caring for patients with cardiomyopathy
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Caring For Patients With Cardiomyopathy. J.O. Medina,RN, MSN,FNP,CCRN Education Specialist / Nurse Practitioner Critical Care & Emergency / Trauma Services California Hospital Medical Center. Objectives :. Define cardiomyopathy. - PowerPoint PPT PresentationTRANSCRIPT
Caring For Patients With Cardiomyopathy
J.O. Medina,RN, MSN,FNP,CCRNEducation Specialist / Nurse Practitioner
Critical Care & Emergency / Trauma Services
California Hospital Medical Center
Objectives :
Define cardiomyopathy. Differentiate between dilated,
restrictive , and hypertrophic cardiomyopathy with regard to etiology, pathophysiology, and management.
Cardiomyopathy: Overview
Disease of cardiac muscle myofibril degeneration affecting heart globally
Not as a result of HTN, coronary atherosclerosis, valvular dysfunction or pericardial abnormalities
cause often unknown (idiopathic) categorized into 3 groups based on functional
and structural abnormalities dilated(congestive)cardiomyopathy hypertrophy cardiomyopathy restrictive cardiomyopathy
Cardiomyopathy : Types Dilated (congestive) cardiomyopathy
systolic dysfunction related to abnormal dilation of heart chambers
Hypertrophic cardiomyopathy diastolic dysfunction related to
abnormal hypertrophy of IVS / ventricles
Restrictive cardiomyopathy diastolic dysfunction related to non-
compliant stiff ventricles
Cardiomyopathy : Major Consequences
Systolic or diastolic heart failure or combination of both
arrhythmias other problems specific to type of
disorder
Dilated (Congestive)Cardiomyopathy
most common form of cardiomyopathy
diffuse dilation of cardiac chambers : ventricle(s) and atria
systolic dysfunction caused by decreased contractility
pulmonary and systemic congestion : CO
embolic episodes
Dilated (Congestive)Cardiomyopathy :
Causes Often unknown Alcohol (15 – 40%) Pregnancy (last trimester) / post
partum (6 months post partum) Collagen-viral infections Oncologic agents : adriamycin Hederofamillial neuromuscular
disease
Dilated (Congestive)Cardiomyopathy : Causes Postmyocarditis Toxins Nutritional (beriberi, selineum
deficiency, thiamine deficiency) Cocaine, heroine, organic solvents
“glue-sniffer’s heart” Infection ( viral HIV, rickettsial,
myobacterial, toxoplasmosis ) Antiretroviral agents
Dilated (Congestive)Cardiomyopathy : Pathophysiology
diffuse dilation of ventricle(s) causing decreased contractility
leads to CO compensatory mechanisms :
ST to maintain CO catecholamine release stimulating
renin-angiotensin system sodium/water retention and vasoconstriction (preload,afterload)
Dilated (Congestive)Cardiomyopathy : Pathophysiology
poor contractility : LVEDV LVEDP dilates
annulus of AV valve papillary dysfunction valve incompetency atrial enlargement pulmonary congestion
Dilated (Congestive)Cardiomyopathy : Clinical Presentation LVF
chronic fatigue ; weakness orthopnea ; paroxysmal nocturnal
dyspnea (PND) cough ; chest pain weight gain palpitations dizziness ; syncope impotence insomnia
Dilated (Congestive)Cardiomyopathy : Physical Examination
Precordium tachycardia enlarged apical impulse, laterally displaced
(cardiomegaly) right ventricular impulse along LSB heart sounds: S, S, systolic murmur
Lungs tachypnea : if dyspnea present at rest end
stage disease auscultation : clear crackles / wheezes
Dilated (Congestive)Cardiomyopathy : Physical Examination
LV Failure signs : LOC cool, pale extremities pulsus alternans
alternating strong / weak pulse due to severe LV failure
RV failure signs indicate severe disease
Dilated (Congestive)Cardiomyopathy : Diagnosis
EKG arrhythmias
ST (compensatory for CO) atrial; fibrillation (Af) : ominous sign
(due to dilated atria) atrial and ventricular arrhythmias (high
grade ectopy portent to sudden death) Q waves : pseudoinfarction due to
fibrosis ; ST-T wave abnormalities QRS widened : LVH, LBBB
