inflammatory and structural heart disorders

cardiac muscle layers

 Heart consists of 3 layers

•Epicardium

•Outermost layer of the heart

•Myocardium

•Middle layer

•Actual contracting muscle of the heart

•Endocardium

•Inner most layer

•Lines the inner chambers and heart valves

infective endocarditis (IE)

•Disease of the endocardium and the heart valves

•IE is associated with a poor prognosis and a decreased life expectancy

 Main Causes include:

•IV drug use

•History of IE

•Having a prosthetic heart valve

•Healthcare-associated infection from an intravascular device (central line)

•Dialysis

 Oral cavity risk increases if dental procedure in previous 3-6 months

 Infections (cutaneous, genitourinary, gastrointestinal, and systemic)

IE patho

•Blood flow allows organisms to contact and infect previously damaged heart valves or other endothelial surfaces

•Mitral & aortic valves commonly affected

•Staphylococcus aureus most common bacteria

•Bacteria creates biofilms; protect against antibiotics

 Typically develops in 3 stages:

◦Bacteremia

◦Adhesion

◦Vegetations

◦Primary lesions of IE

◦Often causes embolization

◦Left-sided move to organs and limbs

◦Right-sided move to lungs (PE)

IE clinical manifestations

 Nonspecific, involve multiple organ systems

◦Fever, chills, weakness, malaise, fatigue, anorexia, clubbing

Heart failure is common

◦Most patients have a new or worsening systolic murmur in most patients

IE Vascular manifestations from microembolizations:

◦Splinter hemorrhages in nail beds

◦Petechiae

◦Osler’s nodes on fingertips or toes

◦Janeway lesions on fingertips, palms,  soles of feet, and toes

◦Roth’s spots (retinal lesions)

IE diagnostics

Health history

- Recent surgeries

- Dental, urologic, gynecologic procedures (childbirth)

- IV drug use

-Heart disease

-Infection

Laboratory tests

-Blood cultures x3 in 60 minutes

-CBC with differential

-Erythrocyte Sedimentation Rate (ESR)

-C-reactive protein (CRP)

Echocardiogram

-Vegetation

IE Management Prophylactic Antibiotic Use

•Certain congenital heart diseases

•Heart transplant recipients who develop heart valve disease

•History of infective endocarditis

•Prosthetic heart valve or prosthetic material used to repair heart valve

•Dental procedures

•Oropharyngeal surgery

•Skin and/or musculoskeletal surgery

IE treatment

Long term IV antibiotics → picc line

Several weeks

Repeat blood cultures

Every 24-48 hours

Follow-up echocardiogram & inflammatory markers

Obtained once treatment complete

Complete at 1, 3, 6, and 12 months

Valve replacement

→ Completed in up to 60% of cases

• Supportive care

Antipyretics

Fluids

Rest

IE pt teaching

Stress need to avoid people with infections

Avoidance of stress and fatigue

Plan rest periods

Good oral hygiene

Schedule regular dental visits

Prophylactic antibiotics

Rehabilitation for IV drug abuse

pericarditis overview

 Pericardial sac encases and protects the heart from trauma and infection

◦5-20mL of fluid lubricates and cushions the heart

Has two layers:

•Parietal pericardium

◦Tough, fibrous outer membrane

•Visceral pericardium

◦Thin, inner layer that closely adheres to the heart

pericarditis patho

 Inflammation of the pericardial sac

 Leads to pericardial leak (effusion)

 Most common causes are idiopathic or from a viral illness

pericarditis clinical manifestations

•Chest pain

•Progressive, severe, sharp

•May radiate

•Referred pain to the trapezius muscle

•Pain is worse with deep inspiration and when lying flat

•Pain is relieved when sitting up and leaning forward

•**Pericardial friction rub

◦Scratching, grating, high-pitched sound

◦Heard loudest at lower left sternal border with patient leaning forward

◦Have patient hold their breath for a few seconds

•Fever, chills, malaise, fatigue

complications of pericardial effusions

•Build-up of fluid in the pericardium

•Can occur rapidly or slowly

•Large effusions compress nearby structures

•Symptoms:

•Cough, dyspnea, tachypnea, hiccups (phrenic nerve), hoarseness

•Heart sounds are muffled and distant; bp remains constant

complications of cardiac tamponade

•Pericardial cavity fills with fluid and compresses the heart leading to decreased cardiac output

•Symptoms:

•Chest pain, JVD, Paradoxical pulse, Tachycardia, muffled heart sounds, hypotension, tachypnea

 Medical Emergency!!

