INFECTIOUS DISEASE OF HEART

VALVULAR DISORDERS

CARDIOMYOPATHY

Any of the layers of the heart may be affected

DESCRIPTION by an infectious process. Diseases are named by the layer of the heart that is affected. Diagnosis is made by patient symptoms and echocardiogram. Blood cultures may be used to identify the infectious agent and to monitor therapy. Treatment is with appropriate antimicrobial therapy. Patients need to be instructed to complete the course of appropriate antimicrobial therapy, and require teaching about infection prevention and health promotion. RHEUMATIC ENDOCARDITIS Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis. Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci. Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves. Need to promptly recognize and treat strep throat to prevent rheumatic fever. PATHOPHYSIOLOGY Leukocytes accumulate in the affected tissues and form nodules, which eventually are replaced by scar tissue. Involvement of myocardium - rheumatic myocarditis develops temporarily weakens the contractile power of the heart Pericardium also is affected - rheumatic pericarditis

Regurgitation: the valve does not close

a series of progressive events that

culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias

properly and blood backflows through the valve Stenosis: the valve does not open completely and blood flow through the valve is reduced Valve prolapse: the stretching of an atrioventricular valve leaflet into the atrium during diastole MITRAL VALVE PROLAPSE formerly known as mitral prolapse syndrome a deformity that usually produces no symptoms rarely progresses and can result in sudden death occurs more frequently in women than in men PATHOPHYSIOLOGY a portion of a mitral valve leaflet balloons back into the atrium during systole rarely the valve does not remain closed during systole (ie, ventricular contraction) blood then regurgitates from the left ventricle back into the left atrium (Braunwald et al., 2001)

Possible etiologic factors: heavy alcohol intake recent illness or pregnancy, or history of the disease in immediate family members Types:
Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Arrhythmogenic cardiomyopathy Unclassified cardiomyopathies Pathophysiology series of progressive events that culminate in impaired cardiac output Decreased stroke volume stimulates the sympathetic nervous system and the renin-angiotensinaldosterone response Results in increased systemic vascular resistance and increased sodium and fluid retention Alterations can lead to heart failure

MITRAL REGURGITATION involves blood flowing back from the left ventricle into the left atrium during systole Often, the margins of the mitral valve cannot close during systole. May be caused by problems on: mitral valve leaflet may shorten or tear chordae tendineae may elongate, shorten, or tear

Rheumatic endocarditis results in permanent and

often crippling side effects. INFECTIVE ENDOCARDITIS A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body. Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy. Types: Acute Subacute PATHOPHYSIOLOGY most often caused by streptococci, enterococci, pneumococci, staphylococci) causes deformity of the valve leaflets and chordae tendineae Hospital-acquired endocarditis most often in patients with debilitating disease, those with indwelling catheters, and those receiving prolonged intravenous or antibiotic therapy Patients receiving immunosuppressive medications or corticosteroids may develop fungal endocarditis. Onset of infection - weeks to months, diagnosed as subacute infective endocarditis (Braunwald et al., 2001). MYOCARDITIS inflammatory process involving the myocardium

annulus may be stretched by heart

enlargement or deformed by calcification papillary muscle may rupture, stretch, or be pulled out of position by changes in the ventricular wall (eg, scar from a myocardial infarction or ventricular dilation) and may be unable to contract because of ischemia. MITRAL STENOSIS an obstruction of blood flowing from the left atrium into the left ventricle most often caused by rheumatic endocarditis progressively thickens the mitral valve leaflets and chordae tendineae mitral valve orifice narrows and progressively obstructs blood flow into the ventricle

PATHOPHYSIOLOGY Mitral valve opening is as wide as the diameter of three fingers. In marked stenosis, opening narrows to the width of a pencil. left atrium has great difficulty moving blood into the ventricle Left atrium dilates (stretches) and hypertrophies (thickens) Because there is no valve to protect the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails.

