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Caring For Patients With Cardiomyopathy

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Presentation on theme: "Caring For Patients With Cardiomyopathy"— Presentation transcript:

1 Caring For Patients With Cardiomyopathy
J.O. Medina,RN, MSN,FNP,CCRN Education Specialist / Nurse Practitioner Critical Care & Emergency / Trauma Services California Hospital Medical Center

2 Objectives : Define cardiomyopathy.
Differentiate between dilated, restrictive , and hypertrophic cardiomyopathy with regard to etiology, pathophysiology, and management.


4 Cardiomyopathy: Overview
Disease of cardiac muscle myofibril degeneration affecting heart globally Not as a result of HTN, coronary atherosclerosis, valvular dysfunction or pericardial abnormalities cause often unknown (idiopathic) categorized into 3 groups based on functional and structural abnormalities dilated(congestive)cardiomyopathy hypertrophy cardiomyopathy restrictive cardiomyopathy

5 Cardiomyopathy : Types
Dilated (congestive) cardiomyopathy systolic dysfunction related to abnormal dilation of heart chambers Hypertrophic cardiomyopathy diastolic dysfunction related to abnormal hypertrophy of IVS / ventricles Restrictive cardiomyopathy diastolic dysfunction related to non-compliant stiff ventricles

6 Cardiomyopathy : Major Consequences
Systolic or diastolic heart failure or combination of both arrhythmias other problems specific to type of disorder

7 Dilated (Congestive) Cardiomyopathy
most common form of cardiomyopathy diffuse dilation of cardiac chambers : ventricle(s) and atria systolic dysfunction caused by decreased contractility pulmonary and systemic congestion :  CO embolic episodes

8 Dilated (Congestive) Cardiomyopathy : Causes
Often unknown Alcohol (15 – 40%) Pregnancy (last trimester) / post partum (6 months post partum) Collagen-viral infections Oncologic agents : adriamycin Hederofamillial neuromuscular disease

9 Dilated (Congestive) Cardiomyopathy : Causes
Postmyocarditis Toxins Nutritional (beriberi, selineum deficiency, thiamine deficiency) Cocaine, heroine, organic solvents “glue-sniffer’s heart” Infection ( viral HIV, rickettsial, myobacterial, toxoplasmosis ) Antiretroviral agents

10 Dilated (Congestive) Cardiomyopathy : Pathophysiology
diffuse dilation of ventricle(s) causing decreased contractility leads to  CO compensatory mechanisms : ST to maintain CO catecholamine release stimulating renin-angiotensin system  sodium/water retention and vasoconstriction (preload,afterload)

11 Dilated (Congestive) Cardiomyopathy : Pathophysiology
poor contractility :  LVEDV   LVEDP  dilates annulus of AV valve  papillary dysfunction  valve incompetency  atrial enlargement  pulmonary congestion

12 Dilated (Congestive) Cardiomyopathy : Clinical Presentation
LVF chronic fatigue ; weakness orthopnea ; paroxysmal nocturnal dyspnea (PND) cough ; chest pain weight gain palpitations dizziness ; syncope impotence insomnia

13 Dilated (Congestive) Cardiomyopathy : Physical Examination
Precordium tachycardia enlarged apical impulse, laterally displaced (cardiomegaly) right ventricular impulse along LSB heart sounds: S, S, systolic murmur Lungs tachypnea : if dyspnea present at rest  end stage disease auscultation : clear  crackles / wheezes

14 Dilated (Congestive) Cardiomyopathy : Physical Examination
LV Failure signs :  LOC cool, pale extremities pulsus alternans alternating strong / weak pulse due to severe LV failure RV failure signs indicate severe disease

15 Dilated (Congestive) Cardiomyopathy : Diagnosis
EKG arrhythmias ST (compensatory for  CO) atrial; fibrillation (Af) : ominous sign (due to dilated atria) atrial and ventricular arrhythmias (high grade ectopy portent to sudden death) Q waves : pseudoinfarction due to fibrosis ; ST-T wave abnormalities QRS widened : LVH, LBBB

16 Dilated (Congestive) Cardiomyopathy : Diagnosis
CXR multichamber enlargement, pulmonary congestion, pleural effusions Echocardiogram LV dysfunction chamber enlargement valve dysfunction hypokinesis and wall motion abnormalities  EF

17 Dilated (Congestive) Cardiomyopathy : Diagnosis
Medical history with emphasis on : Dyspnea on exertion, orthopnea, PND Palpitations Systemic and pulmonary embolism Cardiac Troponin T Persistent elevation marker of poor outcome

