing hypertrophic cardiomyopathyhypertrophic cardiomyopathy

CardiomyopathiesCardiomyopathiesDILATED CARDIOMYOPATHYDILATED CARDIOMYOPATHY

Primarily Primarily affects systolic affects systolic function function ** ** (pumping action) **(pumping action) **

Results from Results from extensive extensive damage to damage to myocardial myocardial muscle fibersmuscle fibers

End-result End-result → → LV contractility LV contractility ↓↓

Poor CompensationPoor Compensation

SV, EF, and CO SV, EF, and CO ↓↓** (D/T decreased in pumping ** (D/T decreased in pumping

action) **action) **

Pulmonary CongestionPulmonary Congestion** If end-diastolic volumes increase ** If end-diastolic volumes increase

↑↑ ** **

↑ ↑ End-Diastolic End-Diastolic Volume is a Volume is a

Compensatory Compensatory ResponseResponse

** Preserves SV even though there ** Preserves SV even though there is is ↓ EF **↓ EF **

DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY


Sympathetic Nervous System is Sympathetic Nervous System is stimulatedstimulated

** Increases HR & Contractility **** Increases HR & Contractility **

Kidneys are stimulated (Renin-Kidneys are stimulated (Renin-Angiotensin) to Retain Na & HAngiotensin) to Retain Na & H22OO

** Maintain adequate CO **** Maintain adequate CO **

Vasoconstriction also OccursVasoconstriction also Occurs



When compensatory triggers can no When compensatory triggers can no longer keep up to maintain longer keep up to maintain

adequate CO…adequate CO…

The Heart Begins to Fail!!!The Heart Begins to Fail!!!


Detrimental DilationDetrimental Dilation

Venous Return & Systemic Vascular Venous Return & Systemic Vascular Resistance IncreaseResistance Increase

** LV Dilation Occurs **** LV Dilation Occurs **

With Time, Atria Also Dilate (Atrial With Time, Atria Also Dilate (Atrial Remodeling)Remodeling)

** More work required to pump blood into full ventricles **** More work required to pump blood into full ventricles **

Cardiomegaly is a consequence of Cardiomegaly is a consequence of atrioventricular dilationatrioventricular dilation


Dilated Dilated CardiomyopathyCardiomyopathy

STATISTICS:STATISTICS:

Affects 5 to 8 of 100,000 peopleAffects 5 to 8 of 100,000 people

50% of all deaths resulting from DCM 50% of all deaths resulting from DCM occur suddenlyoccur suddenly

In a study conducted in 1988, 5-year In a study conducted in 1988, 5-year mortality rate of 50% has been reported mortality rate of 50% has been reported for DCM of various etiologies with EF < for DCM of various etiologies with EF <

50%50%

A more recent study in 2000 showed a 5-A more recent study in 2000 showed a 5-year survival rate of 75%year survival rate of 75%

Woods et al, 2005, p. 783Woods et al, 2005, p. 783

Idiopathic Dilated Idiopathic Dilated CardiomyopathyCardiomyopathy

Has a prevalence of 0.04% and is a Has a prevalence of 0.04% and is a relatively common cause of heart relatively common cause of heart

failurefailure

Incidence increases with age and is Incidence increases with age and is higher in maleshigher in males

50% of IDC cases may be familial50% of IDC cases may be familial

Endomyocardial biopsy provides a Endomyocardial biopsy provides a definitive diagnosisdefinitive diagnosis

Moser & Riegel, 2008, p. 1110Moser & Riegel, 2008, p. 1110

Secondary Dilated Secondary Dilated CardiomyopathyCardiomyopathy

Ischemic Dilated CardiomyopathyIschemic Dilated Cardiomyopathy

The most common type of dilated The most common type of dilated cardiomyopathycardiomyopathy

Caused by Coronary Artery DiseaseCaused by Coronary Artery Disease

About 15% to 45% of patients who have a About 15% to 45% of patients who have a myocardial infarction will develop dilatation of myocardial infarction will develop dilatation of

the left ventricle with a decrease in ejection the left ventricle with a decrease in ejection fractionfraction

Prognosis is worse for ischemic cardiomyopathy, Prognosis is worse for ischemic cardiomyopathy, than for non-ischemic cardiomyopathiesthan for non-ischemic cardiomyopathies