can cause heart dilation, thrombi on the heart

wall, infiltration of circulating blood cells around

the coronary vessels and between the muscle fibers, and degeneration of the muscle fibers may result to cardiomyopathy and heart failure PATHOPHYSIOLOGY from a viral, bacterial, mycotic, parasitic, protozoal, or spirochetal infection may occur in patients after acute systemic infections such as rheumatic fever, in those receiving immunosuppressive therapy, or in those with infective endocarditis may result from an allergic reaction to pharmacologic agents used in the treatment of other diseases degree of myocardial involvement determines the degree of hemodynamic effect and resulting signs and symptoms dilated cardiomyopathy - latent manifestation PERICARDITIS inflammation of the pericardium may be a primary illness, or it may develop in the course of a variety of medical and surgical disorders may be acute or chronic may be classified by the layers of the pericardium attached to each other (adhesive) serum (serous) pus (purulent) calcium deposits (calcific) clotting proteins (fibrinous), or blood (sanguinous) Potential complications Pericardial effusion Cardiac tamponade

AORTIC REGURGITATION flow of blood back into the left ventricle from the aorta during diastole may be caused by inflammatory lesions that deform the leaflets of the aortic valve, preventing them from completely closing the aortic valve orifice may result from endocarditis, congenital abnormalities, diseases such as syphilis, a dissecting aneurysm that causes dilation or tearing of the ascending aorta, or deterioration of an aortic valve replacement PATHOPHYSIOLOGY Blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. It also hypertrophies, trying to increase muscle strength to expel more blood with abovenormal forceraising systolic blood pressure. The arteries attempt to compensate for the higher pressures by reflex vasodilation; the peripheral arterioles relax, reducing peripheral resistance and diastolic blood pressure. AORTIC STENOSIS narrowing of the orifice between the left ventricle and the aorta In adults, may involve congenital leaflet malformations or an abnormal number of leaflets (ie, one or two rather than three), or may result from rheumatic endocarditis or cusp calcification of unknown cause (leaflets of the aortic valve may fuse)

PATHOPHYSIOLOGY Idiopathic or nonspecific causes Infection: viral (eg, Coxsackie, in.uenza) and bacterial (eg, streptococci, staphylococci, meningococci, gonococci); and mycotic (fungal) Disorders of connective tissue: systemic lupus erythematosus, rheumatic fever, rheumatoid arthritis Hypersensitivity states: immune reactions, medication reactions Disorders of adjacent structures: myocardial infarction, dissecting aneurysm, pleural and pulmonary disease (pneumonia) Neoplastic disease: caused by metastasis from lung or breast cancer, leukemia, and primary (mesothelioma) neoplasms Radiation therapy Trauma: chest injury, cardiac surgery, cardiac catheterization, pacemaker implantation Renal failure and uremia Tuberculosis

PATHOPHYSIOLOGY Left ventricle overcomes the obstruction to circulation by contracting more slowly but with greater energy than normal, forcibly squeezing the blood through the very small orifice. The obstruction to left ventricular outflow increases pressure on the left ventricle, which results in thickening of the muscle wall. The heart muscle hypertrophies and when these compensatory mechanisms of the heart begin to fail, clinical signs and symptoms develop.

SIGN AND SYMPTOMS

Regurgitation and stenosis may occur in the mitral valve Murmurs and thrills Signs and symptoms of CHF
INFECTIVE ENDOCARDITIS onset is insidious signs and symptoms develop from the toxic effect of the infection, from destruction of the heart valves, and from embolization of fragments of vegetative growths on the heart Murmurs and thrills Signs and symptoms of CHF Complications Heart failure Stroke may occur before, during,

Usually asymptomatic Fatigue shortness of breath light-headedness, dizziness, syncope palpitations chest pain Anxiety Symptoms may be explained by
dysautonomia (a dysfunction of the autonomic nervous system) MITRAL REGURGITATION often asymptomatic Acute mitral regurgitation (eg, that resulting from a myocardial infarction) usually manifests as severe congestive heart failure.

