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Cardiomyopathies & Cardiomyopathies & ValvularValvular DisordersDisorders
Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MS
Telemetry Telemetry CourseCourse
Clinical Educator for Cardiac TelemetryClinical Educator for Cardiac Telemetry
CardiomyopathiesCardiomyopathiesDisease of the Heart MuscleDisease of the Heart Muscle
FACTS:FACTS:Cardiomyopathy is the 2Cardiomyopathy is the 2ndnd most most common cause of sudden deathcommon cause of sudden death
** CAD is #1**** CAD is #1**
Prognosis for Dilated Prognosis for Dilated Cardiomyopathy is very poorCardiomyopathy is very poor
** Undiagnosed until in advanced stages **** Undiagnosed until in advanced stages **
CardiomyopathiesCardiomyopathies
RISK FACTORS:RISK FACTORS:
Hypertension Hypertension
PregnancyPregnancy
Viral InfectionsViral Infections
ETOH AbuseETOH Abuse
Males (overall)Males (overall)
African descent (both sexes)African descent (both sexes)
DIAGNOSTIC DIAGNOSTIC EVALUATION:EVALUATION:
EchocardiographyEchocardiography → confirms dilated → confirms dilated cardiomyopathycardiomyopathy
Chest X-RayChest X-Ray → reveals cardiomegaly → reveals cardiomegaly associated with any of the associated with any of the
cardiomyopathiescardiomyopathies
Cardiac Cath with possible BiopsyCardiac Cath with possible Biopsy → → can be definitive in diagnosing can be definitive in diagnosing hypertrophic cardiomyopathyhypertrophic cardiomyopathy
CardiomyopathiesCardiomyopathiesDILATED CARDIOMYOPATHYDILATED CARDIOMYOPATHY
Primarily Primarily affects systolic affects systolic function function ** ** (pumping action) **(pumping action) **
Results from Results from extensive extensive damage to damage to myocardial myocardial muscle fibersmuscle fibers
End-result End-result → → LV contractility LV contractility ↓↓
Poor CompensationPoor Compensation
SV, EF, and CO SV, EF, and CO ↓↓** (D/T decreased in pumping ** (D/T decreased in pumping
action) **action) **
Pulmonary CongestionPulmonary Congestion** If end-diastolic volumes increase ** If end-diastolic volumes increase
↑↑ ** **
↑ ↑ End-Diastolic End-Diastolic Volume is a Volume is a
Compensatory Compensatory ResponseResponse
** Preserves SV even though there ** Preserves SV even though there is is ↓ EF **↓ EF **
DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY
Poor CompensationPoor Compensation
Sympathetic Nervous System is Sympathetic Nervous System is stimulatedstimulated
** Increases HR & Contractility **** Increases HR & Contractility **
Kidneys are stimulated (Renin-Kidneys are stimulated (Renin-Angiotensin) to Retain Na & HAngiotensin) to Retain Na & H22OO
** Maintain adequate CO **** Maintain adequate CO **
Vasoconstriction also OccursVasoconstriction also Occurs
DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY
Poor CompensationPoor Compensation
When compensatory triggers can no When compensatory triggers can no longer keep up to maintain longer keep up to maintain
adequate CO…adequate CO…
The Heart Begins to Fail!!!The Heart Begins to Fail!!!
DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY
Detrimental DilationDetrimental Dilation
Venous Return & Systemic Vascular Venous Return & Systemic Vascular Resistance IncreaseResistance Increase
** LV Dilation Occurs **** LV Dilation Occurs **
With Time, Atria Also Dilate (Atrial With Time, Atria Also Dilate (Atrial Remodeling)Remodeling)
** More work required to pump blood into full ventricles **** More work required to pump blood into full ventricles **
Cardiomegaly is a consequence of Cardiomegaly is a consequence of atrioventricular dilationatrioventricular dilation
DILATED DILATED CARDIOMYOPATHYCARDIOMYOPATHY
Dilated Dilated CardiomyopathyCardiomyopathy
STATISTICS:STATISTICS:
Affects 5 to 8 of 100,000 peopleAffects 5 to 8 of 100,000 people
50% of all deaths resulting from DCM 50% of all deaths resulting from DCM occur suddenlyoccur suddenly
In a study conducted in 1988, 5-year In a study conducted in 1988, 5-year mortality rate of 50% has been reported mortality rate of 50% has been reported for DCM of various etiologies with EF < for DCM of various etiologies with EF <
50%50%
A more recent study in 2000 showed a 5-A more recent study in 2000 showed a 5-year survival rate of 75%year survival rate of 75%
Woods et al, 2005, p. 783Woods et al, 2005, p. 783
Idiopathic Dilated Idiopathic Dilated CardiomyopathyCardiomyopathy
Has a prevalence of 0.04% and is a Has a prevalence of 0.04% and is a relatively common cause of heart relatively common cause of heart
failurefailure
Incidence increases with age and is Incidence increases with age and is higher in maleshigher in males
50% of IDC cases may be familial50% of IDC cases may be familial
Endomyocardial biopsy provides a Endomyocardial biopsy provides a definitive diagnosisdefinitive diagnosis
Moser & Riegel, 2008, p. 1110Moser & Riegel, 2008, p. 1110
Secondary Dilated Secondary Dilated CardiomyopathyCardiomyopathy
Ischemic Dilated CardiomyopathyIschemic Dilated Cardiomyopathy
The most common type of dilated The most common type of dilated cardiomyopathycardiomyopathy
Caused by Coronary Artery DiseaseCaused by Coronary Artery Disease
About 15% to 45% of patients who have a About 15% to 45% of patients who have a myocardial infarction will develop dilatation of myocardial infarction will develop dilatation of
the left ventricle with a decrease in ejection the left ventricle with a decrease in ejection fractionfraction
Prognosis is worse for ischemic cardiomyopathy, Prognosis is worse for ischemic cardiomyopathy, than for non-ischemic cardiomyopathiesthan for non-ischemic cardiomyopathies
Moser & Riegel, 2008, p. 1111Moser & Riegel, 2008, p. 1111
Secondary Dilated Secondary Dilated CardiomyopathyCardiomyopathy
Hypertensive Dilated CardiomyopathyHypertensive Dilated Cardiomyopathy
Valvular Dilated CardiomyopathyValvular Dilated Cardiomyopathy
Anthracycline Dilated CardiomyopathyAnthracycline Dilated Cardiomyopathy(Anthracycline = Anticancer Agent)(Anthracycline = Anticancer Agent)
Peripartum Dilated CardiomyopathyPeripartum Dilated Cardiomyopathy
Alcohol-Related Dilated Alcohol-Related Dilated CardiomyopathyCardiomyopathy
Moser & Riegel, 2008Moser & Riegel, 2008
Dilated CardiomyopathyDilated Cardiomyopathy
May be overlooked until LV Failure May be overlooked until LV Failure OccursOccurs
SOB, orthopnea, DOESOB, orthopnea, DOE PND, Dry Cough @ night, FatiguePND, Dry Cough @ night, Fatigue Peripheral Edema, Hepatomegaly, Peripheral Edema, Hepatomegaly,
JVD, Weight GainJVD, Weight Gain
Signs & SymptomsSigns & Symptoms
Dilated CardiomyopathyDilated Cardiomyopathy
Peripheral CyanosisPeripheral Cyanosis TachycardiaTachycardia
Pansystolic Murmur Pansystolic Murmur (mitral/tricuspid insufficiency)(mitral/tricuspid insufficiency)
SS33 & S & S44 gallops rhythms gallops rhythms Irregular Pulse (with A-Fib)Irregular Pulse (with A-Fib)
Signs & SymptomsSigns & Symptoms
TREATMENTTREATMENTDilated CardiomyopathyDilated Cardiomyopathy
Management of underlying cause, if Management of underlying cause, if knownknown
ACEI (First-line), to reduce afterloadACEI (First-line), to reduce afterload
Diuretics with ACEI’sDiuretics with ACEI’s
DigoxinDigoxin
Hydralazine/Isosorbide DinitrateHydralazine/Isosorbide Dinitrate
AntiarrhythmicsAntiarrhythmics