Moser & Riegel, 2008, p. 1111Moser & Riegel, 2008, p. 1111

Secondary Dilated Secondary Dilated CardiomyopathyCardiomyopathy

Hypertensive Dilated CardiomyopathyHypertensive Dilated Cardiomyopathy

Valvular Dilated CardiomyopathyValvular Dilated Cardiomyopathy

Anthracycline Dilated CardiomyopathyAnthracycline Dilated Cardiomyopathy(Anthracycline = Anticancer Agent)(Anthracycline = Anticancer Agent)

Peripartum Dilated CardiomyopathyPeripartum Dilated Cardiomyopathy

Alcohol-Related Dilated Alcohol-Related Dilated CardiomyopathyCardiomyopathy

Moser & Riegel, 2008Moser & Riegel, 2008

Dilated CardiomyopathyDilated Cardiomyopathy

May be overlooked until LV Failure May be overlooked until LV Failure OccursOccurs

SOB, orthopnea, DOESOB, orthopnea, DOE PND, Dry Cough @ night, FatiguePND, Dry Cough @ night, Fatigue Peripheral Edema, Hepatomegaly, Peripheral Edema, Hepatomegaly,

JVD, Weight GainJVD, Weight Gain

Signs & SymptomsSigns & Symptoms


Peripheral CyanosisPeripheral Cyanosis TachycardiaTachycardia

Pansystolic Murmur Pansystolic Murmur (mitral/tricuspid insufficiency)(mitral/tricuspid insufficiency)

SS33 & S & S44 gallops rhythms gallops rhythms Irregular Pulse (with A-Fib)Irregular Pulse (with A-Fib)


TREATMENTTREATMENTDilated CardiomyopathyDilated Cardiomyopathy

Management of underlying cause, if Management of underlying cause, if knownknown

ACEI (First-line), to reduce afterloadACEI (First-line), to reduce afterload

Diuretics with ACEI’sDiuretics with ACEI’s

DigoxinDigoxin

Hydralazine/Isosorbide DinitrateHydralazine/Isosorbide Dinitrate

AntiarrhythmicsAntiarrhythmics

Cardioversion (A-Fib to Sinus)Cardioversion (A-Fib to Sinus)

TREATMENT:TREATMENT:


Pacemaker InsertionPacemaker Insertion

AnticoagulantsAnticoagulants

Revascularization (CABG) if d/t Revascularization (CABG) if d/t ischemiaischemia

Valvular Repair/ReplacementValvular Repair/Replacement

Lifestyle ModificationsLifestyle Modifications

Heart TransplantHeart Transplant

CardiomyopathiesCardiomyopathiesHYPERTROPHIC CARDIOMYOPATHYHYPERTROPHIC CARDIOMYOPATHY

Primarily Affects Primarily Affects Diastolic Function Diastolic Function

(**filling***)(**filling***)Features of HCM:Features of HCM:

Asymmetrical LV Asymmetrical LV HypertrophyHypertrophy

Hypertrophy of Hypertrophy of Intraventricular Septum Intraventricular Septum

(HOCM)(HOCM)

Rapid, forceful Rapid, forceful contractions of LVcontractions of LV

Impaired RelaxationImpaired Relaxation

Obstruction of LV Obstruction of LV outflowoutflow

Hypertrophied ventricles Hypertrophied ventricles become stiffbecome stiff

Do not relax during Do not relax during ventricular fillingventricular filling

** aka Diastole **** aka Diastole **

Ventricular filling Ventricular filling ↓↓, LV , LV pressure pressure ↑↑

↑ ↑ Left Atrial & Pulmonary Left Atrial & Pulmonary Venous PressuresVenous Pressures

** Leads to Venous Congestion & ** Leads to Venous Congestion & Dyspnea **Dyspnea **

HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY

Compensatory response Compensatory response kicks in kicks in → ↑ HR→ ↑ HR

** Ventricular Filling Decreases Even ** Ventricular Filling Decreases Even More **More **

↓ ↓ Ventricular Filling Time Ventricular Filling Time & Obstruction of & Obstruction of

Ventricular Outflow → ↓ Ventricular Outflow → ↓ COCO

MVR occurs if papillary MVR occurs if papillary muscles hypertrophy muscles hypertrophy

and valve doesn’t closeand valve doesn’t close



STATISTICS:STATISTICS:

