CARDIOMYOPATHY 101

Elaine M. Szewc, RN, BS Medical Underwriting Consultant John Hancock Life Insurance

Life Underwriting
Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595. 2009 John Hancock. All rights reserved. MLINY09300911611

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Definition
The term cardiomyopathy is purely

descriptive, meaning disease of the heart muscle myocardium associated with mechanical &/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic.
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a heterogeneous group of diseases of the

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 Cardiomyopathies either are confined to the heart or are a part of generalized systemic disorders, often leading to cardiovascular death or progressive heart failure-related disability. (2006 AHA) A broad term that includes subacute or chronic disorders of the myocardium. (Black & Hawks)

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Cardiomyopathy

Nursing Review, 2001

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CAuses
Risk increases in clients who: Chronically ingest excessive amounts of alcohol Pregnant Have systemic hypertension Have had some forms of infections.

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Dilated Cardiomyopathy

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Dilated Cardiomyopathy - Definition

Primary (idiopathic) is a disease of unknown etiology

that principally affects the myocardium leading to LV dilation and systolic dysfunction dysfunction, and heart failure.

Characterized by ventricular dilatation, contractile

Most common of the cardiomyopathies.

Also known as hypertrophic subaortic stenosis, and

asymmetrical septal hypertrophy

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DCM - Incidence and Prognosis

Third most common cause of heart failure Most frequent cause of heart transplantation

Complete recovery is rare

Highest incidence in middle age Symptoms may be gradual in onset

Source: UpToDate (www.uptodate.com) "Definition and classification of the cardiomyopathies Leslie T Cooper, Jr, MD last updated 2/14/08
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Clinical Manifestations (Cont)

Symptoms/Signs of heart failure Pulmonary congestion (left heart failure) dyspnea (rest, exertional, nocturnal), orthopnea Systemic congestion (right heart failure) edema, nausea, abdominal pain, nocturia Low cardiac output Hypotension, tachycardia, tachypnea Fatigue and weakness Arrhythmia Atrial fibrillation, conduction delays, complex PVCs, sudden death

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Diagnostics
CXR (enlarged heart, CHF) Electrocardiogram (tachycardia, A-V block, PVCs)

24-hour Holter monitor if with lightheadedness, palpitation, syncope

Echocardiogram (left ventricular dilation) Myocardial biopsy, rare Cardiac catheterization (R/O CAD)

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DCM - Treatment
Limit activity based on functional status
Salt restriction Fluid restriction

Initiate medical therapy ACE inhibitors, diuretics Digoxin Hydralazine/nitrate combination Anticoagulation prn Implantable defibrillators

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DCM Treatment (Cont)

Cardiac transplantation This disorder is the most common indication for cardiac transplantation Survival after transplant is
80% one year 70% 5 years

Left Ventricular Reduction Procedures LV-reshaping

Source: UpToDate (www.uptodate.com) "Diagnosis and management of ischemic cardiomyopathy" James C Fang MD, Sary Aranki MD, last updated 4/7/09
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Nursing Management
Encourage rest. Clients should avoid poorly tolerated activities. Advise clients that physical and emotional stress

exacerbate the disease.

Clients should abstain from drinking alcohol

beverages.

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Hypertrophic Cardiomyopathy

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Hypertrophic Cardiomyopathy (HCM)

Defined

Prevalence 2:1000 Genetic disease characterized by hypertrophy of the left ventricle with marked variable clinical manifestations morphologic and hemodynamic abnormalities Small LV cavity, septal hypertrophy which can be asymmetric, obstruction of left ventricular outflow with low stroke volume,

Source: UpToDate (www.uptodate.com) Natural history of hypertrophic cardiomyopathy" Perry M Elliott, MD, William J McKenna, MD, last updated 9/18/07
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Clinical Manifestations
Asymptomatic Echocardiographic finding only
Symptomatic Dyspnea in 90% Angina pectoris in 75% Fatigue, pre-syncope, syncope, risk of SCD Palpitation, PND, CHF, dizziness Atrial fibrillation, thromboembolism

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EKG Findings
Abnormal in 85-90% of cases LVH, Strain pattern

Abnormal ST-Ts, giant T wave inversions

Abnormal Qs, Bundle Branch Block Left atrial enlargment Ventricular arrhthymias

Source: UpToDate (www.uptodate.com) "Clinical manifestations and diagnosis of arrhythmogenic right ventricular cardiomyopathy William J McKenna, MD, last updated 3/18/09
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Management of HCM
Beta-adrenergic blockers (atenolol, toprol, sotalol,

tenormin etc)

Calcium channel blockers (norvasc, cardizem, etc) Anti-arrhythmics Amiodarone, norpace Pacemakers Myomectomy (resection of septum) Transplantation

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Restrictive Cardiomyopathy

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Restrictive Cardiomyopathies
Hallmark: abnormal diastolic function Rigid ventricular wall with impaired ventricular filling

Bear some functional resemblance to constrictive pericarditis

Importance lies in its differentiation from operable constrictive pericarditis

Much less common then DCM or HCM outside the tropics, but frequent cause of death in Africa, India, South and Central America and Asia primarily because of the high incidence of endomyocardial fibrosis in those regions

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Clinical Manifestations
Symptoms of right and left heart failure Jugular Venous Pulse

Echo-Doppler
Abnormal mitral inflow pattern

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Treatment
No satisfactory medical therapy Drug therapy must be used with caution
Diuretics for extremely high filling pressures Vasodilators may decrease filling pressure (?) Calcium channel blockers to improve diastolic compliance Digitalis and other inotropic agents are not indicated

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Questions?

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