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

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Presentation on theme: "Caring For Patients With Cardiomyopathy J.O. Medina,RN, MSN,FNP,CCRN Education Specialist / Nurse Practitioner Critical Care & Emergency / Trauma Services."— 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 : n Define cardiomyopathy. n Differentiate between dilated, restrictive, and hypertrophic cardiomyopathy with regard to etiology, pathophysiology, and management.


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

23 n Low dose ß blockers u Controversial F Atenolol F Metoprolol F Carvedilol n Anticoagulation for patients : u In atrial fibrillation u Moderate or severe failure

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

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

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

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

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

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

30 HCM : Pathophysiology n septum : disproportionately enlarged creating narrow, long cavity n 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 n  contractility (exercise, positive inotropes) n  heart rate (exercise, fever,  CO) n  preload (hypovolemia, sepsis, fluid shifts) n loss of atrial kick (atrial fibrillation, AVB, ventricular arrhythmias) Arrhythmias may occur and cause sudden death !

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

56 Questions ? Thank You !

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