◦Pericardiocentesis

◦Pericardial window

◦Temporary pericardial drain

pericardial window

•May be required for recurrent tamponade or effusions

•Part (pericardial window) or all pericardiectomy) of the pericardium may be removed

•Allows for adequate ventricular filling and contraction

pericarditis diagnostic

•EKG

•May show ST elevation and/or PR segment depression

•Physical assessment

•Note friction rub, pulsus paradoxus

•Laboratory

•Elevated C-reactive protein

•Elevated sedimentation rate

•Elevated WBC count

•Pericardial biopsy

•Determine cause

•Echocardiogram

•Identify pericardial effusion or cardiac tamponade

•Other imaging

•Echocardiogram

•CT scan

•MRI

pericarditis treatment

Identify and treat underlying problem and symptoms

Bed rest

HOB at 45 degrees

Place overbed table for support

Pericardiocentesis

Pericardial window

Drug therapy

NSAIDs: control pain and inflammation

Corticosteroids: in select patients

Antibiotics: bacterial pericarditis

Aspirin: STEMI

Colchicine: anti-inflammatory

pericarditis nursing management

Keep patient on bedrest with HOB elevated 45 degrees

Administration of anti-inflammatory agents

Monitor for signs of cardiac tamponade and prepare for possible pericardiocentesis

myocarditis

•Inflammation of the myocardium

•Most often caused by a viral illness

•Causative agent invades the myocytes and causes cellular damage and necrosis

•Autoimmune response generated

•Further destruction of cardiac myocytes occurs

myocarditis clinical manifestations

•Symptoms vary from minor to severe

•Early symptoms:

•Fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and nausea/vomiting

•Cardiac symptoms:

•Pleuritic chest pain, friction rub, signs of heart failure

•Appear 7 to 10 days after viral infection

myocarditis diagnostics

CBC

•Mild to moderate leukocytosis

•Inflammatory markers

•Increased ESR and CRP

Cardiac enzymes

•Elevated troponins

Endomyocardial biopsy

•Provides histologic confirmation of myocarditis

•Obtain within 6 weeks of illness

12 lead EKG

•ST segment changes

myocarditis management

Drug therapy

ACE Inhibitors

Beta blockers

Diuretics

Digoxin

Anticoagulants

Myocarditis with an autoimmune cause: given immunosuppressants and antivirals

Supportive measures

Oxygen therapy

Bed rest

High-fowler’s position

Restrictive activity

⭐️Goal is to decrease workload of the heart

rheumatic fever

•Rheumatic fever (RF) is an acute inflammatory disease that can involve all layers of the heart

•Occurs as a complication 2-3 weeks after an URI with group A streptococcal pharyngitis

•Strep throat

rheumatic heart disease overview

•Rheumatic heart disease is chronic scarring and deformity of the heart valves resulting from RF

•Results from an abnormal immune response to streptococcus bacteria

•Mitral and aortic valves most affected

•Valvular swelling and erosion of the leaflets

◦Vegetation forms on leaflets leading to calcification and impaired mobility (stenosis)

◦Valves unable to close completely causing regurgitation

rheumatic heart disease clinical manifestations

•Carditis (inflammation of the heart)

•New murmur or change in current murmur

•Cardiomegaly

•Signs of HF

•Friction rub, chest pain, muffled heart sounds

•Monoarthritis or Polyarthritis

•Joint pain, swelling, heat, redness, limited ROM of large joints

•Knees, ankles, elbows, and wrists

•CNS manifestations

•Uncontrolled movement of face and limbs

rheumatic heart disease diagnostics

 Evidence of existing streptococcal infection

 EKG change

◦Prolonged PR interval

◦Delayed AV conduction

 Chest x-ray

◦Enlarged heart

 Echocardiogram

◦Evaluate valve involvement

rheumatic heart disease treatment

 Penicillin is antibiotic of choice

 Cephalexin, Clindamycin, or Azithromycin effective is an alternative for PCN allergy

