Inflammatory Conditions and Valvular Disorders PDF

Inflammatory Conditions and Valvular Disorders After this module, you will be able to: 1.Describe the structural changes that happens in the heart during inflammation and damage to the valves. 2.Describe the problems in the course of inflammatory problems and valvular disorders 3.Plan a c...

Inflammatory Conditions and Valvular Disorders After this module, you will be able to: 1.Describe the structural changes that happens in the heart during inflammation and damage to the valves. 2.Describe the problems in the course of inflammatory problems and valvular disorders 3.Plan a comprehensive concept map for the patient with inflammatory and valvular heart problems integrating all the possible risk factors, etiology and causes  Prevalence of Rheumatic Heart Disease Worldwide, there are over 15 million cases of rheumatic heart disease, with 282,000 new cases and 233,000 deaths from this disease each year (Chin ,2019) Before staring with this module, see if you can name the cardiac valves, label the parts of the heart pointed by the arrows The following are areas where to listen to heart sounds. Label the area and specify the location. The Heart Valves 1. Semilunar Valves -Outflow valves: Pulmonic and aortic valves -Made up of 3 crescent shaped flaps called cusps -The valves open and close to allow blood to flow out when the ventricles contract and to prevent backflow between contractions Let’s look at the Heart valves 2.Atrioventricular Valves -separate the atria from the ventricles -open when the atria pump blood into the ventricles a. Tricuspid valve- right AV valve with 3 leaflets b. Mitral valve- left AV valve with 2 leaflets They are attached by chordae tendinae to papillary muscles on the ventricle walls  The Heart Sounds S1- produced by vibrations generated by closure of the mitral and tricuspid valves; corresponds to the end of diastole and beginning of ventricular systole and precedes the upstroke of carotid pulsation. S2-sound produced by the closure of the aortic and the pulmonary valves at the end of systole. Heart sounds … S3- a low-pitched, early diastolic sound audible during the rapid entry of blood from the atrium to the ventricle. -When arising from the LV, it is best audible at the apex with patient in left lateral decubitus position with breath held at end expiration. -When it is of RV origin, S3 is best audible at the left lower sternal border or the xiphoid with the patient in supine position. Conditions associated with pathological S3 include the following a. Ischemic heart disease b. Hyperkinetic states - Anemia, fever, pregnancy, thyrotoxicosis, AV fistula c. Systemic and pulmonary hypertension d. Acute aortic regurgitation e. Volume overload - Renal failure Heart sounds … S4- fourth heart sound is a late diastolic sound that corresponds to late ventricular filling through active atrial contraction. It is a low-intensity sound heard best with the bell of the stethoscope. When of LV origin, S4 is best heard at the apex with the patient in the left lateral decubitus position at end expiration. When of RV origin, it is heard best at the left lower sternal border. low-pitched diastolic heart sound audible just before S1 in the cardiac cycle. Heart sounds … Conditions associated with pathological S4 include the following: a. Ventricular hypertrophy b. Ischemic heart disease - Acute MI c. Ventricular aneurysm Heart sounds … Murmurs: results from turbulent flow across valves Three main factors have been attributed to cause a murmur: (1) high flow rate through normal or abnormal orifices, (2) forward flow through a constricted or irregular orifice or into a dilated vessel or chamber (3) backward or regurgitant flow through an incompetent valve How to Grade a Murmur Rheumatic Heart Disease: cardiac inflammation and scarring triggered by an autoimmune reaction to infection with group A beta hemolytic streptococci.  