Concepts of Care for Patients with Cardiac Conditions (NUR 411)

Valvular Heart Disease

Acquired valvular dysfunctions that prevent the heart valves from functioning properly…

i.) Mitral stenosis → valve leaflets fuse & become stiff & chordae tendinae contract/shorten

ii.) Mitral regurgitation → incomplete closure (during systole) allows backflow of blood into the left atrium (when left ventricle contracts)

iii.) Mitral valve prolapse (MVP) → valvular leaflets enlarge & prolapse in the L atrium during systole

iv.) Aortic stenosis → aortic valve orifice narrows & obstructs L ventricular flow during systole

v.) Aortic regurgitation → aortic valve leaflets do not close properly (during diastole), allowing blood to flow from aorta into L ventricle

Mitral Stenosis

Mitral valve leaflets fuse/stiffen & the chordae tendineae contract/shorten…

i.) Most commonly caused by rheumatic fever/carditis

ii.) L atrial pressure rises → pulmonary artery pressure elevates → R ventricle hypertrophies

iii.) Pulmonary congestion & R-sided HF occur first → preload ↓ & CO falls

Clinical Manifestations of Mitral Stenosis

Mild Stenosis

i.) Usually asymptomatic

Progressive Stenosis

i.) Dyspnea on exertion

ii.) Orthopnea

iii.) Paroxysmal nocturnal dyspnea

iv.) Palpitations

v.) Dry cough

vi.) Fatigue

Advanced Stenosis

i.) Hemoptysis (coughing up blood)

ii.) Pulmonary edema

iii.) R-sided HF (signs & symptoms)

Mitral Valve Prolapse (MVP)

Valvular leaflets enlarge & prolapse into the L atrium during systole (usually benign)…

i.) Associated w/ Marfan syndrome & familial tendency

ii.) Normal HR & BP are expected findings → mid-systolic click & late systolic murmur (at apex) possible

iii.) May progress to mitral regurgitation

Clinical Manifestations of Mitral Valve Prolapse (MVP)

Most patients are asymptomatic…

i.) Atypical chest pain (sharp, localized to L side of chest)

ii.) Palpitations

iii.) Exercise intolerance

iv.) Dizziness

v.) Syncope

Mitral Regurgitation

Fibrotic & calcific changes prevent the mitral valve from closing completely during systole…

i.) Blood flows backward from L ventricle to L atrium (systole)

ii.) Regurgitant blood flows back to L ventricle along w/ normal flow (diastole) → higher volume must ejected during next systole

iii.) L atrium & L ventricle dilate/hypertrophy to compensate for ↑ volume/pressure

iv.) Commonly caused by mitral valve prolapse, rheumatic heart disease, & MI

Clinical Manifestations of Mitral Regurgitation

Disease progression is slow, w/ onset of symptoms occurring when L ventricle fails…

i.) Fatigue & chronic weakness (from ↓ CO)

ii.) Dyspnea on exertion

iii.) Orthopnea

iv.) Atypical chest pain

v.) Palpitations

vi.) Atrial fibrillation (AF)

vii.) R-sided HF (signs & symptoms)

viii.) High-pitched systolic murmur (at the apex)

ix.) S₃ (severe regurgitation)

Aortic Stenosis

Aortic valve orifice narrows, obstructing L ventricular outflow during systole…

i.) Most common cardiac valve dysfunction "(‘wear & tear” disease);

ii.) Ventricular hypertrophy caused by ↑ afterload

iii.) Surgery indicated when surface area is ≤ 1 cm

iv.) L ventricle fails → blood pools in L atrium → pulmonary congestion

v.) CO becomes fixed as stenosis worsens; R-sided HF occurs late in disease

Common Causes of Aortic Stenosis

Younger/Middle-Aged Adults

i.) Congenital bicuspid or unicuspid aortic valves

ii.) Rheumatic aortic stenosis (occurs w/ rheumatic mitral valve disease)

Older Adults

i.) Atherosclerosis

ii.) Degenerative calcification

Clinical Manifestations of Aortic Stenosis

Classic Triad

i.) Dyspnea on exertion

ii.) Angina on exertion

iii.) Syncope on exertion

Additional Manifestations

i.) Fatigue

ii.) Orthopnea

iii.) Paroxysmal nocturnal dyspnea

iv.) Palpitations

v.) Systolic crescendo-decrescendo murmur

Aortic Regurgitation

Aortic valve leaflets do not close properly during diastole…

i.) The annulus (valve ring) may be dilated, loose, or deformed

ii.) Blood flows backward from aorta into l ventricle during diastole

iii.) L ventricle dilates to accommodate greater blood volume → eventually hypertrophies

