Diseases Of The Heart

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Diseases Of The Heart

• Terri Slifer Lynch, MSN, RN, BC

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Heart Failure

• Heart failure is a clinical syndrome
• Heart is unable to pump sufficient blood to meet
  the needs of the tissues
  
• Heart failure is the number 1 DRG for
  hospitalization in people over 65 years
  

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Etiology of Heart Failure

• CAD
• Systemic or pulmonary hypertension
• Cardiomyopathy
• Valvular disease
• Septal defects
• Myocarditis

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• Dysrhythmias
• Hypervolemia
• Metabolic disorders
• Autoimmune disorders
• Anemia in the elderly

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Pathophysiology Of Heart Failure

• Decreased amount of blood ejected from
  ventricles
  
• Stimulation of SNS - increases myocardial
  workload or O2 demand
  
• Ventricular hypertrophy
• Decreased renal perfusion

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• Activation of Renin-Angiotensin-Aldosterone
  System
  
• Renin interacts with Angiotensinogen to produce
  Angiotensin I
  
• Angiotensin I converts to Angiotensin II
• Angiotensin II stimulates release of Aldosterone

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• Blood backs up in left atrium and pulmonary
  veins
  
• Increased hydrostatic pressure forces fluid out
  of pulmonary capillaries into alveoli and
  interstitial spaces
  
• Right ventricle dilates due to increased
  pulmonary pressures (pulmonary HTN)
  
• Engorgement of venous system extends backwards
  into systemic veins and organs
  

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• Right ventricular failure usually follows left
  ventricular failure
  
• Right ventricular failure can occur solely
  without left ventricular failure cor pulmonale
  
• Heart failure can affect systolic function or
  diastolic function
  

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Clinical Manifestations Of Left Ventricular
Failure (LVF)

• Dyspnea
• Dyspnea on exertion (DOE)
• Orthopnea
• Paroxysmal nocturnal dyspnea (PND)
• Cough
• Crackles
• Hypoxia, cyanosis
• Tachycardia, palpitations

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• S3, S4, murmurs
• Weak, thready pulses
• Fatigue
• Pale, cool, clammy skin
• Restlessness, anxiety, confusion
• Nocturia, oliguria
• Decreased GFR, increased creatinine

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Clinical Manifestations of Right Ventricular
Failure (RVF)

• Elevated JVD
• Positive HJR
• Hepatomegaly, splenomegaly
• Ascites
• Anorexia, nausea, constipation

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• Sacral edema
• Peripheral edema
• Anasarca
• Weight gain
• Decreased activity tolerance

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Acute Pulmonary Edema

• Life threatening situation
• Large accumulation of fluid in lungs
• Manifestations
• Severe dyspnea, sense of suffocation
• Cough, large amounts of frothy, blood tinged
  sputum
  
• Wheezing and coarse crackles
• Cyanosis

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New York Heart AssociationsFunctional
Classification of Heart Disease

• Class I Ordinary activity does not cause
  symptoms
  
• Class II Slight limitation of ADLs
• Class III Comfortable at rest but any activity
  causes symptoms
  
• Class IV Symptoms at rest

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Diagnostic Findings With Heart Failure

• Echocardiogram with Doppler flow studies
• Chest x-ray
• ECG
• B-Type Natriuretic Peptide (BNP)

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• BUN and creatinine
• T4 and TSH
• Liver function tests
• Stress testing or cardiac cath

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Objectives In Treating Heart Failure

• Identify and eliminate the precipitating cause
• Reduce the workload on the heart
• Enhance patient and family coping with lifestyle
  changes

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Medical Management of Heart Failure

• Exercise
• Bed rest in upright position in acute and
  refractory stages
  
• Regular exercise program
• Oxygen therapy
• Dietary restrictions
• Sodium restriction
• Fluid restriction

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• Cardiac resynchronization biventricular pacing
  (Medtronic InSyn)
  
• Mechanical assist devices
• Transplantation

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Pharmacologic Management of Heart Failure