Facts on Rheumatic Heart Disease Rheumatic heart disease is a major cause of heart problems in children and adolescents especially the 5 to 15 years age group. (https://www.healthline.com/health/rheumatic-fever treatments ,WHO 2019). WHO ( 2015) study : 33.4 M cases of RHD globally with 319,400 deaths due to RHD Higher deaths among the low socioeconomic and overcrowded groups. Account for 15% of the cause of heart failure Africa ,Asia and other developing communities ( WHO,2018). Impact of Rheumatic heart disease can be devastating as the consequences can be debilitating or even kill those affected at a young age In the Phils, the leading cause of heart disease is rheumatic fever, accounting for 54.9 per cent of cardiac children and 46.6 per cent of cardiac adults, giving an average prevalence of 47.1 per cent. Risk factors for Rheumatic heart Disease Children ( 5-15 years old) Undertreated throat infections Living in crowded dwelling Poor oral hygiene Lower socio economic group Signs and Symptoms of Rheumatic Heart Disease ✓ Fever , especially early stages ✓ Sore throat or pharyngitis – from the streptococcal infection ✓ Polyarthritis ✓Chest pain / murmurs ✓Carditis,- from involvement of the cardiac tissues ✓Chorea- jerky movements ✓Subcutaneous nodules, and erythema marginatum or a rash associated with ARF Patient Assessment and Diagnosis 1.Comprehensive history taking to track: previous throat infections fevers, joint pains or swelling myalgias , althralgia, chorea  Patient Assessment and diagnosis… 2. Laboratory work up- looks for criteria to establish diagnosis Echocardiography with Doppler studies (all cases of confirmed and suspected ARF) -show the damage to the valve flaps, backflow of blood - fluid around the heart, and heart enlargement. -most useful test for diagnosing heart valve problems. Anti-streptolysin O titer or other streptococcal antibodies (anti- DNASE B) A positive throat culture for group A β-hemolytic streptococci. Patient Assessment and diagnosis… A positive rapid group A streptococcal carbohydrate antigen test in a child whose clinical presentation suggests a high pretest probability of streptococcal pharyngitis Cardiac MRI – to show clearer details of the heart valves including heart muscles Raised ESR or CRP Prolonged P-R interval on ECG Revised Jones criteria for diagnosis of Rheumatic Fever : Major criteria: ✓carditis (clinical and/or subclinical), ✓arthritis (monopolyarthritis or polyarthritis, or polyarthralgia), ✓Chorea, ✓Erythema marginatum, and subcutaneous nodules Minor criteria: ✓fever (≥38.5° F) ✓ Erythrocyte sedimentation rate ≥30 mm and/or ✓CRP ≥3.0 mg/dl ✓ prolonged PR interval (unless carditis is a major criteria) Revised Jones criteria for diagnosis of Rheumatic Fever : Treatment of Rheumatic Heart Disease: 1.Antibiotics Penicillin group to treat the infection a. Phenoxymethylpenicillin - oral (twice a day) or b. Amoxicillin once a day c. Erythromycin or Roxythromycin if allergic to penicillin Benzathine Penicillin (IM) may be continuously given for minimum of 10 years. Treatment of Rheumatic Heart Disease…. 2.Anti-inflammatory drugs a. aspirin b. steroids to reduce inflammation and lower the risk of heart damage 3.Mitral valve repair (newer technique in place of valve replacement) 4.Heart valve transplant in severe cases (if repair is not possible ) Complications of rheumatic heart disease: a. Endocarditis- inflammation and damage extends to the inner layer of the heart b. Heart failure- the heart is not able to pump the adequate blood to sustain perfusion c. Embolic stroke- from the slowed circulation that favors stasis/ thrombus formation d. Atrial fibrillation- valve damage increases the resistance and backflow ; the weakened cardiac muscle responds by faster but ineffective contractions.  Nursing care management 1.Maintain bed rest during the acute and febrile stages to decrease cardiac work load 2.Comfort measures to relieve fever and pain 3.Administer prescribed medications like antibiotics to maintain therapeutic levels and control descending infection to the heart 4. Monitor alterations in heart and kidney functions 5. Monitor changes in vital signs, urine output and level of consciousness Nursing care management …. 6. Teach hygiene measures like thorough mouth care to control oral and throat infections 7. Teach compliance to long term antibiotic therapy as needed. 8. Encourage regular follow up. Therapy to prevent cardiac damage - is long term management. 