Infective Endocarditis & Valvular Heart Disease

Inflammatory and Structural Heart Disorders

• These include endocarditis, pericarditis, and valve disease

Infective Endocarditis (IE)

• A disease of the endocardium and heart valves
• IE has a poor prognosis and decreases life expectancy
• Increase in the number of cases of IE is largely related to IV drug use
• Risk factors include history of IE, IV drug use, prosthetic valve, or health care-associated infections from intravascular devices
• Methicillin-resistant S. aureus (MRSA) and renal dialysis are also risk factors

Etiology and Pathophysiology

• Occurs in 3 stages: Bacteremia, adhesion, and vegetation
• Vegetation consists of fibrin, leukocytes, platelets, and microbes
• Vegetation sticks to the valve or endocardium
• Parts break off and enter circulation (embolization)
• A left-sided vegetation embolizes to the brain, kidneys, spleen, and extremities
• A right-sided vegetation embolizes to the lungs (PE)

Clinical Manifestations-Assessment

• Nonspecific symptoms involve multiple organ systems: Includes fever, chills, weakness, malaise, fatigue and anorexia
• Subacute can manifest in arthralgias, myalgias, back pain, abdominal discomfort, weight loss, headache, clubbing of fingers
• Possible vascular manifestations
• Can be indicated by new or worsening systolic murmur
• Can also lead to heart failure
• Secondary manifestations include septic embolism, splinter hemorrhages in nail beds, petechiae, Osler's nodes on fingertips or toes, Janeway's lesions on fingertips, palms, soles of feet, and toes, and Roth's spots

Diagnostic Studies

• Collect Health history for 3-6 months/dental, surgical, gyn, IVDA, implants, infections, dialysis
• Laboratory tests include blood cultures from multiple sites, CBC with differential, ESR, C-reactive protein (CRP)
• Echocardiography is also useful
• Duke criteria applies for major and minor criteria

Interprofessional Care

• Give prophylactic antibiotics to high risk patients with specific heart conditions or procedures
• Heart conditions: CHD, valvular disease, Hx of IE, and prosthetic valve
• Procedures: Certain dental procedures, respiratory tract incisions, tonsillectomy and adenoidectomy, and surgical procedures involving infected skin, skin structures, or musculoskeletal tissue
• Active infection treatment includes accurate identification of organism, blood cultures, IV antibiotics (long-term), repeat blood cultures, valve replacement if needed, antipyretics, fluids, and rest

Nursing Assessment

• Subjective data include History-FHP (IVDA---Alcohol use), Meds/Drugs-Immunosuppressive therapy, Weight changes---Chills---Night sweats, Hematuria, exercise intolerance, weakness, fatigue, Cough, DOE, orthopnea, palpitations, and pain, headache, joint or muscle tenderness
• Objective data found on Clinical Manifestation slide and table

Nursing Clinical Problems and Planning

• Impaired cardiac output
• Infection
• Fatigue
• Substance use
• Goals include normal or baseline function, ability to perform ADLs without fatigue, and understanding of the treatment plan to prevent recurrence

Nursing Implementation

• Identify those at high risk
• Assess history and understanding of disease process
• Teach importance of adherence to a treatment regimen
• Stress the need to avoid people with infections, avoid stress and fatigue, plan rest periods, good oral hygiene, schedule regular dental visits, give prophylactic antibiotics, and provide drug rehabilitation

Nursing Implementation

• Implement ambulatory care & discharge planning: Antibiotic therapy for 4 to 6 weeks, assess home setting, monitor laboratory data (including blood cultures), assess IV access and long-term lines, suggest coping strategies, encourage adequate rest, moderate activity, compression stockings, ROM exercises, and deep breathing and cough every 2 hours

Nursing Implementation and Evaluation

• Patient teaching: Monitor body temperature, signs and symptoms of complications, nature of disease and how to reduce risk of reinfection, stress follow-up care, good nutrition, prompt treatment of common infections, signs and symptoms of infection, and need for prophylactic antibiotic therapy
• Evaluation: Expected outcomes are that the patient will maintain adequate tissue and organ perfusion, maintain normal body temperature, and report an increase in physical and emotional comfort

