NSG210 Exam 2 Reading Outline - Hinkle Ch. 24: Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 15th ed., Chapter 24 (~/Documents/texts/nursing/NSG210/exam02/HINKLE_MS_CH24.pdf). Part of nsg210-exam-2-readings-outline. The weekly outline assigns “Ch. 25” for Week 04 valvular heart disease; this is the chapter that matches the topic. Related raw notes: raw/nsg210_wk04_VavularDisorders.md, raw/nsg210_wk04_UCSMtralRegurgitationB_answers.md.

Learning Outcomes

1. Define valvular disorders and describe pathophysiology, manifestations, and management of mitral and aortic disorders.
2. Differentiate valve repair and replacement procedures and related care.
3. Describe pathophysiology, manifestations, and management of cardiomyopathies.
4. Describe infections of the heart.
5. Apply the nursing process to cardiomyopathy and pericarditis.

Key Terms

• Annuloplasty - repair of a valve’s outer ring
• Aortic valve - semilunar valve between the left ventricle and aorta
• Autograft - replacement valve from the patient’s own valve (e.g., pulmonic valve moved to aortic position)
• Bioprosthesis (heterograft) - replacement valve from animal tissue
• Cardiomyopathy - disease of the heart muscle
• Chordae tendineae - nondistensible fibrous strands connecting papillary muscles to AV valve leaflets
• Commissurotomy - splitting or separating fused valve leaflets
• Ejection fraction - percentage of end-diastolic volume ejected with each beat
• Homograft (allograft) - replacement valve from a human donor
• Leaflet repair - repair of a valve’s movable flaps
• Mitral valve - AV valve between left atrium and left ventricle
• Orthotopic transplantation - recipient heart removed and donor heart grafted into the same site
• Prolapse - stretching of an AV valve leaflet into the atrium during systole
• Pulmonic valve - semilunar valve between right ventricle and pulmonary artery
• Regurgitation (insufficiency) - backward flow through a valve
• Stenosis - narrowing or obstruction of a valve opening
• Total artificial heart - device replacing both ventricles
• Tricuspid valve - AV valve between right atrium and right ventricle
• Valve replacement - insertion of a mechanical or tissue valve
• Valvuloplasty - repair of a stenosed or regurgitant valve by commissurotomy, annuloplasty, or leaflet repair
• Ventricular assist device - mechanical device supporting a failing ventricle

I. Valvular Disorders - Overview

• Valves open and close in response to pressure changes during systole (contraction) and diastole (relaxation)
• Atrioventricular (AV) valves: tricuspid (3 leaflets, right side) and mitral (2 leaflets, left side); both anchored by chordae tendineae to papillary muscles
• Semilunar valves: pulmonic (RV to pulmonary artery) and aortic (LV to aorta)
• Regurgitation - valve doesn’t close completely, so blood flows backward
• Stenosis - valve doesn’t open completely, so forward flow is reduced
• Any valve can be affected; mitral and aortic disorders cause more symptoms and complications than tricuspid and pulmonic
• Asymptomatic disease may just be monitored; symptomatic disease treated by severity - lifestyle changes, medications, repair or replacement
• Left-sided valve disease can lead to left heart failure and eventually right ventricular failure (Figure 24-2)

II. Mitral Valve Prolapse (MVP)

• Deformity where part of one or both mitral leaflets balloons back into the left atrium during systole; usually no symptoms; rarely progresses to sudden death
• Up to 2.5% of the population; twice as common in women
• Often no clear cause; associated with inherited connective tissue disorders (enlarged leaflets); annulus may dilate; chordae and papillary muscles may elongate or rupture
• Can lead to mitral regurgitation, which can cause heart enlargement, atrial fibrillation, pulmonary hypertension, heart failure
• Manifestations: most never have symptoms; some have fatigue (regardless of rest), shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, anxiety
• Assessment: first and often only sign is a mitral click (systolic click - leaflet ballooning into the atrium); a regurgitation murmur if blood flows back; echocardiography diagnoses and monitors
• Medical management: control symptoms; for arrhythmias eliminate caffeine and alcohol and stop tobacco and electronic nicotine products; some need antiarrhythmics; chest pain rarely needs nitrates, calcium channel blockers, or beta-blockers; prophylactic antibiotics NOT recommended before dental or invasive procedures; severe regurgitation with heart failure may need repair or replacement
• Nursing: teach about the diagnosis and that it may be hereditary (first-degree relatives may be screened with echocardiograms); report new symptoms; read OTC labels (cough medicines may contain alcohol, caffeine, ephedrine, epinephrine that can trigger arrhythmias); explore diet, activity, sleep links to symptoms
• Pregnancy: women with MVP without regurgitation or complications can complete pregnancy without close cardiac monitoring and deliver vaginally

