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Acquired Cardiac Disorders

It refers to disease process or


abnormalities that occur after birth and
can be seen in the normal heart or in the
presence of congenital heart defects.
Congestive Heart Failure (CCF)

Definition:
It refers to the heart unable to pump enough

amount of blood to meet the metabolic

needs of the body.


Causes:
1. Demands for increased cardiac output:

 Left to Right shunt

 Valvular insufficiencies

 Hyper metabolic states

 Fluid overloads
2. Demands for increased pressure
generation:

 Aortic/ Pulmonary stenosis

 Coarctation of aorta/ pulmonary artery

 Aortic/ pulmonary hypertension


3. Decreased Myocardial functions:
 Myocarditis
 Metabolic abnormalities
 Dysrrthymias
 Nutritional and toxic insults
 Electrolyte disturbances
 Myopathy
 Coronary artery disease
4. Other causes according to age:

Age Condition
Premature infants PDA

Birth to 1st week Hypoplastic left heart


syndrome, coarctation
of aorta, PDA,
myocarditis, atrio
venous malformation
Age
Condition
1st week to 3rd month VSD, truncus arteriosus,
endocardial cushion defect,
total anomalous pulmonary
venous return, coarctation of
aorta.

Tricuspid atresia, endocardial


3rd month to 1st year
cushion defect, VSD, TA

Bacterial endocarditis,
Over 1 year
myocarditis, rheumatic fever
Pathophysiology conte….
Clinical Manifestations:
Impaired myocardial function:

Tachycardia (sleeping heart rate more than


160/min.)

Gallop rhythm

Diaphoresis, decreased urinary output


Fatigue, weakness, restlessness, anorexia,
decreased blood pressure

Pale cool extremities

Cardiomegaly, week peripheral pulse


Pulmonary congestion:

Tachycardia, dyspnea, costal retractions

Flaring nares, exercise intolerence,

arthopnea

Cough, hoarsness, cyanosis

Gasping and granting respiration


Systemic venous congestion:
Weight gain, hepatomegaly, periphral
oedema
Ascitis, pleural effusion, neck vein
distension
Developmental delay
Others
Irritability, lethargy, fatigue during feeding
and crying, and poor food intake.
Diagnosis:
Chest X-Ray:

Enlarged heart and pulmonary venous


enlargement

ECG:

Cardiomegaly, ventricular hypertrophy.


Management:
1. Goal To improve cardiac function
(increase contractility and after load).
 Digitalis glycosidesImprove contractility
Action- ses the force of contraction, ses
the heart rate, slow the conduction of
impulses through the AV node indirectly,
enhances diuresis by sed renal perfusion.
Beneficial effect: ses cardiac out put, ses
heart size, ses venous pressure, relief of edema.
 Digoxin (lanexin)  is used as-
• 50μg/ml-oral
• 0.1mg/ml-parenteral administration.
• The dose divided into 24 hours
maintain dose usually 1/8th of the
digitalizing dose-orally-BD.
• Monitor ECG and detect side effects
especially dysarrhytmias.
Other inotropic agents
To Improve contractility
Dopamine, dobutamine, amrinone

(5-10μg/kg/min)
Angiotension converting enzyme(ACE)
inhibitors
 To inhibit the normal function of the Renin
Angiotensin system in the kidney.
ACE inhibitors

Block the conversion of angiotensin 1st to


angiotensin 2nd.

Instead of vasoconstriction, vasodilatation occur


Reduces secretion of aldosterone

Reduces preload by preventing volume


expension from fluid retention

ses risk of Hypokalemia

Renal blood flow improved  enhances


diuresis
Captopril –TDS
Used in infants and young children
Side effects- hypotension, renal dysfunction,
cough.
Enalopril-BD
Side effects- fever, allergic reaction.
2. Goal  Remove accumulated fluid and
sodium:
 Diuretics, fluid restriction and sodium
restriction
 Furosimide and Thiazide- cause loss of
potassium give K+ suppliments and rich
dietary sources of the electrolyte are
given.
 Sodium restricted diet-less often in
children.
3. Goal Decrease cardiac demands: To
decrease the work load on the heart,
metabolic needs are minimized by-
 Providing a natural thermal environment
to prevent cold, stress in infants.
 Treating any existing infection.
 Reducing the effect of breathing (semi
fowler position).
 Using medication to sedate an irritable
child providing rest and reducing
environmental stimuli.
4. Goal  Improve tissue oxygenation:
 Improving myocardial function
 Decrease tissue O2 demand
 Supplement cool humidified O2,
 O2 hood is preferred for young infants
to provide increased concentration of
the gas.
 Nasal canula / Face tent- For old infant
and children.
Rheumatic Fever
(RF)
Rheumatic fever (RF)
Definition:
It is an inflammatory disease that usually
follows infection with group-A beta
hemolytic streptococci. The infection is
usually of upper respiratory tract and often
goes unnoticed. After an interval of 3
weeks, manifestation of rheumatic fever
may appear. Acute episodes may reoccur
with subsequent streptococcal infection,
frequently resulting in cardiac damage.
Incidence:
It occur most frequently in older children
and adolescents less than 1%

