Nursing management of a patient with cardiomyopathy
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Transcript of Nursing management of a patient with cardiomyopathy
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CARDIOMYOPATHY
Cardiomyopathy (CMP)is a primary
disorder of the heart muscle that causes
abnormal myocardial performance and is
not the result of disease or dysfunction of
other cardiac structures.
( K.V. Krishnadas)
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CARDIOMYOPATHY
A heterogeneous group of diseases of the
myocardium associated with mechanical
and/or electrical dysfunction, which usually
(but not invariably) exhibit inappropriate
ventricular hypertrophy or dilatation, and are
due to a variety of etiologies that frequently are
genetic.
( Hurst’s text book of cardiology)
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RELATED ANATOMY AND
PHYSIOLOGY
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RELATED ANATOMY AND
PHYSIOLOGY
• Cardiac muscle (heart muscle)
involuntary striated muscle
• The myocardium is the muscle tissue of the heart,
and forms a thick middle layer between the
outer epicardium layer and the
inner endocardium layer
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INCIDENCE
• Dilated cardiomyopathy, the most common form,
affects five in 100,000 adults and 0.57 in 100,000
children.
• Hypertrophic cardiomyopathy, the leading cause of
sudden death in athletes, with an incidence of one in
500 persons.
• Restrictive cardiomyopathy and arrhythmogenic right
ventricular cardiomyopathy are rare, and their
diagnoses require a high index of suspicion.
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CLASSIFICATION
OF
CARDIOMYOPATHIES
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WHO classification of cardiomyopathy(1995)
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American Heart Association
classification of cardiomyopathy
Primary
secondary
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Secondary cardiomyopathy
• Infiltrative
• Storage
• Toxicity
• Inflammatory
• Endocrine
• Nutritional deficiencies
• Consequence of cancer therapy
• Autoimmune/ collagen
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Hypertrophic Cardiomyopathy
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Hypertrophic Cardiomyopathy
• It is characterized by inappropriate left
ventricular hypertrophy, decreased cardiac
output and outflow obstruction.
• Hypertrophic subaortic stenosis
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Common causes
• Genetic(autosomal dominant) or familial
• Hypertension
• Ischemia( coronary artery disease)
• Aortic stenosis
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PATHOPHYSIOLOGY
Four main characteristics
• Massive ventricular hypertrophy
• Rapid, forceful contraction of the left
ventricle.
• Impaired relaxation( diastole)
• Obstruction to aortic outflow
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CLINICAL MANIFESTATIONS
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• Rapid, pounding heartbeat.
• Chest tightness or pressure.
• Fluid retention resulting in swollen feet or
ankles or unexplained weight gain.
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Diagnostic studies
• History and physical examination
• Palpation and auscultation of the chest.
• ECG findings
• Echocardiogram
• Chest X ray
• Cardiac catheterization
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Management of hypertrophic
cardiomyopathy
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GOAL
• Improve ventricular filling.
• Reduce ventricular contractility
• Relieve left ventricular outflow
obstruction.
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Management of cardiomyopathy
Lifestyle changes
• Reduced alcohol consumption, weight loss,
exercise, smoking cessation, and a low-sodium
diet.
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Management of cardiomyopathy
• ᵦ adrenergic blockers
• Calcium channel blockers
• Antidysrrhythmics
• Implantable Cardioverter Defibrillator
• Dual-Chamber Pacing
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Symptomatic management
Percutaneous Transluminal Septal Myocardial
Ablation(PTSMA)
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Surgical management
• Ventriculomyotomy and myectomy
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Arrhythmogenic Right Ventricular
Cardiomyopathy/ Dysplasia
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• It predominantly involves the right ventricle
with progressive loss of myocytes and
fibrofatty tissue replacement, resulting in
regional (segmental) or global
abnormalities.
• Genetic defects of the part of the heart
muscle, desmosome.
• It shows autosomal dominant inheritance
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• 80% of individuals present with syncope,
palpitations or sudden cardiac death.
• Noninvasive tests
• 12-lead ECG, signal-average ECG,
echocardiography, right ventricular angiography,
CMR imaging, CT, and electroanatomic mapping
of the right ventricle
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• Endomyocardial biopsy
Treatment
• includes lifestyle alterations (i.e., avoiding
intense physical activity), antiarrhythmic drugs,
and implantable cardioverter-defibrillators in
high-risk patients.
