cardiomyopathies

1. KAHER INSTITUTE OF NURSING SCIENCES,
BELAGAVI
CARDIOMYOPATHY
Presented By:
Ms. Tincy Thomas
Msc (N)-1

2. INTRODUCTION:
 Cardiovascular system includes heart and blood
vessels.
 Heart is a hollow muscular organ situated in the
middle mediastinum i.e. between the lungs.
 Heart is placed behind the body of the sternum and
adjoining parts of the costal cartilages so that 1/3 of the
heart lies to the right and 2/3 of the heart lies to the left
of the medial plane.

3.  It has four chambers Right Atrium,
Right Ventricle, Right Ventricle, Left ventricle.
 It measures about 12x9 cm, weights
300gm in males and in 250gm females.
 Layers of the heart are Pericardium,
Myocardium and Endocardium.

4. CARDIOMYOPATHY:
 Cardiomyopathy is a group of disease that directly
affect the myocardial structure of function.
 It is a heart muscle disease.

5.  It is the weakening of the heart muscles or associated
with other problems with the heart muscle.
 It may be associated with heart failure, endocarditis or
other heart problems which alter the normal
architecture of heart.
 Most of the patients with cardiomyopathy
have heart failure.

7. CLASSIFICATION:
Cardiomyopathy
Primary CMP
Secondary CMP

8. PRIMARY CMP:
 It refers to those conditions in which the etiology of the
disease is idiopathic.
 The heart muscle is only involved in this case.
 Other structures of the heart are unaffected.

9. SECONDARY CMP:
 The cause of secondary cardiomyopathy is known and
secondary due to any other disease conditions.
 Common causes are Dilated cardiomyopathy or
restrictive or hypertrophic cardiomyopathy.

10. TYPES OF CMP:
 Dilated Cardiomyopathy (DCM).
 Hypertrophic Cardiomyopathy (HCM)
 Restrictive Cardiomyopathy.
 Arrhythmogenic Right ventricular
Cardimyopathy.
 Unclassified Cardimyopathy.

12. DILATED CARDIOMYOPATHY (DCM):
 It is the most common type of CMP and has a genetic
link of 30%.
 Incidence is 5-8 cases per 100,000 people per year.
 Dilated cardiomyopathy is a condition in which heart
becomes weak and the chambers get large as a result
the heart cannot pump enough blood out to the body.
 The heart with dilated cardiomyopathy is striking in
appearance.

13.  Dilated CMP is characterized by a diffuse
inflammation and rapid degeneration of the heart fibers.
 This results in ventricular dilation, impaired systolic function,
atrial enlargement and stasis of blood in the left ventricle.
 DCM is distinguished by significant dilation of the ventricles
without simultaneous hypertrophy and systolic dysfunction.

14. CAUSES OF DCM:
 Cardiotoxic agents, alcohol, cocaine, doxorubicin.
 Coronary Artery Disease
 Genetic
 Hypertension
 Metabolic disorders
 Muscular dystrophy
 Myocarditis
 Pregnancy
 Valve disease

15. CLINICAL MANIFESTATIONS:
 Decreased exercise capacity
 Fatigue
 Dyspnea at rest
 Paroxysmal nocturnal dyspnea
 Orthopnea
 Palpitations
 Abnormal bloating
 Dry cough
 Nausea, vomiting and anorexia.

16.  Signs include abnormal S3 and S4
 Dysrhythmias
 Heart murmurs
 Pulmonary crackles
 Edema
 Weak peripheral pulse
 Pallor
 Hepatomegaly
 JVD.

17. DIAGNOSTIC EVALUATION:
 History Collection
 Doppler Echocardiography
 Chest X-ray
 b- type natriuretic peptide (BNP)
 Cardiac Catheterization
 Multiple Gated Acquisition (MUGA)
 Nuclear Imaging studies
 Endomyocardial biopsy.

18. MANAGEMENT:
 Drug Therapy:
 Nitrates (Except Hypertrophic CMP)
 Beta blockers
 Antidysrhythmics
 ACE Inhibitors
 Diuretics
 Digitalis
 Anticoagulants.

19.  Ventricular Assist Device
 Cardiac Resynchronization therapy
 Implantable Cardioverter defibrillator
 Surgical repair
 Heart transplantation
 Cardiac rehabilitation
 Palliative and hospice care.

20. HYPERTROPHIC CMP (HCM):
 It is the condition in which the heart muscle becomes
thick.
 This disease is a genetically inherited disease and
affects younger people (Mean age 26).
 HCM is a rare autosomal dominant condition
occurring in men, women, children with an estimated
prevalence rate of 0.05% -0.2%.

21.  It is asymmetric left ventricular hypertrophy without
ventricular dilation.
 The classic anatomic feature is the profound
hypertrophy of the myocardium of the left ventricle.
 Hypertrophic CMP can be idiopathic, about half of all
cases have a genetic basis characterized by
inappropriate myocardial hypertrophy.

