NCM 109: Acquired Heart Disease and Inflammatory Disorders

Congestive Heart Failure (Definition)

The failure of the heart to efficiently pump, leading to excessive blood or fluids in the lungs, the body, or both.

- Common Pediatric Emergency

- Results from structural or functional cardiac disorders that impair the ability of the ventricles to fillwith and/or eject blood.

- Clinical condition in which the heart fails to meet the metabolic and circulatory demands of the body.

- CHF is most apt to occur in children under 1 year of age.

Congestive Heart Failure (Etiology)

-either left or right ventricles or both may be sources of inadequate pumping

- Various forms of congenital heart disease such as ventricular septal defect (VSD), patent ductus arteriosus (PDA) or common AV canal

- Heart valve disease caused by Rheumatic fever or other infections

Infections of the heart valves and/or heart muscle (endocarditis)

- Cardiac arrhythmias (irregular heartbeats)

- Cardiomyopathy or another primary disease of the heart muscle

- Coronary artery disease

Inflammation of heart muscle (myocarditis)

- Complication of CHD, rheumatic fever, Kawasaki disease, etc.

Congestive Heart Failure (S/S)

- Tachycardia: Early sign

- Tachypnea

- Right heart failure

- Left heart failure:

In infants: Breathless, Tires easily, Difficulty feeding, Diaphoresis, Generalized edema

*left heart failure causes right heart failure

Signs of left sided heart failure

Dyspenea, Orthopenea, Cough, Rales, Tachycardia

(pulmonary flow)

Signs of right sided heart failure

edema, jugular vein distension, peripheral edema, ascites, hepatomegaly

(systemic flow)

Compensatory systems of the heart in cases of dec. cardiac output

RAAS System = fluid retention, vasoconstriction (may cause congestion such as in CHF)

Inc. Heart Rate = to increase cardiac output, may fatigue the heart

Congestive Heart Failure (Management)

Pharmacologic Treatment

Diuretics: Furosemide

Inotropic Agent: Digoxin

Vasodilator: Hydralazine

ACE Inhibitor: Captopril

Calcium Channel Blocker: Nifedipine

- Provide for rest periods.

- Put the patent in a semi-fowler’s position (to alleviate LHF symptoms)

- Sedation with morphine

- Provide oxygen as necessary

- Maintain proper nutrition

- Diet should be planned with low salt for sodium restriction and to be given in small amounts frequently

Congestive Heart Failure (HOPE)

H: Head of Bed (Semi Fowler's)

O: Oxygen

P: Push Morphine

E: End Sodium, LOF

Kawasaki Disease (Other name)

mucocutaneous lymph node syndrome

Kawasaki Disease (Definition)

- an acute systemic vasculitis or the inflammation of the blood vessels of unknown origin

- usually occurs in children less than 5 years of age.

- a febrile, multisystem disorder that occurs almost exclusively in children before the age of puberty.

- It has replaced rheumatic fever as the most likely cause of acquired heart disease in children.

= The peak incidence is in boys under 4 years of age.

After infection, altered immune function occurs and an increase in antibody production which creates circulating immune complexes that bind to the vascular endothelium and cause inflammation.

Kawasaki Disease (Acute Phase)

-Onset of fever greater than 38.9 (102) lasting 5 days to 2 weeks, no response to antiphyretics

-RED eyes without drainage

-Bright RED, chapped lips

-Strawberry tongue with white coating or RED bumps on the posterior aspect

-RED oral mucous membranes with inflammation

-Swelling of hand and feet with RED palms and soles

- Cervical lymph nodes become enlarged.

- Children may develop abdominal pain, anorexia, and diarrhea.

- Joints may swell and redden, simulating an arthritic process.

Kawasaki Disease (Subacute Phase)

10 days after onset

- Skin: desquamates, particularly on the palms and soles.

- Platelet count rises; this increases the possibility of clotting, which could result in necrosis of distant body cells, particularly the fingertips, if they no longer receive adequate blood.

- Aneurysms may form in coronary arteries, compromising heart activity.

- Sudden death from accumulating thrombi or rupture of an aneurysm may occur (most dangerous phase)

Kawasaki Disease (Convalescent Phase)

complete resolution of symptoms until all signs of inflammation have disappeared after 8 weeks

Kawasaki Disease (Criteria for Diagnosis)

- Fever >5 days + 4/5:

- bilateral nonexudative conjuctival injection

- changes in lips, tongue or oral mucosa (drying, fissuring, red strawberry tongue)

- changes in the peripheral extremities (edema, erythema, desquamation)

- Polymorphous truncal exanthem

- Cervical lymphadenopathy

Kawasaki Disease (Management)

Acetylsalicylic acid (aspirin) or Ibuprofen:

- decreases inflammation and blocks platelet aggregation.

Abciximab:

- platelet receptor inhibitor specific for Kawasaki disease.

IV immune globulin (IVIG):

- to reduce the immune response

- Caution: patients should not receive routine immunizations while taking IVIG or the immunization will be ineffective.

Steroids:

- may increase aneurysm formation; arecontraindicated.

Coronary artery bypass surgery:

- if the child is left withcoronary artery disease from stenosis of the coronary arteries

Rheumatic Heart Disease (Definition)

- It is an inflammatory disease that can develop as a complication of inadequately treated streptococcus infection.

- Common in children 6 to 15 years of age with a peak incidence at 8 years. It is most seen in a poor crowded urban area

- Children appear well again in 1 to 3 weeks. However if the child is not treated, the rheumatic fever’s symptoms can begin.

