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TRANSCRIPT
Inflammatory and Valvular Disorders
Infective Endocarditis (IE)
• Inflammation of the innermost layer of the
heart (endocardium) • High mortality – 25% in the United States • May develop rapidly or gradually
• Turbulent blood flow promotes vegetative
growth
Sub-acute-affects those with preexisting valve disease, may extend over months
Acute-affects those with healthy valves-rapid progressive illness
Infective Endocarditis Etiology
Occurs primarily with:
• IV drug abuse • Prosthetic valves • Systemic infections • Structural cardiac
defects/lesions (MVP, CHD)
Infective Endocarditis Pathophysiology
• Causative agent infects previously damaged valves or other endothelial surfaces (vegetation)
Most common bacterial organisms : Staphylococcus aureus and Streptococcus viridans
• Can also be caused by fungi and viruses
• Vegetation: o Embolization of portions of
vegetation into circulation – Spleen, kidneys, brain
Signs and Symptoms
• Non-specific-multiple organ systems
• Low grade fever • Chills • Weakness • Malaise • Fatigue • Anorexia
Signs and symptoms secondary to vascular changes: o Janeway lesions (nontender
maculae on palms and soles) o Osler’s nodes (tender,
erythematous raised nodules on fingers and toes)
o Splinter hemorrhages (under fingernails)
o Roth’s Spots (hemorrhages on retina)
o Petechiae (pinpoint red spots)
• New murmur • HF (esp. aortic valve
involvement) • Manifestations secondary to
embolization
Infective Endocarditis
Diagnostic criteria
Must included at least two of the following:
• Positive blood cultures • New or changed murmur • Intra-cardiac mass or
vegetation per echo Chest x-ray: will show
cardiomegaly
Medical Management
• Prevention: pt’s that have specific cardiac conditions
Antibiotic prophylaxis
Treatment: o Eradicate infection
(Antibiotics) o Prevent complications
(embolic and HF) o Valve replacement o Support cardiac function
Health Promotion
• Prophylactic Antibiotics for at risk patients o IV drug abuse oProsthetic valves oSystemic infections oStructural cardiac defects/lesions
(MVP, CHD)
Myocarditis
Location: myocardium
o Causes local or diffuse swelling & damage.
Causes: o Infectious process o Immunologic response o Effects of radiation o Toxins or drugs
Manifestations and treatment
Inflammatory symptoms usually preceded by febrile illness or UTI
• Treatment specific to the
cause • Primarily Supportive • Preserve cardiac function
and prevent heart failure • In acute phase, keep patient
on bed rest • Immunoglobulin
Pericarditis
• Inflammation of pericardium • Primary or secondary • Fibrosis and scarring
• Can progress to chronic constrictive pericarditis or to cardiac tamponade
Pericarditis
• Manifestations oChest pain oFever oPericardial friction rub
• Diagnostics oECG oEchocardiogram oChest X-ray to rule out pulmonary pathology oPericardiocentesis oCardiac enzymes oCBC
Pericarditis Management
• Treated outpatient if stable • NSAIDs, aspirin, indomethacin up to 2
weeks • Severe pain – prednisone may be
required • Large effusions – pericardiocentesis • Pericardectomy/window
Pericardial Effusion
• Accumulation of excess fluid in the pericardium
• Can occurs rapidly or slowly • Large effusions compress
adjoining structures
Cardiac Tamponade
• Develops as pericardial effusion increases in volume—compresses the heart
• Impaired diastolic filling of heart • Volume of pericardial fluid (normal 30-50 ml)
interferes with filling of atria and ventricles • Stroke Volume is decreased • Rate of fluid accumulation is critical
.