Common Causes of Aortic Regurgitation

Usually results from nonrheumatic conditions…

i.) Infective endocarditis

ii.) Congenital anatomic aortic valvular abnormalities

iii.) Hypertension

iv.) Marfan syndrome

Clinical Manifestations of Aortic Regurgitation

Patients remain asymptomatic for years due to L ventricular compensation…

i.) Dyspnea on exertion\

ii.) Orthopnea

iii.) Paroxysmal nocturnal dyspnea

iv.) Palpitations

v.) Nocturnal angina w/ diaphoresis

vi.) Fatigue

vii.) Sinus tachycardia

viii.) Bounding arterial pulse

ix.) Widened pulse pressure (↑ SBP w/ ↓ DBP)

x.) Decrescendo diastolic murmur

Interventions/treatment for Valvular Disease

Drug Therapy

i.) Diuretics → reduce fluid overload & pulmonary/systemic congestion (i.e. Furosemide, Hydrochlorothiazide, Spironolactone)

ii.) Beta Blockers → control HR to improve cardiac function; manage AF & ventricular response (i.e. Metropolol)

iii.) ACE Inhibitors → reduce afterload & improve CO (i.e. Lisinopril)

iv.) Digoxin → improve contractility to aid flow of blood

v.) Vasodilators (Calcium Channel Blockers) → reduce regurgitant flow in stenosis (i.e. Losartan)

Surgical Interventions

i.) Valve replacement (require Warfarin & INR goal of 3.0-4.0)

ii.) Balloon valvuloplasty

Diagnostic Imaging for Valvular Disease

Echocardiography

i.) Primary diagnostic test

ii.) Measures chamber size, EF, & flow gradient across valves

Chest X-Ray

i.) Mitral Stenosis → L atrial enlargement, prominent pulmonary arteries, R ventricular enlargement

ii.) Mitral Regurgitation → cardiac shadow increase

iii.) Aortic Stenosis → L ventricular enlargement, pulmonary congestion

iv.) Aortic Regurgitation → L atrial/ventricular dilation, pulmonary congestion (if HF present)

Electrocardiogram (ECG)

i.) Evaluate heart rhythm

ii.) Atrial fibrillation commonly found in mitral stenosis/regurgitation & aortic stenosis

Infective Endocarditis

Infection of endocardium & heart valves ; often occurs w/ those who use IV drugs…

i.) Blood flows rapidly from high-pressure to low-pressure zone → erodes endocardium

ii.) Platelets and fibrin adhere → form vegetative lesion

iii.) Bacteria trapped during bacteremia → deposited in vegetation

iv.) Vegetation grows → destroys endocardium & valve

v.) Valvular insufficiency or stenosis results

vi.) Vegetations may embolize into systemic circulation

Clinical Manifestations of Infective Endocarditis

Cardiovascular

i.) Murmurs

ii.) S₃ or S₄ heart sounds

iii.) R-side or L-sided HF

Embolic

i.) L-sided involvement → spleen, kidneys, GI tract, brain, extremities

ii.) R-sided involvement → pulmonary emboli

iii.) Splenic infarction (sudden ABD pain radiating to L shoulder, rebound tenderness)

iv.) Renal infarction (flank pain to groin w/ hematuria or pyuria)

v.) Neurologic changes

vi.) Pleuritic chest pain, dyspnea, cough

Integumentary

i.) Petechiae (mucous membranes, palate, conjunctivae, skin above clavicles)

ii.) Splinter hemorrhages

iii.) Osler nodes (palms/soles)

iv.) Janeway lesion (flat, reddened maculae on hands/feet)

v.) Roth spots (hemorrhagic lesions that appear as round or oval spots on retina)

Interventions/Treatment for Infective Endocarditis

Antibiotic Therapy

i.) Long-term (weeks to months) IV therapy

Oral Hygiene

i.) Proper oral hygiene is the BEST intervention for prevention

ii.) Brush ≥2×/day w/ a soft toothbrush

iii.) Avoid irrigation devices & flossing

Surgical Intervention

i.) Valve repair or replacement if indicated

ii.) Vegetation excision

Pericarditis

Inflammation/alteration of the pericardium…

i.) Acute pericarditis r/t infection, autoimmune disorders, MI, or trauma

ii.) Chronic (constrictive) pericarditis r/t TB, radiation therapy, trauma, renal failure, or metastatic cancer

iii.) Pericardium becomes rigid → prevents adequate ventricular filling → cardiac failure

Clinical Manifestations of Pericarditis

Acute Pericarditis

i.) Substernal precordial pain (radiating to left neck, shoulder, or back)

ii.) Grating, oppressive pain aggravated by breathing (especially inspiration), coughing, swallowing

iii.) Worse when supine; relieved by sitting up and leaning forward

iv.) Pericardial friction rub (scratchy, high-pitched sound at left lower sternal border)

v.) Elevated WBC count & fever

vi.) ST elevation in all leads

vii.) Atrial fibrillation (AF) common

viii.) Echocardiogram shows pericardial effusion

Chronic Pericarditis

i.) Signs of R-sided HF

Interventions/Treatment for Pericarditis

Drug Therapy

i.) NSAIDs (first-line for pain)

ii.) Corticosteroids

iii.) Colchine (NSAID adjunct to reduce symptoms/recurrence)