2. Infective Endocarditis noncontagious but serious infection of the endocardium of the heart, particularly the heart valves, mainly caused by bacteria(streptococci or staphylococci), sometimes fungi. Facts on Infective Endocarditis There is a high mortality rate associated with infective endocarditis (22-27% within 6 months to one year form complications like heart failure and emboli ( Webb et al. 2016,Spelman, 2017). Can occur at any age with more men affected. IV drug abusers, immunocompromised patients, and patients with prosthetic heart valves and other intracardiac devices are at highest risk.  Types of Bacterial Endocarditis : 1. Acute bacterial endocarditis – develops quickly with rapid progression over days source of infection or portal of entry is often evident can affect normal valves. usually caused by Staphylococcus Aureus, group A hemolytic streptococci, pneumococci, or gonococci. 2. Sub acute bacterial endocarditis -develops insidiously and progresses slowly (.ie, over weeks to months). no evident source of infection or portal of entry mostly caused by streptococci (especially viridans, microaerophilic, anaerobic, nonenterococcal group D streptococci and enterococci) Types of Bacterial Endocarditis …. 3. Prosthetic valvular endocarditis (PVE) - occur more after aortic than after mitral valve replacement and affects mechanical and bioprosthetic valves develops in within 1 year after valve replacement Early-onset infections (< 2 months after surgery) are caused mainly by contamination during surgery with antimicrobial-resistant bacteria (eg, S. epidermidis, diphtheroids, coliform bacilli, Candida species, Aspergillus species) Watch this video to better understand endocarditis https://www.youtube.com/watch?v=8YSfsHjTMx8  Patient Assessment and Diagnosis in Bacterial Endocarditis : A. Early Signs / Symptoms of bacterial endocarditis : Low to moderate-grade fever (< 39° C), night sweats, fatigability, malaise, and weight loss, chills and arthralgias may occur. Murmur, (may develop new regurgitant murmur), and tachycardia. B.Later manifestations: Roth spots- round or oval hemorrhagic retinal lesions with small white centers –caused by retinal emboli ; vision loss may occur Janeway lesions- non tender hemorrhagic macules on the palms or soles Patient Assessment and Diagnosis in Bacterial Endocarditis ….. Janeway lesions- non tender hemorrhagic macules on the palms or soles Osler nodes- painful erythematous subcutaneous nodules on the tips of digits  Osler nodes (A) Splinter hemorrhages in nails with Endocarditis ( B) Patient Assessment and Diagnosis in Bacterial Endocarditis ….. Later manifestations… Central nervous system (CNS) effects- transient ischemic attacks, stroke, toxic encephalopathy, and, if a mycotic CNS aneurysm ruptures, brain abscess and subarachnoid hemorrhage. Renal emboli - may cause flank pain, gross hematuria. Splenic emboli -may cause left upper quadrant pain. Prolonged infection may cause splenomegaly or clubbing of fingers and toes. Management of Bacterial Endocarditis a. Cardiac stabilization – i.e. addresses the congestive heart failure b. Oxygenation- to maintain adequate perfusion c. Blood culture –to identify causative microorganism for appropriate antibiotic therapy d. Antibiotic therapy ( Penicillin, ceftriaxone, gentamycin , flucloxacillins and vancomycin are used according to culture results e. Hemodialysis -may be required in patients who develop renal failure f. Salt restriction among those with congestive heart failure g. Limitation of activities in patients with heart failure Nursing care of patients with Endocarditis A. Monitor vital signs to detect hemodynamic instability- i.e tachycardia can cause more burden to the ailing heart B. Monitor for changes in level consciousness of signs of CNS involvement. C. Maintain oxygenation -to keep SPO2 above 93 %- prevent tissue hypoxemia and damage to vital organs D. Provide comfort measures-especially to relieve any fever or pain Nursing care of patients with Endocarditis E. Assist in activities of daily living for those on bed rest to decrease cardiac stress F. Teach the need for salt & fluid restriction for those with congestive heart failure. Teach to measure I&O even at home G. Teach preventive measures against re infection – i.e thorough mouth care to prevent oral infections and gingivitis and other sources of infections. H. Teach