Cardiomyopathy - Tutorial

Life Underwriting

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Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595.

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CARDIOMYOPATHY 101

Elaine M. Szewc, RN, BS Medical Underwriting Consultant John Hancock Life Insurance

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Definition

•The term cardiomyopathy is purely descriptive, meaning disease of the heart muscle

• “a heterogeneous group of diseases of the myocardium associated with mechanical &/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic.

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•Cardiomyopathies either are confined to the heart or are a part of generalized systemic disorders, often leading to cardiovascular death or progressive heart failure-related disability.” (2006 AHA)

•A broad term that includes subacute or chronic disorders of the myocardium. (Black & Hawks)

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CardiomyopathyCardiomyopathy

Nursing Review, 2001

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CAuses

• Risk increases in clients who:

Chronically ingest excessive amounts of alcohol

Pregnant

Have systemic hypertension

Have had some forms of infections.

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Dilated Cardiomyopathy

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Dilated Cardiomyopathy - Definition

• Primary (idiopathic) is a disease of unknown etiology that principally affects the myocardium leading to LV dilation and systolic dysfunction

• Characterized by ventricular dilatation, contractile dysfunction, and heart failure.

• Most common of the cardiomyopathies.

• Also known as hypertrophic subaortic stenosis, and asymmetrical septal hypertrophy

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DCM - Incidence and Prognosis

• Third most common cause of heart failure

• Most frequent cause of heart transplantation

• Complete recovery is rare

• Highest incidence in middle age

• Symptoms may be gradual in onset

Source: UpToDate (www.uptodate.com) "Definition and classification of the cardiomyopathies“ Leslie T Cooper, Jr, MD last updated 2/14/08

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Clinical Manifestations (Cont)

• Symptoms/Signs of heart failure

– Pulmonary congestion (left heart failure) dyspnea (rest, exertional, nocturnal), orthopnea

– Systemic congestion (right heart failure) edema, nausea, abdominal pain, nocturia

– Low cardiac output

– Hypotension, tachycardia, tachypnea

– Fatigue and weakness

• Arrhythmia

– Atrial fibrillation, conduction delays, complex PVC’s, sudden death

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Diagnostics

• CXR (enlarged heart, CHF)

• Electrocardiogram (tachycardia, A-V block, PVC’s)

• 24-hour Holter monitor – if with lightheadedness, palpitation, syncope

• Echocardiogram (left ventricular dilation)

• Myocardial biopsy, rare

• Cardiac catheterization (R/O CAD)

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DCM - Treatment

• Limit activity based on functional status

• Salt restriction

• Fluid restriction

• Initiate medical therapy

– ACE inhibitors, diuretics

– Digoxin

– Hydralazine/nitrate combination

– Anticoagulation prn

– Implantable defibrillators

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DCM – Treatment (Cont)

• Cardiac transplantation

– This disorder is the most common indication for cardiac transplantation

– Survival after transplant is

• 80% one year

• 70% 5 years

• Left Ventricular Reduction Procedures

– LV-reshaping

Source: UpToDate (www.uptodate.com) "Diagnosis and management of ischemic cardiomyopathy" James C Fang MD, Sary Aranki MD, last updated 4/7/09

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Nursing Management

• Encourage rest.

• Clients should avoid poorly tolerated activities.

• Advise clients that physical and emotional stress exacerbate the disease.

• Clients should abstain from drinking alcohol beverages.

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Hypertrophic Cardiomyopathy

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Hypertrophic Cardiomyopathy (HCM)

• Defined

– Prevalence 2:1000 – Genetic disease characterized by hypertrophy

of the left ventricle with marked variable clinical manifestations morphologic and hemodynamic abnormalities

– Small LV cavity, septal hypertrophy which can be asymmetric, obstruction of left ventricular outflow with low stroke volume,

Source: UpToDate (www.uptodate.com) “Natural history of hypertrophic cardiomyopathy" Perry M Elliott, MD, William J McKenna, MD, last updated 9/18/07

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Clinical Manifestations

• Asymptomatic

– Echocardiographic finding only

• Symptomatic

– Dyspnea in 90%

– Angina pectoris in 75%

– Fatigue, pre-syncope, syncope, risk of SCD

– Palpitation, PND, CHF, dizziness

– Atrial fibrillation, thromboembolism

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EKG Findings

• Abnormal in 85-90% of cases

• LVH, Strain pattern

• Abnormal ST-T’s, giant T wave inversions

• Abnormal Q’s,

• Bundle Branch Block

• Left atrial enlargment

• Ventricular arrhthymias

Source: UpToDate (www.uptodate.com) "Clinical manifestations and diagnosis of arrhythmogenic right ventricular cardiomyopathy“ William J McKenna, MD, last updated 3/18/09

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Management of HCM

• Beta-adrenergic blockers (atenolol, toprol, sotalol, tenormin etc)

• Calcium channel blockers (norvasc, cardizem, etc)

• Anti-arrhythmics – Amiodarone, norpace

• Pacemakers

• Myomectomy (resection of septum)

• Transplantation

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Restrictive Cardiomyopathy

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Restrictive Cardiomyopathies

• Hallmark: abnormal diastolic function

• Rigid ventricular wall with impaired ventricular filling

• Bear some functional resemblance to constrictive pericarditis

• Importance lies in its differentiation from operable constrictive pericarditis

• Much less common then DCM or HCM outside the tropics, but frequent cause of death in Africa, India, South and Central America and Asia primarily because of the high incidence of endomyocardial fibrosis in those regions

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Clinical Manifestations

• Symptoms of right and left heart failure

• Jugular Venous Pulse

• Echo-Doppler

– Abnormal mitral inflow pattern

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Treatment

• No satisfactory medical therapy

• Drug therapy must be used with caution

– Diuretics for extremely high filling pressures

– Vasodilators may decrease filling pressure

– (?) Calcium channel blockers to improve diastolic compliance

– Digitalis and other inotropic agents are not indicated

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Questions?