CH 35 Pts with Cardiac Problems

AS a. S/S of aortic stenosis? b. Resulting from?

a. Dyspnea, angina, and syncope occurring on exertion. b. Fixed cardiac output

AR a. What are the major symptoms? b. What can be heard on palpation? c. What happens to the Pulse Pressure? d. What is the classic auscultatory finding?

a. Exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Palpitations may be noted w severe disease, especially when the pt lies on the left side. Nocturnal angina with diaphoresis often occurs. b. A "bounding" arterial pulse. c. Usually widened, with an elevated systolic pressure and diminished diastolic pressure. d. a high-pitched, blowing, decrescendo diastolic murmur.

MR a. What happens when it results from rheumatic heart disease? b. Who does it affect more?

a. It usually coexists with some degree of mitral stenosis b. It affects women more often than men.

MR a. What are the primary causes of mitral regurgitation? b. Other Causes? c. #1 cause n developing nations?

a. Mitral valve prolapse and rheumatic heart disease b. Other causes include infective endocarditis papillary muscle dysfunction rupture resulting from ischemic heart disease congenital anomalies. c. Rheumatic heart disease is the number-one cause in developing nations.

MS a. What occurs 1st? b. Later?

a. Pulmonary congestion and right-sided heart failure. b. The left ventricle receives insufficient blood volume, preload is decreased and cardiac output (CO) falls.

MR a. How does Mitral regurgitation usually progresses? b. When do symptoms begin to occur? c. What are the symptoms? As a result of? d. What develops later? e. What do a large number of patients tend to report? f. What will you see on assessment?

a. Slowly; patients may remain symptom-free for decades. a. When the left ventricle fails in response to chronic blood volume overload. c. Fatigue and chronic weakness as a result of reduced CO. d. Dyspnea on exertion and orthopnea e. Anxiety, atypical chest pains, and palpitations. f. Normal BP, atrial fibrillation, or changes in respirations characteristic of left ventricular failure.

AS a. What occurs in aortic stenosis during systole? b. What does it result in? c. What happens when it worsens? d. What happens to the pulmonary system? e. What occurs late in the disease?

a. The aortic valve orifice narrows and obstructs left ventricular outflow. b. This increased resistance to ejection or afterload results in ventricular hypertrophy. c. Cardiac output becomes fixed and cannot increase to meet the demands of the body during exertion. Symptoms then develop. d. Eventually the left ventricle fails, blood backs up in the left atrium, and the pulmonary system becomes congested. e.Right-sided HF. When the surface area of the valve becomes 1 cm or less, surgery is indicated on an urgent basis!

Drug Alert a. What should be taught to patients with valve disease? b. What does this include? Prophylactic antibiotics are not recommended before GI procedures such as upper GI endoscopy, colonoscopy, or procedures requiring genitourinary instrumentation.

a. The importance of prophylactic antibiotic therapy before any invasive dental or oral procedure b. Patients previous history of endocarditis and cardiac transplant or valve recipients.

MS a. What happens in mitral stenosis? b.What is a result of these changes?

a. The valve leaflets fuse and become stiff, and the chordae tendineae contract and shorten. The valve opening narrows, preventing normal blood flow from the left atrium to the left ventricle. b. The left atrial pressure rises, the left atrium dilates, pulmonary artery pressures increase, and the right ventricle hypertrophies.

AS a. Rheumatic aortic stenosis occurs... b. What are major causative factors in older adults?

a. With rheumatic disease of the mitral valve and develops in young and middle-age adults. b. Atherosclerosis and degenerative calcification of the aortic valve.

AS Aortic stenosis is the... and is ...

-Most common cardiac valve dysfunction in the US -Often considered a disease of "wear and tear."

MR What can be noted when right-sided HF develops?

-Neck veins become distended, the liver enlarges (hepatomegaly), and pitting edema develops. -A high-pitched systolic murmur at the apex, with radiation to the left axilla, is heard on auscultation. -Severe regurgitation often exhibits a third heart sound (S3)

MS The development of atrial fibrillation indicates that the.... And what should be done when noted?

... patient may decompensate The health care provider should be notified immediately of the development of an irregularly irregular rhythm.

Diuretics, beta blockers, ACE inhibitors, digoxin, and oxygen are often administered...

...to improve the symptoms of HF.

What is usually found on physical examination?

A normal heart rate and BP A midsystolic click and a late systolic murmur may be heard at the apex of the heart.

MS What can be noted on auscultation?

A rumbling, apical diastolic murmur

MS a. Mitral stenosis usually results from... b. Which can cause? c. What is the most common cause of the problem?

a. rheumatic carditis b. valve thickening by fibrosis and calcification. c. Rheumatic fever

Nitrates are administered cautiously to patients with... Why?

Aortic stenosis Because of the potential for syncope associated with a reduction in left ventricular volume (preload).

What is the best intervention to prevent endocarditis?

Appropriate oral hygiene. Optimal oral health is the best intervention to prevent endocarditis.

MVP Why doesMitral valve prolapse (MVP) occur?