III. Mitral Regurgitation

• Blood flows from the left ventricle back into the left atrium during systole; leaflets don’t close completely because leaflets and chordae are thickened and fibrotic
• Chronic or, less often, acute
• Causes: developed countries - degenerative changes (including MVP) and left ventricular ischemia; developing countries - rheumatic heart disease; also myxomatous changes, infective endocarditis (leaflet perforation, scarring), collagen vascular disease (lupus), cardiomyopathy, ischemic heart disease (functional or secondary MR)
• Pathophysiology: problems with leaflets (shorten, tear), chordae (elongate, shorten, tear), annulus (stretched by heart enlargement or calcified), or papillary muscles (rupture, stretch, displaced, or unable to contract from ischemia)
  • Each beat pushes blood back into the left atrium, adding to blood from the lungs
  • Left atrium stretches, hypertrophies, then dilates
  • Backflow blocks blood coming from the lungs, so the lungs become congested, straining the right ventricle
  • During diastole the extra volume fills the left ventricle; volume overload causes hypertrophy, then dilation, then systolic heart failure
• Manifestations: chronic often asymptomatic; acute (e.g., from MI) presents as sudden severe heart failure; dyspnea, fatigue, weakness most common; palpitations, exertional dyspnea, cough from pulmonary congestion
• Assessment: systolic murmur - high-pitched blowing sound at the apex, may radiate to the left axilla; pulse regular or irregular (extrasystoles, atrial fibrillation); echocardiography
• Medical management: heart failure medications for pulmonary congestion; afterload reduction with ACE inhibitors (captopril, lisinopril) or ARBs (losartan, valsartan), hydralazine, beta-blockers (carvedilol, metoprolol); heart failure symptoms are an indication to consider valvuloplasty or valve replacement

IV. Mitral Stenosis

• Reduced flow from the left atrium into the left ventricle; usually caused by rheumatic endocarditis, which thickens leaflets and chordae and fuses the leaflets
• Pathophysiology: normal orifice is about three fingers wide; severe stenosis narrows it to a pencil width
  • Left atrium can’t empty; residual volume leads to left atrial hypertrophy and dilation
  • Less LV filling, so lower cardiac output
  • Backflow into pulmonary veins causes pulmonary congestion
  • Right ventricle pumps against high pulmonary pressure, hypertrophies, enlarges, and fails
  • Faster heart rate shortens diastole (less time for forward flow), so cardiac output falls further and pulmonary pressure rises
• Manifestations: first symptom often dyspnea on exertion (DOE) from pulmonary venous hypertension; symptoms usually appear after the valve opening is reduced by one-third to one-half; progressive fatigue, decreased exercise tolerance; enlarged left atrium presses on the left bronchus (dry cough, wheezing); severe - hemoptysis, palpitations, orthopnea, PND, repeated respiratory infections; dilated left atrium becomes electrically unstable (atrial arrhythmias)
• Assessment: low-pitched rumbling diastolic murmur at the apex; weak irregular pulse with atrial fibrillation; heart failure signs; echocardiography diagnoses and grades severity; ECG, exercise testing, cardiac catheterization with angiography
• Prevention: prevent and treat bacterial infections; prevent acute rheumatic fever with effective antibiotic treatment of group A strep; secondary prophylaxis for recurrent rheumatic fever with carditis may last 10 or more years (penicillin G IM every 4 weeks, oral penicillin V twice daily, sulfadiazine daily, or erythromycin twice daily)
• Medical management: heart failure treatment; anticoagulation for severe left atrial dilation (atrial thrombi); atrial fibrillation - cardioversion, or rate control (beta-blockers, digoxin, calcium channel blockers) plus anticoagulation; avoid strenuous activity, competitive sports, and pregnancy (all raise heart rate); surgical - valvuloplasty, usually commissurotomy; percutaneous transluminal valvuloplasty or replacement