 Teach patient to complete full 10-day course of antibiotic

 Manage fever with hydration and antipyretics

 Plenty of rest

 Prophylactic antibiotics are necessary lifelong to prevent infective endocarditis

rheumatic heart disease management

•Bed rest or limited activity

•Drug therapy

•Antibiotics

•NSAIDs

•Corticosteroids

 Prevention is KEY!!

 Treat patients with antibiotics for:

◦Moderate-to-high fever

◦Abrupt onset of sore throat

◦Reddened throat with exudate

◦Enlarged and tender lymph nodes

stenosis vs regurgitation

 Stenosis: Constriction or narrowing of valve leaflets opening

 Regurgitation: Incomplete closure of the valve causing backward flow of blood

Mitral Valve Stenosis

•Most common cause is RHD

•Scarring of valve leaflets and chordae tendineae from RHD

•“Fish mouth” shape

•Mitral valve narrows preventing normal blood flow from the left atrium to the left ventricle

•Left atrium dilates, pulmonary artery pressure increases, right ventricle hypertrophies

Mitral stenosis clinical manifestations

Dyspnea on exertion

Loud S₁

Low-pitched, diastolic murmur

Symptoms of right-sided heart failure as condition progresses

Hoarseness (atrial enlargement)

Hemoptysis (pulmonary hypertension)

Atrial fibrillation

Fatigue

Palpitations

mitral regurgitation

•Change in structure of mitral valve causes inability to fully close during systole

•Blood backflows into from the left ventricle into the left atrium

•Increase in blood volume and pressure causes the left atrium and left ventricle to dilate and enlarge

mitral regurgitation clinical manifestations

• Acute onset:

Thready peripheral pulses

Cool, clammy extremities

New systolic murmur

Pulmonary edema

Cardiogenic shock may occur

• Chronic:

May be asymptomatic for years

Palpitations, weakness, fatigue, dyspnea

May progress to right and left-sided heart failure symptoms

mitral prolapse

 Abnormality of the mitral valve leaflets and surrounding structures

 Mitral valve prolapses back into the left atrium during systole

 Hereditary link

◦Marfan syndrome or other hereditary conditions that affect collagen structure

mitral prolapse clinical manifestations

Most patients are asymptomatic for their entire lives

About 10% of population become symptomatic

Regurgitation murmur that is louder during systole

◦Other manifestation:

◦Atypical chest pain

◦Palpitations

◦Exercise intolerance

◦Dizziness

◦Syncope

mitral prolapse pt teaching

Take cardiac medications as prescribed

Adopt healthy eating habits

Avoid caffeine & other stimulants

Begin or maintain adequate exercise program

Contact HCP or EMS for worsening symptoms

aortic stenosis

•Most common cardiac valve dysfunction

•Most common valvular disorder of the aging population

•Disease of “wear & tear”

•Aortic valve orifice narrows and obstructs left ventricular outflow during systole

•Ventricular hypertrophy occurs

aortic stenosis clinical manifestations

 May be asymptomatic

 Angina

 Syncope

 Dyspnea on exertion

 Symptoms of heart failure

 Systolic murmur

aortic regurgitation

•Aortic valve leaflets do not close properly during diastole

•Blood flow from the aorta backflows into the left ventricle during diastole

•The left ventricle dilates to accommodate the greater blood volume causing the LV to hypertrophy

◦Pulmonary hypertension and RV heart failure occur

aortic regurgitation clinical manifestations

Asymptomatic for years

• Acute onset:

Severe dyspnea

Chest pain

Hypotension

Cardiogenic shock

• Chronic onset:

◦Exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

◦Palpitations when laying on left side

◦Nocturnal angina with diaphoresis

aortic regurgitation diagnostic

 History and Physical

 Echocardiography (Echo)

