Cardiomyopathy NCLEX Review

Cardiomyopathy is a term that describes a disease affecting the heart muscle, and is most commonly related to damage of the myocardium. There are four categories of cardiomyopathy – dilated, restrictive, hypertrophic and arrhythmogenic right ventricular cardiomyopathies.  

Dilated cardiomyopathy involves an enlargement of one of the ventricles (usually the left) that leads to decreased stroke volume and systolic dysfunction. With decreased stroke volume, blood sits in the heart chambers and increases the patient’s risk for developing blood clots. Dilated cardiomyopathy can be a consequence of numerous conditions including hypertension, arrhythmias, diabetes, obesity, heart valve dysfunction, alcohol use disorder, exposure to some chemotherapy medications, and illicit drug use (such as amphetamines or cocaine). Interestingly, it is the most common type of cardiomyopathy and the leading reason for heart transplantation. When you think of dilated cardiomyopathy, think “weak walls.

Restrictive cardiomyopathy involves stiff ventricles that don’t contract easily or fill with blood adequately. Restrictive cardiomyopathy is the least common type and typically occurs with constrictive disorders such as cardiac amyloidosis, cardiac sarcoidosis, pericarditis or pericardial effusion. Because a patient with restrictive cardiomyopathy will have higher diastolic pressure, this leads to increased atrial pressure and enlarged atria. When you think of restrictive cardiomyopathy, think “stiff walls.”

Hypertrophic cardiomyopathy is a genetic condition that causes an enlarged left ventricular muscle, typically the interventricular septum. The thickened wall makes it difficult for the heart muscle to relax and the ventricles do not fill adequately. Patients with hypertrophic cardiomyopathy will often also have an enlarged left atrium due to increased pressures in the left ventricle. There are two types of hypertrophic cardiomyopathy – nonobstructive and obstructive. When there is no significant outflow obstruction this is considered “nonobstructive hypertrophic cardiomyopathy.” When there is an obstruction to blood flow from the heart, this is considered “obstructive hypertrophic cardiomyopathy.” Obstructive hypertrophic cardiomyopathy specifically has a reputation as the most common cause of sudden death in young, active individuals who are otherwise healthy. When you think of hypertrophic cardiomyopathy, think “thick walls.” 

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic condition in which the muscle tissue of the right ventricle is replaced by fatty and fibrous tissue. In some cases, the left ventricle is also affected. This abnormal tissue disrupts the electrical signals in the heart and can cause significant dysrhythmias. 

Complications of cardiomyopathy

General complications of cardiomyopathy include heart failure, atrial fibrillation, blood clots, dangerous dysrhythmias and sudden cardiac death.

Now that you have some background information on cardiomyopathy, it’s time to dive deeper into it using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

The signs and symptoms of cardiomyopathy can vary based on the type. In some cases the individual may have no symptoms, but they will progressively worsen as the disease progresses.

Dilated cardiomyopathy – Key signs/symptoms include dyspnea, orthopnea, lower limb edema, activity intolerance, fatigue, and palpitations.

Restrictive cardiomyopathy – In early stages the patient may have no symptoms. When symptoms do develop they are similar to that of dilated cardiomyopathy – dyspnea, orthopnea, lower limb edema and fatigue. The patient may also have arrhythmias, syncope, a cough, and abdominal pain secondary to hepatic congestion.

Hypertrophic cardiomyopathy – Many individuals with hypertrophic cardiomyopathy never show any symptoms and are never diagnosed. When symptoms do develop (typically in adolescents or adulthood), they tend to include dyspnea on exertion, angina at rest or with exertion, fatigue and lightheadedness or syncope. Patients with obstructive hypertrophic cardiomyopathy are more likely to develop symptoms which can be severe and also involve mitral valve regurgitation and dysrhythmias. 

Arrhythmogenic right ventricular cardiomyopathy – As with hypertrophic cardiomyopathy, ARVC can cause sudden death in otherwise healthy individuals and athletes with the condition. Symptoms usually don’t begin to appear until adolescence and are often secondary to ventricular tachycardia (palpitations, syncope, dizziness or lightheadedness, chest pain, and even cardiac arrest). 

A: How do you ASSESS the patient?

Key nursing assessments include:

• Monitor vital signs – patients may have a normal to low SBP with a narrow pulse pressure
• Listen to heart sounds – you may hear heart sounds associated with valve disorders (such as a murmur) as well as S3 and/or S4. S3 is often an earlier sign of heart failure and is associated with rapid ventricular filling and blood sloshing around in the ventricles. When you think of S3, think “sloshing in.” The fourth heart sound, S4, is heard with hypertrophic cardiomyopathy. When you think of S4, think “a stiff wall.”
• Auscultate lung sounds to listen for pulmonary edema which may be present when the heart is not pumping adequately
• Assess the patient for signs of fluid overload which can include peripheral edema, ascites, and/or jugular vein distension.
• If the patient is taking a diuretic, monitor for S/S of electrolyte imbalances and fluid volume deficit. 
• Weigh the patient daily and report sudden weight gain to the physician.
• Perform a fall risk assessment, especially in patients with low cardiac output, those taking medications that cause orthostatic hypotension, and in patients with weakness or fatigue.

