Wesleyan University- Philippines

Mabini Extension, Cabanatuan City

Case Study
Cardiomyopathy

Submitted by:

Kristal M. Orpilla
(Bsn4-4 SN14)

Submitted To:
Clinical Instructor
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TABLE OF CONTENTS

I. Definition............................................................................................................................................. 3 II. Main types of Cardiomyopathy........................................................................................................ 3 III. Causes................................................................................................................................................ 4 IV. Clinical Manifestations..................................................................................................................... 5 V. Diagnostic Procedures........................................................................................................................6 VI. Medical Management ...............................................................................................................7 VII. Surgical Management...................................................................................................................... 8 VIII. Outlook (Prognosis) ............................................................................................................. 10 IX. Complications..................................................................................................... 10 X. Prevention ........................................................................................................... 10 XI. Possible Nursing Diagnosis .............................................................................................. 11 XII. Nursing Intervention for Cardiomyopathy .................................................................... 11 XII. References................................................................................................ 11

I. DEFINITION Cardiomyopathy (kahr-dee-oh-my-OP-uh-thee) is a disease that weakens and enlarges your heart muscle. There are three main types of cardiomyopathy dilated, hypertrophic and restrictive. Cardiomyopathy makes it harder for your heart to pump blood and deliver it to the rest of your body. Cardiomyopathy can lead to heart failure. II. TYPES OF CARDIOMYOPATHY Main types of cardiomyopathy Dilated cardiomyopathy is Hypertrophic cardiomyopathy Restrictive cardiomyopathy Arrhythmogenic Right Ventricular Dysplasia Dilated Cardiomyopathy Dilated cardiomyopathy is the most common type of the disease. It mostly occurs in adults aged 20 to 60. Men are more likely than women to have this type of cardiomyopathy. Dilated cardiomyopathy affects the heart's ventricles and atria. These are the lower and upper chambers of the heart, respectively. The disease often starts in the left ventricle, the heart's main pumping chamber. The heart muscle begins to dilate (stretch and become thinner). This causes the inside of the chamber to enlarge. The problem often spreads to the right ventricle and then to the atria as the disease gets worse. When the chambers dilate, the heart muscle doesn't contract normally. Also, the heart can't pump blood very well. Over time, the heart becomes weaker and heart failure can occur. Symptoms of heart failure include fatigue (tiredness); swelling of the ankles, feet, legs, and abdomen; and shortness of breath. Dilated cardiomyopathy also can lead to heart valve problems, arrhythmias, and blood clots in the heart. Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is very common and can affect people of any age. About 1 out of every 500 people has this type of cardiomyopathy. It affects men and women equally. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac arrest (SCA) in young people, including young athletes. This type of cardiomyopathy occurs when the walls of the ventricles (usually the left ventricle) thicken. Despite this thickening, the ventricle size often remains normal. Hypertrophic cardiomyopathy may block blood flow out of the ventricle. When this happens, the condition is called obstructive hypertrophic cardiomyopathy. In some cases, the septum thickens and bulges into the left ventricle. (The septum is the wall that divides the left and right sides of the heart.) In both cases, blood flow out of the left ventricle is blocked. As a result of the blockage, the ventricle must work much harder to pump blood out to the body. Symptoms can include chest pain, dizziness, shortness of breath, or fainting.
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Hypertrophic cardiomyopathy also can affect the heart's mitral valve, causing blood to leak backward through the valve. Sometimes the thickened heart muscle doesn't block blood flow out of the left ventricle. This is called nonobstructive hypertrophic cardiomyopathy. The entire ventricle may become thicker, or the thickening may happen only at the bottom of the heart. The right ventricle also may be affected. In both types (obstructive and nonobstructive), the thickened muscle makes the inside of the left ventricle smaller, so it holds less blood. The walls of the ventricle also may stiffen. As a result, the ventricle is less able to relax and fill with blood. These changes cause increased blood pressure in the ventricles and the blood vessels of the lungs. Changes also occur to the cells in the damaged heart muscle. This may disrupt the heart's electrical signals and lead to arrhythmias. Rarely, people who have hypertrophic cardiomyopathy have no signs or symptoms, and the condition doesn't affect their lives. Others have severe symptoms and complications, such as serious arrhythmias, an inability to exercise, or extreme fatigue with little physical activity. Rarely, people who have this type of cardiomyopathy can have SCA during very vigorous physical activity. The physical activity can trigger dangerous arrhythmias. If you have this type of cardiomyopathy, talk to your doctor about what types and amounts of physical activity are safe for you. Restrictive Cardiomyopathy Restrictive cardiomyopathy tends to mostly affect older adults. In this type of the disease, the ventricles become stiff and rigid. This is due to abnormal tissue, such as scar tissue, replacing the normal heart muscle. As a result, the ventricles can't relax normally and fill with blood, and the atria become enlarged. Over time, blood flow in the heart is reduced. This can lead to problems such as heart failure or arrhythmias. Arrhythmogenic Right Ventricular Dysplasia Arrhythmogenic right ventricular dysplasia (ARVD) is a rare type of cardiomyopathy. ARVD occurs when the muscle tissue in the right ventricle dies and is replaced with scar tissue. This process disrupts the heart's electrical signals and causes arrhythmias. Symptoms include palpitations and fainting after physical activity. ARVD usually affects teens or young adults. It can cause SCA in young athletes. Fortunately, such deaths are rare. III. CAUSES: Generally, there are four things that are known to cause cardiomyopathy Viral infection. A common cause of cardiomyopathy is a viral infection in your heart. The infection can damage your heart muscle, but the damage may not show for months or longer.
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Alcohol drinking. Family history. If you have a family history of cardiomyopathy (when more than one of your relatives has cardiomyopathy and the cause is not known), your chances of developing it can increase. All members of your family should be checked by a cardiologist. Heart attack. One or more heart attacks can cause ischaemic cardiomyopathy. Heart attacks can severely damage your heart muscle and the more heart attacks you have, the worse the damage is. Scar tissue forms where your heart muscle is damaged. Scar tissue in your heart doesnt contract like normal heart muscle does, so the rest of your heart has to work harder. This makes the healthy parts of your heart muscle tired and weak. Other Causes: Long-term high blood pressure Heart valve problems Heart tissue damage from a previous heart attack Chronic rapid heart rate Metabolic disorders, such as thyroid disease or diabetes Nutritional deficiencies of essential vitamins or minerals, such as thiamin (vitamin B-1), selenium, calcium and magnesium Pregnancy Excessive use of alcohol over many years Abuse of cocaine or antidepressant medications, such as tricyclic antidepressants Use of some chemotherapy drugs to treat cancer Certain viral infections, which may injure the heart and trigger cardiomyopathy Iron buildup in your heart muscle (hemochromatosis) Genetic conditions

