CARDIOMYOPATHYCARDIOMYOPATHY

PRESENTER: MODERATOR:

DAINY THOMAS MADAM RACHEL ANDREWS

MSc NURSING IST YEAR STUDENT, LECTURER,

AIIMS. AIIMS.

INTRODUCTIONINTRODUCTION

OBJECTIVESOBJECTIVES

Define cardiomyopathy. Explain the types of cardiomyopathy. List down the etiological factors. Describe the pathophysiology of cardiomyopathy. Enlist the clinical features. Explain the medical and surgical management. Discuss the nursing management.

LAYERS OF HEARTLAYERS OF HEART

Epicardium Myocardium Endocardium

Pericardium

DefinitionDefinition

Diseases that involve the myocardium primarily

and are not the result of hypertension, or

congenital, valvular, coronary or arterial or

pericardial abnormalities.

Cardiomyopathy -"heart muscle disease" -

deterioration of the function of the myocardium

(i.e., the actual heart muscle) for any reason.

DefinitionDefinition

Disease of the heart muscle in which the heart loses its

ability to pump blood effectively.

Heart muscle- enlarged or abnormally thick or rigid.

Rare cases- heart muscle tissue- replaced with scar tissue.

Disease progresses heart becomes weaker and less able

to pump blood to heart failure, arrhythmias, systemic and

pulmonary edema and, more rarely, endocarditis.

IncidenceIncidence

3rd most common form of heart disease in U.S.

2nd most common cause of adolescent sudden

death.

Directly affects cardiac structure and impairs

myocardial function.

ClassificationClassification

Extrinsic or Intrinsic cardiomyopathy .

Extrinsic - primary pathology - outside the

myocardium itself.

Most common cause - ischemia.

WHO- specific cardiomyopathies.

Intrinsic - Weakness in the heart muscle that is

not due to an identifiable external cause

(idiopathic cardiomyopathies).

Consist of a variety of disease states, each with

their own causes.

ClassificationClassification

According to the structural and According to the structural and functional abnormalitiesfunctional abnormalities

Dilated cardiomyopathy (DCM)

Hypertrophic cardiomyopathy (HCM)

Restrictive or constrictive cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC)

Unclassified cardiomyopathy

Ischemic cardiomyopathy

Types and Causes:Types and Causes:

Ischemic cardiomyopathy - caused by CAD & MI ,

which leave scars in the heart muscle

Idiopathic cardiomyopathy - the cause is unknown.

Hypertensive cardiomyopathy - seen in people who

have high BP for a long time, particuarly when it has

gone untreated for years.

Infectious cardiomyopathy - HIV, viral myocarditis

Diabetes and thyroid disease

Alcoholic cardiomyopathy - usually begins about 10 years

after sustained, heavy alcohol consumption.

Toxic cardiomyopathy – due to cocaine, amphetamines,

and some chemotherapy drugs (doxorubicin, daunorubicin)

Peripartum cardiomyopathy: This type appears in women

during the last trimester of pregnancy or after childbirth.

Radiotherapy (cobalt)

Types and Causes:Types and Causes:

DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY

Most common cause of Most common cause of clinical syndrome of heart clinical syndrome of heart

failurefailure

Dilated CardiomyopathyDilated CardiomyopathyDefined - a ventricular chamber exhibiting increased diastolic and systolic volumes and a low < 45% ejection fraction. Generally occurs - 20 to 60 years More common in men

Heart muscle begins to dilate or stretch and become thinner

Ventricular chamber size

Over time, the heart becomes weaker Heart failure

Anatomical specimenAnatomical specimen

DILATED CMPDILATED CMP

LV and or RV dilatation Systolic dysfunction CCF Arrhythmias Emboli

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy Occurs when the heart muscle thickens abnormally (left

ventricle)

Obstructive type - septum thickens and bulges into the LV

blocks the flow of blood into the aorta the ventricle must

work much harder to pump blood past the blockage and out to

the body.

Symptoms - chest pain, dizziness, SOB, or fainting

Can also affect the MV, causing blood to leak backward

through the valve.

Non-obstructive typeNon-obstructive type

- The entire ventricle may become thicker

(symmetric ventricular hypertrophy) or it may

happen only at the bottom of the heart (apical

hypertrophy).

- The right ventricle also may be affected.

Left ventricular hypertrophy (thick ventricular wall)

ventricular chamber size hold less blood

CO pressure in the ventricles and lungs

changes in the cardiac muscles interfere with the

heart's electrical signals, leading to arrhythmias

sudden cardiac arrest

Pathophysiology:Pathophysiology:

Causes:

Inherited because of a gene mutation

Develop over time because of high

blood pressure or aging

Often, the cause is unknown.