• ACE inhibitors
• Vasodilate
• Promote diuresis
• Drugs Vasotec, Captopril, Zestril,
• Angiotensin II Receptor Blockers (ARBs)
• Prescribed when patient intolerant of ACE-I
• Drugs Diovan, Aticand

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• Beta1 Blockers
• Decrease cytotoxic effects of constant
  stimulation of SNS
  
• Decrease workload by decreasing heart rate
• Drugs - Coreg, Lopressor, Atenolol

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• Vasodilators
• Cause venous dilation
• Cause arterial dilation
• Drugs Nitrates ie. Isordil (isosorbide) and
  other meds ie. Apresoline (hydralazine) BiDil (
  isosorbide hydralazine combination)
  

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• Diuretics
• Control Na and H2O retention
• Three types
• Potassium sparing Aldactone (spironalactone),
  Inspra (eplerenone)
  
• Loop diuretics Lasix (furosemide)
• Thiazide diuretics Zaroxolyn (metolazone), HCTZ
  (hydrochlorazide)
  
• Monitor for hypotension, lyte imbalances and
  dehydration, worsening renal failure

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• Cardiac glycosides
• Increase force of myocardial contraction and slow
  conduction through AV node
  
• Drugs Lanoxin (digoxin), Primacor, Inocor
• Precautions with Lanoxin administration
• Decreased renal function slows elimination
• Will need to decrease dose with certain meds ie.
  amiodarone, erythromycin, quinidine
  
• Usual dose 0.125 mg to 0.5 mg (PO,IV,IM)

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• Lanoxin toxicity Therapeutic level 0.5-2.0
  ng/mL
  
• Symptoms anorexia, N/V, fatigue, H/A, yellow or
  green halos, new dysrhythmias
  
• Reversal hold dose or administer Digibind
  (digoxin immune FAB)
  
• Nursing considerations for Lanoxin
  administration
  
• Assess heart rate for 1 min
• Give after breakfast
• Monitor for hypokalemia

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• Calcium channel blockers
• Contraindicated with severe systolic dysfunction
• Drugs Norvasc, Cardizem, Procardia

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• Natrecor (nesiritide)
• Indicated for the IV treatment of clients with
  acutely decompensated congestive heart failure
  with dyspnea at rest
  
• Manufactured from E-coli
• Effects - dilates veins and arteries, suppresses
  Aldosterone
  
• Administration - IV bolus, then drip for 48 hrs
• Contraindications - systolic pressure binds with Heparin
  
• Side effects - hypotension, VT, HA, nausea
• Incompatible with Heparin in same line

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Medical Management Of Pulmonary Edema

• Sit patient in high Fowlers with legs and feet
  dependent
  
• Oxygen
• Morphine
• Diuretics
• Other meds as with heart failure

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Nursing Diagnoses For The Client With Heart
Failure
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Nursing Interventions For The Client With Heart
Failure

• Monitor and manage potential complications
• Assess cardiovascular status frequently
• Vital signs
• Heart sounds
• Degree of JVD HJR
• All peripheral pulses

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• Assess respiratory status frequently
• Lung sounds
• Assess degree of dyspnea
• Assess O2 sats
• Assess renal status
• IO
• BUN Cr
• Assess for nocturia

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• Assess GI system
• HJR
• Ascites
• Appetite and constipation
• Monitor fluid status closely
• Daily weights
• IO
• Peripheral and sacral edema

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• Reduce fatigue
• Promote activity tolerance
• Control anxiety
• Referrals
• Teach client and family

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Client and Family Teaching Related to Heart
Failure

• Weigh daily
• 2-3 gm Na diet
• Fluid restrictions
• Meds and side effects

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• Signs and symptoms to report to physician
• Weight gain
• Loss of appetite
• Syncopy or palpitations
• Worsening SOB
• Persistent cough

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Expected Outcomes

• Maintains or improves cardiac function
• Maintains or increases activity tolerance
• Adheres to self-care program
• Absence of complications

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Cardiomyopathy

• Disease of the myocardium which affects its
  function
  
• Three major types of cardiomyopathy
• Dilated - DCM
• Hypertropic - HCM
• Restrictive

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Dilated Cardiomyopathy

• Contractility decreases and ventricles dilate.
  Affects systolic function.
  
