NCLEX Review: Management of Valvular, Inflammatory, and Infectious Cardiovascular Disorders

Key Terms

• Allograft refers to a graft from one person to another.
• Annuloplasty is the surgical reconstruction of a heart valve annulus.
• Autograft is a graft taken from one part of the same person's body to another.
• Bioprosthesis refers to a valve made from animal tissue.
• Cardiac tamponade is the compression of the heart caused by fluid accumulation in the pericardial sac.
• Cardiomegaly refers to an enlarged heart.
• Cardiomyopathy is disease of the heart muscle.
• Chorea is characterized by involuntary, jerky movements.
• Commissurotomy refers to a surgical incision of a commissure (usually of a heart valve) to relieve stenosis.
• Dressler syndrome is a type of pericarditis believed to be an autoimmune reaction.
• Emboli refers to a blood clot, air bubble, piece of fatty deposit, or other object that has been carried in the bloodstream to lodge in a vessel and cause an embolism.
• Heterograft is a tissue graft from an animal to a human.
• Homograft is a tissue graft from one human to another.
• Infective endocarditis (IE) is an infection of the endocardium.
• Insufficiency refers to the state of being inadequate or not sufficient.
• International normalized ratio (INR) is the ratio of a patient’s prothrombin time (PT) to a control PT, used to monitor the effectiveness of anticoagulant therapy, such as warfarin
• Murmur is an abnormal whooshing or humming sound.
• Myectomy is the surgical removal of a portion of muscle.
• Myocarditis refers to inflammation of the heart muscle.
• Pericardial effusion is fluid around the heart.
• Pericardial friction rub is a leathery sound heard during auscultation.
• Pericardiectomy is the removal of a portion or all of the pericardium.
• Pericardiocentesis is a procedure where a needle is used to remove fluid from the pericardial sac around the heart.
• Pericarditis refers to inflammation of the pericardium.
• Petechiae are small, red or purple spots on the skin, caused by a minor bleed from broken capillary blood vessels.
• Regurgitation is to flow or pour backwards usually through a valve.
• Rheumatic fever is an inflammatory disease usually following streptococcal infection.
• Stenosis is the narrowing or restriction of a blood vessel or valve area.
• Streptococci are bacteria that can cause several diseases.
• Thrombophlebitis is inflammation of a vein associated with a blood clot (thrombus).
• Valvotomy is an incision into a valve.
• Valvuloplasty is the repair of a stenotic heart valve.
• Xenograft refers to a tissue graft or organ transplant from a donor of a different species than the recipient.

Cardiac Valvular Disorders

• Blood flows in one direction due to heart valves, which include the mitral, tricuspid, pulmonic, and aortic valves.
• Chordae tendineae and papillary muscles ensure the mitral and tricuspid valves close tightly.
• Damage to valves or surrounding structures can result in stenosis, where the valve doesn't open completely, reducing forward blood flow.
• Insufficiency (regurgitation) occurs when the valve doesn't close completely, causing blood to back up.
• Either stenosis or insufficiency increases the heart's workload and pressure, potentially leading to congenital defects, infections, or rheumatic fever.

Rheumatic Fever

• Rheumatic fever: autoimmune reaction 2-4 weeks after tonsillopharyngitis due to group A streptococci.
• Typically occurs between ages 5 and 15; prevented by promptly treating streptococcal infections with penicillin.
• Common worldwide (developing countries), but rare in the US.
• Throat culture to diagnose streptococcal infection.
• Signs and symptoms include polyarthritis, subcutaneous nodules (painless), painless rash, carditis with valvulitis, Sydenham chorea (rapid, uncontrolled movements with unusual exhibition of emotions).
• Other signs and symptoms include fever, arthralgia (joint pain), red/hot/swollen joints, pneumonitis (rare).
• Rheumatic heart disease may not be evident for years after rheumatic fever.