T: What TESTS will be conducted for a patient with cardiomyopathy?

• 12-lead EKG to assess for arrhythmias and conduction abnormalities such as a bundle branch block.
• Echocardiography uses ultrasound to assess the heart’s structure, it’s ability to pump effectively, and heart valve function. When you hear someone refer to the patient’s ejection fraction, this number is often obtained from an echocardiogram. A normal EF is 50 to 70%.
• A cardiac stress test looks at how the heart responds to stress (either induced by exercise or with medication).
• Chest x-ray may show pulmonary congestion, which is common in patients with heart failure related to cardiomyopathy. It is also useful for evaluating the heart’s overall shape and size. 
• Radionuclide studies and cardiac catheterization may be utilized to more closely evaluate the heart and its function.
• A cardiac muscle biopsy may be performed to assess for damage to the heart muscle.
• A Holter monitor provides long-term monitoring of the patient’s heart which can be helpful if the patient has periodic arrhythmias. Patients typically wear the Holter monitor for 24 to 48 hours.
• Genetic testing or screening may be utilized in patients with a family history of cardiomyopathy, especially hypertrophic cardiomyopathy and ARVC. 

T: What TREATMENTS will be provided for a patient with cardiomyopathy?

Treatments for cardiomyopathy are aimed at relieving the symptoms, improving cardiac function, decreasing potential complications (such as blood clots and fluid overload), reducing hospitalizations, and slowing or preventing disease development. 

Treatment options are wide ranging and include:

• Diuretics remove excess fluid from the body, which can build up when the heart is not pumping effectively. Volume overload puts additional stress on the heart and can cause pulmonary edema and respiratory distress. A commonly used diuretic is furosemide.
• Antihypertensives are used to lower blood pressure and reduce the workload of the heart. These often include beta blockers, ARBs and ACE inhibitors.
• Antiarrhythmics such as amiodarone may be needed to suppress ventricular arrhythmias or atrial fibrillation.
• Digoxin is a medication that causes the heart to beat more slowly but also more forcefully. Be watchful for signs of digoxin toxicity which always seem to show up on nursing exams. These include bradycardia, seeing yellow, and feeling nauseous.
• Anticoagulants are used to prevent blood clots and the associated complications such as stroke.
• An implantable cardioverter-defibrillator (ICD) delivers an electrical shock when dangerous abnormal rhythms are detected.
• A biventricular pacemaker stimulates both ventricles to beat at a set rate determined by the physician, which leads to improved cardiac output.
• Cardiac ablation may be considered in the cases of ARVC. This procedure destroys tissue in areas of the heart where arrhythmias initiate.
• In severe cases, the patient may need a left ventricular assist device (LVAD). This device assists the left ventricle to reduce workload on the heart and improve circulation. An LVAD may be used long-term, but can also be utilized as the individual waits for a heart transplant.
• Heart transplantation may be needed if other therapies are ineffective. 

E: How do you EDUCATE the patient/family?

Much of your patient education will revolve around encouraging lifestyle changes that can help manage symptoms. And, in the case of dilated cardiomyopathy, lifestyle changes can slow or prevent progression of the disease. These include things like losing weight, increasing activity as tolerated, smoking cessation, stopping illicit drug use, avoiding alcohol, and following a heart healthy diet. Additionally, patients with ARVC may be advised by their physician to avoid strenuous activity due to the risk for sudden cardiac death.

A patient with an ICD device should receive education on how the device works and that they may or may not be aware when the device fires. Some individuals feel nothing while others may feel they’ve been “kicked in the chest.” If the patient receives a shock from the ICD, they should stop activity and rest. Other teaching for an ICD include:

• Avoid areas or items with strong magnetic fields (whether the patient can get an MRI depends on type of ICD)
• Ensure all household appliances are properly grounded
• Their ICD will set off metal detectors
• Avoid carrying a cell phone in a pocket near the ICD
• Hold cell phones to the ear farthest from the ICD
• Tell all healthcare practitioners (including dentists) about the ICD

And lastly, ensure the patient understands how to take all their medications, the need for daily weighing, when to report weight gain or other symptoms to their MD, and the importance of attending all appointments with their cardiologist.

Review cardiomypathy for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 305 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

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