Cardioversion (A-Fib to Sinus)Cardioversion (A-Fib to Sinus)
TREATMENT:TREATMENT:
Dilated CardiomyopathyDilated Cardiomyopathy
Pacemaker InsertionPacemaker Insertion
AnticoagulantsAnticoagulants
Revascularization (CABG) if d/t Revascularization (CABG) if d/t ischemiaischemia
Valvular Repair/ReplacementValvular Repair/Replacement
Lifestyle ModificationsLifestyle Modifications
Heart TransplantHeart Transplant
CardiomyopathiesCardiomyopathiesHYPERTROPHIC CARDIOMYOPATHYHYPERTROPHIC CARDIOMYOPATHY
Primarily Affects Primarily Affects Diastolic Function Diastolic Function
(**filling***)(**filling***)Features of HCM:Features of HCM:
Asymmetrical LV Asymmetrical LV HypertrophyHypertrophy
Hypertrophy of Hypertrophy of Intraventricular Septum Intraventricular Septum
(HOCM)(HOCM)
Rapid, forceful Rapid, forceful contractions of LVcontractions of LV
Impaired RelaxationImpaired Relaxation
Obstruction of LV Obstruction of LV outflowoutflow
Hypertrophied ventricles Hypertrophied ventricles become stiffbecome stiff
Do not relax during Do not relax during ventricular fillingventricular filling
** aka Diastole **** aka Diastole **
Ventricular filling Ventricular filling ↓↓, LV , LV pressure pressure ↑↑
↑ ↑ Left Atrial & Pulmonary Left Atrial & Pulmonary Venous PressuresVenous Pressures
** Leads to Venous Congestion & ** Leads to Venous Congestion & Dyspnea **Dyspnea **
HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY
Compensatory response Compensatory response kicks in kicks in → ↑ HR→ ↑ HR
** Ventricular Filling Decreases Even ** Ventricular Filling Decreases Even More **More **
↓ ↓ Ventricular Filling Time Ventricular Filling Time & Obstruction of & Obstruction of
Ventricular Outflow → ↓ Ventricular Outflow → ↓ COCO
MVR occurs if papillary MVR occurs if papillary muscles hypertrophy muscles hypertrophy
and valve doesn’t closeand valve doesn’t close
HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY
HYPERTROPHIC HYPERTROPHIC CARDIOMYOPATHYCARDIOMYOPATHY
STATISTICS:STATISTICS:
As many as 60% to 80% of cases are As many as 60% to 80% of cases are inherited through autosomal dominant inherited through autosomal dominant
transmissiontransmission
Usually goes undetected until Usually goes undetected until adulthoodadulthood
It prevalence is 1 per 500 in the general It prevalence is 1 per 500 in the general U.S. population and is higher in blacksU.S. population and is higher in blacks
Woods et al, 2005, p. 784Woods et al, 2005, p. 784
Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
AnginaAngina DyspneaDyspnea FatigueFatigue
Systolic ejection murmurSystolic ejection murmur(left sternal border & apex)(left sternal border & apex)
Pulsus biferiens Pulsus biferiens (peripheral pulse with a characteristic double impulse)(peripheral pulse with a characteristic double impulse)
Abrupt arterial PulseAbrupt arterial Pulse Irregular Pulse (with A-fib)Irregular Pulse (with A-fib)
Signs & SymptomsSigns & Symptoms
Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy
Beta-Blockers Beta-Blockers
((↓ HR, ↓ O↓ HR, ↓ O22 demand, demand, improve ventricular filling)improve ventricular filling)
Cardioversion Cardioversion (A-Fib to (A-Fib to Sinus)Sinus)
AnticoagulantsAnticoagulants
Ca Channel Blockers Ca Channel Blockers
(reduce stiffness, (reduce stiffness, ↑ diastolic ↑ diastolic pressures)pressures)
TREATMENT:TREATMENT:
Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy
Ablation of AV Node Ablation of AV Node (HOCM)(HOCM)
Dual Chamber Pacemaker Dual Chamber Pacemaker (HOCM)(HOCM)
AICDAICD
Ventricular Ventricular myotomy/myectomymyotomy/myectomy
Mitral Valve ReplacementMitral Valve Replacement
Heart TransplantHeart Transplant
TREATMENT:TREATMENT:
CardiomyopathiesCardiomyopathiesRESTRICTIVE CARDIOMYOPATHYRESTRICTIVE CARDIOMYOPATHY
Characterized as Characterized as stiffness of the stiffness of the
ventricleventricle** LV Hypertrophy & Endocardial Fibrosis ** LV Hypertrophy & Endocardial Fibrosis
Thickening **Thickening **
Ventricle does not relax Ventricle does not relax during diastoleduring diastole
** Ventricular Filling Reduced **** Ventricular Filling Reduced **
The rigidity of the The rigidity of the myocardium causesmyocardium causes failure to completely failure to completely