Mitral Valve Prolapse (MVP)

• Mitral valve prolapse (MVP) is where one or both mitral valve flaps bulge backward into the left atrium during systole.
• Caused by one flap being too large, a defect in the chordae tendineae, myxomatous degeneration, connective tissue disorders (Ehler-Danlos syndrome), hereditary trait, or gene mutation.
• Risk increases with age.
• Symptoms range from murmur to chordae tendineae rupture with mitral regurgitation.
• Murmur is best heard at the heart apex, beginning mid systole and intensifying until the end of systole.
• Other symptoms include anxiety, atypical chest pain, arrhythmias, palpitations, dizziness/syncope, fatigue, and dyspnea (especially when lying flat or during activity).
• Rare complications include mitral regurgitation, arrhythmias, heart failure (HF), emboli, or infective endocarditis (IE).

Mitral Stenosis (MS)

• Mitral stenosis is the thickening of mitral valve flaps and shortening of chordae tendineae.
• It causes narrowing of mitral valve opening, which obstructs blood flow from the left atrium into the left ventricle.
• The left atrium enlarges to hold extra blood volume caused by obstruction; the pressure rises in the pulmonary circulation and the right ventricle.
• Major cause is rheumatic fever, also congenital defects, systemic lupus erythematosus, and calcium deposits.
• Patients can be asymptomatic.
• Most common symptoms are exertional dyspnea and intolerance to activity.
• Additional pulmonary symptoms are hemoptysis, hoarseness, cough, and respiratory infections.
• Fatigue, dizziness, syncope, and rare chest pain from decreased cardiac output.
• Palpitations from atrial flutter or atrial fibrillation caused by atrial enlargement.
• Blood stasis in the left atrium could form a thrombus or emboli leading to stroke. Right ventricle failure can lead to right-sided HF.
• Gold standard tests are transthoracic two-dimensional color flow Doppler echocardiogram and Doppler ultrasound.
• ECG shows enlargement of the left atrium and right ventricle and changes in the P waveform.
• An incidental chest x-ray examination shows enlargement of the left atrium.
• No treatment needed if patient is asymptomatic; anticoagulants prevent emboli from stasis of blood in the atrium.
• Atrial fibrillation, irregular heart rhythm, or HF requires treatment.
• Invasive treatment is percutaneous balloon valvotomy, valvular repair (valvuloplasty), and mitral valve replacement.

Mitral Regurgitation (MR)

• Mitral regurgitation (MR) is incomplete closure of the mitral valve leaflets, causing blood backflow into the left atrium during left ventricle contraction.
• Causes include rheumatic heart disease, endocarditis, rupture/dysfunction of chordae tendineae or papillary muscle, MVP, hypertension, MI, cardiomyopathy, annulus calcification, aging, or congenital defects.
• Patients are asymptomatic at first.
• Murmur begins with S1 and continues during systole up to S2; severe MR leads to HF symptoms, exertional dyspnea, fatigue, syncope, cough, hemoptysis, and edema; acute MR leads to pulmonary edema and shock symptoms.
• Palpitations from atrial fibrillation; pulmonary hypertension or HF may occur. Endocarditis is a risk.
• Two-dimensional echocardiogram with Doppler or transesophageal echocardiogram (TEE) confirms MR. Cardiovascular MRI may be useful.
• Medical treatment is not usually required; calcium channel blockers or beta blockers may be ordered if atrial fibrillation with rapid heart rate develops.
• Anticoagulants are used to prevent thromboembolisms. Mitral valve or percutaneous mitral valve repair is favored over mitral valve replacement.

Aortic Stenosis (AS)