IV. CLINICAL MANIFESTATIONS: Some people who have cardiomyopathy never have signs or symptoms. Others don't have signs or symptoms in the early stages of the disease. As cardiomyopathy worsens and the heart weakens, signs and symptoms of heart failure usually occur. These signs and symptoms include: Shortness of breath or trouble breathing, especially with physical exertion Fatigue (tiredness) Swelling in the ankles, feet, legs, abdomen, and veins in the neck Breathlessness with exertion or even at rest Bloating of the abdomen due to fluid buildup Irregular heartbeats that feel rapid, pounding or fluttering Dizziness, lightheadedness and fainting Other signs and symptoms may include dizziness; light-headedness; fainting during physical activity; arrhythmias (irregular heartbeats); chest pain, especially after physical exertion or heavy meals; and heart murmurs. (Heart murmurs are extra or unusual sounds heard during a heartbeat.)

V. DIAGNOSTIC TESTS/ PROCEDURES: Medical and Family Histories Physical Exam Your doctor will use a stethoscope to listen to your heart and lungs for sounds that may suggest cardiomyopathy. These sounds may even suggest a certain type of the disease. For example, the loudness, timing, and location of a heart murmur may suggest obstructive hypertrophic cardiomyopathy. A "crackling" sound in the lungs may be a sign of heart failure. (Heart failure often develops in the later stages of cardiomyopathy.) Physical signs also help your doctor diagnose cardiomyopathy. Swelling of the ankles, feet, legs, abdomen, or veins in your neck suggests fluid buildup, a sign of heart failure. Your doctor may notice signs and symptoms of cardiomyopathy during a routine exam. For example, he or she may hear a heart murmur, or you may have abnormal test results. Blood Tests One blood test can measure B-type natriuretic peptide (BNP), a protein produced in your heart. Your blood level of BNP rises when your heart is subjected to the stress of heart failure, a common complication of cardiomyopathy. Chest X Ray This test can show whether your heart is enlarged. A chest x ray also can show whether fluid is building up in your lungs. Cardiac magnetic resonance imaging (MRI). Cardiac MRI is an imaging technique that uses magnetic fields and radio waves to create images of your heart. Cardiac MRI is often used in addition to echocardiography, particularly if the images from your echocardiogram aren't helpful in making a diagnosis. EKG (Electrocardiogram) An EKG is a simple test that records the heart's electrical activity. The test shows how fast the heart is beating and its rhythm (steady or irregular). An EKG also records the strength and timing of electrical signals as they pass through each part of the heart. This test is used to detect and study many heart problems, such as heart attacks, arrhythmias (irregular heartbeats), and heart failure. EKG results also can suggest other disorders that affect heart function. A standard EKG only records the heartbeat for a few seconds. It won't detect problems that don't happen during the test. To diagnose heart problems that come and go, your doctor may have you wear a portable EKG monitor. The two most common types of portable EKGs are Holter and event monitors. Holter and Event Monitors Holter and event monitors are small, portable devices. They record your heart's electrical activity while you do your normal daily activities. A Holter monitor records the heart's electrical activity for a full 24- or 48-hour period. An event monitor records your heart's electrical activity only at certain times while you're wearing it. For many event monitors, you push a button to start the monitor when you feel symptoms. Other event monitors start automatically when they sense abnormal heart rhythms. Echocardiography Echocardiography (echo) is a test that uses sound waves to create a moving picture of your heart. The picture shows how well your heart is working and its size and shape. There are several types of echo, including stress echo. This test is done as part of a stress test (see below). Stress echo can show whether you have decreased blood flow to your heart, a sign of coronary heart disease. Another type of echo is transesophageal echo, or TEE. TEE provides a view of the back of the heart.