Restrictive CardiomyopathyRestrictive Cardiomyopathy

Tends to mostly affect older adults

Ventricles - stiff and rigid due to replacement of the

normal heart muscle with abnormal tissue, such as

scar tissue ventricles cannot relax normally and

expand to fill with blood atria to become enlarged

blood flow in the heart is reduced complications

- heart failure or arrhythmias occur.

Causes:Causes: Radiation treatments,

Infections, or

Scarring after surgery

Hemochromatosis

Amyloidosis

Sarcoidosis

Major Risk Factors…Major Risk Factors…

Family history of cardiomyopathy, heart failure, or sudden cardiac death Disease or condition that can lead to cardiomyopathy:

CAD A previous heart attack Myocarditis

Long-term alcoholism Long-term high blood pressure Diabetes and other metabolic diseases

Clinical ManifestationsClinical Manifestations Remain stable without symptoms. Signs and symptoms of heart failure (eg, dyspnea on exertion,

fatigue). PND, cough (especially with exertion), and orthopnea. Fluid retention, peripheral edema, and nausea, (poor

perfusion of GI system). Chest pain, palpitations, dizziness, nausea, and syncope with

exertion. HCM- cardiac arrest -initial manifestation in young people,

including athletes.

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Symptoms of heart failure Pulmonary congestion (left HF)

Dyspnea (rest, exertional, nocturnal), Orthpnea Systemic congestion (right HF)

Edema, Nausea, Abdominal pain, Nocturia Low cardiac output

Fatigue and Weakness Hypotension, Tachycardia, Tachypnea, JVD If EF<20% high risk for embolism and SV arrhythmias

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

Physical examination : Tachycardia, extra heart

sounds, Signs and symptoms of heart failure

Patient history -Myocardial Infarction.

Echocardiogram

Radionuclide imaging

ECG - Dysrhythmias and changes of LVH.

Chest X-ray - Heart enlargement, pulmonary

congestion.

Cardiac catheterization – CAD

Endomyocardial biopsy- Analyze myocardial tissue

cells.

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

DIAGNOSISDIAGNOSIS

Cardiac catheterization Age >40, ischemic history, abnormal

ECG ↑LVEDV,LA, PCWP, RVEDV, RA,

CVP

Chest X-Ray PA viewChest X-Ray PA view

NORMALNORMAL

2D Echo finding M Mode2D Echo finding M Mode

Parasternal longitudinal viewParasternal longitudinal view

Massive cardiomegalyMassive cardiomegalywater bottle shaped heartwater bottle shaped heart

TREATMENTTREATMENT

Manage any conditions that cause or contribute to

the cardiomyopathy

Control symptoms so that the person can live as

normally as possible

Stop the disease from getting worse

Reduce complications and the chance of sudden

cardiac death

Medications:Medications: Diuretics -remove excess fluid and sodium from the

body.

Angiotensin-converting enzyme (ACE) inhibitors - lower

blood pressure and reduce stress on the heart.

Beta-blockers- slow the heart rate by reducing the speed

of the heart's contractions and also lower BP.

Calcium channel blockers- slow a rapid heartbeat by

reducing the force and rate of heart contractions, decrease

BP

MedicationsMedications Digoxin - increases the force of heart contractions and

slows the heartbeat.

Anticoagulants- prevent blood clots from forming, used in

the treatment of dilated cardiomyopathy.

Antiarrhythmics - keep the heart beating in a normal rhythm.

Antibiotics- used before dental or surgical procedures, help to

prevent endocarditis.

Corticosteroids, which reduce inflammation.

Contd…Contd… Treatment of CCF Avoid dehydration Cardiac pacing Mx of arrhythmias ICD implantation Cardiac transplantation Stem cell transplantation

Lifestyle ChangesLifestyle Changes

Quit smoking

Lose excess weight

Eat a low-salt diet

Get moderate exercise, such as walking

Avoid strenous exercise

Fluid restriction, <2l/ day.

Avoid the use of alcohol and illegal drugs

Get enough sleep and rest

Reduce stress

Treat underlying conditions, such as DM and

high BP.

Lifestyle ChangesLifestyle Changes

Left Ventricular Outflow Tract Left Ventricular Outflow Tract Surgery. Surgery.

Myectomy (myotomymectomy)- some of the heart

tissue is excised.

Removing the MV , chordae, and papillary muscles.

MV then is replaced with a low-profile disk valve.

Open-heart surgery for hypertrophic obstructive

cardiomyopathy

Heart TransplantationHeart Transplantation

Orthotopic transplantation - most common

Recipient’s heart- removed, donor heart is implanted

at the vena cava and pulmonary veins.