18 Dilated (Congestive) Cardiomyopathy : Diagnosis
Exercise electrocardiogram determines patient’s functional status and if arrhythmias may develop with exercise Cardiac catheterization may be helpful to identify concomitant coronary artery disease

19 Dilated (Congestive) Cardiomyopathy : Management
Goals  cardiac workload Limit activity Improve symptoms Treat underlying disease

20 Dilated (Congestive) Cardiomyopathy : Pharmacologic Management
Treat CHF ( cause of death in 70% of patients) diuretics ; sodium restriction ACEI ; β-blockers, spirolactone, and Digitalis  preload ;  pulmonary and systemic congestion  wall tension   demand

21 Dilated (Congestive) Cardiomyopathy : Pharmacologic Management
vasodilators  afterload :  LV workload acute setting : NTG, SNP ACE inhibitors (first line oral agents)  mortality rate  afterload and preload Hydralazine (Apresoline) ; Isordil second line oral combination if unable to tolerate ACE inhibitor

22 Dilated (Congestive) Cardiomyopathy : Pharmacologic Management
Inotropes  contractility and SV acute setting : dopamine, dobutamine, amrinone, epinephrine digoxin Antiarrhythmias treat symptomatic arrhythmias consider implanted defibrillator

23 Dilated (Congestive) Cardiomyopathy : Pharmacologic Management
Low dose ß blockers Controversial Atenolol Metoprolol Carvedilol Anticoagulation for patients : In atrial fibrillation Moderate or severe failure

24 Dilated (Congestive) Cardiomyopathy : Management
Activity : reduced physical activity during period of decompensation cardiac rehab program to  exercise tolerance Diet : sodium restriction small frequent meals during liver congestion  nutrition (prevent cachexia) vitamins ; no alcohol

25 Dilated (Congestive) Cardiomyopathy : Management
Growth Hormone : increase myocardial mass (controversial) Surgical Therapy cardiac transplantation for end stage disease (>50% of cardiac transplants are DCM) latissimus dorsi muscle wrap around heart with muscle pacing synchronized to heart increase contractility

26 Dilated (Congestive) Cardiomyopathy : Disposition
Annual mortality 20% in patients with moderate HF > 50% in severe HF AICD with severe nonischemic DCM Referral Heart transplant if < 60 years old and no longer responding to medical therapy

27 Hypertrophic Cardiomyopathy (HCM)
formally referred to as idiopathic hypertrophic subaortic stenosis (IHSS) hypertrophic obstructive cardiomyopathy (HOCM)

28 HCM : Characteristics Asymmetrical hypertrophy of LV with disproportional septum enlargement as compared to free wall decreased LV cavity creates diastolic stiffness impairing filling thickened, elongated MV leaflets are displaced and may obstruct LV outflow tract  LVSDP   atrial and pulmonary pressure

29 HCM : Causes 1/3 familial 2/3 unknown
sporadic occurrence Autosomal dominant trait causing encoding of cardiac sarcomere

30 HCM : Pathophysiology septum : disproportionately enlarged creating narrow, long cavity excessive, early LV systole displaces MV leaflets (along with altered papillary muscle position) toward IVS  preventing complete closure of MV  obstruct LV outflow tract . Septum can obstruct outflow tract  ventricular wall becomes rigid   LVEDP   LAP  pulmonary congestion

31 HCM : Factors That Aggravate Condition
 contractility (exercise, positive inotropes)  heart rate (exercise, fever, CO)  preload (hypovolemia, sepsis, fluid shifts) loss of atrial kick (atrial fibrillation, AVB, ventricular arrhythmias) Arrhythmias may occur and cause sudden death !

32 HCM : Clinical Presentation
Varies with degree of hypertrophy dyspnea on exertion : pulmonary congestion dizziness / syncope : result of ischemic induced arrhythmias: CO chest pain: due to  supply with  demand; narrowed transluminal coronary arteries sudden death from arrhythmias may be first sign

33 HCM : Physical Examination
precordium sustained, possibly lateral displacement of ventricular impulse - cardiomegaly presystolic atrial impulse felt harsh, mid systolic murmur at apex, LSB, possible radiation to axilla or base of heart S, S may be present lungs : tachypnea LV failure especially if atrial fibrillation present

34 HCM : Diagnosis EKG  voltage of LV hypertrophy ST-T wave abnormalities Q waves in inferior/lateral leads due to septal hypertrophy PVC : 75% SVT : % atrial fib : % CXR : normal or enlarged heart, atrial enlargement, pulmonary congestion