V. Aortic Regurgitation (Aortic Insufficiency)

• Backward flow from the aorta into the left ventricle during diastole
• Causes: congenital (bicuspid aortic valve), inflammatory lesions, aortic dilation, rheumatic endocarditis, syphilis, dissecting aneurysm, blunt chest trauma, deterioration of a replaced valve
• Pathophysiology: blood flows back into the LV, which dilates, then hypertrophies to eject more blood forcefully, raising systolic BP; arteries compensate with reflex vasodilation, lowering peripheral resistance and diastolic BP
• Manifestations: usually no symptoms at first; awareness of a pounding, forceful heartbeat, especially in the head or neck; visible or palpable carotid or temporal pulsations; later DOE, fatigue, then left ventricular failure (dyspnea, orthopnea, PND)
• Assessment: high-pitched blowing diastolic murmur at the 3rd or 4th intercostal space, left sternal border; widened pulse pressure; water hammer (Corrigan’s) pulse - strikes the finger with a quick, sharp stroke and then collapses; echocardiography (preferably TEE), cardiac MRI, catheterization; echo every 6 months if symptomatic, every 2-5 years if not
• Prevention: prevent and treat bacterial infections; same rheumatic fever prevention as mitral stenosis
• Medical management: avoid physical exertion, competitive sports, isometric exercise if symptomatic or LV function declining; treat arrhythmias and heart failure; control BP with ACE inhibitors and dihydropyridine calcium channel blockers (afterload reduction); beta-blockers used less (slower heart rate may raise BP); sodium restriction if symptomatic
• Treatment of choice: aortic valve replacement or valvuloplasty, ideally before LV failure; surgery recommended for any significant LV dilation (with or without symptoms) and for any symptomatic patient

VI. Aortic Stenosis

• Narrowing of the opening between the left ventricle and aorta; in adults usually degenerative calcification (similar to atherosclerosis); also congenital leaflet malformation (one or two leaflets instead of three) or rheumatic endocarditis (fused commissures, stiff cusps, calcific nodules)
• Pathophysiology: progresses over years to decades; LV contracts more slowly and forcibly to overcome the obstruction; pressure load causes LV hypertrophy; heart failure develops when compensation fails
• Manifestations: many asymptomatic; first symptom often DOE (rising pulmonary venous pressure from a dilating LV); later orthopnea, PND, pulmonary edema; dizziness and syncope (reduced cerebral flow); angina (limited coronary flow, shorter diastole for perfusion, higher oxygen demand of hypertrophied LV); BP normal or low; low pulse pressure (30 mmHg or less)
• Classic triad to remember: angina, syncope, dyspnea on exertion / heart failure
• Assessment: loud, harsh systolic murmur over the aortic area (right 2nd intercostal space), radiates to carotids and apex; low-pitched, crescendo-decrescendo, rough, rasping; S4 may be heard; accentuated by leaning forward during exhalation; palpable thrill at the base and along the carotids; LV hypertrophy on 12-lead ECG or echo; echo every 6-12 months if symptomatic, every 2-5 years if not; left heart catheterization before surgery; stress testing used cautiously in severe AS (risk of VT or VF) and not in symptomatic patients
• Prevention: control risk factors for inflammation - diabetes, hypertension, high cholesterol and triglycerides, tobacco and electronic nicotine
• Medical management: treat arrhythmias and LV failure; definitive treatment is aortic valve replacement - surgical or transcatheter aortic valve replacement (TAVR); balloon valvuloplasty for symptom relief if not a replacement candidate

VII. Valve Murmur Summary

Memory aid: stenosis murmurs occur when the valve should be open; regurgitation murmurs occur when the valve should be closed. Mitral and tricuspid are open in diastole and closed in systole; aortic and pulmonic are open in systole and closed in diastole.

VIII. Nursing Management - Valvular Heart Disorders

• Teach diagnosis, progressive nature, treatment plan; report new or changing symptoms
• Teach that bacteria adhere to diseased valves more easily, causing endocarditis; teach infection prevention
• Compare vital signs to prior data; auscultate heart and lungs; palpate peripheral pulses
• Assess for:
  • Heart failure - fatigue, DOE, decreased activity tolerance, increased cough, hemoptysis, repeated respiratory infections, orthopnea, PND
  • Arrhythmias - pulse strength and rhythm, palpitations, forceful heartbeats
  • Dizziness, syncope, weakness, angina
• Medication schedule and teaching (name, dose, actions, adverse effects, interactions)
• Aortic stenosis and nitroglycerin: venous dilation reduces return to the heart, lowering cardiac output and raising risk of syncope and reduced coronary flow; teach to try rest and relaxation before nitroglycerin and to expect side effects
• Heart failure: daily weight, report sudden gain; plan activity and rest

IX. Surgical Management - Valve Repair and Replacement

A. Valvuloplasty (Repair)

• Repair rather than replacement; procedure depends on cause and type of dysfunction
• Open-heart (general anesthesia, cardiopulmonary bypass) or percutaneous (cath lab or hybrid room, no general anesthesia or bypass); TEE at the end to evaluate

Commissurotomy (for fused leaflets, usually mitral stenosis):