contract during systolecontract during systole** End-result is decreased CO **** End-result is decreased CO **
Restrictive CardiomyopathyRestrictive Cardiomyopathy
Chest PainChest Pain DyspneaDyspnea FatigueFatigue
OrthopneaOrthopnea EdemaEdema
Systolic murmursSystolic murmurs PallorPallor
SS33 & S & S44 gallops rhythms gallops rhythms
Signs & SymptomsSigns & Symptoms
Restrictive Restrictive CardiomyopathyCardiomyopathy
Management of Management of underlying causeunderlying cause
DigoxinDigoxin
DiureticsDiuretics
Restricted Na DietRestricted Na Diet
Oral VasodilatorsOral Vasodilators
TREATMENT:TREATMENT:
Valvular DisordersValvular Disorders
Malfunction of the Heart Malfunction of the Heart ValvesValves
Mitral & Aortic Valve Disorders:Mitral & Aortic Valve Disorders:
Insufficiency (Regurgitation)Insufficiency (Regurgitation)
StenosisStenosis
Prolapse (Mitral Only)Prolapse (Mitral Only)
Valvular DisordersValvular Disorders
Main Problems with Valvular Main Problems with Valvular Disorders:Disorders:
Atrial and Ventricular Atrial and Ventricular RemodelingRemodeling
Heart FailureHeart Failure
Mitral Valve Mitral Valve InsufficiencyInsufficiency
The abnormal leaking of blood through mitral The abnormal leaking of blood through mitral valve, from the left ventricle into the left atriumvalve, from the left ventricle into the left atrium
May be caused by stenosis or prolapse of the May be caused by stenosis or prolapse of the mitral valvemitral valve
Dysfunctions of the following valvular Dysfunctions of the following valvular components can cause MVI:components can cause MVI:
Valve LeafletsValve Leaflets Papillary MusclesPapillary Muscles Chordae TendonaeChordae Tendonae Annulus (stretched Annulus (stretched d/t cardiac d/t cardiac enlargement)enlargement)
Mitral Valve Mitral Valve InsufficiencyInsufficiency
Mitral Valve StenosisMitral Valve Stenosis
Narrowing of the mitral valve; Narrowing of the mitral valve; Results in impedance of blood flow to Results in impedance of blood flow to
ventriclesventriclesResults in decreased ventricular filling = Results in decreased ventricular filling =
↓↓COCOBackflow to Left Atrium = Backflow to Left Atrium = Atrial Atrial
RemodelingRemodeling
MVS is very commonly caused by MVS is very commonly caused by atherosclerotic disease which atherosclerotic disease which
results in calcification of valvesresults in calcification of valves
Other Causes:Other Causes:
Congenital Congenital Heart DiseaseHeart Disease
Rheumatic Rheumatic Heart DiseaseHeart Disease
Mitral Valve Mitral Valve ProlapseProlapse
Folding, inversion, and displacement of Folding, inversion, and displacement of mitral valve leaflets towards the left mitral valve leaflets towards the left
atriumatrium
Mitral Valve Mitral Valve ProlapseProlapse
Chordae tendonae Chordae tendonae becomes elongationbecomes elongation
May cause it to May cause it to rupturerupture
Displacement > 2 mm Displacement > 2 mm above mitral above mitral annulusannulus
Aortic Valve Aortic Valve InsufficiencyInsufficiency
Aortic Valve fails to close completely Aortic Valve fails to close completely Causes backflow of blood into ventricleCauses backflow of blood into ventricle
May be caused by stenosis or prolapse of the aortic May be caused by stenosis or prolapse of the aortic valvevalve
Aortic Valve Aortic Valve InsufficiencyInsufficiency
VENTRICULAR REMODELING:VENTRICULAR REMODELING:Eccentric Hypertrophy – Eccentric Hypertrophy – (ventricular wall thickening (ventricular wall thickening
with dilatation)with dilatation)Concentric Hypertrophy – Concentric Hypertrophy – (ventricular wall thickening (ventricular wall thickening
with diminished capacity)with diminished capacity)
Aortic Valve StenosisAortic Valve Stenosis
The hardening of the aortic valve or aorta itself
Aortic Valve Aortic Valve StenosisStenosis
AVS is very commonly caused by AVS is very commonly caused by atherosclerotic disease which atherosclerotic disease which
results in calcification of valvesresults in calcification of valves
Other Causes:Other Causes: Congenital Congenital
aortic bicuspid aortic bicuspid valve valve (associated with (associated with coarctation of coarctation of the aorta) the aorta)
Rheumatic Rheumatic Heart DiseaseHeart Disease
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