 Transesophageal echocardiography (TEE) → pictured

◦See next slide

 Exercise tolerance testing (ETT)

 Chest x-ray

 Cardiac catheterization

 EKG

aortic regurgitation management

• Prophylactic antibiotics

Rheumatic fever and infective endocarditis

• Sodium restriction

• Drug therapy to treat or control HF

Vasodilators, positive inotropes, diuretics, beta blockers

Anticoagulation therapy

Anti-dysrhythmics

• Percutaneous transluminal balloon valvuloplasty

• Percutaneous valve replacement

percutaneous transluminal balloon valvuloplasty

◦Invasive nonsurgical procedure for mitral/aortic stenosis

◦Guidewire is inserted through femoral vein or artery

◦Balloon is inserted into affected valve and inflated to enlarge orifices and leaflet mobility

◦Immediate symptom relief usually occurs

◦Not a permanent fix for stenosis

valve repair

 Preferred over replacement when possible

 Often used for mitral or tricuspid valve disease

•Valvuloplasty

•Repair of the valve by suturing the torn leaflets or surrounding structure

•Annuloplasty

•Reconstruction of the annulus with or without the aid of prosthetic rings

valve replacement

• Mechanical valves

Made from artificial material

More durable; last longer

Increased risk for thromboembolism

Long-term anticoagulant therapy necessary

• Biologic valves

Made from bovine, porcine, or human heart tissue

Less durable; early calcification

Must be replaced every 7-10 years

Long-term anticoagulants not needed

transcatgeter aortic valve replacement (TAVR)

 Option for patients with severe, symptomatic aortic stenosis

 Transfemoral approach

◦Small incision is made in the groin to allow for bilateral transfemoral access

 Bedrest for 6 hours

 Dual therapy of aspirin and Plavix for at least 6 months

◦Aspirin daily for life

valve repair/ replace pt teaching

 May require home health for medication management, wound care

 Prophylactic antibiotics

◦Antibiotics are required before any dental procedures

◦Dental procedures should wait at least 6 months after surgery due to risk of endocarditis

 Periods of rest

 Understand medications

 High risk for infective endocarditis

 Notify all providers of heart valve history

 Prosthetic heart valve recipients need lifelong anticoagulants

◦Educate about bleeding tendencies

◦Dietary considerations for Warfarin (Coumadin) therapy

 Medical alert bracelet

 Carry manufacturer’s valve information card

 Avoid MRI for prosthetic valves

 Report changes in cardiovascular status to provider

Cardiomyopathy

A group of diseases that directly affect myocardial structure and function

• Classified as primary or secondary

Primary: idiopathic conditions involving only the heart muscle

Secondary: another disease process causes myocardial disease

• Three major types of cardiomyopathy

Dilated cardiomyopathy

Hypertrophic cardiomyopathy

Restrictive cardiomyopathy

Dilated Cardiomyopathy

 Most common type of cardiomyopathy

 Diffuse inflammation and rapid degeneration of heart fibers

◦Results in ventricular dilation, impaired systolic function, atrial enlargement, and blood stasis in the left ventricle

◦Ventricular dilation causes cardiomegaly

◦HEART MUSCLE TOO THIN

Dilated Cardiomyopathy manifestations

• May develop acutely after an infection or slowly over time

Decreased exercise capacity

Fatigue

Dyspnea at rest

Paroxysmal nocturnal dyspnea

Orthopnea

• Disease progression:

Dry cough

Palpitations

Abdominal bloating

Nausea/vomiting/anorexia

Symptoms of RV/LV heart failure

Poor Prognosis

Dilated Cardiomyopathy diagnostic

Patient history

Echocardiogram

Chest x-ray

EKG

Increased BNP

Heart catheterization w/Endomyocardial biopsy

Dilated Cardiomyopathy treatment

Focus on controlling HF be enhancing heart contractility and decreasing preload and afterload