Some remove the recipient’s heart leaving a portion

of the recipient’s atria (with the vena cava and

pulmonary veins) in place.

Heart Transplant (cont.)Heart Transplant (cont.)

Orthotopic transplantationOrthotopic transplantation

Donor heart - implanted by suturing the donor atria

to the residual atrial tissue of the recipient’s heart.

Both techniques then connect the recipient’s

pulmonary artery and aorta to those of the donor

heart.

Heterotopic transplantationHeterotopic transplantation Less common.

Donor heart - placed to the right and slightly anterior to the

recipient’s heart.

Recipient’s heart -not removed.

Transplanted heart - denervated

Sympathetic and vagus nerves do not affect the

transplanted heart.

Resting rate of transplanted heart – approx 70 - 90 bpm,

increases gradually if catecholamines are in the

circulation.

Patients – gradually and their exercise (extended

warm-up and cool-down periods.

Atropine does not increase the heart rate of these patients.

Heterotopic transplantationHeterotopic transplantation

Advanced age

Poor blood circulation throughout the body

Diseases of the kidney, lungs, or liver that can't be reversed.

History of cancer or malignant tumors.

Inability or unwillingness to follow lifelong medical

instructions

Pulmonary arterial hypertension that can't be reversed.

Active infection throughout the body.

Heart Transplant :Contra indicationsHeart Transplant :Contra indications

Organs are matched for blood type and size of donor and recipient.

Guidelines on how a donor heart is selected :

The donor meet the legal requirement for brain death

Consent forms are signed

Younger than 65 years of age

Have little or no history of heart disease or trauma to the chest

Not exposed to hepatitis or HIV

Donor heart must be transplanted within 4 hrs. After removal from

the donor

Heart Transplant (cont.)Heart Transplant (cont.)

A bypass machine is hooked up to the arteries and veins of

the heart. The machine pumps blood through the patient's

lungs and body while the diseased heart is removed and the

donor heart is sewn into place.

Watching for Signs of Rejection

Shortness of breath , Fever

Fatigue , Weight gain

Reduced amounts of urine

Preventing Infection

Heart Transplant (cont.)Heart Transplant (cont.)

Postoperative CoursePostoperative Course Balance the risk of rejection with the risk of infection.

Complex regimen of diet, medications, activity,

follow-up laboratory studies, biopsies (to diagnose

rejection), and clinic visits.

Patients receive cyclosporine or tacrolimus,

azathioprine or mycophenolate mofetil, and

corticosteroids (prednisone) to minimize rejection.

ComplicationsComplications

Rejection and infection

Accelerated atherosclerosis of the coronary arteries

(cardiac allograft vasculopathy [CAV]or accelerated

graft atherosclerosis [AGA])

Hypertension

Osteoporosis

Post transplantation lymphoproliferative disease

Cancer - skin and lips

Weight gain, obesity, diabetes, dyslipidemias (eg,

hypercholesterolemia), hypotension, renal failure,

CNS, respiratory, and GI disturbances -

corticosteroids or other immunosuppressants.

ComplicationsComplications

ComplicationsComplications Immunosuppressant medication toxicities

Psychosocial stresses

Guilt

Anxiety about the new heart

Depression or fear when rejection is identified

Difficulty with family role changes

Mechanical Assist Devices and Mechanical Assist Devices and Total Artificial Hearts. Total Artificial Hearts.

Patients who cannot be weaned from cardiopulmonary bypass

Patients in cardiogenic shock may benefit from a period of

mechanical heart assistance.

Intra-aortic balloon pump- most common

This pump decreases the work of the heart during contraction

but does not perform the actual work of the heart.

Ventricular Assist Devices. Ventricular Assist Devices.

Can circulate as much blood per minute as the

patient’s heart.

Used to support one ventricle.

Some combined with an oxygenator-

extracorporeal membrane oxygenation (ECMO).

Used for the patient whose heart cannot pump

adequate blood through the lungs or the body.

Left Ventricular Left Ventricular Assist DeviceAssist Device(LVAD)(LVAD)

VADsVADs

3 basic types of devices: centrifugal, pneumatic, and electric

or electromagnetic.

Centrifugal VADs - external, nonpulsatile, cone-shaped

devices with internal mechanisms that spin rapidly, creating a

vortex (tornado-like action) that pulls blood from a large vein

into the pump and then pushes it back into a large artery.

 

Pneumatic VADs-Pneumatic VADs-

External or implanted pulsatile devices with a flexible

reservoir housed in a rigid exterior.