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For this test, a sound wave wand is put on the end of a special tube. The tube is gently passed down your throat and into your esophagus (the passage leading from your mouth to your stomach). Because this passage is right behind the heart, TEE can create detailed pictures of the heart's structures. Before TEE, you're given medicine to help you relax, and your throat is sprayed with numbing medicine. Stress Test Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise (or are given medicine if you're unable to exercise) to make your heart work hard and beat fast while heart tests are done. These tests may include nuclear heart scanning, echo, and positron emission tomography (PET) scanning of the heart. Cardiac Catheterization This procedure checks the pressure and blood flow in your heart's chambers. During cardiac catheterization, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. This allows your doctor to study the inside of your arteries for blockages. Coronary Angiography This procedure often is done with cardiac catheterization. Dye also may be injected into your heart chambers. This allows your doctor to study the pumping function of your heart. Myocardial Biopsy For this procedure, your doctor removes a piece of your heart muscle. This can be done during cardiac catheterization. The heart muscle is studied under a microscope to see whether changes in cells have occurred. These changes may suggest cardiomyopathy. Myocardial biopsy is useful for diagnosing some types of cardiomyopathy. Genetic Testing Some types of cardiomyopathy run in families. Thus, your doctor may suggest genetic testing to look for the disease in your parents, brothers and sisters, or other family members. Genetic testing can show how the disease runs in families. It also can find out the chances of parents passing the genes for the disease on to their children. Genetic testing also may be useful if your doctor thinks you have cardiomyopathy, but you don't yet have signs or symptoms. If the test shows you have the disease, your doctor can start treatment early, when it may work best. VI. MEDICAL MANAGEMENT: Hypertrophic cardiomyopathy Your doctor may recommend beta blockers to relax your heart, slow its pumping action and stabilize its rhythm. These medications include Lopressor or calcium channel blockers, such as verapamil (Calan, Isoptin, others). Medications are often the preferred treatment for hypertrophic cardiomyopathy. Restrictive cardiomyopathy Treatment for restrictive cardiomyopathy focuses on improving symptoms. Your doctor will recommend you pay careful attention to your salt and water intake and monitor your weight daily. Your doctor may also recommend you take diuretics if sodium and water retention becomes a problem. You may be prescribed medications to lower your blood pressure and control fast or irregular heart rhythms. Many of the medications that doctors prescribe for cardiomyopathy may have side effects. Be sure to discuss these possible side effects with your doctor before taking any of these drugs.
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Dilated cardiomyopathy If you're diagnosed with dilated cardiomyopathy, your doctor may recommend medications, surgically implanted devices or a combination of both. The medications you may be prescribed include: Angiotensin-converting enzyme (ACE) inhibitors to improve your heart's pumping capability, such as enalapril (Vasotec), lisinopril (Zestril, Prinivil), ramipril (Altace) and captopril (Capoten). Angiotensin receptor blockers (ARBs) for those who can't take ACE inhibitors, such as losartan (Cozaar) and valsartan (Diovan). Beta blockers to improve heart function, such as carvedilol (Coreg) and metoprolol (Lopressor, Toprol-XL). Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with cardiomyopathy. Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for heart failure include bumetanide (Bumex) and furosemide (Lasix). The drugs also decrease fluid in your lungs, so you can breathe more easily. One diuretic, spironolactone (Aldactone), may also be helpful in treating scarring of your heart tissue. There are several medicines used to treat cardiomyopathy. ACE inhibitors block the effects of some hormones that affect your blood pressure to dilate your blood vessels, which help to reduce your hearts workload. Fluid pills (diuretics) help to rid your body of excess fluid. Some cause potassium loss, so you may need to take a potassium supplement. Beta-blockers block the effect of nerves that act on your heart and other parts of your body to lower your heart rate and blood pressure, which reduces your hearts workload. Digitalis (digoxin) helps your heart to pump more efficiently and helps to regulate an abnormal heart rhythm (arrhythmia). Anti-coagulant (warfarin) thins your blood to prevent it clotting. You will need regular blood tests to monitor this medicine and its effect on your body. Rhythm control drugs (antiarrhythmics) help to control your hearts rhythm. Other medicines may be needed depending on your needs. For example, if you get angina, you may need to take nitroglycerine spray or tablets