• Closed commissurotomy / balloon valvuloplasty (percutaneous transvenous mitral commissurotomy):
  • Mitral: catheter from right atrium through the atrial septum into the left atrium, across the mitral valve; balloon (three sections that inflate in stages - ventricle side, atrial side, then the orifice) or two smaller balloons (smaller atrial septal defect, allow some forward flow); inflated 10-30 seconds, repeated
  • Used for younger patients or high surgical risk; contraindicated with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral regurgitation, severe calcification
  • Complications: some mitral regurgitation in all patients, bleeding at insertion sites, emboli (stroke), rarely left-to-right atrial shunt
  • Aortic balloon valvuloplasty: less effective; restenosis about 50% within 6 months; used for palliation or as a bridge to TAVR; complications include aortic regurgitation, emboli, ventricular perforation, annulus rupture, ventricular arrhythmia, mitral damage, bleeding
• Open commissurotomy: general anesthesia, bypass, direct visualization (can remove thrombus or calcification, repair chordae and papillary muscles); used less now

Annuloplasty (for regurgitation):

• Repair of the annulus (junction of leaflets and heart wall), narrowing the orifice
• Urgent indication: ruptured chordae with severe MR - annuloplasty with chordae resuspension
• Techniques: annuloplasty ring (leaflets sutured to a ring; the ring bears the stress, preventing progressive regurgitation) or folding and tacking tissue with sutures (may degenerate faster)

Leaflet repair:

• Remove excess tissue; plication (tuck and suture); leaflet resection (wedge removed and gap sutured); release short chordae; extend with pericardial patch; patch holes

B. Valve Replacement

• Preferred when anatomy makes repair unlikely to succeed (extensive calcification, severely fibrotic or fused structures); multidisciplinary team decides surgical vs minimally invasive
• Surgical: general anesthesia, bypass, median sternotomy (mitral may use right thoracotomy); minimally invasive options with smaller incisions or robot assistance (less bleeding, pain, infection, scarring, shorter stay)
• Aortic and pulmonic leaflets removed; mitral structures partly left to preserve LV shape; prosthesis sutured to the annulus
• TAVR: cath lab or hybrid room, general anesthesia, no bypass or sternotomy; balloon valvuloplasty then a catheter-delivered tissue valve; now used for intermediate and low-risk patients too
• MitraClip: transcatheter clip joining two leaflets for degenerative MR; fewer symptoms and heart failure admissions
• Surgery abruptly changes intracardiac pressures; all prostheses create mild stenosis
• Stenotic valve replaced - heart failure signs improve in hours to days; regurgitant valve replaced - may take months to recover
• Postop complications: bleeding, thromboembolism, infection, heart failure, hypertension, arrhythmias, hemolysis, mechanical obstruction

C. Types of Replacement Valves

D. Nursing Management - Valvuloplasty and Valve Replacement

• Prepare patient and family, reinforce explanations, psychosocial support
• After percutaneous balloon valvuloplasty: telemetry or ICU; assess for heart failure and emboli; heart sounds at least every 4 hours; care as for post-cardiac catheterization; hospital stay 24-48 hours
• After surgical repair or replacement: ICU; vitals every 5-15 minutes until recovered from anesthesia; IV vasoactive and antiarrhythmic drips weaned; neuro, respiratory, cardiovascular assessments every 1-4 hours; transfer to telemetry in 24-72 hours; discharge in 3-7 days
• Anticoagulation teaching:
  • Warfarin target INR usually 2-3.5 for mitral replacement, 1.8-2.2 for aortic replacement (per text)
  • Annuloplasty ring or tissue valve: anticoagulation usually for only 3 months unless atrial fibrillation or prior thromboembolism
  • Aspirin with warfarin for bioprostheses or high embolic risk
  • Frequent follow-up and lab tests
• Prosthetic valves and repair materials raise infective endocarditis risk - teach prevention
• Echocardiogram 3-4 weeks after discharge as a baseline, then every 1-2 years
• Home care checklist (Chart 24-1): name the procedure; diet and activity (walking, breathing exercises; avoid lifting, driving, contact sports as instructed); medications including anticoagulant at the same time daily, lab appointments, avoid injury, report bleeding (gums, petechiae, tarry stools); report fevers, chills, petechiae clusters, malaise, weight loss; tell all providers about the surgery (possible antibiotic prophylaxis); oral hygiene and dental visits; wound care; follow-up; support resources; health promotion

X. Cardiomyopathy

A. Overview

• Disease of the heart muscle associated with cardiac dysfunction
• Types: dilated (DCM), hypertrophic (HCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC/D), unclassified
• Ischemic cardiomyopathy - enlarged heart from coronary artery disease, usually with heart failure
• AHA classification: primary (genetic, nongenetic, acquired - mainly heart muscle) vs secondary (heart involved as part of systemic disease: amyloidosis, sarcoidosis, scleroderma, Fabry disease)
• Pathophysiology of all types ends in impaired cardiac output; low stroke volume triggers the sympathetic nervous system and RAAS, raising vascular resistance and sodium and fluid retention, increasing the heart’s workload; ejection fraction often falls; leads to heart failure
• Concept Mastery Alert: sodium is the key electrolyte - fluid overload is often tied to high sodium intake

