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