compliance to long term antibiotic therapy as needed. Myocarditis inflammation of myocardium with necrosis of cardiac myocyte cells A. Types of myocarditis 1. Infectious myocarditis- caused by virus (HIV, Coxsakie, Epstein -Barr, Flu virus, etc ) or bacteria (like streptococci, staphylococci , enterococci, mycobacteria), Fungi and parasites 2.Non infectious myocarditis caused by : a. Cardiotoxins- exogenous poisonings (ethanol, heavy metals, envenomation, and radiation therapy), b. Inflammatory disease processes (Kawasaki disease, Takayasu's disease, and sarcoidosis). c. certain drugs - for hypersensitivity myocarditis- chemotherapeutic drugs - doxorubicin and daunorubicin -cyclophosphamide , etc. Types of myocarditis… 3. Giant cell myocarditis- rare form of myocarditis – with unclear etiology but linked to an autoimmune mechanism. ***Biopsy shows characteristic multinucleated giant cells. Patients may develop intractable ventricular arrhythmias or complete heart block. B. Symptoms and Signs of Myocarditis) ( depends on the severity of myocardial inflammation Fatigue, dyspnea, and edema ( in those with Heart failure Fever, myalgias, -in infectious myocarditis Crackles, elevated jugular venous pulses, Third (S3) or fourth (S4) heart sound. – from systolic murmurs of mitral regurgitation and tricuspid regurgitation in patients with ventricular enlargement. Palpitation / syncope, sinus tachycardias to fatal arrhythmias Patient Assessment and Diagnosis: 1.Complete medical history & physical exams -Vital signs , esp. fever /chills, -Heart murmurs -Exposure to infections or toxins -Shortness of breath - Edema Patient Assessment and Diagnosis: 2. Laboratory work up ECG – check heart rhythms CBC- complete count - eosinophil count is high in myocarditis Enzymes test /antibody tests X-ray- size and shape of heart Acid fast stain – for TB suspected myocarditis Patient Assessment and Diagnosis: 3.Endomyocardial biopsy - (gold standard for diagnosis of myocarditis) checks for inflammatory infiltrate of the myocardium and necrosis of adjacent myocytes 4.Cardiac catheterization - to rule out ischemia since myocarditis can mimic myocardial infarction or myocardial ischemia. 5.Other tests -HIV, histoplasmosis complement fixation (in endemic areas), and antibody tests for HIV related myocarditis or coxsackievirus, influenza virus, and streptococcus.  Treatment and Management : A. Treatment is symptomatic and depends on type of myocarditis Withdrawal of drug -in hypersensitivity myocarditis Diuretics and nitrates to decongest heart failure Intraaortic balloon pump (IABP), left ventricular assist device (LVAD), in fulminant heart failure Treatment and Management : Long-term drug treatment of heart failure - angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, aldosterone antagonists, angiotensin II receptor blockers (ARBs), or angiotensin receptor/neprilysin inhibitors (ARNIs). Antiarrhythmic therapy for arrhythmias Permanent pacemaker – for persistent conduction abnormalities Corticosteroids and cyclosporine – for giant cell myocarditis Antivirals- for viral origin myocarditis Antibiotics – in bacterial myocarditis Ventilatory support – in severe cases to decrease afterload, decreased pulmonary edema, and improved efficiency of gas exchange if desaturated. Nursing Care in Myocarditis Monitor closely the vital signs to check fever, dyspnea or decreased blood pressure Check frequently and report any arrhythmias or chest pains immediately Maintain oxygenation therapy as needed (required if sPO2 less than 93 %) Maintain bed rest to decrease cardiac work load until patient is stable Relieve fever and malaise with prescribed medications. Nursing Care in Myocarditis Auscultate for crackles regularly –may signal onset of pulmonary edema from congestive heart failure Measure weight, intake and output accurately Administer prescribed medications (may include antibiotics, diuretics & antiarrhythmics, inotropic support accordingly to maintain vital signs and hemodynamic stability Encourage compliance to activity and diet restrictions Cardiac Tamponade Accumulation of fluid in the pericardial space or congestion in intra thoracic space “squeezing” the heart in hence unable to pump  Causes of Cardiac Tamponade 1.Severe chest