B. Types

C. Clinical Manifestations and Diagnosis

• May be stable and asymptomatic for years; DCM or RCM often first diagnosed when heart failure appears: DOE, fatigue, PND, cough (with exertion or at night), orthopnea, peripheral edema, early satiety, nausea; also chest pain, palpitations, dizziness, syncope with exertion
• Exam: tachycardia, S3 and S4; RCM may have diastolic murmurs; DCM and HCM may have systolic murmurs; later crackles, JVD, pitting edema, hepatomegaly
• Diagnosis: history and ruling out other causes (MI); echocardiogram is one of the most helpful tools; cardiac MRI (HCM, ARVC/D); ECG (arrhythmias, LVH changes); chest x-ray (enlargement, congestion); catheterization, coronary CT, or stress test to rule out CAD; endomyocardial biopsy (especially RCM)

D. Medical Management

• Treat underlying cause; heart failure medications, low-sodium diet, exercise and rest regimen; antiarrhythmics and possibly ICD
• Fluid limit about 2 L/day if congested; but HCM patients must avoid dehydration (may need beta-blockers to prevent LVOT obstruction)
• Anticoagulants no longer routine
• Biventricular pacing (cardiac resynchronization therapy) can raise EF and reverse remodeling in some DCM
• Family history; genetic counseling and testing of first-degree relatives

E. Surgical Management

• LVOT surgery for symptomatic HCM despite medical therapy: septal myectomy (Morrow procedure) - about 1 cm of septum removed below the aortic valve; complications include complete heart block (pacemaker), VSD, inadequate relief; mortality under 1% to 16%
• Heart transplantation:
  • For end-stage disease (cardiomyopathy, ischemic disease, valve disease, prior graft rejection, congenital disease); candidates have severe symptoms despite therapy, no other surgical options, and life expectancy under 1-2 years
  • UNOS allocates by ABO compatibility, body size, age, severity, wait time, geography
  • Orthotopic transplantation - bicaval technique now preferred (fewer AV valve regurgitation, arrhythmia, conduction problems)
  • Immunosuppression: corticosteroids (prednisone), calcineurin inhibitors (tacrolimus, cyclosporine), antiproliferatives (mycophenolate, azathioprine, sirolimus); balance rejection against infection and cancer; endomyocardial biopsies to detect rejection
  • Denervated heart: resting rate 90-110 bpm; responds only to circulating catecholamines, so exercise needs extended warm-up and cool-down (20-30 minutes to reach target rate); atropine won’t raise the rate; digoxin won’t slow atrial fibrillation; often no angina with ischemia (may present with heart failure, silent MI, sudden death)
  • Complications: rejection, infection, cardiac allograft vasculopathy (accelerated atherosclerosis), hypertension (cyclosporine, tacrolimus), osteoporosis, lymphoproliferative disease and skin and lip cancers, weight gain, diabetes, dyslipidemia, kidney failure
  • Median survival over 12 years
  • Psychosocial: most have better quality of life; some feel indebtedness or guilt toward the donor, which is linked to nonadherence (64% reported nonadherence in one study; older age improved adherence; time since transplant and guilt worsened it)
• Mechanical assist devices:
  • Intra-aortic balloon pump - reduces cardiac workload but doesn’t pump for the heart
  • Ventricular assist devices (VADs) - support one ventricle (or two for biventricular); pneumatic, electric, axial flow, centrifugal (newer axial and centrifugal pumps are smaller, nonpulsatile, less thrombus); ECMO = VAD plus oxygenator
  • Uses: bridge to recovery, bridge to transplant, destination therapy (now about 50% of patients)
  • Ethical dilemma: patient request to deactivate an LVAD - autonomy vs nonmaleficence; debated whether it is withdrawal of treatment or euthanasia
  • Total artificial heart - replaces both ventricles; SynCardia approved as bridge to transplant
  • Complications: bleeding, thromboemboli, hemolysis, infection, kidney injury, right heart failure, multisystem failure, mechanical failure

F. Nursing Process - The Patient With Cardiomyopathy

Assessment:

• Detailed history of symptoms; causes (heavy alcohol, recent illness or pregnancy, family history of sudden death or cardiomyopathy); chest pain details; orthopnea, PND, syncope, exertional dyspnea; number of pillows; weight changes; ADL limits
• ACC/AHA heart failure stages and NYHA functional class
• Diet (sodium, nutrition)
• Psychosocial: role changes, stressors, support systems, emotional status; depression in about 19-21% of heart failure patients
• Physical: vital signs, pulse pressure, pulsus paradoxus, weight, point of maximal impulse (often shifted left), systolic murmur, S3 and S4, crackles, JVD, edema

Nursing diagnoses: impaired cardiac output; risk for impaired cardiac function and tissue perfusion; impaired gas exchange; activity intolerance; anxiety; powerlessness; self-care management.