23. CHARACTERISTICS:
 Massive ventricular Hypertrophy
 Rapid, forceful concentration of the left ventricle
 Impaired relaxation
 Obstruction to aortic outflow.

24. CLINICAL MANIFESTATIONS:
 Asymptomatic
 Exertional dyspnea
 Fatigue
 Angina
 Syncope
 Dysrhythmias
 Supraventricular tachycardia & Atrial fibrillation
 Ventricular tachycardia & Ventricular fibrillation.

25. DIAGNOSTIC STUDIES:
 History Collection
 On Palpation- Apical impulses can be exaggerated and
displaced to the left.
 Auscultation – S4 and systolic murmur between the
apex & sternal border at the 4 th Intercostals space.
 ECG- Ventricular Hypertrophy, ST-T wave
abnormalities, prominent Q waves in the precordial or
inferior leads ,ventricular & atrial dysrhythmias.

26.  Echocardiography- Confirm Hypertrophic CMP, wall
motion abnormalities and diastolic dysfunction.
 Cardiac Catheterization
 Nuclear Stress testing.

27. MANAGEMENT:
 Beta Blockers- (Eg: Metoprolol)
 Ca channel blockers- (Eg: Verampil)
 Digitalis- to treat atrial fibrillation.
 Antidysrhythmic drugs- Aminodarone
 Cardioverter defibrillator.
 AV pacing is helping for patients with hypertrophic CMP.

28. SURGICAL MANAGEMENT:
 Ventriculomytomy
 Myectomy
 Percutaneous Transluminal Septal Myocardial
Ablation (PTSMA)- This procedure consists of
injecting alcohol into the septal artery branching of the
left anterior descending artery. This causes ischemia
and septal wall infraction. Ablation of the septal wall
decreases the obstruction to flow and patients
symptoms decrease.

29. NURSING MANAGEMENT:
 Avoid strenuous activity and Dehydration
 Rest and elevation of the feet to improve venous return
to the heart can manage chest pain.
 Vasodilators such as nitroglycerine should be avoided
because it may worsen the chest pain by decreasing
venous return and increasing obstruction of blood flow
from the heart.

30. RESTRICTIVE CMP:
 R CMP is the least common type.
 It is characterized by diastolic dysfunction caused by
rigid ventricular walls that impair diastolic fillings and
ventricular stetch.
 It can be either idiopathic or can be caused by disease
that deposit abnormal substances within the
myocardium.

31.  Systolic function will be normal.
 Myocardial fibrosis, hypertrophy and infiltration procedure
stiffness of the ventricular wall with loss of ventricular
compliance.
 Secondary causes of Restrictive CMP include amyloidosis,
endocardial fibrosis, sarcoidosis, fibrosis of different
etiology and radiation to the thorax.
 With Restrictive CMP the ventricles are resistant to filling
and therefore demand high diastolic filling pressures to
maintain CO.

33. CLINICAL MANIFESTATION:
 Fatigue
 Exercise intolerance
 Dyspnea
 Non productive cough
 Chest pain
 Angina pectoris
 Orthopnea
 Syncope
 Palpitations.

34.  Peripheral edema
 Weight gain
 Ascities
 Hepatomegaly
 JVD
 Syncope
 Palpitations.

35. DIAGNOSTIC EVALUATION:
 Chest X ray may show cardiomegaly from right and left
atrial enlargement, pulmonary congestion and pleural
effusion.
 ECG may be reveal mild tachycardia.
 Dysrhythmias are supraventricular or AV block.
 Echocardiography may reveal left ventricle that is
normal size with a thickened wall, slightly dilated right
ventricle and dilated atria.

36.  Endomyocardial biopsy
 CT Scan or MRI Scan shows normal thickness of
pericardium.
 Nuclear Imaging

37. ARRHYTHMOGENIC RIGHT VENTRICULAR
CARDIOMYOPATHY:
 ARVC occurs when myocardium of the right ventricle
is progressively infiltrated and replaced by fibrous scar
and adipose tissue.
 Localized areas of the right ventricle are affected but as
the disease progresses the entire heart is affected.
 Eventually right ventricle dilates and develops poor
contractility right ventricular wall abnormalities and
dysrhythmias.

38.  The prevalence of ARVC is unknown because many
cases are not recognized.
 Palpitations or syncope may develop between 15 and 40
years of age.
 ARVC should be suspected in patients with ventricular
tachycardia originating in the right ventricle or sudden
death especially among previously symptom-free
athletes.
 First degree blood relatives should be screened for the
disease with a 12 Lead ECG, Holter monitor and
Echocardiography.

40. UNCLASSIFIED CARDIOMYOPATHIES:
 Unclassified cardiomyopathies are different from or
have characteristics of more than one of the previously
described types.
 Examples of unclassified cardiomyopathies include
fibroelastosis, non compacted myocardium, systolic
dysfunction with minimal dilation and mitochondrial
involvement.