Cardiac Tamponade
• Presentation • Pulsus paradoxus (↓SBP during
inspiration) • Tachycardia • Hypotension, JVD • Narrowing pulse pressure • Muffled heart sounds • ↓ LOC, UO • Cool mottled skin, weak peripheral pulses
Cardiac Tamponade Management
• IV Fluids • Pericardiocentesis
Rheumatic Fever Rheumatic Heart Disease (RHD)
Description o Abnormal immune response to A beta-hemolytic
streptococcus bacteria o Leads to inflammation in connective tissue of
heart, joints, and skin o Carditis develops in 50% of people affected with
Rheumatic Fever • Endocardial inflammation causes swelling,
erythema and vegetative lesions on leaflets. Fibrous scarring causes deformity of valve leaflets.
Management
• Antibiotics (penicillin) x 10 days-eliminates residual group A strep
• Prophylactic antibiotics 5-10 yrs • ASA or other NSAID
• Prevention: Proper ID and treatment of strep throat
infections
Valvular Heart Disease
• Type depends on: o Valve or valves affected o Functional alterations:
• Stenosis oValve orifice is restricted o Impeding forward blood flow
• Regurgitation /Insufficiency o Incomplete closure of valve leaflets oResults in backward flow of blood
Valvular disorders occur in children and adolescents primarily from congenital conditions and in adults from degenerative heart disease
Valvular stenosis and regurgitation. A, Normal position of the valve leaflets, or cusps, when the valve is open and closed. B, Open position of a stenosed valve (left) and position of closed
regurgitant valve (right). C, Hemodynamic effect of mitral stenosis. The stenosed valve is unable to open sufficiently during left atrial systole, inhibiting left ventricular filling. D, Hemodynamic effect of mitral regurgitation. The mitral valve does not close completely during left ventricular
systole, permitting blood to reenter the left atrium.
Mitral Valve Disease
• MS (mitral stenosis) • MR (mitral regurgitation) • MVP (mitral valve prolapse)
Mitral Valve Stenosis (MS)
Etiology: Results from Rheumatic heart disease
Scarring of valve leaflets and chordae tendinea
Obstruction of blood flow create pressure difference between left atrium and left ventricle
Hypertrophy of pulmonary vessels
• DOE Orthopnea-due to reduced lung compliance
• Atrial fibrillation • Fatigue • Peripheral edema
(RHF)
Mitral Regurgitation Blood ejected back into the left atrium during contraction
Causes • Acute regurgitation:
Rupture of chordae tendineae or papillary muscles
• Chronic regurgitation: Rheumatic fever, MVP,
CAD, congestive heart failure • Asymptomatic for
years until development of left ventricular failure
Signs and Symptoms
• Thready peripheral pulses • cool clammy extremities • Low CO
CHRONIC-may be asymptomatic for
years
• Atrial enlargement • Ventricular dilation-
ventricular hypertrophy
Mitral Valve Prolapse (MVP)
• Abnormality of mitral valve leaflets and papillary muscle or chordae tendinae
• Allows the leaflets to
prolapse back into the left atrium during systole
• Unknown etiology • Usually benign, but serious
complications can occur
Most patients asymptomatic for life
• Dysrhythmias • Palpitations • Lightheadedness • Dizziness • Chest pain • Risk for IE
• Treated symptomatically
Aortic Valve Stenosis (AS)
• Usually discovered in childhood, adolescence, or young adulthood (bicuspid valve)
• Adult presentation due to rheumatic fever or senile fibrocalcific degeneration
Aortic Stenosis Manifestations
Cardinal symptoms: Angina, syncope, and exertional dyspnea due to left ventricular failure.