Potential complications: heart failure, ventricular and atrial arrhythmias, conduction defects, pulmonary or cerebral embolism, valvular dysfunction.

Interventions:

• Improving cardiac output and peripheral flow: rest during symptoms; sitting up with legs down (pools blood, reduces preload); check SpO2 at rest and with activity; oxygen by nasal cannula as needed; medication schedule and reminders (pillbox, link to daily routines); low-sodium food choices; daily weight; compare dyspnea and pillow count; keep warm, reposition often
• Increasing activity tolerance: alternate rest and activity; sit for tasks (chopping, drying hair, shaving); recognize symptoms that call for rest; HCM, ARVC/D, RCM - avoid strenuous activity, isometric exercise, competitive sports
• Reducing anxiety: spiritual, psychological, emotional support; information; realistic hope for those awaiting transplant; anticipatory grieving
• Decreasing powerlessness: identify losses and emotional responses; identify what remains in their control (food, medications); food and weight diary; some manage a self-titrated diuretic
• Home care: medication regimen, symptom monitoring; read nutrition labels; daily weights and symptoms; organize activities; teach family CPR and AED use (arrhythmia risk); women often advised to avoid pregnancy (individualized); build trust for end-of-life discussions; transitional or home care

Home care checklist (Chart 24-4):

• Take medications exactly as prescribed; monitor breathing and edema
• Balance activity and rest; avoid strenuous activity, isometric exercise, competitive sports
• Avoid tobacco and alcohol; manage stress
• Know arrhythmia signs (lightheadedness, dizziness, orthostatic hypotension, racing heart, diaphoresis, confusion); emergency response, CPR, AED
• Daily weight at the same time in the same clothes
• Sodium no more than 2 g/day; read labels; avoid canned and processed foods and added salt
• Daily walking if no unusual fatigue or dyspnea
• Report: weight gain of 2-3 lb in 1 day or 5 lb in 1 week; unusual shortness of breath; increased swelling of ankles, feet, or abdomen; persistent cough; loss of appetite; restless sleep or needing more pillows; profound fatigue

Expected outcomes: improved cardiac function (normal HR and RR, less dyspnea, no weight gain, better peripheral flow), increased activity tolerance, less anxiety, less powerlessness, effective self-care.

XI. Infectious Diseases of the Heart

Named for the layer involved: endocarditis (endocardium), myocarditis (myocardium), pericarditis (pericardium). Diagnosis mainly from symptoms and echocardiography; prevention is ideal; IV antibiotics usually needed once infection develops.

A. Rheumatic Endocarditis

• Acute rheumatic fever (mostly school-age children) can follow group A beta-hemolytic streptococcal pharyngitis
• Rheumatic heart disease signs: new murmur, cardiomegaly, pericarditis, heart failure
• Prevented by prompt, complete antibiotic treatment of strep throat
• Spread by oral and respiratory secretions; risk with malnutrition, crowding, poor hygiene, low income; now mainly a disease of the developing world
• Can cause lifelong mitral stenosis or regurgitation
• Strep pharyngitis signs (Chart 24-5): sudden sore throat, painful swallowing, fever, red swollen tonsils with white patches or pus, palatal petechiae, swollen anterior neck nodes; rapid strep test, then throat culture if negative but suspected (usually not needed in adults); penicillin or amoxicillin; complete the full course