Usually fills with blood drained from the patient’s

atrium or ventricle.

It then forces pressurized air into the rigid housing,

compressing the reservoir and returning the blood to the

patient’s circulation, usually into the aorta.

Electric or electromagnetic Electric or electromagnetic VADsVADs

Similar to the pneumatic VADs,

But instead of pressurized air, one or more flat metal

plates are pushed against the reservoir to return the

blood to the patient’s circulation.

Total Artificial Hearts. Total Artificial Hearts.

Designed to replace both ventricles.

Some require the removal of the patient’s heart to

implant the total artificial heart; others do not.

Temporary treatments while the patient’s own heart

recovers or until a donor heart becomes available for

transplantation (ie, “bridge to transplant”).

NURSING DIAGNOSESNURSING DIAGNOSES Decreased cardiac output related to structural

disorders caused by cardiomyopathy or to dysrhythmia from the disease process and medical treatments.

Diagnostic Assessment Review ECG Echocardiography Cardiac catheterization

Patient MonitoringPatient Monitoring

Obtain BP hourly or more frequently if the patient’s

condition is unstable.

Monitor hourly urine output to evaluate effects of

decreased cardiac output or pharmacologic

intervention.

Analyze ECG rhythm strip at least every 4 hours and

note rate.

Continuously monitor oxygen status with pulse

oximetry.

Monitor patient activities and nursing interventions

that may adversely affect oxygenation.

Patient AssessmentPatient Assessment

Obtain vital signs every 15 minutes during acute phase.

Assess the patient for changes in neurological function

hourly and as clinically indicated.

Assess for skin warmth, color, and capillary refill time.

Assess for chest discomfort because

myocardial ischemia may result from poor

perfusion.

Assess heart and lung sounds to evaluate the

degree in heart failure.

Patient ManagementPatient Management

Provide oxygen at 2 to 4 L/min to maintain or improve

oxygenation.

Minimize oxygen demand by maintaining the patient at bed rest.

Provide liquid diet on acute phase,

Administer diuretic as prescribed to reduce preload and

afterload.

Monitor serum potassium before and after administration

of loop diuretics.

Prophylactic heparin may be ordered to prevent

thromboembolus formation secondary to venous poisoning.

Institute pressure ulcer prevention strategies secondary to

hypoperfusion or vasoconstriction agents.

Obstructive Hypertrophic Obstructive Hypertrophic Cardiomyopathy: Nursing ImplicationsCardiomyopathy: Nursing Implications

Electrolyte monitoring

Maintain an adequate hydration status

Vigilant monitoring for tachycardias or

dysrhythmias.

Emotional support, frequent teaching

Counseling to assist in patient and family coping

should be strongly encouraged.

Lifelong dental prophylaxis with antibiotics is

necessary.

Medic-alert bracelets are recommended

Nitroglycerin and positive inotropic agents are not

standard therapy in the patient with HCM.

Diuretics may be used, however, when initiated, close

supervision of electrolyte and hydration status must

be maintained.

Monitor for dysrhythmias - primary focus.

Dehydration- preload and HR LVOTgradient and

obstruction.

Restrict from playing competitive sports, the rationale

should be explained thoroughly (i.e., complications

secondary to dehydration and increased heart rate).

Severe problems may also present after exercise

when decreasing heart rate and vasodilatation

occurs.

Make aware of the potential complications so they

may take the necessary precautions.

Ineffective cardiopulmonary, cerebral, peripheral, and

renal tissue perfusion related to decreased peripheral

blood flow (resulting from decreased cardiac output)

Impaired gas exchange related to pulmonary congestion

caused by myocardial failure (decreased cardiac output)

• Activity intolerance related to decreased cardiac

output or excessive fluid volume, or both

• Anxiety related to the change in health status and in

role functioning.

• Powerlessness related to disease process

• Noncompliance with medication and diet therapies

NURSING DIAGNOSESNURSING DIAGNOSES

SUMMARYSUMMARY

Nursing care of the patient is composed of advocacy, emotional support, complication prevention, monitoring, and education.

Consideration must be given to the presenting symptoms, lifestyle expectations, impact of treatment selection, risks, benefits, psychological implications, and insurance concerns. Therefore, the nurse must have understanding of the complexities of this disease and its varied treatment options to be able to provide the appropriate individualized care that all patients require.

CONCLUSIONCONCLUSION

BIBLIOGRAPHYBIBLIOGRAPHY http://www.medscape.com/viewarticle/495035_5 http://nursingcrib.com/category/nursing-care-plan/ inomemoirofaschizo.blogspot.com/2009/08/review-your-

medical-surgical-nursing.html o.in/

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