Because the valvular leaflets enlarge and prolapse into the left atrium during systole.

Action Alert What should you observe the patient closely for after valvuloplasty?

Bleeding from the catheter insertion site and institute post-angiogram precautions. Bleeding is likely because of the large size of the catheter. Assess for signs of a regurgitant valve by closely monitoring heart sounds, CO, and heart rhythm. Because vegetations (thrombi) may have been dislodged from the valve, observe for any indication of systemic emboli

AS What are the primary causes for aortic stenosis in many patients?

Congenital bicuspid or unicuspid aortic valves

MVP What may be associated with atrial or ventricular dysrhythmias?

Dizziness, syncope ("blackouts"), and palpitations

What is Exercise tolerance testing (ETT) and stress echocardiography?

Done to evaluate symptomatic response and assess functional capacity.

MS As the valvular orifice narrows and pressure in the lungs increases what does the patient experience ?

Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea (sudden dyspnea at night), palpitations, and dry cough.

What is the noninvasive diagnostic procedure of choice to visualize the structure and movement of the heart?

Echocardiography

MS As pulmonary hypertension and congestion progress what may occur?

Hemoptysis (coughing up blood) and pulmonary edema

MR What does a chest x-ray show in patients with mitral regurgitation (insufficiency)?

Increased cardiac shadow, indicating left ventricular and left atrial enlargement.

AR S/S? Initially? As the disease progresses?

Initially- Asymptomatic for many years because of the compensatory mechanisms of the left ventricle. Left ventricular failure occurs

What istransesophageal echocardiography (TEE) or transthoracic echocardiography (TTE)?

It is more invasive and is also performed to assess most valve problems.

What would affect the tricuspid valve?

It is not affected often and may occur following endocarditis in IV drug abusers.

AR What does a chest x-ray show in patients with aortic regurgitation (insufficiency)?

Left atrial and left ventricular dilation. If HF is present, pulmonary venous congestion is also evident.

MS What does a chest x-ray show in patients with mitral stenosis?

Left atrial enlargement, prominent pulmonary arteries, and an enlarged right ventricle.

AS What does a chest x-ray show in patients in the later stages of aortic stenosis?

Left ventricular enlargement and pulmonary congestion.

What abnormalities will an ECG to assess in: mitral regurgitation aortic regurgitation severe mitral stenosis aortic stenosis

Left ventricular hypertrophy- mitral regurgitation and aortic regurgitation Right ventricular hypertrophy- severe mitral stenosis. Atrial fibrillation- mitral stenosis and mitral regurgitation and may develop in aortic stenosis because of left atrial dilation.

MVP What has the etiology of MVP been associated with ?

Marfan syndrome and other congenital cardiac defects. Familial

MVP S/S of MVP?

Mostly asymptomatic. Some report chest pain, palpitations, or exercise intolerance. Chest pain is usually atypical, with patients describing a sharp pain localized to the left side of the chest.

AR Aortic insufficiency usually results from?

Nonrheumatic conditions -Infective endocarditis, congenital anatomic aortic valvular abnormalities, hypertension, and Marfan syndrome (a rare, generalized, systemic disease of connective tissue).

Valvular Diseases What information during assessment should be noted and gathered?

Patient suddenly become ill or slowly develop symptoms over many years. Genetic predisposition. Previous attacks of rheumatic fever and infective endocarditis HX of IV drug abuse- common cause of infective endocarditis.

MS Who is usually asymptomatic?

People with mild mitral stenosis

MR What happens during diastole with Mitral Regurgitation (Insufficiency)?

Regurgitant output again flows from the left atrium to the left ventricle along with the normal blood flow. The increased volume must be ejected during the next systole. To compensate for the increased volume and pressure, the left atrium and ventricle dilate and hypertrophy.

AR What happens in Aortic Regurgitation (Insufficiency)?

The aortic valve leaflets do not close properly during diastole; and the annulus (the valve ring that attaches to the leaflets) may be dilated, loose, or deformed. This allows flow of blood from the aorta back into the left ventricle during diastole. The left ventricle, in compensation, dilates to accommodate the greater blood volume and eventually hypertrophies.

MR What happens during systole with Mitral Regurgitation (Insufficiency)?

The fibrotic and calcific changes occurring in mitral regurgitation (insufficiency) prevent the mitral valve from closing completely. Incomplete closure of the valve allows the backflow of blood into the left atrium when the left ventricle contracts.

AS What happens when cardiac output falls in the late stages of the disease?

The patient experiences marked fatigue, debilitation, and peripheral cyanosis. A narrow pulse pressure is noted when the BP is measured. A diamond-shaped, systolic crescendo-decrescendo murmur is usually noted on auscultation.

When is cardiac catheterization indicated?

With either mitral or aortic stenosis, to assess the severity of the stenosis and its other effects on the heart.

MS Right-sided HF can cause

hepatomegaly (enlarged liver) neck vein distention pitting dependent edema late in the disorder.

Vasodilators

such as calcium channel blockers may be used to reduce the regurgitant flow for patients with aortic or mitral stenosis.