signs and symptoms of heart

failure (eg, dyspnea on exertion, fatigue) paroxysmal nocturnal dyspnea, cough (especially with exertion), and orthopnea peripheral edema nausea chest pain, palpitations dizziness, nausea, and syncope with exertion

Valvular stenosis or regurgitation Myocardial damage Mycotic (fungal) aneurysms Septic or nonseptic emboli Abscess of the spleen Mycotic aneurysm Hemodynamic deterioration
MYOCARDITIS

Dyspnea, fatigue, and weakness,

palpitations, shortness of breath on exertion, and cough from pulmonary congestion MITRAL STENOSIS Breathing difficulty (ie, dyspnea) on exertion as a result of pulmonary venous hypertension Progressive fatigue as a result of low cardiac output Hemoptysis, cough, and experience repeated respiratory infections

symptoms depend on the type of infection, the

degree of myocardial damage, and the capacity of the myocardium to recover may be asymptomatic sudden cardiac death or severe congestive heart failure mild to moderate case fatigue and dyspnea, palpitations, and occasional discomfort in the chest and upper abdomen PERICARDITIS

chest pain or pain beneath the clavicle, in the

neck, or in the left scapula region may worsen with deep inspiration and when lying down or turning relieved with a forward leaning or sitting position friction rub mild fever Lab: increased WBC and ESR Signs and symptoms of CHF as the result of pericardial compression due to constrictive pericarditis or cardiac tamponade

AORTIC REGURGITATION Forceful heartbeat, especially in the head or neck visible or palpable at the carotid or temporal arteries a result of the increased force and volume of the blood ejected from the hypertrophied left ventricle Exertional dyspnea and fatigue Signs and symptoms of left ventricular failure breathing difficulties (eg, orthopnea, paroxysmal nocturnal dyspnea), especially at night. AORTIC STENOSIS Exertional dyspnea caused by left ventricular failure dizziness and syncope because of reduced blood flow to the brain Angina pectoris from the increased oxygen demands of the hypertrophied left ventricle, the decreased time in diastole for myocardial perfusion, and the decreased blood flow into the coronary arteries

Blood pressure: normal to low Low pulse pressure (30 mm Hg or less) because of diminished blood flow

DIAGNOSTIC FINDINGS

Left-sided heart failure shortness of breath with crackles and wheezes in

the lungs Severity of the symptoms depends on the size and location of the lesion. Risk for embolic phenomena lung (eg, recurrent pneumonia, pulmonary abscesses) kidney (eg, hematuria, renal failure) spleen (eg, left upper quadrant pain) heart (eg, myocardial infarction) brain (eg, stroke), or peripheral vessels INFECTIVE ENDOCARDITIS Flu-like symptoms: vague complaints of malaise, anorexia, weight loss, cough, and back and joint pain Intermittent fever Integumentary splinter hemorrhages (ie, reddish-brown lines and streaks) under the fingernails and toenails petechiae in the conjunctiva and mucous membrane small, painful nodules (Oslers nodes) in the pads of fingers or toes CV: heart murmurs CNS: headache, temporary or transient cerebral ischemia, and strokes Lab:

Systolic click early sign of

valve leaflet ballooning into the left atrium Extra heart sound (mitral click) - a murmur of mitral regurgitation as a result of progressive valve leaflet stretching and regurgitation Signs and symptoms of heart failure if with mitral regurgitation MITRAL REGURGITATION systolic murmur a high-pitched, blowing sound at the apex regular/irregular pulse as a result of extrasystolic beats or atrial fibrillation Echocardiography to diagnose and monitor the progressio of mitral regurgitation

Physical examination Echocardiogram ECG Chest x-ray Cardiac catheterization Endomyocardial biopsy
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Congestive heart failure Ventricular dysrhythmias Atrial dysrhythmias Cardiac conduction defects Pulmonary or cerebral embolism Valvular dysfunction

