Does insufficient myocardial blood supply affect the recruitment of institutions?

Overview of diseases

The cause of disease

clinical picture

accessory examination

differential diagnosis

therapeutic method

complication

Nursing common sense

Treatment criteria of perinatal cardiomyopathy: disease overview

The cause of disease

clinical picture

accessory examination

differential diagnosis

therapeutic method

complication

Nursing common sense

Treatment criteria of perinatal cardiomyopathy:

[Edit this paragraph] Overview of diseases

Cardiomyopathy (DDM) is a group of pathological changes that lead to progressive cardiac dysfunction due to structural changes in the lower part of the heart (that is, the ventricle) and impaired myocardial wall function.

[Edit this paragraph] Etiology

Cardiomyopathy is a kind of myocardial disease with unknown causes, which is generally considered to be related to virus infection, autoimmune reaction, heredity, drug poisoning and abnormal metabolism. Specific cardiomyopathy with definite etiology or secondary to systemic diseases is not included. Cardiomyopathy can be divided into three types: dilated cardiomyopathy, hypertrophic cardiomyopathy and restrictive cardiomyopathy. Among them, dilated cardiomyopathy and hypertrophic cardiomyopathy are more common. The cause of cardiomyopathy is still unknown.

(1) Dilated cardiomyopathy: Dilated cardiomyopathy may be related to some factors. It is related to myocardial injury caused by abnormal metabolism caused by bacterial drug poisoning, among which viral myocarditis is considered to be the most important cause.

(2) Hypertrophic cardiomyopathy may be related to autosomal dominant inheritance. Among them, about 1/3 has obvious family history, and abnormal catecholamine metabolism, hypertension and high-intensity exercise are secondary factors.

(3) Restrictive cardiomyopathy: Endocardial myocardial fibrosis, myocardial stiffness and blocked ventricular diastolic filling. The onset is slow, with symptoms such as fever, fatigue, dizziness and shortness of breath in the early stage, and heart failure in the late stage. Atrial fibrillation is also very common, and some cases are complicated with visceral embolism.

[Edit this paragraph] Clinical manifestations

(1) Dilated cardiomyopathy: The onset is slow, and there is no obvious abnormality except cardiac enlargement in the early stage, and it is often heart failure in the later stage. The patient has fatigue, shortness of breath after exercise, paroxysmal dyspnea at night, edema, ascites and hepatomegaly. In addition, various arrhythmias, brain, kidney, pulmonary embolism and even sudden death may occur. Auscultation often smells the third and fourth heart sounds, galloping rhythm and systolic murmur of tricuspid or mitral insufficiency, and moist rales can be heard at the bottom of both lungs. X-ray examination showed enlargement of cardiac shadow, congestion of both lungs and interstitial edema. Electrocardiogram showed ST segment depression, flat or inverted T wave, accompanied by a small number of pathological Q waves. Arrhythmia is mainly ectopic rhythm and conduction disorder. Two-dimensional echocardiography showed that the cardiac chambers were enlarged, the motion of interventricular septum and left ventricular posterior wall was weakened, the ejection fraction was reduced, and the outflow channels of left and right ventricles were enlarged. The diagnosis is mainly based on the aforementioned clinical manifestations. Besides other types of heart diseases, these heart diseases can often be diagnosed by combining X-ray and echocardiography.

(2) Hypertrophic cardiomyopathy: It is characterized by ventricular hypertrophy, especially asymmetric ventricular septal hypertrophy, which can partially cause ventricular outflow tract obstruction. The onset is slow, and the early manifestations are dyspnea, fatigue and palpitation after fatigue. Angina pectoris is also common, and nitroglycerin has no obvious effect. Syncope is a signal of serious illness, and heart failure may occur in the late stage, often complicated with atrial fibrillation. During physical examination, the cardiac boundary can be enlarged to the left, ejection murmur can be heard in the precordial area in the middle and late systolic period, and the second heart sound is often split. Ventricular angiography showed that the ventricular cavity was narrow and hypertrophic myocardium protruded into the ventricular cavity. Electrocardiogram (ECG) often shows left ventricular hypertrophy and ST-T changes, and some Q waves appear, and atrioventricular block and bundle branch block are also common. Echocardiography is of great value in the diagnosis of this disease, which is characterized by ventricular septum and left ventricular wall hypertrophy, and its thickness ratio is greater than normal 1.3: 1. Clinical manifestations, combined with echocardiography and ventriculography, can often be diagnosed.

(3) Restrictive cardiomyopathy: mainly distributed in tropical and subtropical regions. It is characterized by endocardial myocardial fibrosis, myocardial stiffness and blocked ventricular diastolic filling. The onset is slow, with symptoms such as fever, fatigue, dizziness and shortness of breath in the early stage, and heart failure in the late stage. Atrial fibrillation is also very common, and some cases are complicated with visceral embolism. Physical examination found that the heartbeat was weak, the heart sound was pure, and the second heart sound in the pulmonary valve area was hyperactive. Diastolic galloping rhythm and arrhythmia can be heard. X-ray shows that the heart is slightly enlarged, and some endocardial calcification shadows can be seen. Electrocardiogram showed arrhythmia such as low voltage, atrial and ventricular hypertrophy, bundle branch block, ST-T change and atrial fibrillation. Two-dimensional echocardiography showed that the heart cavity was narrow, the apex was occluded, the endocardium was thickened, and the ventricular diastolic function was seriously damaged. The diagnosis is difficult, which mainly depends on clinical symptoms, X-ray and echocardiography.