Pericarditis

• Pericardial sac inflammation and fluid accumulation
• Normal volume is 10-15 mL
• Causes: infectious (bacterial, fungal, viral), non-infectious (MI, Cancers, Aortic Dissection, renal failure, trauma),
• Autoimmune (Meds, Post-Op, RF, RA, SLE, Scleroderma, AS)
• Dressler Syndrome = Post MI irritation and fluid 4-6 weeks after

Clinical Manifestations

• Chest Pain worse with deep inspiration and when lying flat
• Radiation arm, neck, shoulder, upper back
• Tachypnea, shallow breathing, coughing, hiccups
• Pericardial friction rub-left lower sternum when forward
• Pericardial effusion leading to Tamponade
• Compression of the heart prevents filling volumes-Low CO
• Muffled heart sounds, tachycardia, JVD,
• EKG-diffuse ST segment elevation-not like an MI
• CXR-enlargement of silouette
• Echocardiogram
• CT MRI
• Labs (CBC, CRP, ESR, Troponin)
• Pericardial fluid testing, cultures and biopsy

Interprofessional Care

• Treat cause with antibiotics, NSAIDS-initially, Corticosteroids-autoimmune
• Procedures: Pericaridocentesis and pericarcial window

Nursing Management

• Manage Pain and GI monitoring
• Position of comfort: Bed rest, HOB elevated 45 degrees-leaning forward
• Monitor VS and CO, watch for tamponade
• PR elevation in aVR (Thumbprint sign)
• PR depression
• Diffuse concave ST elevation
• Etiology can be viral, neoplastic, uremic or connective tissue disorder
• Treat with NSAIDs, colchicine, or Steroid (refractory cases)

Valvular Heart Disease

• Heart has: 2 atrioventricular valves (Mitral, Tricuspid) and 2 semilunar valves (Aortic, Pulmonic)
• Stenosis (constriction/narrowing) occurs when the valve opening is smaller, forward blood flow is impeded, and pressure differences on the two sides of the valve reflect degree of stenosis
• Regurgitation (incompetence or insufficiency) occurs with incomplete closure of valve leaflets and results in a backward flow of blood
• Both stenosis or regurgitation lead to heart failure
• Most common cause is rheumatic heart disease = scarring and contractures
• Results in deceased blood flow from left atrium to left ventricle
• Increases pressure LA and Pulmonary system

Mitral Valve Stenosis

• Clinical Manifestations = Left side of Heart- Exertional dyspnea, loud S1, diastolic murmur, fatigue, palpitations Hoarseness, hemoptysis, and atrial fibrillation with risk for stroke

Mitral Valve Regurgitation

• Damage caused by: MI, chronic rheumatic heart disease, mitral valve prolapse, ischemic papillary muscle dysfunction, and IE
• Incomplete valve closure causes backward flow
• With acute MR: pulmonary edema, untreated leads to cardiogenic shock, and thready peripheral pulses --Cool, clammy extremities
• Chronic MR leads to left atrial enlargement, ventricular dilation, eventual ventricular hypertrophy, decreased CO, weakness, fatigue, palpitations, dyspnea, PND, edema, S3, and murmur
• Consider Clinical manifestations = Left side of Heart

Mitral Valve Prolapse

• Leaflets prolapse back into left atrium during systole-Most asymptomatic for life--Only 10% with symptoms
• Murmur is d/t regurgitation, severe MR is uncommon
• Dysrhythmias can cause palpitations, light-headedness, and syncope
• Infective endocarditis-Prophylaxis needed, and chest pain unresponsive to nitrates
• Treat symptoms with Beta-blockers
• Valve surgery for MR if develops
• Consider a teaching plan and education

Aortic Valve Stenosis

• Congenital aortic stenosis AS generally found in childhood, adolescence, or young adulthood, in adults-degenerative or caused by rheumatic fever
• Obstruction of blood flow from left ventricle to aorta
• Left ventricular hypertrophy and increased myocardial oxygen consumption
• Decreased CO leads to decreased tissue perfusion, pulmonary hypertension, and HF
• Poor prognosis if left untreated
• Clinical manifestations: angina, syncope, and exertional dyspnea
• Auscultatory findings show normal to soft S1, decreased or absent S2, systolic murmur with radiation to the carotids, and a prominent S4
• Use nitroglycerin cautiously as it reduces preload and BP