MITRAL STENOSIS Pulse weak and often irregular because of atrial fibrillation Murmur low-pitched, rumbling, diastolic murmur is heard at the apex Atrial dysrhythmias as a result of the increased blood volume and pressure atrium dilates, hypertrophies, and becomes electrically unstable

Blood culture Echocardiogram

Electrocardiography (ECG) and cardiac

catheterization with angiography are used to determine the severity of the mitral stenosis. AORTIC REGURGITATION Diastolic murmur a high-pitched, blowing sound at the third or fourth intercostal space at the left sternal border widened pulse pressure water-hammer pulse pulse strikes the palpating finger with a quick, sharp stroke and then suddenly collapse Echocardiogram, radionuclide imaging, ECG, MRI, and cardiac catheterization. AORTIC STENOSIS A loud, rough systolic murmur may be heard over the aortic area Systolic crescendo-decrescendo murmur may radiate into the carotid arteries and to the apex of the left ventr low-pitched, rough, rasping, and vibrating Vibration over the base of the heart caused by turbulent blood flow across the narrowed valve orifice

MYOCARDITIS chest pain (with a subsequent cardiac catheterization demonstrating normal coronary arteries) Dysrhythmias cardiac enlargement, faint heart sounds, gallop rhythm, and a systolic murmur PERICARDITIS Health history, signs, and symptoms Echocardiogram detect inflammation and fluid build-up, as well as indications of heart failure 12-lead ECG detects ST changes

Evidence of left ventirucular hypertrophy on

a 12-lead ECG and echocardiogram. Echocardiography to diagnose and monitor the progression of aortic stenosis Left-sided heart catheterization to measure the severity of the valvular abnormality and evaluate the coronary arteries. Pressure tracings from the left ventricle and

the base of the aorta Systolic pressure in the left ventricle is considerably higher than that the aorta during systole.

MEDICAL MANAGEMENT

Objectives:

to eradicate the causative organism prevent additional complications, such as a

thromboembolic event Long-term antibiotic therapy (penicillin)

directed at controlling symptoms directed toward determining and For dysrhythmias managing possible underlying or Eliminate caffeine and alcohol from the diet precipitating causes
and to stop smoking. Antiarrhythmic medications may be prescribed. For chest pain Calcium channel blockers or beta-blockers if does not respond to nitrates. Heart failure is treated. Mitral valve repair or replacement. MITRAL REGURGITATION same as that for CHF Surgical intervention: mitral valve replacement or valvuloplasty (ie, surgical repair of the heart valve)

Medications
correcting the heart failure antiarrhythmic medications

INFECTIVE ENDOCARDITIS PHARMACOLOGIC THERAPY Antibiotic therapy for 2 to 6 weeks (penicillin) Periodic blood cultures In fungal endocarditis, an antifungal agent, such as amphotericin B (Abelect, Amphocin, Fungizone) SURGICAL MANAGEMENT Valve replacement MYOCARDITIS Antibiotic therapy Bed rest decrease the cardiac workload decrease myocardial damage and complications Activities should be limited for a 6-month period or at least until heart size and function have returned to normal. Report any symptoms that occur with increasing activity, such as a rapidly beating heart.

Diet and Activity

a low-sodium diet, and an exerciserest fluid intake may be limited to 2 liters each day

Pacemaker
to alter the electrical stimulation of the muscle and prevent the forceful hyperdynamic contractions

MITRAL STENOSIS Antibiotic prophylaxis therapy Anticoagulants to decrease the risk for developing atrial thrombus Treatment for anemia Surgical intervention: Valvuloplasty (commissurotomy) to open or rupture the fused commissures of the mitral valve

NSAIDs such as aspirin and ibuprofen are not to

be used during the acute phase or if the patient develops heart failure. Management of CHF PERICARDITIS When cardiac output is impaired, the patient is placed on bed rest until the fever, chest pain, and friction rub have subsided. Analgesics and NSAIDs such as aspirin or ibuprofen hasten the reabsorption of fluid in the patient with rheumatic pericarditis Corticosteroids (eg, prednisone) Pericardiocentesis PREVENTION Early and adequate treatment of streptococcal infections Signs and symptoms of streptococcal pharyngitis: high fever (38.9C to 40C) and chills sore throat, redness of the throat with exudate enlarged lymph nodes abdominal pain acute rhinitis Teaching patients about the: disease and treatment preventive steps needed to avoid potentia complications need to take prophylactic antibiotics before invasive procedure