As many as 60% to 80% of cases are As many as 60% to 80% of cases are inherited through autosomal dominant inherited through autosomal dominant

transmissiontransmission

Usually goes undetected until Usually goes undetected until adulthoodadulthood

It prevalence is 1 per 500 in the general It prevalence is 1 per 500 in the general U.S. population and is higher in blacksU.S. population and is higher in blacks

Woods et al, 2005, p. 784Woods et al, 2005, p. 784

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy

AnginaAngina DyspneaDyspnea FatigueFatigue

Systolic ejection murmurSystolic ejection murmur(left sternal border & apex)(left sternal border & apex)

Pulsus biferiens Pulsus biferiens (peripheral pulse with a characteristic double impulse)(peripheral pulse with a characteristic double impulse)

Abrupt arterial PulseAbrupt arterial Pulse Irregular Pulse (with A-fib)Irregular Pulse (with A-fib)


Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

Beta-Blockers Beta-Blockers

((↓ HR, ↓ O↓ HR, ↓ O22 demand, demand, improve ventricular filling)improve ventricular filling)

Cardioversion Cardioversion (A-Fib to (A-Fib to Sinus)Sinus)

AnticoagulantsAnticoagulants

Ca Channel Blockers Ca Channel Blockers

(reduce stiffness, (reduce stiffness, ↑ diastolic ↑ diastolic pressures)pressures)


Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

Ablation of AV Node Ablation of AV Node (HOCM)(HOCM)

Dual Chamber Pacemaker Dual Chamber Pacemaker (HOCM)(HOCM)

AICDAICD

Ventricular Ventricular myotomy/myectomymyotomy/myectomy

Mitral Valve ReplacementMitral Valve Replacement

Heart TransplantHeart Transplant


CardiomyopathiesCardiomyopathiesRESTRICTIVE CARDIOMYOPATHYRESTRICTIVE CARDIOMYOPATHY

Characterized as Characterized as stiffness of the stiffness of the

ventricleventricle** LV Hypertrophy & Endocardial Fibrosis ** LV Hypertrophy & Endocardial Fibrosis

Thickening **Thickening **

Ventricle does not relax Ventricle does not relax during diastoleduring diastole

** Ventricular Filling Reduced **** Ventricular Filling Reduced **

The rigidity of the The rigidity of the myocardium causesmyocardium causes failure to completely failure to completely

contract during systolecontract during systole** End-result is decreased CO **** End-result is decreased CO **

Restrictive CardiomyopathyRestrictive Cardiomyopathy

Chest PainChest Pain DyspneaDyspnea FatigueFatigue

OrthopneaOrthopnea EdemaEdema

Systolic murmursSystolic murmurs PallorPallor

SS33 & S & S44 gallops rhythms gallops rhythms


Restrictive Restrictive CardiomyopathyCardiomyopathy

Management of Management of underlying causeunderlying cause

DigoxinDigoxin

DiureticsDiuretics

Restricted Na DietRestricted Na Diet

Oral VasodilatorsOral Vasodilators


Valvular DisordersValvular Disorders

Malfunction of the Heart Malfunction of the Heart ValvesValves

Mitral & Aortic Valve Disorders:Mitral & Aortic Valve Disorders:

Insufficiency (Regurgitation)Insufficiency (Regurgitation)

StenosisStenosis

Prolapse (Mitral Only)Prolapse (Mitral Only)

Valvular DisordersValvular Disorders

Main Problems with Valvular Main Problems with Valvular Disorders:Disorders:

Atrial and Ventricular Atrial and Ventricular RemodelingRemodeling

Heart FailureHeart Failure

Mitral Valve Mitral Valve InsufficiencyInsufficiency

The abnormal leaking of blood through mitral The abnormal leaking of blood through mitral valve, from the left ventricle into the left atriumvalve, from the left ventricle into the left atrium

May be caused by stenosis or prolapse of the May be caused by stenosis or prolapse of the mitral valvemitral valve

Dysfunctions of the following valvular Dysfunctions of the following valvular components can cause MVI:components can cause MVI:

Valve LeafletsValve Leaflets Papillary MusclesPapillary Muscles Chordae TendonaeChordae Tendonae Annulus (stretched Annulus (stretched d/t cardiac d/t cardiac enlargement)enlargement)

Mitral Valve Mitral Valve InsufficiencyInsufficiency

Mitral Valve StenosisMitral Valve Stenosis

Narrowing of the mitral valve; Narrowing of the mitral valve; Results in impedance of blood flow to Results in impedance of blood flow to

ventriclesventriclesResults in decreased ventricular filling = Results in decreased ventricular filling =

