cardiac: structural, infectious, and inflammatory disorders

what are the 3 types of valve disorders

1. regurgitation - valve doesn't close properly and blood back flows

2. stenosis - narrowed valve and blood flow is reduced

3. valve prolapse - mitral valve leaflet is stretched into the atrium during systole (only mitral)

murmurs are often ?

• different kinds of murmurs

• systolic murmurs ?

• diastolic murmurs?

• how do we dx valve disease

• Cardiac murmurs are often the first sign of underlying Valvular disease.

• May be systolic or diastolic, pathological or benign.

• Systolic murmurs may be due to physiological increases in blood velocity or might indicate asymptomatic cardiac disease.

• Diastolic murmurs are almost always pathological and require further evaluation.

• Echo cardiogram usually gold standard with murmurs and
  valve disease

mitral valve prolapse s/s

• May be asymptomatic or

• Sensation of feeling the heart beat: palpitations

• Chest pain not caused by CAD

• Exertional dyspnea

• Shortness of breath when lying flat (orthopnea)

• Fatigue

• Cough

• Mitral click and possible Systolic heart murmur

mitral valve regurgitation

• Blood flows back from the left ventricles into the left atrium during systole (contraction)

• Edges of mitral valve leaflets do not close completely

most common causes of MVR

• Degenerative changes in the mitral valve

• Ischemia of the left ventricle

• In developing countries, Rheumatic heart disease

MVR s/s

• often ?

• if acute ?

• Often asymptomatic

• If acute MVR (resulting from a myocardial infarction) may manifest as Congestive HF

• Dyspnea

• Fatigue

• Weakness

• Palpitations

• SOB on exertion

• Cough from pulmonary congestion

• A systolic murmur at the apex

tx of MVR

• treat

• treat as ? meds?

• Treat symptoms of shortness of breath, dyspnea and edema, H

• Treat as heart failure due to the resulting hypertrophy
  ACE inhibitors
  ARBs
  Beta Blockers

aortic stenosis

• narrowing of aortic valve

• common with old age

• Left ventricle thickens as heart tries to compensate - hypertrophies

• If symptomatic- management aimed at treating Left ventricular failure

s/s of aortic stenosis

• may be asymptomatic

• SAD - syncope, angina , dyspnea or exertion dyspnea

• pulmonary edema

• decreased CO - decrease exercise tolerance , low O2, weak pulses coolness low BP

• s/s of LSHF

how can we treat stenosis

• ballon vaalvulopasty placed via cath lab

• stretches it out to allow for more blood flow

how can we treat valve prolapse

• Annuloplasty Ring Insertion

• strengthens muscles around valve to make it stronger and close properly

valve surgery

• what kinds of replacements

• if mechanical ?

• valve replaces either by a mechanical valve or biological (human or porcine)

• mechanical valve - r/o clotting, needs to be on Coumadin lifelong after the procedure

• must get INR, & clotting factors checked weekly

• can also be done non invasively for patients who are not surgical candidates for open heart surgery

nursing care with valvular disorders

• Baseline date: Neuromuscular (r/o stroke and transischemic attack with clots), needs anticoagulants if mechanical valve replacement

• Symptoms associated w/ valve disorder

• History of infection/ cormorbidites

• monitor Central venous pressure with central catheter (normal is 2-6mmHg)

• monitor EKG, V/s, CO, respiratory staus

• prophylaxis antibiotics before surgery needed

• teach about warafin guidelines and ensure adherence to med

warafin/ Coumadin guidelines when pt has a mechanical valve

• mitral valve - INR 2 - 3.5

• aortic valve INR 1.8 - 2.2

• If Annuloplasty is performed, Warfarin is needed for several months

• Aspirin may be prescribed w/ Warfarin for high risk patients

• teach pt to take at same time daily

aortic valve regurgitation

• what is it

• leads to?

• decreased ?

• increased ?

• hallmarksign

• leaflets of aortic valve do not close properly allowing regurgitation into left ventricle

• 60% of blood can be regurgitated

• leads to LV hypertrophy

• decreased CO

• increased preload

• hallmark sign - water hammer pulse (carotid artery has a bounding pulse )

s/s of aortic valve regurgitation

• SOB, orthopnea

• Paroxysmal nocturnal dyspnea - dyspnea that wakes you out of sleep

• Signs of heart failure

• Diastolic murmur - high pitched

• Fatigue and dyspnea on exertiom(especially during times of increased activity)

• Angina pectoris
  

tx of aortic valve regurgitation

• treat as HF

• aortic valve replcacemt

dilated cardiomyopathy

• heart chambers?

• effects what function

• leads to ? and risk of ?

• caused by

• most common

• all heart chambers dilate

• poor systolic function (contraction)

• leads to stasis of blood & risk of clots

• can be caused by many drugs- cocaine

hypertrophic cardiomyopathy

• heart muscle ?

• impaired ?

• risk of?

• due to ?