Aortic Valve Regurgitation

• Acute AR can be caused by IE, trauma, or aortic dissection but is a life-threatening emergency
• Chronic AR may develop from Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, connective tissue problem, or post-surgical cause
• Backward blood flow from ascending aorta into left ventricle develops with chronic AR, left ventricular dilation and hypertrophy
• This leads to a decrease in myocardial contractility and pulmonary hypertension and right ventricular failure

Aortic Valve Regurgitation

• Clinical manifestations of acute AR includes severe dyspnea, chest pain, hypotension, cardiogenic shock, and life-threatening emergency
• Clinical manifestations of chronic AR may be asymptomatic for years, exertional dyspnea, orthopnea, paroxysmal dyspnea, angina, soft or absent S1, S3 or S4, and murmur
• Can also have a Water-hammer pulse if severe

Right Sided Heart Valves

• Tricuspid Almost usually caused by rheumatic fever, or TOF (Tetralogy of Fallot), and congenital valve disease
• Clinical manifestations include fluttering discomfort in the neck, fatigue and right upper quadrant pain
• Stenosis is almost always be congenital and causes right ventricular hypertension and hypertrophy
• Clinical manifestations are syncope, dyspnea, and angina
• Pulmonic regurgitation is often asymptomatic but can cause RV dilation, potential causes include pulmonary hypertension and surgical repair of tetralogy of Fallot

Valvular Heart Disease Diagnostic Studies

• History and physical assessment
• Real-time 3-D echocardiography
• TEE
• Doppler color flow
• Chest x-ray
• ECG

Valvular Heart Disease

• Conservative therapy depends on the valve involved and disease severity
• Prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent RF and IE
• Administer Prophylactic antibiotic therapy to prevent recurrent RF and IE
• Drugs treat/control HF: Vasodilators (e.g., nitrates, ACE inhibitors), Positive inotropes (e.g., digoxin), Diuretics, B-blockers, and Low sodium diet
• Give meds or perform interventions For atrial dysrhythmias • Calcium channel blockers, Beta-blockers • Anti-dysrhythmic drugs • Anticoagulation therapy for A-fib

Surgical Therapy

• Percutaneous transluminal balloon valvuloplasty (PTBV) split open fused commissures to treat mitral, tricuspid, pulmonic, and AS
• Balloon- tipped catheter inserted via femoral artery is inflated to separate valve leaflets
• Valve repair is a preferred surgical procedure with lower operative mortality rate than replacement
• While it May not restore total valve function include Commissurotomy (valvulotomy), Valvuloplasty, and Annuloplasty.
• Valve Replacements can be Mechanical or Biological
• Transcatheter aortic valve replacement (TAVR)
• Transfemoral approach used for severe AS

Valve Replacement

• Mechanical (artificial) valves are More durable and last longer
• Come with a risk of thromboembolism and require long-term anticoagulation
• Biologic Tissue bovine, porcine, and human; have more natural blood flow with No anticoagulation required but are less durable

Vavlular Heart Disease Nursing Assessment

• Subjective data include medical history or implanted devices, IVDA, fatigue, palpitations, weakness, activity intolerance, dizziness, fainting, DOE, cough, hemoptysis, orthopnea, PND, and angina or atypical chest pain
• Objective data on assessment include fever, diaphoresis, flushing, cyanosis, clubbing, peripheral edema, crackles, wheezes, hoarseness, and S3 and S4 with dysrhythmias
• Possible increases or decrease in pulse pressure
• May observe hypotension
• May also notice water-hammer or thready peripheral pulses
• Includes hepatomegaly, ascites, and weight gain

Clinical Problems & Planning

• Impaired cardiac function
• Fatigue
• Fluid imbalance
• Goals:
• Normal heart function
• Improved activity tolerance
• Understanding of the disease process and health maintenance measures