• Etiology viral myocarditis, toxins, alcohol,
  pregnancy, ischemia

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• Clinical manifestations same as with LVF
• Dx tests ECHO, endomyocardial biopsy, ECG,
  chest x-ray, blood chemistries
  
• Tx same as with LVF tx dysrhythmias heart
  transplant
  

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Hypertropic Cardiomyopathy

• Myocardium increases in size and mass
• Reduces inner cavity of ventricles and ventricles
  take longer to relax and fill. Affects diastolic
  function
  
• Etiology genetic, HTN, and hypoparathyroidism

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• Appears most often in young adults
• Clinical manifestations sudden cardiac death
  dyspnea, palpitations, dizziness
  
• Dx tests radionuclide scans, ECHO, chest x-ray,
  ECG
  
• Tx Beta blockers and Ca channel blockers. Avoid
  meds that decrease preload or increase
  contractility (Lanoxin). Tx dysrhythmias - may
  insert ICD

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Restrictive Cardiomyopathy

• Ventricle walls are rigid and do not stretch
  normally during filling. Cardiac output
  decreases. Affects diastolic function.
  
• Etiology - Amylodiosis, Sarcoidosis

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• Clinical manifestations fatigue, activity
  intolerance, dyspnea and other symptoms of LVF
  
• Dx tests same as other cardiomyopathies
• Tx similar to hypertropic cardiomyopathy tx
  dysrhythmias. Also tx underlying cause
  

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Rheumatic Endocarditis

• Results directly from group A beta-hemolytic
  strep
  
• Can be prevented if strep infection treated
  early
  
• Myocardium, valves and pericardium are affected
• Contractility is decreased
• Valve leaflets develop vegetative bodies

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• Clinical manifestations
• Signs of rheumatic fever (fever, chills, sore
  throat)
  
• Heart murmur, heart failure
• Dx tests Positive throat culture ECHO
  increased strep antibody titer
  
• Tx
• Prevention is best treatment
• Bed rest and treat heart failure if present
• Penicillin or mycin drugs (Cleocin, EES) if
  Penicillin allergy
  

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Infective Endocarditis

• Infection of the endocardium and valves
• Etiology staph, strep, fungi
• Increased risk in patients with valve disorders
  and IV drug abusers
  

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• Clinical manifestations malaise, intermittent
  fever and chills, night sweats, Roth spots,
  splinter hemorrhages in nails, Janeway lesions,
  Oslers nodes, murmur, HF, stroke, pulmonary
  embolus

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• Dx blood cultures, CBC, transesophageal ECHO
  (TEE)
  
• Prevent in patients with valve disorders with
  prophylactic antibiotics before and after
  invasive procedures
  
• Tx - parenteral antibiotics for 6 wks
  (penicillin, vancomycin, gentamycin,
  ciprofloxacin)
  

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Myocarditis

• Inflammation of myocardium results in
  degeneration and dilation
  
• Thrombi form on endocardial lining (mural
  thrombi)
  
• Etiology viruses, parasites, bacteria, toxins,
  radiation

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• Clinical manifestations asymptomatic or fever,
  fatigue, tachycardia, palpitations, dyspnea,
  symptoms of HF
  
• Dx endomyocardial biopsy, ECHO, chest x-ray,
  ECG, elevated cardiac enzymes

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• Tx
• Tx underlying cause
• Bed rest
• Tx heart failure
• Anti-inflammatory or immunosuppressive medications

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Pericarditis

• Inflammation of the pericardial sac
• Fibrinous adhesions or exudate can form in
  pericardial sac
  
• Etiology viruses, bacteria, fungi, myocardial
  injury, collagen diseases, drug reaction,
  radiation, neoplasms

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• Clinical manifestations chest pain, pericardial
  friction rub, fever, chills, dyspnea
  