Dilated (Congestive)Cardiomyopathy : Diagnosis
CXR multichamber enlargement, pulmonary
congestion, pleural effusions Echocardiogram
LV dysfunction chamber enlargement valve dysfunction hypokinesis and wall motion
abnormalities EF
Dilated (Congestive)Cardiomyopathy : Diagnosis Medical history with emphasis on :
Dyspnea on exertion, orthopnea, PND
Palpitations Systemic and pulmonary embolism
Cardiac Troponin T Persistent elevation marker of poor
outcome
Dilated (Congestive)Cardiomyopathy : Diagnosis
Exercise electrocardiogram determines patient’s functional
status and if arrhythmias may develop with exercise
Cardiac catheterization may be helpful to identify
concomitant coronary artery disease
Dilated (Congestive)Cardiomyopathy : Management
Goals cardiac workload
Limit activity Improve symptoms Treat underlying disease
Dilated (Congestive)Cardiomyopathy : Pharmacologic Management
Treat CHF ( cause of death in 70% of patients) diuretics ; sodium restriction ACEI ; β-blockers, spirolactone,
and Digitalis preload ; pulmonary and
systemic congestion wall tension demand
Dilated (Congestive)Cardiomyopathy : Pharmacologic Management vasodilators
afterload : LV workload acute setting : NTG, SNP ACE inhibitors (first line oral agents)
mortality rate afterload and preload
Hydralazine (Apresoline) ; Isordil second line oral combination if unable to tolerate ACE inhibitor
Inotropes contractility and SV acute setting : dopamine,
dobutamine, amrinone, epinephrine
digoxin Antiarrhythmias
treat symptomatic arrhythmias consider implanted defibrillator
Dilated (Congestive)Cardiomyopathy : Pharmacologic Management
Dilated (Congestive)Cardiomyopathy : Pharmacologic Management Low dose ß blockers
Controversial Atenolol Metoprolol Carvedilol
Anticoagulation for patients : In atrial fibrillation Moderate or severe failure
Dilated (Congestive)Cardiomyopathy : Management
Activity : reduced physical activity during period of
decompensation cardiac rehab program to exercise
tolerance Diet :
sodium restriction small frequent meals during liver
congestion nutrition (prevent cachexia) vitamins ; no alcohol
Dilated (Congestive)Cardiomyopathy : Management
Growth Hormone : increase myocardial mass (controversial)
Surgical Therapy cardiac transplantation for end stage
disease (>50% of cardiac transplants are DCM)
latissimus dorsi muscle wrap around heart with muscle pacing synchronized to heart increase contractility
Dilated (Congestive)Cardiomyopathy : Disposition Annual mortality
20% in patients with moderate HF > 50% in severe HF
AICD with severe nonischemic DCM
Referral Heart transplant if < 60 years old
and no longer responding to medical therapy
Hypertrophic Cardiomyopathy (HCM) formally referred to as
idiopathic hypertrophic subaortic stenosis (IHSS)
hypertrophic obstructive cardiomyopathy (HOCM)
HCM : Characteristics Asymmetrical hypertrophy of LV with
disproportional septum enlargement as compared to free wall
decreased LV cavity creates diastolic stiffness impairing filling
thickened, elongated MV leaflets are displaced and may obstruct LV outflow tract
LVSDP atrial and pulmonary pressure
HCM : Causes
1/3 familial 2/3 unknown
sporadic occurrence Autosomal dominant trait causing
encoding of cardiac sarcomere
HCM : Pathophysiology septum : disproportionately enlarged
creating narrow, long cavity excessive, early LV systole displaces MV
leaflets (along with altered papillary muscle position) toward IVS preventing complete closure of MV obstruct LV outflow tract . Septum can obstruct outflow tract ventricular wall becomes rigid LVEDP LAP pulmonary congestion
HCM : Factors That Aggravate Condition
contractility (exercise, positive inotropes)
heart rate (exercise, fever, CO) preload (hypovolemia, sepsis,
fluid shifts) loss of atrial kick (atrial fibrillation,
AVB, ventricular arrhythmias)
Arrhythmias may occur and cause sudden death !