• Cardiac transplantation
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ION CHANNELOPATHIES
• Brugada syndrome
• Long QT syndrome
• Short QT syndrome
• SUNDS( Sudden Unexplained Nocturnal Death
Syndrome)
• Idiopathic ventricular fibrillation.
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Brugada Syndrome
• Associated with mutations in
the gene (SCN5A)that encodes for
the sodium ion channel in
the cellmembranes of the muscle cells of the
heart (the myocytes).
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• A distinctive ECG pattern consisting of
right bundle-branch block and coved ST-
segment elevation in the anterior precordial
leads (V1–V3).
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Management
• Treatment of underlying arrhythmias
• Implantable cardioverter defibrillator
• Quinidine class Ia antiarrhythmic.
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DILATED CARDIOMYOPATHY
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DILATED CARDIOMYOPATHY
It is characterized by dilatation of the
ventricles with subsequent impairment of
systolic function.
Most common cardiomyopathy
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ETIOLOGY
• Idiopathic
• Autosomal dominant , recessive and X-
linked modes of inheritance.
• Gene mutation
• Inflammatory and Infectious Myocarditis
• Autoimmunity
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OTHER CAUSES
• Cardiotoxic agents- alcohol, cocaine,
doxorubicin( adriamycin)
• Hypertension
• Ischemia ( coronary artery disease)
• Metabolic disorders
• Muscular dystrophy
• Pregnancy
• Valve disease
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PATHOPHYSIOLOGY
Diffuse inflammation and rapid degeneration of myocardial fibers.
Ventricular dilation Cardiomegaly
Impairment of systolic function(contractile dysfunction)
Atrial enlargement and stasis of blood in the left ventricle.
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Heart becomes weak and the chambers get
large.
Heart cannot pump enough blood out to the
body
Decreased cardiac output
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• Chamber enlargement frequently leads to a
dilation of the valvular orifice.
• Intracavitary thrombi located in the
ventricular apices
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CLINICAL MANIFESTATIONS
• Decreased exercise capacity
• Fatigue
• Dyspnea at rest
• Paroxysmal nocturnal dyspnea
• Orthopnea
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As the disease progresses the patient may
experience
• Dry cough
• Palpitations
• Abdominal bloating
• Nausea
• Vomiting
• Anorexia
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Signs
• Irregular heart rate with an abnormal S3
and/or S4
• Tachycardia or bradycardia
• Pulmonary crackles
• Edema
• Weak peripheral pulses
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• Pallor
• Hepatomegaly
• Jugular venous distension
• Heart murmurs
• Dysrhythmias
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DIAGNOSTIC STUDIES
• Doppler echocardiography
• Chest X-Ray
• ECG
• Elevated serum BNP( if heart failure)
• Cardiac catheterization
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EMB (Endomyocardial biopsy)
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• Biochemical testing
• Endocrine function
• Radionuclide imaging (radionuclide
ventriculography)
• Cardiac MRI
• Multidetector computed tomography
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MANAGEMENT
Goal
• Enhance myocardial contractility
• Decrease afterload.
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MANAGEMENT
• Nitrates (eg: Nitroglycerin)
• ACE inhibitors( Eg: captopril)
• ᵦ adrenergic blockers( Eg: metoprolol)
• Aldosterone antagonists ( Eg: spironolactone)
• Diuretics to maintain the volume balance.
• Cardiac glycosides( Eg: Digoxin)
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MANAGEMENT
• Antiarrhythmics( Eg: Amiodarone)
• Anticoagulation therapy
• Treatement of underlying disease process.
• Continuous infusion of dobutamine followed
by aggressive diuresis.
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• Implantable cardiac defibrillators.
• Biventricular pacemakers.
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SURGERY
• Left ventricular reconstruction
• Implantation of external restraint devices
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• Left ventricular assist devices
• Heart transplantation
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EMERGING SPECIFIC THERAPIES
• Agents to eradicate persistent viral infections
and immunomodulatory agents.
• Stem cells for cardiac regeneration and gene
therapy approaches are in clinical trials.
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RESTRICTIVE CARDIOMYOPATHY
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Restrictive cardiomyopathy
• It is a disease of the heart muscle that impairs
diastolic filling and stretch.
