cardiac path & intervention II

cardiomyopathy

disease of heart muscle which impairs ability of fibers to contract/relax → heart failure

• acquired or hereditary!

• can be seen in kids and adults

symptoms:

• dyspnea

• orthopnea

• palpitations

• peripheral edema/JVD

types:

• dilated

• hypertrophic

• restrictive

dilated cardiomyopathy

enlargement of heart chambers, impaired pumping → decreased SV & CO

Causes:

• CAD/MI

• ETOH abuse

• systemic HTN

• DM

• viral infections

• toxins

• pregnancy

• drugs

• or idiopathic!

Symptoms: fatigue, weakness, chest pain, BP is normal/low

Treatment (depends on cause)

• lifestyle mod

• meds

• surgery

• cardiac device implantation

hypertrophic cardiomyopathy

LV hypertrophy & rigid ventricular wall, reduction in chamber size

• decreased SV & CO

• usually genetic

• most common CM

often asymptomatic & undiagnosed!!!

• heart failure symptoms (SOB, lower leg edema, fatigue)

can cause sudden death in young athletes!!!

types: obstructive or non-obstructive

Treatment:

• meds - cardiac myosin inhibitor

• surgical: septal myectomy, septal ablation, implantation of cardiac device, transplant

restrictive cardiomyopathy

marked endocardial scarring (fibrosis) → impairs diastolic filling → decreased CO

risk factors: sarcoidosis, connective tissue disorder, some cancer treatments

Symptoms: heart failure symptoms

Treatment: manage symptoms and treat underlying cause

takotsubo cardiomyopathy

stress cardiomyopathy or broken heart syndrome!!

transient form of CM that causes LV to temporarily weaken/balloon out

cause: elevated catecholamines that are released due to stress

symptoms: SOB, chest pain, syncope

heart failure

chronic progressive condition where heart muscle is unable to pump enough blood to meet body’s needs → decreased CO

symptoms: fatigue, SOB, lower leg edema, weight gain

risk factors/causes:

• CAD/MI

• HTN

• DM/metabolic syndrome

• family history

• obesity

• chronic pulmonary disease

• inflammation/infection

• some cardiotoxic agents - chemo

BNP > 400

NT-ProBNP > 1800

imaging/tests: chest x-ray, echo, EKG, stress test

Treatment:

• diet change/less water intake

• ACE inhib/ARBs

• diuretics

• beta blockers

• inotropes

• exercise!!! → reduces failty

PT Assessment!!!: 6MWT → <300 m = poor prognosis, MCID = 32 m

• HF → low aerobic capacity

right heart failure

venous congestion & systemic symptoms!

• congestion of peripheral tissues

• liver congestion → impaired liver function

• GI congestion → anorexia, GI distress, weight loss

• edema & ascites

main causes:

• CAD of right ventricle MI

• COPD

• pulmonary HTN

• pulmonary stenosis

• PE

• tricuspid regurgitation

s3 heart sound!!!

JVD: increased volume in venous system or R side heart failure!

left heart failure

reduced cardiac output & pulmonary symptoms

• low CO → activity intolerance & decreased tissue perfusion

• pulmonary congestion

  • impaired gas exchange → cyanosis

  • pulmonary edema → orthopnea, paroxysmal nocturnal dyspnea, cough with frothy sputum

Common causes:

• CAD of left ventricle MI

• HTN

• valvular heart disease

• cardiomyopathies

• myocarditis

systolic heart failure

HFrEF (reduced ejection fraction)

• impaired contraction/pumping

• enlarged dilated heart within myocardium

• EF <40%

diastolic heart failure

HFpEF (preserved ejection fraction)

• impaired filling/relaxation

• ventricular wall hypertrophy

• often have EF >50%

acute decompensated heart failure

sudden or gradual onset of signs/sympts of HF that requires unplanned medical visit

hospitalizations are due to:

• noncomplicance to meds

• dietary restrictions

• uncontrolled HTN

• ischemia

• arrhythmias

• COPD

treatment: diuretics, vasodilators, inotropic meds

NYHA stages class I

no symptoms

can perform ordinary activities without any limitations

NYHA stages class II

mild symptoms

occasional swelling

somewhat limited ability to exercise

no symptoms at rest

NYHA stages class III

noticeable limitations in ability to exercise

comfortable only at rest

NYHA stages class IV

unable to do any physical activity without discomfort

symptoms at rest

cardiac resynchronization therapy

special type of pacemaker that treats HF

paces both ventricles & R atrium → coordinate myocardial contractions → stronger contraction = increased CO

• can improve symptoms and decrease mortality

• NOT all patients achieve expected results

intra aortic balloon pump

used for patients with cardiogenic shock!

• catheter is inserted into large artery (femoral or axillary)

• inflates during diastole

• deflates during systole

decreases afterload!

increases coronary blood flow!

impella device

mini ventricular assist device that provides short term support of left ventricle; continuously draws blood from LV then expels it to ascending aorta

• decreases LV work load & myocardial demand

• increases MAP, CO, systemic perfusion, and coronary flow

epicardial pacemaker

temporary PM

• placed after CT surgery

• sewn onto outside of heart and wires exit the skin

• able to be mobilized!!!

transvenous pacemaker

temporary PM

• placed in emergent situations

• pacing wire inserted into large vein → RV

• usually on BED REST!

permanent pacemaker

implantable pulse generator and lead wires that connect to the myocardium

endocardial leads attached to RA/ventricles with generator placed below clavical

precautions:

• NO shoulder flex/abd >90

• no extension

• no lifting/pushing/pulling for 4-6 wks

• groin precautions → 1 week if used for placing PM

leadless pacemaker

all components of PM are inside one device, placed in RV, doesn’t need leads or generator

• can only pace one ventricle

• cannot defibrillate

• NO post op precautions!!

AICD

detects and corrects life threatening arrhythmias by delivering electrical shock

• vtach or vfib!!

• same post op precautions as PM

KNOW what rate the device fires at & keep HR 10-15 beats below the rate !!!!

PT considerations in acute care setting:

• may have blunted or delayed HR response to activity

• observe EKG & ensure PM is working

• know firing rate

• monitor for signs of exercise intolerance

• teach modifications for ADLs

• ROM/lifting precautions