35 HCM : Diagnosis Echocardiogram : Cardiac Catheterization :
septal hypertrophy LA enlargement narrow outflow tract wall motion abnormalities MV leaflet abnormality Cardiac Catheterization :  chamber pressures MR altered LV outflow gradient

36 HCM : Management Goals :  ventricular filling by slowing HR
 contractility by reducing obstruction

37 HCM : Management maintain normal sinus rhythm
if atrial fibrillation : convert pharmacologically / electrically avoid hypotension, vasodilators, dehydration, strenuous exercise, sepsis, chemical withdrawal, shivering, seizures surgery : excise part of septum implant defibrillator avoid alcohol

38 HCM : Management Avoid : digitalis, diuretics, nitrates and vasodilators Arrhythmia control Disopyramide ( Norpace )has negative inotropic properties Amiodarone for atrial and ventricular arrhythmias

39 HCM : Pharmacologic Support
ß blockers Propranolol 160mg – 240 mg/day for dyspnea and chest pain  HR ( provides longer filling)  contractility (  outflow obstruction;  demand ) blocks SNS ( catecholamines may be a causative factor) may  arrhythmias

40 HCM : Pharmacologic Support
Calcium Channel Blockers : Verapamil :  LV obstruction second line for β-blockers for hospital patients  diastolic filling time promotes relaxation  contractility  outflow gradient

41 HCM : Referral Management
Myotomy-myectomy Resection of basal septum For > 50% mmHg outflow gradient Nonsurgical reduction of IVS Controversial Injection of ethanol in septal perforator branch of LAD Associated with high incidence of heart block ; patient may require permanent pacemaker


43 Restrictive Cardiomyopathy : Characteristics
uncommon type restricted ventricular filling due to replacement of ventricular muscle with a non elastic material diastolic dysfunction may develop systolic dysfunction later in disease symptoms of pulmonary / systemic congestion

44 Restrictive Cardiomyopathy : Causes
90% Infiltrative and storage disorders amyloidosis deposits of insoluble protein into muscle and connective tissue sarcoidosis ; hemochromatosis myocardial fibrosis (after open heart) radiation scleroderma diabetic cardiomyopathy

45 Restrictive Cardiomyopathy : Pathophysiology
stiff ventricles   ventricular filling   CO  biatrial dilation  pulmonary and systemic congestion

46 Restrictive Cardiomyopathy : Clinical Presentation
subjective symptoms RUQ discomfort ( right sided failure symptoms predominate vs. left sided symptoms ) dyspnea : pulmonary congestion chronic fatigue :  CO poor exercise tolerance

47 Restrictive Cardiomyopathy : Physical Signs
right sided failure : JVD ascitis hepatic enlargement edema

48 Restrictive Cardiomyopathy : Physical Signs
left sided failure : pulmonary congestion  BP narrowed pulse pressure weak, tired DOE

49 Restrictive Cardiomyopathy : Clinical Presentation
precordial exam : palpable apical pulse; may be displaced laterally cardiomegaly systolic murmur : TVR / MVR due to atrial dilation or amyloid infiltrates of papillary muscles S, S

50 Restrictive Cardiomyopathy : Diagnosis
EKG changes : low voltage QRS sinus tachycardia, atrial fibrillation, sinus bradycardia if SA node infiltrated complex ventricular arrhythmias : are poor prognostic sign Q waves : pseudo infarct from fibrosis BBB, AVB

51 Restrictive Cardiomyopathy : Diagnosis
CXR : cardiomegaly with biatrial enlargement Echocardiogram : normal contractility no pericardial effusion biatrial enlargement LV hypertrophy with small ventricular cavity Myocardial Biopsy : amyloidosis, hemochromatosis, etc.

52 Restrictive Cardiomyopathy : Management
Goal : symptom relief primarily by  pulmonary / systemic congestion

53 Restrictive Cardiomyopathy : Management
Pharmacological support : mild diuretic therapy : prevent excessive volume depletion to prevent syncope from  SV secondary to  ventricular filling vasodilator : NTG, ACE inhibitors No digoxin : prone to digitalis induced arrhythmias and heart block No calcium channel blockers : predisposes to hypotension due to amyloidosis

54 Restrictive Cardiomyopathy : Management
restrict sodium intake Hemochromatosis CM repeated phlebotomy to reduce iron deposition in the heart Sarcoidosis may respond to corticosteroids Eosinophilic CM corticosteroids and cytotoxic drugs

55 Restrictive Cardiomyopathy : Management
there are no effective therapy for other causes questionable therapies : AV sequential pacemaker antiarrhythmics surgical interventions mitral valve replacement tricuspid valve replacement excision of thickened endomyocardial plaque

56 Questions ? Thank You !

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