Cardiomyopathy

WHAT WENT WRONG?

The middle layer of the heart wall that contains cardiac muscle (myocardium)

weakens and stretches, causing the heart to lose its pumping strength and become

enlarged. The heart remains functional; however, contractions are weak, resulting

in decreased cardiac output. Most are idiopathic and not related to the major causes

of heart disease. The three types of cardiomyopathy are:

1. Dilated cardiomyopathy (common): The heart muscle thins and enlarges,

which leads to congestive heart failure. Progressive hypertrophy and dilatation

result in problems with pumping action of ventricles.

2. Hypertrophic cardiomyopathy: The ventricular heart muscle thickens, resulting

in outflow obstruction or restriction. There is some blood flow present.

3. Restrictive cardiomyopathy (rare): The heart muscle becomes stiff and restricts

blood from filling ventricles, usually as a result of amyloidosis, radiation,

or myocardial fibrosis after open-heart surgery.

 PROGNOSIS

Prognosis is variable. Sudden cardiac death is a possible outcome in dilated or

hypertrophic cardiomyopathy; arrhythmia is often a precursor to sudden death.

HALLMARK SIGNS AND SYMPTOMS

• Asymptomatic—Many clients with hypertrophic cardiomyopathy (HCM)

are asymptomatic. Those with signs do not present until their mid-twenties.

• Dyspnea—The most frequent symptom is shortness of breath due to increase

pressure in the lungs. The heart may not sufficiently relax resulting in higher

pressure and a backup of blood into the lungs.

• Angina—Clients experience chest pain related to increase oxygen demand

of the extra heart muscle and due to thick, narrowing coronary blood vessels

within the heart’s wall

• Syncope—Fainting is caused by heart arrhythmias related to the inability of

the cardiac muscle to conduct electrical impulses.

• Sudden death—Young adults are at risk of sudden death during physical

exercise resulting from ventricular fibrillation, which is a cardiac arrhythmia.

• Abnormal heart sounds

• Murmur, which is the sound of turbulence results from abnormal blood flow

• S3, which is a third heart sound commonly heard in heart failure. S3 is a

soft sound made by the vibration of the ventricular wall when the ventricle

fills too rapidly. S3 is heard after the S2 heart sound and is best found

over the apex of the left ventricle, which is the fourth intercostal space

along the mid-clavicular line

• S4, which is the heart sound heard before the S1 heart sound is the result

of the heart being too stiff. This is vibration of the valves and the ventricular

walls when the atria contracts and the ventricles fill.

INTERPRETING TEST RESULTS

• Chest x-ray (CXR) shows enlarged heart, pulmonary congestion.

• Echocardiography shows left ventricular hypertrophy (LVH) and dysfunction

in dilated and hypertrophic cardiomyopathy; small ventricular size and

function in restrictive cardiomyopathy.

• Electrocardiogram: ST changes, conduction abnormalities, LVH.

• Left ventricular hypertrophy shows as a broad QRS wave, usually in leads

4, 5, and 6 because of high voltage.

• Cardiac catheterization—to measure chamber pressures, cardiac output, ventricular

function, but is often unable to add to information that has already

been received from echocardiogram.

• Exercise testing may show poor cardiac function not evident in a resting

state.

TREATMENT

Treatment is based on the specific cause. Avoiding the offending drug/treatment is

imperative. Manage the underlying disease and provide cardiac support; however,

few therapies can halt the process of cardiomyopathy.

• Change to a low-sodium diet.

• Beta adrenergic blockers—cause the heart to beat slowly, allowing more

time for ventricular filling and improve contractile function:

• propranolol, nadolol, metoprolol (for hypertropic cardiomyopathy)

• Angiotensin-converting enzyme (ACE) inhibitors—to decrease left ventricular

filling pressures.

• Calcium channel blockers—reduced cardiac workload by increasing contractile

ability:

• verapamil (for hypertrophic cardiomyopathy)

• Diuretics reduce fluid retention:

• furosemide, bumetanide, metolazone (for dilated cardiomyopathy)

• spironolactone (aldosterone antagonist)

• Administer inotropic agent to enable the heart to have greater contractile

force:

• dobutamine

• milrinone

• digoxin (for dilated cardiomyopathy)

• Administer oral anticoagulant to reduce the coagulation of blood:

• warfarin (for dilated and hypertrophic cardiomyopathy)

• Implantable cardioverter-defibrillator for high risk.

• Myectomy—incision into septum and removal of tissue.

DIAGNOSES

• Activity intolerance

• Impaired gas exchange

• Decreased cardiac output

INTERVENTION

• Place patient in a semi-Fowler’s position for comfort, which eases respiratory

effort.

• Record intake and output of fluids.

• Monitor vital signs to assess for increased respiratory rate, arrythmias.

• Monitor electrocardiogram to look for changes from previous tracing.

• Explain to the patient: fluids restriction may be necessary as heart failure is

a concurrent disease with dilated cardiomyopathy.

• Record daily weight and call physician if weight increases 3 lbs (1.4 kg).

• No smoking or drinking alcohol.

• No straining during bowel movements.

• Increase exercise.

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