Calcifications can lead to
atrioventricular (AV) blocks and left bundle branch block
Aortic Stenosis Management
• Surgical valve replacement for severely
symptomatic patients • Prophylactic antibiotics • Avoid nitrates (reduces preload-which is
necessary to open the stiffened aortic valve)
Aortic Valve Disease Diagnostics
• TEE: The gold standard: • ECG • Chest X-ray • Cardiac catheterization:
Measure heart pressures and pulmonary artery pressures
Valvular Disorders Medical (conservative) Management
• Drug therapy • Prophylactic antibiotic • Management of atrial fibrillation- cardioversion,
anticoagulant • Rest with limited activity • Low-sodium diet • Focus on preventing
o Exacerbations of heart failure o Acute pulmonary edema o Thromboembolism o Recurrent endocarditis
Valvular Disorders Surgical Management
• Balloon Valvuloplasty • Surgery:
o Commissurotomy- dilation of valve o Valvuloplasty/annuloplasty (Rings)-
repair/suturing of leaflets o Valves replacements- Mechanical or
bioprosthetic/pericardial tissue oMechanical (long term anticoagulant
therapy)
Balloon Angioplasty
Percutaneous Valve Replacement
• PAVR
Valve replacement
Mechanical Valve –manufactured form man made materials
More durable, last longer increased risk for thoromboemoli
Biologic valve –bovine, porcine, human cardiac tissue-if person can’t take anticoagulant
Education Post Valve Surgery
• Anticoagulants • Prophylactic Abx • Oral Hygiene
• Post op surgical instructions
Cardiomyopathy
Diseases that affect the structural or functional ability of the myocardium
• Dilated-most common type • Hypertrophic • Restrictive
Primary-(idiopathic) etiology of heart disease is unknown
Secondary- cause of myocardial disease is known and is secondary to another disease process
Dilated Cardiomyopathy
Most common type of cardiomyopathy • Causes heart failure in 25-40% cases • Seen more frequently in middle aged African Americans/ men • Genetic link in 30% cases
Characterized by: • Diffuse inflammation • Rapid degeneration of myocardial fibers RESULTS IN: • Ventricular dilation (cardiomegaly) • Impairment of systolic function • Atrial enlargement • Stasis of blood in left ventricle
Signs and symptoms
May develop acutely after infectious process or slowly over time.
• Heart failure • Decreased exercise tolerance • fatigue • dyspnea at rest • PND, orthopnea
Diagnosis: made on pt history –echo, cardiac cath , MUGA determine EF
Care of patient with Dilated cardiomyopathy
Control Heart failure symptoms Medications used: Nitrates, loop
diuretics, ACE inhibitors Beta blockers, Aldosterone antagonists, Digoxin, antidysrhythmics, anticoagulants
Doesn’t respond well to therapy • May need Dobuatamine and
Milrinone infusions • Hospitalization • VAD’s • Heart transplant
Hypertrophic Cardiomyopathy
• Pt may be asymptomatic • Or may have dyspnea, fatigue , angina,
syncope • ECHO-primary diagnostic tool
Goal of treatment • Improve ventricular filling • Relieve ventricular outflow obstruction Use of beta blockers, Ca+ channel blockers antidysrthymics , AICD’s, AV pacing,
surgical procedures Nursing: relieve symptoms, prevent complications Teaching: adjusting lifestyle, avoid strenuous activity and dehydration.
Hypertrophic Cardiomyopathy
Left ventricle hypertrophy without ventricular dilatation
• Septum may become enlarged and obstruct blood flow
• May be idiopathic or genetic Characteristics:
1. Massive ventricular hypotrophy 2. Rapid forceful contraction of left ventricle 3. Impaired relaxation (diastole) 4. Obstruction of aortic outflow
Restrictive Cardiomyopathy
• Least common • Impairs diastolic filling and stretch • Systolic function remains unaffected
Manifestations: • Fatigue • Exercise intolerance dyspnea-heart can’t CO by HR without
compromising ventricular filling • Angina • Orthopnea • syncope • Palpitations
Collaborative Care for cardiomyopathy
• See table on Page 860 • Nursing care –individualized based on patients
signs and symptoms • Treatment of underlying cause if possible • Conventional therapy heart failure and
dysthryhmias • Anticoagulants if needed • VAD’s/AICD’s, transplants
• All patients are at risk for infectious endocarditis