VII. SURGICAL MANAGEMENT: -> Hypertrophic cardiomyopathy Septal myectomy. Septal ablation.Also called septal alcohol ablation, Pacemaker implantation Implantable cardioverter-defibrillator (ICD). Septal Myectomy Septal myectomy is open-heart surgery. It's used for people who have obstructive hypertrophic cardiomyopathy and severe symptoms. This surgery generally is used for younger patients and for people whose medicines aren't working well.

During the surgery, a surgeon removes part of the thickened septum that's bulging into the left ventricle. This improves blood flow through the heart and out to the body. The removed tissue doesn't grow back. The surgeon also can repair or replace the mitral valve at the same time (if needed). Septal myectomy often is successful and allows you to return to a normal life with no symptoms.
Surgically Implanted Devices

Surgeons can place several types of devices in the heart to help it work better. One example is a pacemaker. This is a small device that's placed under the skin of your chest or abdomen to help control arrhythmias. The device uses electrical pulses to prompt the heart to beat at a normal rate. -Sometimes doctors choose to use a cardiac resynchronization therapy (CRT) device. A CRT device coordinates contractions between the heart's left and right ventricles. -A left ventricular assist device (LVAD) helps the heart pump blood to the body. An LVAD can be used as a long-term therapy or as a short-term treatment for people who are waiting for a heart transplant. -An implantable cardioverter defibrillator (ICD) helps control life-threatening arrhythmias that may lead to SCA. This small device is implanted in the chest or abdomen and connected to the heart with wires. -If an ICD senses a dangerous change in heart rhythm, it will send an electric shock to the heart to restore a normal heartbeat.
Heart Transplant