Treatment guidelines are based on the specific stage of disease progression

Nitrates & loop diuretics→ Decrease preload

Beta blockers and Aldosterone Antagonist

ACE inhibitors→ Decrease afterload

Digoxin (presence of atrial fibrillation

• Anticoagulants

Decrease risk of systemic embolization

Cardiac Resynchronization therapy

Automatic Implantable Cardioverter Defibrillators (AICD)

Ventricular Assist Device

Cardiac transplant

Hospice

Hypertrophic Cardiomyopathy

•Genetic disorder that causes asymmetric left ventricular hypertrophy without ventricular dilation

•More common in males

•Most common cause of sudden cardiac death among healthy young people

•1^st degree relatives of patients with condition should be screened

◦HEART MUSCLE TOO THICK

Hypertrophic Cardiomyopathy patho

• 4 main characteristics

Massive ventricular hypertrophy

Rapid, forceful contraction of the left ventricle

Impaired relaxation (diastole)

Obstruction to aortic outflow (not present in all patients)

• Ventricular hypertrophy results in poor filling of stiff ventricle

Decreased cardiac output

Hypertrophic Cardiomyopathy clinical manifestations

May be asymptomatic

Many are asymptomatic until late adolescence or early adulthood

Atypical chest pain not relieved by nitrates, shortness of breath with exertion, syncope, dizziness, and palpitations

Many athletes that suffer sudden cardiac death may have had hypertrophic cardiomyopathy

Death is usually the first sign

Hypertrophic Cardiomyopathy diagnostics

Echocardiogram- main diagnostic tool

Physical exam may be unremarkable

EKG

Cardiac catheterization

Nuclear stress test

Hypertrophic Cardiomyopathy treatment

⭐️Goal is to Improve ventricular filling by reducing ventricular contractility & relieving LV outflow obstruction

B-Blockers

Calcium channel blockers

Amiodarone

Digitalis contraindicated unless used to treat A-fib

Implantable cardioverter-defibrillator→ Those at risk of SCD

AV pacing

Ventriculomyotomy→Surgically remove piece of thickened septal muscle along with removing some of the ventricular muscle→ Allows for better ventricular wall movement→ Improve cardiac output

Restrictive Cardiomyopathy

•Rarest of the cardiomyopathies

•Stiff ventricles restrict diastolic filling and stretch

•This inability to relax and fill with blood results in a “back up” of blood into the atria, lungs and body

•Symptoms are similar to right/left-sided heart failure

•Can be a primary or secondary disease

•Prognosis is poor

Restrictive Cardiomyopathy clinical manifestations

Fatigue

Exercise intolerance

Dyspnea on exertion

 May develop signs of both left-sided & right-sided heart failure

• Other symptoms:

◦Angina

◦Syncope

◦Orthopnea

◦Palpations

Restrictive Cardiomyopathy diagnostics

CXR: Normal or cardiomegaly. Pleural effusions & pulmonary congestion in more severe disease

ECG: Heart block, A-fib, SVT

ECHO: Thicken ventricular wall, small ventricular cavities & dilated atria

biopsy, CT & nuclear imaging may be helpful

Restrictive Cardiomyopathy management

 Interventions are aimed at improving diastolic filling and underlying disease process

Conventional therapy for HF

Treat arrhythmias

Heart transplant

cardiomyopathies pt teaching

Take all drugs as prescribed and regularly follow up with HCP

Follow a low-sodium diet (if prescribed) and read all product labels (food and over-the-counter drugs) for sodium content

Drink 6 to 8 glasses of water a day unless fluids are restricted

Achieve and maintain a reasonable weight and avoid large meals.

Avoid alcohol, caffeine, diet pills, and over-the-counter cold medicines that may contain stimulants.

At risk for infective endocarditis, required prophylactic antibiotics prior to invasive procedures

Balance activity and rest periods

Avoid heavy lifting or vigorous isometric exercises and check with HCP for exercise guidelines

Use stress management techniques: relaxation breathing, guided imagery

Report any signs of HF to HCP, including weight gain, edema, shortness of breath, and increased fatigue

Encourage caregivers to learn CPR because of the potential for cardiac arrest

Access emergency response system (ERS) according to the HCP’s instructions