B. Infective Endocarditis

• Microbial infection of the heart’s endothelial surface; rare but deadly (14-22% in-hospital mortality, up to 40% within 1 year)
• Usually older adults or those with prosthetic valves or cardiac devices; staphylococcal right-sided endocarditis common in IV drug users; hospital-acquired with debilitating disease, indwelling catheters, hemodialysis, prolonged IV therapy
• Risk factors (Chart 24-6): prosthetic valves or repair material, implanted devices (pacemaker, ICD), prior endocarditis, certain congenital heart disease, transplant recipients with valvulopathy, IV drug use, body piercing, branding, tattooing, hemodialysis
• Pathophysiology: endocardial injury leads to fibrin and platelet clot; organisms (usually staphylococci or streptococci) invade; vegetations (platelets, fibrin, blood cells, microbes) form and can embolize; new clot hides organisms from defenses; infection erodes valve leaflets, chordae, prosthetic valve attachments, forms abscesses
• Manifestations: insidious onset; primary signs are fever and a heart murmur (fever may be absent in patients on antibiotics or steroids, older adults, those with heart failure or kidney injury; murmur develops in 85%; worsening murmur means progressing damage)
  • Petechiae clusters (skin, conjunctiva, mucous membranes)
  • Osler nodes - small painful nodules on finger or toe pads
  • Janeway lesions - painless flat red or purple macules on palms and soles
  • Roth spots - retinal hemorrhages with pale centers
  • Splinter hemorrhages - reddish-brown streaks under the nails
  • Systemic emboli in 22-50%; up to 65% go to the CNS (embolic stroke, often middle cerebral artery); splenic abscess
  • Heart failure is the most frequent complication (valve perforation, chordae rupture, obstruction, prosthetic dehiscence) and an indication for surgery
  • Vague complaints (malaise, anorexia, weight loss, cough, back and joint pain) may mimic flu
• Diagnosis: organism in two separate blood cultures plus vegetation on imaging; at least two sets of blood cultures (aerobic and anaerobic) from different sites, at least 2 hours apart over 24 hours, BEFORE any antibiotics; negative cultures don’t rule it out; elevated WBC, anemia, positive rheumatoid factor, elevated ESR or CRP; echocardiography (TEE better for vegetations and perivalvular complications)
• Prevention: antibiotic prophylaxis for high-risk patients before dental procedures involving gums or oral mucosa is “reasonable” (evidence mixed); good oral hygiene and regular dental care; report fever lasting over 7 days; don’t self-medicate or stop antibiotics early; meticulous hand hygiene and aseptic technique with IV lines; remove devices as soon as no longer needed
• Medical management: IV antibiotics for 2-6 weeks at high serum levels (often at home with home health); monitor drug levels and blood cultures; patients feel better but may be confined by IV therapy - need support
• Surgical: for heart failure, intracardiac abscess, recurrent emboli, or failed medical therapy - valve repair or replacement, debridement, abscess closure; most prosthetic valve endocarditis needs repeat replacement
• Nursing: monitor temperature trend (treatment effectiveness; fever may also be drug reaction); give antimicrobials on time; plan rest; hand hygiene; NSAIDs for fever; light linens, fan, tepid baths (stop if shivering); assess heart sounds (new or worse murmur may mean dehiscence, abscess rupture, leaflet or chordae injury); watch for emboli and pulmonary infarction (right-sided); watch for organ damage (stroke, meningitis, heart failure, MI, glomerulonephritis, splenomegaly); assess IV sites daily; teach activity limits, medications, infection signs; high risk for recurrence

C. Myocarditis

• Inflammation of the myocardium; can cause dilation, mural thrombi, cellular infiltration, and muscle fiber degeneration; most mild cases recover fully, some develop cardiomyopathy and heart failure
• Causes: infections (viral - coxsackievirus A and B, HIV, influenza A; bacterial, rickettsial, fungal, parasitic, protozoal - Chagas; spirochetal), immune-related (after rheumatic fever, autoimmune), toxins or drugs
• DCM and HCM may be late effects of myocarditis
• Manifestations: may be asymptomatic; fatigue, dyspnea, syncope, palpitations, chest and upper abdominal discomfort; most commonly flu-like; can cause sudden death or fulminant heart failure
• Diagnosis: often no abnormalities; tachycardia, chest pain; endomyocardial biopsy is definitive; cardiac MRI with contrast increasingly used; arrhythmias or ST-T changes; with structural disease - cardiac enlargement, faint heart sounds (especially S1), friction rub, gallop, systolic murmur; elevated WBC, CRP, ESR
• Management: treat cause (e.g., penicillin for strep); bed rest to reduce workload and damage; young patients limit activity and athletics for 6 months or until heart size and function normalize; increase activity slowly; treat heart failure and arrhythmias; NSAIDs should NOT be used for pain (linked to more cardiac injury and viral replication)
• Nursing: watch tachycardia and fever resolve; assess for heart failure and arrhythmias; continuous monitoring with arrhythmias
• Safety Alert: patients with myocarditis are sensitive to digitalis - watch for toxicity (new arrhythmia, anorexia, nausea, vomiting, headache, malaise) and notify provider
• Anti-embolism stockings and exercises (venous and mural thrombi); pharmacologic prophylaxis for some