• In aortic stenosis, blood flow from the left ventricle into the aorta is blocked via the stenosed aortic valve. The opening of the aortic valve may be narrowed from thickening, scarring, calcification, or fusing of the valve's flaps.
• The left ventricle contracts more forcefully to compensate for the difficulty in ejecting blood into the aorta.
• In chronic AS, the left ventricle hypertrophies to maintain normal cardiac output, eventually leading to decreased cardiac output and HF.
• Major causes are congenital defects or rheumatic heart disease. Calcification is age related and occurs after age 60.
• Early symptoms include exertional angina, exertional dyspnea/activity intolerance, and exertional dizziness/syncope.
• Late end-stage symptoms: angina, syncope, and HF signs and symptoms.
• Systolic murmur develops, beginning just after systole (S1) with increasing intensity until midsystole, then decreasing/ending right before the second heart sound (S2).
• Complications include HF, pulmonary hypertension, life-threatening arrhythmias, sudden cardiac death, endocarditis, and emboli.
• Ultrasound may be used initially and two-dimensional and Doppler echocardiogram shows thickness of aortic valve leaflets and their reduced motion; ECG shows enlargement of the left ventricle and left atrium.
• Aortic valve replacement is the only effective treatment for AS.
• A transcatheter aortic valve replacement (TAVR) can be done for those considered high risk for traditional open-heart surgery. Valvotomy is used only for those who can't undergo valve replacement.
• Medications that reduce the contractility of the heart are avoided.

Aortic Regurgitation (AR)

• In chronic aortic regurgitation (AR), the aortic valve cusps may become scarred, thickened, or shortened.
• Backflow of blood from the aorta into the left ventricle occurs if aortic valve cusps don't close completely.
• Congenital defects, aging, rheumatic heart disease, syphilis, severe hypertension, and ankylosing spondylitis can cause AR; acute causes include endocarditis or aortic dissection.
• The patient will report feeling a forceful heartbeat more pronounced when lying down since symptoms may not become apparent for many years with chronic AR.
• Palpitations and pounding in the head may be experienced; Next, exertional dyspnea, fatigue, and worsening dyspnea (e.g., orthopnea, paroxysmal nocturnal dyspnea) occur after years of progressive valvular dysfunction; a murmur is heard during diastole after the second heart sound.
• Palpated pulse is forceful and then quickly collapses (Corrigan pulse); diastolic blood pressure decreases to widen the pulse pressure.
• Atypical angina pectoris may occur later on; eventually, HF symptoms develop if the left ventricle fails.
• Echocardiogram, Doppler echocardiogram, or transesophageal echocardiogram detect an enlarged left ventricle and severity of the AR; cardiovascular MRI provides severity assessment and effect on ventricular function.
• Treatment includes vasodilators or diuretics to reduce systolic blood pressure and cardiac workload or heart failure for patients who cannot have surgery, and aortic valve replacement.

Nursing Process for Cardiac Valvular Disorders

• Assessment includes subjective questions on infections, congenital defects, cardiac disease, dyspnea, pillows used, hemoptysis, chest pain, loss of consciousness, edema, palpitations, dizziness, fatigue, activity intolerance, medications, knowledge of condition.
• Assess: murmurs, extra heart sounds, arrhythmias, edema, jugular venous distention, Corrigan pulse, increased or decreased pulse pressure or blood pressure, clubbing, cyanosis, diaphoresis, cold/clammy skin, pallor, and diagnostic test findings.

Nursing Care Plan

• decreased cardiac output is related to cardiac valvular stenosis or insufficiency or heart failure.
• The patient will have adequate cardiac output evidenced by vital signs within normal parameters, strong pulses, warm extremities, lack of dyspnea, and minimal fatigue.
• Monitor heart and lung sounds, vital signs, oxygen saturation, chest pain, skin temperature, capillary refill, and peripheral edema. Indicators of cardiac output decline include new-onset murmurs, hypotension, tachycardia, or crackles in the lungs reduced SaO2 chest pain, edema.
• Administer oxygen, elevate the head of the bed.
• Review cardiac medications and side effects.
• decreased activity tolerance is related to decreased oxygen delivery from cardiac valvular stenosis or insufficiency and output.
• The patient will exhibit normal changes in vital signs and less fatigue in response to activity.
• Assist with activities of daily living (ADLs); promote energy conservation.
• Slow the pace of care and allow extra time for activities; allow patients rest intervals.
• Monitor blood pressure when changing position; ensure safety when mobilizing older patient; assess orthostatic hypotension.
• Assess ambulation (feeling faint/unsteady).
• Main diagnoses include those for heart failure.
• Patient/caregiver education includes understanding the disorder, medications, prevention of complications, and early recognition of symptoms.
• Teach highest-risk patients for prophylactic antibiotics to prevent IE; monitor INR for warfarin (Coumadin); medical ID should be used.
• Vitamin K is important for blood clotting; to maintain a therapeutic level of warfarin, eat a consistent amount of these types of foods on a day-to-day basis rather than increase or decrease the amounts.
• Commissurotomy repairs a stenosed valve, annuloplasty fixes valve flaps or annulus, and heart valve may be mechanical or biological (tissue).
• With TAVR, balloon catheter is introduced via the femoral artery. It is inserted through the diseased valve and inflated to open the stenosed valve leaflets.
• Nursing post-op: the patient goes to a CUB (intensive care unit (ICU) and it is important to document findings, and make sure family has support.