- It occurs in a late reaction of its response to infection.

- The name takes after “Rheumatism”

Caused by abnormal immune response against M protein = causes inflammation of the heart

Rheumatic Heart Disease (Causative Agent)

group A beta hemolytic streptococcus.

Rheumatic Heart Disease (S/S)

Fever

Sydenham’s Chorea

Chest pain

Erythema marginatum

- A subcutaneous rash that does not itch and forms rings that spread out overtime.

Carditis

Bacterial vegetations on tricuspid valve

Wrist inflammation

Rheumatism

- Inflammation occurs in the joints making it painful to move.

Sydenham Chorea

jerky, uncontrollable and purposeless movements of the hands, arms, shoulder, face, legs, and trunk. These movements look like twitches, and disappear during sleep

This is known as chorea or St. Vitus’ dance.

Rheumatic Heart Disease (JONES)

Joint pain

🫀Carditis

Nodules [Subcutaneous]

Erythema Marginatum

Sydenham’s Chorea

Rheumatic Heart Disease (CAFEPAL)

C-reactive protein ↑ [>3 mg/dL]

Arthralgia

Fever

Erythrocyte sedimentation rate [>60 mm/h]

Prolonged PR interval

Anamnesis Suggestive of Rheumatism

Leukocytosis

Rheumatic Heart Disease (Diagnostic Tests)

ECG: blocks

Chest X-ray: congestion/cardiomegaly

Echocardiogram: effusion/any valvular dysfuntion

Throat Culture: usually negative

Serology

- Anti streptolysin O

- Anti deoxyribonuclease B

Rheumatic Heart Disease (Nursing Management)

Encourage bedrest and decrease oxygen demands

Monitor vital signs during the acute phase.

Rheumatic Heart Disease (Pharmacological Management)

Penicillin therapy: Benzathine penicillin

Oral Ibuprofen: ↓ inflammation and joint pain

Corticosteroid: ↓ inflammation on children who are not responding to ibuprofen therapy

Phenobarbital and Diazepam: ↓ the purpose less movement of the chorea

Digoxin and Diuretics: ↓ heart failure

Pericarditis (Definition)

Is an inflammation of the pericardial membrane with or without accumulation of excess pericardial fluid.

Pericarditis (Causative Agent)

The most common causes of pericarditis in North America and Europe are viral or post viral in origin.

Pericarditis (Complications)

pericardial effusion and cardiac tamponade

Cardiac Tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity

Pericarditis (S/S)

Chest pain, which can be sharp, precordial, radiating, and is worse with inspiration or cough.

It is characteristically positional

Fever is also common.

Weakness,

Trouble breathing and coughing.

Palpitations

Pericarditis (Treatment)

Anti-inflammatory Agents (NSAIDS): Ibuprofen

Corticosteroids

Myocarditis (Definition)

inflammation of the myocardium (muscle layer)

- This inflammation can weaken the heart muscle, affect its function, and in severe cases, lead to heart failure, arrhythmias, or sudden cardiac death.

Myocarditis (Causative Agent)

viral agents such as adenovirus, parvovirus, COVID-19, bacterial infections, autoimmune diseases, toxins, or allergic reactions.

Myocarditis (S/S)

Chest pain: This is one of the hallmark symptoms of myocarditis.

Shortness of breath (dyspnea)

Fatigue and weakness

Palpitations

Edema (swelling)

Flu-like symptoms

Arrhythmias

Myocarditis (Treatments)

- Depends on the underlying cause and severity of the condition.

- The use of steroids or immunosuppressants is NOT well established but has been shown to be beneficial with certain types of myocarditis.

- For fulminant myocarditis , the use of mechanical circulatory devices, like - VAD and ECMO may be necessary as a bridge to transplant or recovery.

Bacterial Endocarditis (Definition)

- It is the inflammation and infection of the endocardium or the valves in the heart.

- The incidence of infective endocarditis in children is increasing due to the increased survival of children with chronic heart disease.

Bacterial Endocarditis (Causative Agent)

- typically caused by bacteria, but fungi or other microorganisms can also be responsible.

- The condition usually occurs when bacteria or other germs from another part of the body, such as the mouth, skin, or urinary tract, enter the bloodstream and attach to damaged areas of the heart.

Ex. during dental surgery, impetigo, or UTI

- Staphylococcus aureus or Streptococcus viridans

Bacterial Endocarditis (S/S)

Fever: Persistent or recurrent fever is a hallmark symptom of infective endocarditis.

Chills

Fatigue and weakness

Heart murmurs

Petechiae

Bacterial Endocarditis (Treatment)

Antibiotic therapy until complete eradication achieved

IV therapy

Arrhythmia (Definition)

Abnormal heart rhythm

Sinus arrhythmia is commonly found in children.

Atrial Fibrillation

occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall

Atrial flutter

irregular beating of the atria; often described as "a-flutter with 2 to 1 block or 3 to 1 block"

ventricular fibrillation

the rapid, irregular, and useless contractions of the ventricles

Arrhythmia (Management)

■ Atropine: To counteract the vagal stimulation

■ Digoxin: Decreases and strengthens heart rate

■ Pacemaker: To maintain a steady heart rhythm

Normal digoxin levels

0.5-2 ng/mL

Potassium and Digoxin relationship

Potassium ions compete with Digoxin for binding to receptors

When potassium levels are low, binding of digoxin to receptors increases

Can produce toxicity of Dig

When potassium levels are high, Digoxin affinity to receptors is low

Thus blocks therapeutic response of Digoxin

ACE Inhibitors can increase potassium levels