• Dx ECG changes, elevated ESR and possibly WBC,
  enzymes negative,ECHO
  
• Tx
• Tx cause
• NSAIDS, analgesics, steroids

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Valvular Disorders

• Stenosis valve does not open completely
• Regurgitation valve does not close properly

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Mitral Valve Prolapse (MVP)

• Portion of a leaflet balloons backward during
  systole
  
• Valve may not remain closed and regurgitation can
  occur
  
• Clinical manifestations fatigue, dyspnea, chest
  pain, anxiety, dizziness, syncope, palpitations
  (atrial or ventricular dysrhythmias)

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• Dx ECHO with Doppler flow studies
• Tx
• Beta blockers
• Eliminate caffeine, alcohol, and smoking
• Antibiotics prophylactically before and after
  invasive procedures
  

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Mitral Regurgitation or Mitral Insufficiency

• Leaflets do not close properly and blood flows
  backward
  
• Pressure increases in left atrium and blood backs
  up into lungs
  
• Etiology - MI, heart enlargement, rheumatic
  endocarditis
  
• Clinical manifestations asymptomatic or
  symptoms of LVF, palpitations (atrial fib or
  PVCs), systolic murmur

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• Dx ECHO with Doppler flow , TEE, cardiac cath
• Tx tx LVF, mitral valve replacement (MVR) or
  valvuloplasty
  
• Prophylactic antibiotics for invasive procedures

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Mitral Stenosis

• Leaflets are thickened and contracted
• Flow of blood from left atrium into left
  ventricle is obstructed
  
• Left atrium dilates and hypertropies
• Blood backs up into lungs and eventually the
  right side of heart
  

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• Clinical manifestations Diastolic murmur,
  fatigue, dyspnea, hemoptyosis, cough, crackles,
  atrial fib
  
• Dx ECHO, cardiac cath
• Tx tx LVF, valvuloplasty or MVR,
  anticoagulation if atrial fib

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Aortic Stenosis

• Narrowing of aortic valve orifice or
  calcification of leaflets
  
• LV hypertrophies, dilates, and contractility
  eventually decreases
  
• Blood backs up into lungs and right heart

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• Clinical manifestations angina, dizziness or
  syncope, dysrhythmias, DOE, systolic murmur, and
  possibly a thrill
  
• Dx ECHO, TEE, cardiac cath
• Tx Bed rest, aortic valve replacement (AVR),
  valvuloplasty, prophylactic antibiotics for
  invasive procedures

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Aortic Regurgitation or Aortic Insufficiency

• Backflow of blood into LV from aorta during
  diastole
  
• LV hypertropies and dilates
• Competent mitral valve keeps blood from backing
  up into LA and lungs for a long time
  

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• Clinical manifestations sensations of forceful
  heart beat especially in the head or neck, head
  bobbing, marked visible carotid pulsations,
  water-hammer pulse, widened pulse pressure,
  diastolic murmur, fatigue, DOE, signs of heart
  failure
• Dx ECHO, TEE, cardiac cath
• Tx AVR or valvuloplasty, prophylactic
  antibiotics

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Valvuloplasty

• Commisurotomy procedure to separate fused
  leaflets

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• Annuloplasty repair of the valve annulus
• Chordoplasty repair of chordae tendineae

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Valve Replacement

• Open heart procedure and requires heart lung
  bypass
  
• Two types of valve prostheses
• Mechanical valves
• Ball-and-cage or disc design
• More durable
• Valves are susceptible to thromboemboli

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• Tissue grafts
• Xenograft porcine or bovine
• Homograft (allograft) - from cadavar
• Autograft (autologous) use patients pulmonic
  valve

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Complications Related To Valve Replacement

• Hemorrhage
• Thromboembolism
• Infection
• Dysrhythmias
• Hemolysis of RBCs
• Heart failure

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Educational Needs of Client With Valve Replacement

• Wound care, diet, meds, activity restrictions
• Long term anticoagulant therapy if mechanical
  valve used
  
• Prophylactic antibiotic therapy if mechanical
  valve used