Inflammatory and Infectious Cardiac Disorders

• Layers of the heart include endocardium, pericardium, and myocardium.
• These can become inflamed or infected, leading to endocarditis, pericarditis, and myocarditis.

Infective Endocarditis (IE)

• Infection of the endocardium occurs primarily in hearts with artificial or damaged valves and in those who inject drugs.
• Cardiac defects result in turbulent blood flow eroding the endocardium.
• IE begins when an invading organism (bacteria or fungi) attaches to eroded endocardium where platelets and fibrin deposits form a vegetative lesion.
• Mitral valve is most commonly infected; may result in HF. Risk factors include compromised immune system, intravenous catheter, artificial heart valve, congenital/valvular heart disease, history of IE, IV drug use, and gingival gum disease.
• Prevention includes dental hygiene and care along with antibiotic prophylaxis.
• Rapid or slow onset of fever, chills, anorexia, weight loss, aches/pains, fatigue, dyspnea, cough, night sweats, and hematuria.
• A heart murmur may develop; splinter hemorrhages, petechiae, Janeway lesions, Osler nodes, and Roth spots may occur.
• Vegetative emboli are major IE complications.
• Diagnostic tests include positive blood cultures (to identify organisms), echocardiogram (to show cardiac vegetation and effects), and CT scan or MRI.
• Therapeutic measure includes hospitalization, IV antibiotics, rest, symptom care, and follow-up monitoring with echocardiogram. Prophylaxis per criteria, acute therapy.

Nursing Process for infective endocarditis

• Assess: patient history includes risk factors for IE, and recent infections or invasive procedures.
• Signs and symptoms include HF and emboli.
• Notify HCP immediately if circulatory impairment or organ-related emboli are detected.
• Diversional activities for patient to do during IV therapy, to increase patient self-esteem, through increased patient control.

Pericarditis

• Acute or chronic pericardium inflammation which creates a problem for the heart as it tries to expand and fill, decreases cardiac output and blood pressure.
• Causes may be infections, Dressler syndrome, medications, neoplastic and post-cardiac injury disease, renal disease/uremia, or rheumatic disorders.
• Symptoms include chest pain, orthopnea, low-grade fever, fatigue, cough, and edema.
• A pericardial friction rub results from inflamed pericardial and epicardial layers.
• Complications: pericardial effusion, cardiac tamponade requires emergency treatment with pericardiocentesis. Nursing focuses on relieving patient’s pain/anxiety and maintaining normal cardiac function.

Additional content on key diagnoses

• Myocarditis inflammation of the myocardium (muscle), and is a rare condition that commonly develops after a viral infection.
• Cardiac Trauma is when injuries, which occur from blunt trauma such as motor vehicle accidents or contact sports in which direct compression or force is applied to the upper torso
• There may be no external trauma indicating cardiac injury.
• There are two types of cardiac trauma can occur: nonpenetrating and penetrating.
• Cardiomyopathy is abnormality and enlargement of the heart muscle that leads to ineffective pumping of the blood, there are a few, dilated,hypertrophic, and restrictive.
• venous thromboembolism (VTE) disease includes DVT and pulmonary emboli.
• Thrombophlebitis is the formation of a clot, followed by inflammation within a vein. It is the most common disorder of veins.