41. CLINICAL MANIFESTATIONS OF CMP:
 Breathlessness with exertion or even at rest.
 Swelling of the legs, ankles and feets.
 Bloating of the abdomen due to the fluid buildup.
 Fatigue
 Irregular heart beats that feels rapid, pounding or
fluttering.

42.  Dizziness, lightheadedness and fainting.
 Palpitations
 Fainting
 Chest pain or pressure.

43. DIAGNOSTIC EVALUATION:
 History Collection
 Physical examination may reveal enlarged spleen and heart
size with atrophy.
 Blood culture and sensitivity.
 Chest X-ray
 CBC
 CT Scan of the chest
 Echocardiogram
 ECG

44. TREATMENT:
 When possible the cause of cardiomyopathy is treated.
 Medicines and lifestyle changes are often needed to
treat the symptoms of heart failure, angina and
abnormal heart rhythms.
 Defibrillator sends an electrical impulses to stop life
threatening abnormal heart rhythms.

45.  CABG surgery or angioplasty can improve blood flow
to the damaged or weakened heart muscle.
 Transplantation of heart when all the treatments are
failed.

46. MANAGEMENT:
 Angiotensin converting enzyme Inhibitors to improve
your hearts pumping capability such as enalapril,
lisinopril, ramipril and captopril.
 Angiotensin receptor blockers for those who cannot
take ACE inhibitors such as losartan and valsartan.
 Beta blockers to improve heart function such as
carvedilol and metoprolol.

47.  Digoxin or digitalis to increase the strength of your
heart muscle contractions. It also tends to slow the
heart beat and reduces heart failure symptoms.
 Diuretics such as bumetanide and furosemide. These
drugs decreases fluid in the lungs and breath more
easily.
 Spironolactone (diuretic) is helpful in treating scarring
of the heart tissue.

48. SURGICAL MANAGEMENT:
SEPTAL MYECTOMY:
This is an open heart surgery in which the surgeon
removes part of the thickened overgrown heart muscle
wall that separates the two bottom heart chambers.
Removing the part of this overgrown muscles improves
blood flow and reduces mitral regurgitation. Myectomy
is used if medications do not relieve symptoms.

49. SEPTALABLATION:
 Also called as septal alcohol ablation this is a
treatment in which a small portion of the thickened
heart muscle is destroyed by injecting alcohol through
a catheter into the artery supplying blood to it.
 Possible complication of this procedure are heart block,
disruption of the heart electrical system which requires
implantation of pacemaker.

50. PACEMAKER IMPLANTATION:
A pacemaker is a small electronic device inserted under
the skin which sends electrical signals to your heart to
monitor and regulate your heart beat. Surgery to
implant pacemaker is performed under local anesthesia
and takes less than 3 hours.

51. IMPLANATBLE CARDIOVERTER DEFIBRILLATOR:
It is a device implanted in the chest like a pacemaker. An
ICD continuously monitors heart beat. If a life threatening
arrhythmia occurs ICD delivers precisely calibrated
electrical shocks to restore normal rhythm.

52. HEART TRANSPLANTATION:
The patients with severe cardiomyopathy and
medications cannot control your symptoms, heart
transplant may be an option.

53. VENTRICULAR ASSIST DEVICE:
Mechanical heart assist device can help critically ill
people as they wait for an appropriately matched donor.
These devices known as ventricular assist device
(VAD). It can help the blood to circulate through your
heart for months or even years.

54. NURSING MANAGEMENT:
 Bed rest is important because it reduces myocardial
oxygen demand and usually continues until the
following criteria are meet:
 Temperature remains normal without the use of
salicylates.
 Resting pulse rate remains less than 100 beats/min.
 ECG tracings show no manifestations of myocardial
damage.

55.  Obtain a clear description of the pain or discomfort.
 Administer analgesics as needed and use salicylates.
Balance rest and activity according to the degree of
pain and activity tolerance.
 Provide psychological support while patient is confined
to hospital with restrictive intravenous therapy.
 If patient received surgical treatment provide post
surgical care and instruction.

56.  A high protein, high carbohydrate diet helps to
maintain adequate nutrition in the presence of fever
and infection.
 Take care of teeth and gums obtain prompt dental care
for cavities and gingivitis.

57. NURSING DIAGNOSIS:
 Acute pain related to an impaired ability of blood
vessels to supply oxygen to the tissues.
 Activity intolerance related to compromised oxygen
transport system secondary to the heart muscle
dysfunction.
 Risk for ineffective breathing pattern related to
decreased respiratory depth secondary to pain.

58. REFERENCES:
 Lewis textbook of medical- Surgical Nursing Volume- I Elsevier
Publication 3 rd South Asia Edition Page no: 750-755.
 Brunner & Suddarth’s Textbook of Medical Surgical Nursing
Volume- I Eleventh Edition Page no: 925-932.
 P Hariprasanth Textbook of Cardiovascular & Thoracic Nursing
Jaypee Publications Page no: 212-215.
 Deepak Sethi & Capt Kirti Rani Textbook of Medical Surgical
Nursing I&II Page no: 27-31.