injury- intra-thoracic bleeding congests the pericardial area restricting cardiac contractions 2.Rupture of an aortic aneurysm - can quickly congest thoracic space  Causes of cardiac tamponade 3. Advanced lung cancer – enlarged mass decreases the space for cardiac contraction  Causes of cardiac tamponade 4. Acute pericarditis- massive inflammation increases capillary permeability and fluid accumulation in the heart Causes of cardiac tamponade 5.Heart surgery- can bleed and congest pericardial sac 6. Stab wounds – direct trauma to heart causes bleeding and congestion in the thoracic area that limits space for the heart to contract Causes of cardiac tamponade 7.Heart attack –tissue necrosis in infarction attracts more platelet aggregation and inflammatory substances that can congest the heart tissues  Causes of cardiac tamponade 5. Hypothyroidism, or an underactive thyroid causes pericardial effusion 6. Bacterial infection- causes swelling and congestion in heart tissues 7. Tuberculosis (TB) Causes of cardiac tamponade 8. Systemic lupus erythematosus- immune complex deposits occupy the space for cardiac contraction as the deposits attract more inflammatory substances leading to pericardial effusion Signs and symptoms : Classic signs : Low blood pressure Muffled heart sounds Swollen or distended neck veins Other common signs : ✓ Shortness of breathe, tachypnea, chest pressure ,confusion ✓ Cold clammy extremities from hypo perfusion ✓ Elevated jugular pressure , decreased urine output ✓ Pulsus paradoxus ( Decreased Bp on breathing due to pericardial ✓ congestion Assessment and Diagnosis of cardiac tamponade 1. Quick medical history and physical examination to check: Vital signs ,SPO2, hemodynamic parameters Muffled heart sounds /sounds of shock Neck distention Stab injuries in upper trunk Hx of hypertension (often cause of aortic aneurysm) Lung malignancies or infections Assessment Assessmentand and Diagnosis Cardiactamponade Diagnosis of cardiac Tamponade : 2.Laboratory work up: Echocardiogram, Chest X-ray, Electrocardiogram, Computerized tomography (CT) scan, Cardiac Enzymes Management of cardiac tamponade (including supportive and surgical management) a. Oxygen to reduce stress on the heart b. Intravenous (IV) fluids to maintain normal blood pressure c. Medications like inotropics ( Dpoamine)to increase blood pressure d. Surgery – to address underlying cause : Pericardiocentesis- removal of fluid from the pericardium using a needle. ( choice management ) Pericardiocentesis https://www.resus.com.au/pericardiocentesis/ Management of cardiac tamponade… Pericardiectomy. - surgical removal of part of the pericardium to relieve pressure on the heart Management of cardiac tamponade… Thoracotomy- thoracic opening or tube placement to drain blood or blood clots in the pleural and thoracic cavity to allow decongestion for cardiac contractions Nursing NursingCare careofofpatients pts withwith Cardiac cardiac tamponade tamponade… 1. Maintain 100% oxygen via non-rebreather mask. 2. Administer morphine as ordered for chest pain 3. Establish I.V. access and obtain a 12-lead ECG, chest X-ray, and echocardiogram. 4. Monitor for changes in cardiac rate and rhythm, particularly low ECG voltage and electrical alternans (alternating amplitudes of the P wave, QRS complex, and T waves, the result of the heart swinging in a large pericardial effusion).  Nursing care of pts. with cardiac tamponade… 5. Obtain a blood sample for lab work, ( for complete blood cell count with differential, chemistry panel, cardiac biomarkers, and blood type and cross match). 6. Coordinate for ICU admission if ordered 7. Prepare patient for surgical procedure 8.Follow up, assist NOK with pre-procure preparation. B.Valvular disorders Damage or defect in heart valves -the mitral, aortic, tricuspid or pulmonary. 