For this surgery, a surgeon replaces a person's diseased heart with a healthy heart from a deceased donor. A heart transplant is a last resort treatment for people who have end-stage heart failure. "End-stage" means the condition has become so severe that all treatments, other than heart transplant, have failed. Ventricular assist devices (VADs) If you have severe cardiomyopathy and medications can't control your symptoms, a heart transplant may be an option. Because of the shortage of donor hearts, even people who are critically ill may have a long wait before having a heart transplant. In some cases, a mechanical heart assist device can help critically ill people as they wait for an appropriately matched donor. These devices, known as ventricular assist devices (VADs), can help blood circulate through your heart for months or even years. A VAD may allow you to live outside the hospital while you wait. In some people who aren't candidates for a heart transplant, VAD therapy could be a long-term treatment option. Different procedures or surgeries may also be used: A defibrillator sends an electrical pulse to stop life-threatening abnormal heart rhythms. A pacemaker treats a slow heart rate or helps both sides of your heart beat at the same time. Coronary artery bypass (CABG) surgery or angioplasty can improve blood flow to the damaged or weakened heart muscle. Heart transplant is used when all other treatments have failed. Recently, implantable artificial heart pumps have been developed. However, very few patients are able to have this advanced treatment.
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VIII. OUTLOOK (PROGNOSIS): The outlook depends on many different things, including: Cause and type of cardiomyopathy How well you respond to treatment The severity of the heart problem Heart failure is usually a long-term (chronic) illness. It may get worse over time. Some people develop severe heart failure that medicines, surgery, and other treatments can no longer help. Patients with certain types of cardiomyopathy are at risk for dangerous heart rhythm problems. IX. COMPLICATIONS: Having cardiomyopathy may lead to other heart conditions, including: Heart failure. Heart failure means your heart can't pump enough blood to meet your body's needs. The thickened, stiffened or weakened heart muscle due to cardiomyopathy can become unable to pump or can stop blood from flowing out of the heart. Left untreated, heart failure can be life-threatening. Blood clots. Because your heart can't pump effectively, you're more likely to have blood clots form in your heart if you have cardiomyopathy. If clots are pumped out of the heart and enter your bloodstream, they can block the blood flow to other organs, including your heart and brain. If clots develop on the right side of your heart, they may travel to your lungs (pulmonary embolism). To reduce your risk, your doctor may prescribe a blood thinner (anticoagulant medication), such as aspirin, clopidogrel (Plavix) or warfarin (Coumadin, Jantoven). Valve problems. Because people with dilated cardiomyopathy have an enlarged heart, two of the heart's four valves the mitral and tricuspid valves may not close properly, leading to a backward flow of blood. This flow creates sounds called heart murmurs. Cardiac arrest and sudden death. All forms of cardiomyopathy can lead to abnormal heart rhythms. Some of these heart rhythms are too slow to keep blood flowing through your heart effectively, and some are too fast to allow the heart to beat properly. In either case, these abnormal heart rhythms can result in fainting or, in some cases, sudden death if your heart stops beating. X. PREVENTION: Lifestyle Change Make some simple lifestyle changes. Lose excess weight. Be smoke-free Eat less salt Salt causes your body to retain fluid, which can build up and put more strain on your heart. To reduce the amount of salt that you eat: - eat plenty of fresh fruit and vegetables - when shopping, choose foods labelled no added salt, low salt or salt-reduced where possible - avoid highly salted seasonings, processed foods and take-away foods that are high in salt - use garlic, herbs and spices instead of salt - avoid adding salt during cooking or at the table. Limit alcohol Do regular physical activity

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Your body is designed to move. Regular, light- to moderate-intensity physical activity is good for your heart and is a great way to have fun. Try to do some type of physical activity, such as going for a walk, cycling, lifting light weights and stretching, every day. Do what you can without getting breathless or overtired. You should be able to talk easily while doing physical activity. Talk to your doctor about the type and level of physical activity that is XI. POSSIBLE NURSING DIAGNOSIS: Activity intolerance Impaired gas exchange Decreased cardiac output XII. NURSING INTERVENTION FOR CARDIOMYOPATHY: Provide oxygen at 2 to 4 L/min to maintain or improve oxygenation. Minimize oxygen demand by maintaining the patient at bed rest. Provide liquid diet on acute phase, Administer diuretic as prescribed to reduce preload and afterload. Monitor serum potassium before and after administration of loop diuretics. Prophylactic heparin may be ordered to prevent thromboembolus formation secondary to venous poisoning. Institute pressure ulcer prevention strategies secondary to hypoperfusion or vasoconstriction agents. Place patient in a semi-Fowlers position for comfort, which eases respiratory effort. Record intake and output of fluids. Monitor vital signs to assess for increased respiratory rate, arrythmias. Monitor electrocardiogram to look for changes from previous tracing. Explain to the patient: fluids restriction may be necessary as heart failure is a concurrent disease with dilated cardiomyopathy. Record daily weight and call physician if weight increases 3 lbs (1.4 kg). No smoking or drinking alcohol. No straining during bowel movements. Increase exercise. XIII. References: http://www.nlm.nih.gov/medlineplus/ency/article/001105.html http://www.heartfoundation.org.au/SiteCollectionDocuments/Cardiomyopathy.pdf http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Cardiomyopathy_UCM_4 44459_SubHomePage.jsp http://www.nhlbi.nih.gov/health/health-topics/topics/cm/ http://www.mayoclinic.com/health/cardiomyopathy/DS00519 http://nursingcrib.com/critical-care-and-emergency-nursing/cardiomyopathy/ http://cncplan.blogspot.com/2012/02/what-is-cardiomyopathynursing-diagnosis.html

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