• heart muscle asymmetrically increases in size

• impaired diastolic function (ventricles cannot fill properly)

• risk of sudden death in young athletes

• can be genetic or due to uncontrolled HTN

restrictive cardiomyopathy

• stiff, rigid, ventricular walls

• effects diastolic function (filling of ventricles)

• can be caused by radiation therapy or infection

arrythmogenic RV cardiomyopathy

• right ventricle infiltrated by scar and adipose tissue

• causes electrical disturbances

• genetic causes

s/s of cardiomyopathy

• Impaired cardiac output/ heart failure
  • PND-Paroxysmal nocturnal dyspnea
  • Cough
  • Orthopnea
  • Fluid retention
  • Nausea (poor perfusion to GI)
  • Chest pain (decreased cardiac output)
  • Dizziness; syncope
  • Dysrhythmias

what devices/ procedure can be used for myopathies

• LVAD

• pacemaker

• myectomy: removes hypertrophic cardiac muscle

• muscle wrap around heart to increase strength and contractility

• heart transplant or artificial heart

LVAD - left ventricular assist device

• used in ? how many more years

• what does it do

• control system ? needs ?

• must maintain?

• hard to get?

• what kind of pt is a candidate

• used in end stage HF , gives about 7-10 more Years

• takes load off the failing heart and help maintain blood flow to vital organs

• pumps the heart for you

• control system set for rate, force , rhythm

• must maintain strict sterility when changing dressing - r/o infection

• battery run device - if battery dies, pt dies, always needs extra batteries

• hard to get BP, bc you hear machine running

• very very strict rules, type A patients only who can maintain sterility and maintanance

rheumatic endocarditis

• happens to?

• results from

• what is the consequence

• may not see?

• rare, but mostly occurs in school age children

• consequence of group A strep

• endocarditis results - inflammation of valves , causing permanent damage

• may not see cardiac changes until years later

parent education on rheumatic fever

• must educate parents to take children to get tested if they are showing sings of strep throat

• must be promptly treated With antibiotics to prevent rheumatic fever

s/s of rheumatic fever

• Fever/ Chills

• Sore throat (sudden onset) + Diffuse redness of throat with exudate on oropharynx

• Petechiae on the roof of mouth

• Enlarged lymph nodes

• Abdominal pain (more common in children)

• Acute sinusitis or acute otitis media

• Sandpaper like rash

s/s of infective endocarditis

• 3 hallmark signs

• r/o? why?

• low grade an intermittent fever + headache

• new or worsening heart murmur

• Hallmark signs: osler’s nodes, Jane way lesions and splinter hemorrhages

• r/o TIA and CVA bc blood is stasis (valves are inflamed not working properly)

difference between TIA and CVA

• TIA (trans ischemic attack) - warning sign of CVA, caused by partial blockage or narrowing of arteries to the brain , resolves on its own after 10-15 minutes

• CVA - full on stroke, complete blockage, does not resolve on its own

dx of infective endocarditis

• hx of ?

• tests 2

• based on H and P (hx of strep A? valve replacement?)

• echocardiogram to dx

• blood cultures

tx of infective endocarditis

• 4-6 weeks if IV antibiotics

• surgical - may need valve debridement or full valve replacement bc of stiff valves/ vegetive growth on valves

pericarditis

• inflammation of ?

• normal amount if fluid vs with inflammation?

• what does it do to the heart

• inflammation of pericardial sac - up to 1000ml of fluid

• usually holds 20-50 ml of fluid, needed for lubrication when the heart pumps

• puts major pressure on the heart → decreases ventricle filling and decreases strength of contractions → decreased CO

s/s of pericarditis

• pain worsens when ?

• what can we hear on ascultation? where ? best heard how?

• labs?

• possible ?

• Pain worsens with inspiration; lying down or turning (fluid moving)

• Friction rub at the Left sternal edge - 4th ICS

• Rub best heard sitting leaning forward

• Louder at end of expiration

• Elevated C-RP and ESR (indicates inflammatory process in the body)

• Possible fever if developed from infection

managing pericarditis

• rule out ?

• meds ? 4

• monitor for what r/t meds ?

• rule out MI (EKG, labs drawn)

• NSAIDs and steroids to decrease inflammation

• monitor for bleeding r/t NSAIDs

• monitor for glucose levels r/t steroids

• may require large amount of morhpine for pain

• should also have order for PPI

potential complications of pericarditis

• pericardial effusion - accumulation if fluid in pericardial space, affects heats ability to pump

• cardiac tamponade - advanced pericardial effusion (excessive amount of fluid) , affects CO. medical emergency!!!

other risk factors of pericardial effusion

• pericarditis w/ increased fluid buildup

• blunt chest trauma

• lupus

• neoplasm (cancer)

cardiac tamponade is?

• results in decreased decreased ?

• the restriction of heart function due to this fluid (effusion),

• results in decreased venous return, decreased ventricular filling, and decreased CO

• emergency!! quick assessment necessary, be prepared to call a code

s/s of cardiac tamponade

• becks triad ?

• feeling of?

• pulses ? 3

• resp?

• Nuero? 2

• becks triad: JVD, Low or labile (fluctuating) BP and muffled/ distant heart sounds

• ill defined chest pain/ fullness

• pulsus paradox

• narrowing pulse pressure

• rising venous pressures / falling arterial pressure

• SOB

• Low Bp → syncope → cardiac arrest

• anxiety/ feeling of impending doom

pulsus paradox / paradoxical pulse

• the fall of systolic BP of more than 10 mmHg during the inspiratory phase (breathing in)

• able to see if pt is on continuous hemodynamic monitoring

tx of cardiac tamponade

• pericardotomy - cut made into the pericardium to relieve fluid and pressure

• pericardiocentesis - draining of fluid

• sample of fluid sent to lab if indicative of infection to see what antibiotics to be prescribed

• if fluid is blood - serial CBC and H and H