Nursing Implementation

• Early treatment of streptococcal infections
• Prophylactic antibiotics for patients with history
• Teach patient symptoms to report
• Individualize rest and exercise--Limit activities
• Discourage tobacco use
• Ongoing monitoring and drug effectiveness
• Monitor INR for patient on anticoagulants

Nursing Implementation and Evaluation

• Patient teaching---Medical-alert device or bracelet
• Drug actions and side effects---prophylactic antibiotic therapy
• Information related to anticoagulation therapy
• Follow-up care --Notify HCP for signs of infection, HF, or bleeding and planned invasive or dental work
• Expected patient outcomes include maintaining adequate tissue and organ perfusion, achieve fluid balance, achieve the optimal level of activity and describe disease process and measures to prevent complications.

Cardiomyopathy

• Cardiomyopathy comprises a group of diseases that directly affect the structure or function of the myocardium
• CMP classification: primary-etiology of the heart disease is unknown or secondary-known myocardial disease is known and causes CMP
• Dilated-acute or chronic onset due to infection or other processes is associated with vent. dilation, impaired systole, atrial enlargement, and stasis of blood in the LV
• Hypertrophic-Asymmetric LEFT Ventricular Hypertrophy presents with Impaired diastolic LV filling and obstructs the LV outflow
• It is the Most common cause of Sudden cardiac death in young/athletes
• Restrictive-impaired diastolic filling and stretch is rare and of unknown etiology.

Cardiomyopathy Causes

• Dilated type is associated with cardiotoxic agents (alcohol, cocaine, doxorubicin), CAD, Hypertension or Genetic disorder.
• Myocarditis, Pregnancy and Valve disease may also cause it
• Hypertrophic is linked to aortic stenosis and genetic or hypertension
• Restrictive, is associated with Amyloidosis, endomyocardial fibrosis or neoplastic tumor, post-radiation therapy, sarcoidosis and ventricular thrombus

Cardiomyopathy Diagnostic Assessment

• History and physical examination
• Electrocardiogram
• b-Type natriuretic peptide (BNP)
• Chest x-ray
• Echocardiogram
• Nuclear imaging studies
• Heart catheterization
• Endomyocardial biopsy

Cardiomyopathy Assessment Findings

• Progresses to Heart Failure with decreased exercise capacity and fatigue
• Possible Dyspnea at rest, PND, and Orthopnea
• Presents as dry cough, palpitations, abdominal boating, hepatomegaly, JVD, nausea, vomiting and anorexia
• S3, S4, murmurs, dysrhythmias, pulmonary crackles, edema, weak peripheral pulses, and pallor
• Blood flow stasis risk for embolization

Cardiomyopathy Management

• Drug therapy: Nitrates (except in hypertrophic CMP), B-Blockers, Antidysrhythmics, ACE inhibitors, Diuretics, Digitalis (except in hypertrophic unless atrial fibrillation), and Anticoagulants (if indicated)
• Surgical intervention and devices: Ventricular assist device, Cardiac resynchronization therapy, Implantable cardioverter-defibrillator, Surgical repair, Heart transplantation, and Cardiac rehabilitation
• Care can also be palliative and hospice

Nursing Care Plan

• Decreased cardiac output related to CMP as evidenced by murmurs, dyspnea, dysrhythmias, and/or peripheral edema
• Excess fluid volume related to fluid retention secondary Congestive heart failure as evidenced by peripheral edema, weight gain, adventitious breath sounds, and/or neck vein distention
• Activity intolerance related to insufficient oxygenation secondary to decreased cardiac output and pulmonary congestion as evidenced by weakness, fatigue, shortness of breath, increase or decrease in the pulse rate and/or BP changes.
• This Care is like that of Heart Failure
• Identify interventions for each nursing diagnosis
• Review table for patient teaching

Explore infective endocarditis (IE) risk factors, types, and diagnostic approaches. Understand the prognosis of IE and the use of echocardiography. Learn about managing valvular heart disease through diet and percutaneous transluminal balloon valvuloplasty (PTBV).