• Systolic function remains unaffected.
• Least common of the cardiomyopathic
conditions.
• The heart chambers are unable to fill with
blood because the heart muscle is stiff.
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ETIOLOGY
• Amyloidosis
• Scarring of the heart from an unknown cause.
• Myocardial fibrosis
• Hypertrophy and infiltration
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Secondary causes includes
• Endomyocardial fibrosis
• Sarcoidosis
• Neoplastic tumor
• Ventricular thrombus
• Fibrosis of different etiology
• Radiation to the thorax
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PATHOPHYSIOLOGY
Increase in stiffness of the ventricular walls
Impaired diastolic filling of the ventricle
Reducing preload and end-diastolic volume
Heart failure
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As the disease progresses
Systolic dysfunction
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CLINICAL MANIFESTATIONS
Classic symptoms of restrictive CMP are
• Fatigue
• Exercise intolerance
• Dyspnea
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Additional symptoms
• Angina
• Orthopnea
• Syncope
• Palpitations
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SIGNS OF HEART FAILURE
• Dyspnea
• Peripheral edema
• Ascites
• Hepatomegaly
• Jugular venous distension.
• Kussmaul sign
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DIAGNOSTIC STUDIES
• Chest x ray
• ECG
• Echocardiography
• Endomyocardial biopsy
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MANAGEMENT
GOAL
Improve diastolic filling
Treatment of underlying disease process
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• Treatment include conventional therapy for
heart failure and dysrhythmias.
• Diuretics may help relieve symptoms
• Calcium channel blockers.
• Cardiac transplantation
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COMPLICATIONS
Embolus formation.
Decreased ejection fraction allow stasis of blood
to occur in Lt ventricle.
Thrombus may lodged in spleen kidney,
extremities, cerebral or coronary circulation.
Dysarrhythmias.
Sudden cardiac death.
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Stress provoked (Tako-tsubo or Broken
Heart Syndrome)
• An acute cardiomyopathy can be provoked
by a stressful or emotional situation or
exposure to high doses of catecholamines
(sympathomimetic drugs).
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Typical presentation
• sudden onset of congestive heart failure
• ECG changes mimicking a myocardial infarction of the anterior wall.
• Bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted.
• "tako tsubo", or octopus pot in Japan.
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Treatment
• Supportive management
• Intra-aortic balloon pump
• Fluids, and negative inotropes such as beta
blockers or calcium channel blocker
• Aspirin
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• Common among middle-aged women
• In most cases is fully reversible with supportive care.
• ECG fingings- myocardial infarction in the presence
of left ventricular dysfunction and absence of
epicardial coronary stenoses should prompt the
diagnosis.
• Endomyocardial biopsy is of value to exclude
myocarditis.
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Peripartum Cardiomyopathy
• Peripartum cardiomyopathy is defined as a
cardiomyopathy manifesting between the
last month of pregnancy and 6 months post
partum.
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• Orthopnea
• Dyspnea
• pitting Edema
• cough, frequent night-time urination,
• excessive weight gain during the last month of
pregnancy (1-2+ kg/week; two to four or more
pounds per week),
• Palpitations and chest pain.
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COMPLICATIONS
• stroke, loss of circulation to a limb,
even coronary artery occlusion (blockage)
with typical myocardial infarction
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Treatment
• similar to treatment for congestive heart
failure
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NURSING MANAGEMENT
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NURSING MANAGEMENT
Nursing Assessment
• Evaluate patient's chief complaint, which may include
fever, syncope, general aches, fatigue, palpitations,
dyspnea.
• Evaluate etiologic factors, such as alcohol abuse,
pregnancy, recent infection, or history of endocrine
disorders.
• Assess for positive family history.
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• Auscultate lung sounds for crackles (pulmonary
edema) or decreased sounds (pleural effusion)
• Assess heart size through palpation of chest for point
of maximal impulse (PMI), and auscultate for
abnormal sounds.
• Evaluate cardiac rhythm and ECG for evidence of
atrial or ventricular enlargement and infarction.
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Nursing Diagnoses
• Decreased Cardiac Output related to decreased
ventricular function and/or dysrhythmias
• Activity intolerance related to low cardiac output
• Fluid volume excess in related to ventricular
dysfunction
• Anxiety related to fear of death and hospitalization
• Fatigue related to disease process
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