1. Types : A. Valvular Stenosis -the valve become stiffer, with narrowed valve opening – causes reduced amount of blood flow through it. Types … B. Valvular insufficiency ( Incompetent or leaky valve) the leaflets do not closecompletely, letting blood leak backward across the valve. Causes of valvular disorders Congenital- occur from embryonic development Untreated Infections- like in Rheumatic fever resulting in RHD or Untreated high blood pressure- fr. overstretching - damages the valves Heart attack- can cause tissue necrosis that may affect the endocardium including the valves Causes of valvular disorders Some medications appetite and weight reduction drugs-fenfluramine, dexfenfluramine, and phentermines cause vavulopathies among users anti-migraine drugs- ergotamine and methysergides recreational drugs- methamphetamine, (ecstasy Causes of valvular disorders f. Carcinoid tumors, Rheumatoid arthritis, systemic lupus erythematosus, or syphilis may damage one or more heart valves. g. Uncontrolled atherosclerosis caused by diabetes, hypertension, smoking, and elevated levels of low-density lipoprotein cholesterol and lipoprotein(a). Valvular insufficiencies Signs and Symptoms of valvular disorder: (similar to heart failure) a. Shortness of breath , b. Palpitations, chest pain (may be mild). c. Edema- ( fluid retention in the feet, ankles, hands d. Fatigue. e. Dizziness or fainting (with aortic stenosis). f. Fever (with bacterial endocarditis). g. Rapid weight gain h.murmurs /flutters ( in aortic stenosis) Patient Assessment and Diagnosis 1.Comprehensive history and physical examination to check the following : Vital signs- shortness of breath ; wheezing, low diastolic pressure S3 heart sound -gallop correlates with development of LV dysfunction Congenital heart problems ,history of rheumatic fever, endocarditis , Cardiovascular disease-hypertension Patient Assessment and Diagnosis 2. Laboratory work up : a. Chest X’ray – determines the size including displacement of the heart b. Electrocardiogram- help determine heart rhythm and hypertrophy c. Echocardiogram -to determine the size of the atria and ventricles that correlate with the valve in question, and assessing ventricular functions Patient Assessment and Diagnosis d. Computed Tomography -can provide quantitative assessment of valve calcification (and establish severity of aortic root and ascending aortic dilatation e. Exercise testing may help assess functional capacity and symptoms in patients with documented Aortic Regurgitation and equivocal symptoms. f. Cardiac Magnetic Resonance Imaging. -useful for detecting and reliably measuring the anatomic valve area g. Cardiac catheterization- severity of regurgitation and any left ventricular dysfunction.[ Treatment and management of Valvular disorders 1. Hemodynamic monitoring- Intra arterial monitoring- 2.Medications - Vasodilators ,diuretics, nitrates, digoxin, calcium blockers 3.Low sodium diet 4. Avoiding very strenuous activity Treatment and management of Valvular disorders 5. Surgery a. percutaneous balloon valvuloplasty b. Valvuloplasty c. Valve replacement - Types of artificial valves *Mechanical- synthetic valve *Biologic- Nursing management of patients with Valvular disorders 1.Monitor vital signs and hemodynamic status- slow capillary refill, low BP, cold clammy skin Indicate decreased perfusion 2.Maintain oxygenation as needed if SPO2 is below 94 % 3.Monitor and refer any chest pains or complaints of chest heaviness / palpitations- may denote complications like thromboembolism. 4.Check monitor for arrhythmias – from weakened uncoordinated cardiac contraction 5.Auscultate for murmur-indicates abnormal or turbulent blood flow through the valve. Nursing management of patients with Valvular disorders 6.Monitor for signs of pulmonary congestion- ( shortness of breath, crackles ,pink frothy sputum) 7. Monitor intake and out accurately ( plus daily weight to check fluid retention) 8. Administer prescribed medications (check standing order for anti arrhythmics) and monitor response. 9. Monitor for new onset of murmurs– may indicate deterioration ( esp. aortic stenosis ) 10. Prepare patient for possible surgical interventions as required including completion of : informed consent , physical preparations, laboratory work up, records of patient. Nursing management of patients with Valvular disorders 11.Teach important information to increase compliance and cooperation 12. Psycho emotional care to reduces stress – emotional stress increases cathecolamine and cortisol that further strain the heart ;also drains the needed energy for repair. 13. Encourage to stop smoking , excessive caffeine or recreational drugs Let us elaborate on Mitral Valve Stenosis-