Percutaneous transluminal valvuloplasty or Mitral valve replacement

AORTIC REGURGITATION Antibiotic prophylaxis before invasive or dental procedures to prevent endocarditis Aortic valvuloplasty or valve replacement is the treatment of choice. Surgery is recommended for any patient with left ventricular hypertrophy, regardless of the presence or absence of symptoms.

NURSING MANAGEMENT

Educate patients: Diagnosis Possibility that the condition is hereditary Need to inform the health care provider
about any symptoms Need for prophylactic antibiotic therapy before undergoing invasive procedures (eg, dental work, genitourinary or gastrointestinal procedures) Avoid caffeine and alcohol. Avoid over-the-counter products such as cough medicine that may contain alcohol, caffeine, ephedrine, and epinephrine. AORTIC STENOSIS Teaching: diagnosis progression treatment plan need to report any new symptoms or changes in symptoms need for prophylactic antibiotic therapy

INFECTIVE ENDOCARDITIS Assess: VS and heart sounds signs and symptoms of systemic embolization

IMPROVING CARDIAC OUTPUT Rest Sitting up with legs down to promote pooling of venous blood in the periphery and reducing preload Supplemental oxygen HCM - avoid diuretics DCM - avoid verapamil (Calan, Isoptin) to maintain contractility Low-sodium diet Weight taking Keep warm and frequently change position to stimulate circulation and reduce the possibility of skin breakdown INCREASING ACTIVITY TOLERANCE Alternate periods of rest and actvity Patients with HCM - avoid

pulmonary infarction and infiltrates organ damage such as stroke, meningitis, heart failure, myocardial infarction, glomerulonephritis, and splenomegaly All invasive lines and wounds should be assessing daily for redness, tenderness, warmth, swelling, drainage, or other signs of infection. Instructions on: activity restrictions medications signs and symptoms of infection need for prophylactic antibiotics before, and possibly after, dental, respiratory, gastrointestinal, or genitourinary procedures MYOCARDITIS PREVENTION Appropriate immunizations for influenza and hepatitis Early treatment

before any invasive procedure infection may result to endocarditis and further damage to the valve

strenuous activity and sports. REDUCING ANXIETY Spiritual, psychological, and emotional support Eradicating or alleviating perceived stressors Appropriate information about cardiomyopathy and selfmanagement activities Providing realistic hope DECREASING THE SENSE OF POWERLESSNESS Identify: things that they have lost emotional responses to the loss amount of control that they have in their lives

Assess
heart rate, blood pressure, and respiratory
rate heart and lung sounds peripheral pulses for dysrhythmias and palpitations or felt forceful heartbeats, dizziness, syncope, increased weakness, or angina pectoris signs and symptoms of heart failure fatigue, dyspnea with exertion, increase in coughing, hemoptysis, multiple respiratory infections, orthopnea, or paroxysmal nocturnal dyspnea

Medication:
Schedule name, dosage, actions, side effects, and
any drug-drug or drug-food interactions of the prescribed medications for heart failure, dysrhythmias, angina pectoris, or other symptoms

Keeping a diary
foods eaten weight

Assesses

temperature signs and symptoms of heart failure dysrhythmia

Weight taking (daily)

report the gain of 2 pounds in 1 day or 5
pounds in 1 week to the health care provider

Cardiac monitoring Elastic compression stockings Passive and active exercises WOF digitalis toxicity
PERICARDITIS Triad of symptoms of cardiac tamponade: falling arterial pressure rising venous pressure distant heart sounds

Periods of activity and rest Possible surgery and anticipated recovery

Medications Positioning Activity restrictions and progression