D. Pericarditis

• Inflammation of the pericardium (sac around the heart); 5% of ER visits for chest pain; acute, chronic, or recurrent; infectious or noninfectious
• Causes (Chart 24-7): idiopathic; viral (most common infectious cause); bacterial (rare, usually TB), fungal, parasitic; autoimmune (lupus, rheumatic fever, rheumatoid arthritis, scleroderma); drug reactions; adjacent disease (MI, dissecting aneurysm, pneumonia); cancer (lung or breast metastasis, mesothelioma); chest radiation (peaks 5-9 months after); trauma or cardiac procedures (surgery, catheterization, pacemaker); uremia, myxedema; Dressler syndrome (10 days to 2 months after MI); after cardiac surgery
• Pathophysiology: fluid accumulates (pericardial effusion), compressing the heart (cardiac tamponade); repeated or prolonged episodes thicken, scar, or calcify the pericardium (constrictive pericarditis), restricting filling, lowering cardiac output, raising venous pressure (edema, hepatic failure)
• Manifestations: chest pain is the most characteristic symptom (also under the clavicle, neck, left trapezius); fairly constant; worse with deep inspiration, lying down, turning; relieved by sitting up and leaning forward
  • Pericardial friction rub - most characteristic sign; creaky or scratchy; best at the left lower sternal border
  • Mild fever, elevated WBC, anemia, elevated ESR or CRP, nonproductive cough, hiccups, dyspnea, splinting, tachycardia, heart failure signs with constriction or tamponade
• Diagnosis: history and symptoms; echocardiogram (effusion, tamponade, guide pericardiocentesis); CT (size and location of effusion); cardiac MRI (inflammation, adhesions); biopsy occasionally; 12-lead ECG - concave ST elevation in many or all leads with no reciprocal changes, PR depression, atrial arrhythmias
• Medical management: find the cause, relieve symptoms, watch for tamponade; bed rest until fever, pain, and rub subside if cardiac output impaired; NSAIDs (aspirin, indomethacin, ibuprofen); corticosteroids if NSAIDs contraindicated (kidney disease); colchicine added for severe cases; pericardiocentesis (rare) for diagnosis or relief - fluid for culture and cytology; pericardial window for continuous drainage; pericardiectomy for constriction
• Nursing: pain management, positioning, support; reassure that the pain isn’t a heart attack; forward-leaning or sitting position; restrict activity until pain and fever subside, then increase gradually, resuming restrictions if symptoms return; immune-healthy lifestyle; watch for tamponade and heart failure

Nursing process - the patient with pericarditis:

• Assessment: evaluate pain in various positions and with breathing, breath-holding, spine and arm movement, coughing, swallowing to distinguish from MI pain
• Quality and Safety Alert: a pericardial friction rub is diagnostic; creaky or scratchy, louder at end of exhalation; listen with the diaphragm pressed firmly at the left sternal edge, 4th intercostal space; best heard sitting and leaning forward; if unsure whether it’s pleural, have the patient hold their breath - a pericardial rub continues
• Monitor temperature (abrupt fever onset possible)
• Nursing diagnoses: acute pain; lack of knowledge of diagnosis and self-care
• Potential complications: pericardial effusion, cardiac tamponade
• Relieving pain: rest; sitting upright leaning forward (chair rest); restrict activity until pain subsides; monitor medication responses; watch GI effects of NSAIDs and colchicine; resume rest if pain and rub return
• Teaching: cause, medications, positioning and breathing techniques; when to follow up (relapse, tamponade symptoms - lightheadedness, orthostasis, tachycardia)
• Cardiac tamponade (monitoring and managing):
  • Early: shortness of breath, chest tightness, dizziness, increasing restlessness
  • Pulsus paradoxus - systolic BP falls 10 mmHg or more during inspiration
  • Narrowing pulse pressure (systolic falls, diastolic stable)
  • Tachycardia; low ECG voltage or electrical alternans (QRS heights alternate)
  • Heart sounds distant to inaudible
  • JVD and rising central venous pressure
  • Beck triad - hypotension, muffled heart sounds, elevated jugular venous pressure (severe tamponade)
  • Notify provider immediately; prepare for echocardiography and pericardiocentesis; stay with the patient and reduce anxiety
• Home care: remind about health promotion and screening
• Expected outcomes: pain-free ADLs, normal temperature, no rub; understands cause and treatment; normal BP, strong heart sounds, no JVD

Critical Thinking Exercises (end of chapter)

• 67-year-old with prosthetic aortic valve, fever, malaise, painful finger-pad nodules (Osler nodes) - suspect infective endocarditis; obtain blood cultures before antibiotics
• 57-year-old newly diagnosed with cardiomyopathy (ankle swelling, dyspnea at 20 feet) - education priorities and team roles
• 47-year-old with HCM who fainted on a hot day - dehydration lowers preload, worsening LVOT obstruction and causing syncope; prioritized ED assessment