Among lower socio economic groups –


most prevalent.
Pathophysiology:
The principal manifestations of RF are
observed in the heart, joints, skin and CNS.
An inflammatory hemorrhagic bullous
lesion called as Choff bodies, are formed,
which cause swelling, fragmentation and
alteration in the connective tissues.
These lesions are found in the heart, blood
vessels, brain and serous surfaces of the
joints and pleura.
Clinical manifestation:
According to Jones criteria:
1. Carditis:
 Involving the endocardium, pericardium,
and myocardium.
 In acute illness- valvulitis, myocarditis,
pericarditis.
 It is clinically almost always associated
with a murmur of valvulitis
 Apical systolic murmur reflecting mitral
regurgitation is a common clinical finding.
Murmur is a long, high pitched, blowing
murmur begins with the 1st heart sound
(S1)and continues through systole.
Produces tachycardia especially during rest
and sleep.
S/S of CHF, cardiomegaly on chest X-Ray.
S/S of pericarditis- muffled heart sound due
to pericardial effusion.
Pericardial friction rub and complain of
chest pain.
Pericardial effusion- by ECHO
Child with mitral/ aortic valve involvment
experience progressive valvular damage.
Development of stenosis (mitral stenosis)
A gallop rhythm and arrhythmias are other
findings of carditis.
Enlargement of liver and a rapid heart rate
in severe acute Right carditis.
2. Arthritis:
 Caused by edema, inflammation and
effusion in joint tissues.
 Reversible and migratory, following large
joints such as the knees, elbows, hips,
shoulders and wrists.
 The affected joint is swollen, hot/warmth
red and painful for 1-2 days after with a
other joint is affected.
 Accompanying fertile period 1-2 weeks
persist for 4 weeks in patients.
3. Erythema marginatum:
 It is a distinct erythmatous macule with a
clear central and waxy wall demarcated
border.
 This transitory, nonpruritic rash is most
often found on the trunk and proximal
portion of extremities
 The rash will blanch with pressure and by
heat.
4. Subcutaneous nodules:
These are small (0.5-1cm.), non tender
swelling that persist inefficiently after
onset of disease and gradually resolve
with no resulting damage painless; raw but
found in groups over bony prominences,
such as feet, hands elbows, scalps, and
scapulae.
5. Chorea:
 CNS involvement
 It is characterized by sudden, aimless,
irregular movement of extremities,
involuntary facial grimaces, speech
disturbances, and muscle weakness.
 It is usually exaggerated by anxiety and
deliberate motor activity.
 Relieved by rest, especially by sleep.
Minor manifestations:
 Arthralgia, fever

 ESR-Elevated

 C-reactive protein elevated

 Un explained epistasis, abdominal pain


Diagnostic Evaluation:
• Acute phase reactant- ESR, C-reactive
protein, leukocytosis.
• Prolonged P-R interval on ECG.
• Elevated streptococcal antibodies
• Positive culture for group-A beta hemolytic
streptococcus.
Medical management:
Goals:
• Eradication of hemolytic streptococci

• Prevention of permanent cardiac damage

• Palliation of other symptoms

• Prevention of recurrence of RF.


• Penicillin is drug of choice
• Erythromycin- substitute in penicillin
sensitive children.
• Salicylates- control inflammation.
• Prednisone- child with pancreatitis and
valvular involvement
• Benzathine penicillin G-IM-monthly
• Follow-up care up to 5 years
• Bed rest
Nursing management:
• Encourage compliance with drug regimens
• Facilitate recovery from the illness,
emotional rapport.
• Prevent recurrence of disease, administer
antibiotics, rest and adequate nutrition,
throat culture and good mouth care.
• Restriction of activity

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