Positioning

i.) Sitting upright & leaning slightly forward

Pericardiocentesis

i.) Performed for fluid accumulation around heart

Acute Cardiac Tamponade

Emergency condition characterized by rapid fluid accumulation in the pericardium that compresses the heart & impairs CO…

i.) Compression of atria & ventricles leads to ↓ CO

ii.) Small volumes (20-50 mL) cause tamponade if accumulated rapidly

Common Causes of Acute Cardiac Tamponade

i.) Pericarditis

ii.) Ventricular wall rupture (from acute MI)

iii.) Cancer

iv.) Aortic dissection

v.) Complications from invasive procedures

vi.) Post-CABG (blood clot in pericardium)

Clinical Manifestations of Acute Cardiac Tamponade

i.) Muffled/distant heart sounds

ii.) JVD

iii.) Paradoxical drop in SBP (during inspiration)

iv.) Hypotension

v.) Tachycardia

vi.) Narrowed pulse pressure

vii.) Fluid accumulation (confirmed via ECG or chest X-ray)

Interventions/Treatment for Acute Cardiac Tamponade

Pericardiocentesis

i.) 8 in, 16- or 18 G needle inserted into pericardial space

ii.) Performed under echocardiographic or fluoroscopic guidance

iii.) Catheter inserted to withdraw all available fluid; temporary pericardial drain may be placed

iv.) Monitor pulmonary artery & R atrial pressures during procedure (should normalize as fluid removed)

Post-CABG

i.) Volume expansion + emergency sternotomy w/ drainage

Recurrent Cases

i.) Pericardial window (removes portion of pericardium to drain into pleural space)

ii.) Pericardiectomy (complete removal of pericardium)

Rheumatic Carditis

Sensitivity response after upper respiratory infection w/ group A beta-hemolytic streptococci…

i.) Inflammation occurs in all three layers of the heart

ii.) Aschoff bodies (small nodules in myocardium) form & are replaced by scar tissue

iii.) Pericardium thickens w/ exudate; serosanguineous pleural effusion may develop

iv.) Hemorrhagic & fibrous lesion form on valve surfaces → mitral/aortic stenosis or regurgitation

Clinical Manifestations of Rheumatic Carditis

i.) Inflammation of heart layers

ii.) Impaired myocardial contractile function

iii.) Thickened pericardium

iv.) Valvular damage

v.) S/S of HF

Interventions/Treatment for Rheumatic Carditis

Antibiotic Therapy

i.) Penicillin (drug of choice)

ii.) Erythromycin (penicillin-sensitive patients)

ii.) Begin course immediately & continue for a full 10 days

Symptom Management

i.) Maintain hydration

ii.) Antipyretics

iii.) Encourage adequate rest

Patient Education

i.) Recurrence most likely due to Streptococcus reinfection

ii.) Lifelong antibiotic prophylaxis required

Cardiomyopathy

Subacute or chronic disease of cardiac muscle classified based on structural & functional abnormalities…

i.) Dilated (DCM) → extensive myofibril damage that causes ventricular dilation & impaired systolic function

ii.) Hypertrophic (HCM) → asymmetric ventricular hypertrophy that causes diastolic filling problems & outflow obstruction; mitral valve abnormalities contribute

iii.) Restrictive → sarcoidosis/amyloidosis cause stiff ventricles that restrict diastolic filling; poor prognosis

iv.) Arrhythmogenic R Ventricular → myocardial tissue replaced w/ fibrous/fatty tissue; familial cause

Interventions/Treatment for Cardiomyopathy

Dilated & Restrictive Cardiomyopathy

i.) Diuretics → manage fluid overload

ii.) Vasodilators → improve flow

iii.) Cardiac glycosides → improve CO (i.e. Digoxin)

iv.) Beta-Blockers → block sympathetic stimulation & tachycardia (i.e. Metoprolol)

v.) Antidysrhythmics

vi.) Avoid causative toxins (i.e. alcohol)

Hypertrophic Cardiomyopathy

i) Negative inotropic agents → reduce outflow obstruction & HR to improve angina, dyspnea, syncope (i.e. Carvedilol, Verapamil)

ii.) Prohibit strenuous exercise

iii.) Avoid excess alcohol & dehydration

iv.) Implantable cardioverter/defibrillator (ICD)

v.) Ventricular septal myectomy → excise septum to widen outflow tract

vi.) Percutaneous alcohol septal ablation → alcohol injected into septal artery to cause small infarction & remodeling to reduce obstruction

Arrhythmogenic R Ventricular Cardiomyopathy

i.) Radiofrequency catheter ablation

ii.) Implantable defibrillator (if unresponsive to drugs)