HCM : Clinical Presentation
Varies with degree of hypertrophy dyspnea on exertion : pulmonary
congestion dizziness / syncope : result of ischemic
induced arrhythmias: CO chest pain: due to supply with
demand; narrowed transluminal coronary arteries
sudden death from arrhythmias may be first sign
HCM : Physical Examination
precordium sustained, possibly lateral displacement of
ventricular impulse - cardiomegaly presystolic atrial impulse felt harsh, mid systolic murmur at apex, LSB,
possible radiation to axilla or base of heart S, S may be present
lungs : tachypnea LV failure especially if atrial fibrillation
present
HCM : Diagnosis EKG
voltage of LV hypertrophy ST-T wave abnormalities Q waves in inferior/lateral leads due to
septal hypertrophy PVC : 75% SVT : 25 - 50% atrial fib : 5 - 10%
CXR : normal or enlarged heart, atrial enlargement, pulmonary congestion
HCM : Diagnosis Echocardiogram :
septal hypertrophy LA enlargement narrow outflow tract wall motion abnormalities MV leaflet abnormality
Cardiac Catheterization : chamber pressures MR altered LV outflow gradient
HCM : Management maintain normal sinus rhythm if atrial fibrillation : convert
pharmacologically / electrically avoid hypotension, vasodilators,
dehydration, strenuous exercise, sepsis, chemical withdrawal, shivering, seizures
surgery : excise part of septum implant defibrillator avoid alcohol
HCM : Management Avoid : digitalis, diuretics, nitrates
and vasodilators Arrhythmia control
Disopyramide ( Norpace )has negative inotropic properties
Amiodarone for atrial and ventricular arrhythmias
HCM : Pharmacologic Support ß blockers Propranolol 160mg – 240 mg/day
for dyspnea and chest pain HR ( provides longer filling) contractility ( outflow
obstruction; demand ) blocks SNS ( catecholamines may
be a causative factor) may arrhythmias
HCM : Pharmacologic Support
Calcium Channel Blockers : Verapamil : LV obstruction
second line for β-blockers for hospital patients diastolic filling time promotes relaxation contractility outflow gradient
HCM : Referral Management Myotomy-myectomy
Resection of basal septum For > 50% mmHg outflow gradient
Nonsurgical reduction of IVS Controversial Injection of ethanol in septal
perforator branch of LAD Associated with high incidence of
heart block ; patient may require permanent pacemaker
Restrictive Cardiomyopathy :
Characteristics uncommon type restricted ventricular filling due to
replacement of ventricular muscle with a non elastic material
diastolic dysfunction may develop systolic dysfunction later in disease
symptoms of pulmonary / systemic congestion
Restrictive Cardiomyopathy : Causes
90% Infiltrative and storage disorders
amyloidosis deposits of insoluble protein into muscle and connective tissue
sarcoidosis ; hemochromatosis myocardial fibrosis (after open heart)
radiation scleroderma diabetic cardiomyopathy
Restrictive Cardiomyopathy : Pathophysiology
stiff ventricles ventricular filling CO biatrial dilation pulmonary and systemic congestion
Restrictive Cardiomyopathy :Clinical Presentation
subjective symptoms RUQ discomfort ( right sided failure
symptoms predominate vs. left sided symptoms )
dyspnea : pulmonary congestion chronic fatigue : CO poor exercise tolerance
Restrictive Cardiomyopathy :Physical Signs
right sided failure : JVD ascitis hepatic
enlargement edema
Restrictive Cardiomyopathy :Physical Signs
left sided failure : pulmonary
congestion BP narrowed
pulse pressure
weak, tired DOE
Restrictive Cardiomyopathy :Clinical Presentation
precordial exam : palpable apical pulse; may be
displaced laterally cardiomegaly systolic murmur : TVR / MVR due
to atrial dilation or amyloid infiltrates of papillary muscles
S, S
Restrictive Cardiomyopathy :Diagnosis EKG changes :
low voltage QRS sinus tachycardia, atrial fibrillation,
sinus bradycardia if SA node infiltrated
complex ventricular arrhythmias : are poor prognostic sign
Q waves : pseudo infarct from fibrosis BBB, AVB
Restrictive Cardiomyopathy :Diagnosis
CXR : cardiomegaly with biatrial enlargement
Echocardiogram : normal contractility no pericardial effusion biatrial enlargement LV hypertrophy with small ventricular
cavity Myocardial Biopsy : amyloidosis,
hemochromatosis, etc.
Restrictive Cardiomyopathy :Management
Goal : symptom relief primarily by
pulmonary / systemic congestion
Restrictive Cardiomyopathy :Management
Pharmacological support : mild diuretic therapy : prevent excessive
volume depletion to prevent syncope from SV secondary to ventricular filling
vasodilator : NTG, ACE inhibitors No digoxin : prone to digitalis induced
arrhythmias and heart block No calcium channel blockers :
predisposes to hypotension due to amyloidosis
Restrictive Cardiomyopathy :Management
restrict sodium intake Hemochromatosis CM
repeated phlebotomy to reduce iron deposition in the heart
Sarcoidosis may respond to corticosteroids
Eosinophilic CM corticosteroids and cytotoxic drugs
Restrictive Cardiomyopathy :Management there are no effective therapy for other
causes questionable therapies :
AV sequential pacemaker antiarrhythmics surgical interventions
mitral valve replacement tricuspid valve replacement excision of thickened endomyocardial
plaque