↓↓COCOBackflow to Left Atrium = Backflow to Left Atrium = Atrial Atrial

RemodelingRemodeling

MVS is very commonly caused by MVS is very commonly caused by atherosclerotic disease which atherosclerotic disease which

results in calcification of valvesresults in calcification of valves

Other Causes:Other Causes:

Congenital Congenital Heart DiseaseHeart Disease

Rheumatic Rheumatic Heart DiseaseHeart Disease

Mitral Valve Mitral Valve ProlapseProlapse

Folding, inversion, and displacement of Folding, inversion, and displacement of mitral valve leaflets towards the left mitral valve leaflets towards the left

atriumatrium

Mitral Valve Mitral Valve ProlapseProlapse

Chordae tendonae Chordae tendonae becomes elongationbecomes elongation

May cause it to May cause it to rupturerupture

Displacement > 2 mm Displacement > 2 mm above mitral above mitral annulusannulus

Aortic Valve Aortic Valve InsufficiencyInsufficiency

Aortic Valve fails to close completely Aortic Valve fails to close completely Causes backflow of blood into ventricleCauses backflow of blood into ventricle

May be caused by stenosis or prolapse of the aortic May be caused by stenosis or prolapse of the aortic valvevalve

Aortic Valve Aortic Valve InsufficiencyInsufficiency

VENTRICULAR REMODELING:VENTRICULAR REMODELING:Eccentric Hypertrophy – Eccentric Hypertrophy – (ventricular wall thickening (ventricular wall thickening

with dilatation)with dilatation)Concentric Hypertrophy – Concentric Hypertrophy – (ventricular wall thickening (ventricular wall thickening

with diminished capacity)with diminished capacity)

Aortic Valve StenosisAortic Valve Stenosis

The hardening of the aortic valve or aorta itself

Aortic Valve Aortic Valve StenosisStenosis

AVS is very commonly caused by AVS is very commonly caused by atherosclerotic disease which atherosclerotic disease which

results in calcification of valvesresults in calcification of valves

Other Causes:Other Causes: Congenital Congenital

aortic bicuspid aortic bicuspid valve valve (associated with (associated with coarctation of coarctation of the aorta) the aorta)

Rheumatic Rheumatic Heart DiseaseHeart Disease

ReferencesReferencesDonofrio, J., Haworth,K., Achaeffer, L., & Thompson, G. (2005). Donofrio, J., Haworth,K., Achaeffer, L., & Thompson, G. (2005). Cardiovascular Cardiovascular

care made incredibly easy. care made incredibly easy. Ambler, PA: Lippincott Wilkins & WilliamsAmbler, PA: Lippincott Wilkins & Williams

Hodgson, B. B., & Kizior, R. J. (2007). Hodgson, B. B., & Kizior, R. J. (2007). Saunders nursing drug handbook.Saunders nursing drug handbook. St. St. Louis, MS: Saunders Elsevier.Louis, MS: Saunders Elsevier.

Moser, D. k., & Riegel, B. (2008). Moser, D. k., & Riegel, B. (2008). Cardiac nursing: A companion to braunwald’s Cardiac nursing: A companion to braunwald’s heart disease. heart disease. St. Louis, MS: Saunders Elsevier.St. Louis, MS: Saunders Elsevier.

Skidmore-Roth, L. et al. (2007). Skidmore-Roth, L. et al. (2007). Mosby’s nursing drug reference, Mosby’s nursing drug reference, (20(20thth ed.). St. ed.). St. Louis, MS: Mosby Elsevier.Louis, MS: Mosby Elsevier.

Smeltzer et al. (2008). Smeltzer et al. (2008). Brunner and suddarth’s textbook of medical-surgical Brunner and suddarth’s textbook of medical-surgical nursing, nursing, (11(11thth ed.). Philadelphia, PA: Lippincott Williams and Wilkins. ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

Woods, S. L., Sivarajan Froelicher, E. S., Underhill Motzer, S., & Bridges, E. J. Woods, S. L., Sivarajan Froelicher, E. S., Underhill Motzer, S., & Bridges, E. J. (2005). (2005). Cardiac Nursing Cardiac Nursing (5(5thth ed.). Philadelphia, PA: Lippincott Williams & ed.). Philadelphia, PA: Lippincott Williams & Wilkins.Wilkins.

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