[Edit this paragraph] Auxiliary inspection

(1) ECG examination of dilated cardiomyopathy: ECG examination mainly showed ST segment depression, low or inverted T wave, and a few pathological Q waves appeared. Hypertrophic cardiomyopathy: ECG often shows left ventricular hypertrophy and ST-T changes, and some Q waves appear. Atrioventricular block and bundle branch block are also common. Restrictive cardiomyopathy: ECG shows arrhythmia such as low voltage, atrioventricular hypertrophy, bundle branch block, ST-T change and atrial fibrillation.

(2) Physical examination of hypertrophic cardiomyopathy: the cardiac boundary can be enlarged to the left, the ejection murmur can be heard in the precordial area in the middle and late systolic period, and the second heart sound is often split. Restrictive cardiomyopathy: weak heart beat, pure tone heart sound, hyperactivity of second heart sound in pulmonary valve area, and diastolic galloping rhythm and arrhythmia can be heard.

(3) Echocardiography examination of dilated cardiomyopathy: It showed that each chamber of the heart was enlarged, the motion of interventricular septum and left ventricular posterior wall was weakened, the ejection fraction was reduced, and the outflow channels of left and right ventricles were enlarged. Hypertrophic cardiomyopathy: Echocardiography is of great value in the diagnosis of this disease, which is characterized by ventricular septum and left ventricular wall hypertrophy, and the ratio of their thickness is greater than normal 1.3: 1. Clinical manifestations, combined with echocardiography and ventriculography, can often be diagnosed as restrictive cardiomyopathy: two-dimensional echocardiography shows that the heart cavity is narrow, the apex is occluded, the endocardium is thickened, and the ventricular diastolic function is seriously damaged.

(4) Others: ventriculography showed that the ventricular cavity of hypertrophic cardiomyopathy was narrow, and hypertrophic myocardium protruded into the ventricular cavity. In the examination of dilated cardiomyopathy, X-ray can show that the heart is slightly enlarged, and some endocardial calcification shadows can be seen.

[Edit this paragraph] Differential diagnosis

(1) Rheumatic heart disease cardiomyopathy can also have systolic murmurs in the mitral or tricuspid valve area, but it is generally not accompanied by diastolic murmurs. When heart failure is controlled, the murmurs will be relieved or disappeared, while rheumatic heart disease is the opposite. Cardiomyopathy often has multiple cardiac chambers expanding at the same time, which is not as good as rheumatic heart disease, mainly the left atrium, left ventricle or right ventricle. Ultrasonic examination helps to distinguish.

(2) The difference between cardiomyopathy with pericardial effusion and pericardial effusion is that the heart is enlarged and the heartbeat is weakened. In cardiomyopathy, the apical pulse moves to the lower left, which is consistent with the left outer edge of the voiced boundary. In pericardial effusion, apical pulsation is usually not obvious or located in the left outer edge of voiced boundary. Systolic murmur in mitral or tricuspid valve area, ventricular hypertrophy on ECG, abnormal Q wave and various complex arrhythmia all suggest cardiomyopathy. Ultrasound examination is not difficult to distinguish between the two. A large amount of effusion in pericardium indicates pericardial effusion, and enlargement of the heart is cardiomyopathy. It must be noted that cardiomyopathy may have a small amount of pericardial effusion, but it is not enough to cause cardiac tamponade and will not affect the signs and functions of the heart. This is just the discovery of ultrasound. The systolic time interval is obviously abnormal in cardiomyopathy, but normal in pericarditis.

(3) Hypertensive heart disease Cardiomyopathy may have temporary hypertension, but the diastolic pressure does not exceed14.67 kPa (110 mmHg), which occurs in acute heart failure, and the blood pressure drops after the heart failure improves. Different from hypertensive heart disease, fundus, urine routine and renal function are normal.

(4) Coronary heart disease and cardiomyopathy must be considered in patients with coronary heart disease over middle age if there is no other reason for heart enlargement, arrhythmia or heart failure. If there are induced factors such as hypertension, hyperlipidemia or diabetes, the wall activity is segmental abnormal, which is helpful to diagnose coronary heart disease. In recent years, due to long-term extensive ischemia caused by coronary artery disease, the heart is fibrotic and develops into cardiac insufficiency, which is called "ischemic cardiomyopathy". If there is no angina pectoris or myocardial infarction in the past, it is difficult to distinguish it from myocardial disease. Moreover, cardiomyopathy can also spread to angina pectoris. The differentiation at this time depends on coronary angiography.

(5) Most congenital heart diseases have obvious signs, which are not difficult to distinguish. Tricuspid valve depression is characterized by tricuspid valve murmur, rhythm, weakened heartbeat, enlarged right heart and failure, which should be differentiated from myocardial disease, but the symptoms of this disease appeared earlier, with small left ventricle and cyanosis. Echocardiography can make a definite diagnosis.

(6) Systemic diseases of secondary cardiomyopathy, such as systemic lupus erythematosus, scleroderma, hemochromatosis, amyloidosis, glycogen storage disease, neuromuscular diseases, etc. , has its main manifestations. More importantly, it is different from myocarditis. Acute myocarditis often occurs at the time of virus infection or shortly after infection, and the difference is not very difficult. If there is no clear history of acute myocarditis, chronic myocarditis and cardiomyopathy are inseparable. In fact, many dilated cardiomyopathy are developed from myocarditis and are called "post-myocarditis cardiomyopathy".

In recent years, clinical biopsy of endocardial myocardium has been carried out. Samples obtained from cardiac catheter with biopsy forceps can be examined for pathology and virus, and evidence of myocardial inflammation can be found. However, there are still some problems to be solved in histopathological diagnosis criteria and artifact removal.

[Edit this paragraph] Processing method

About 70% DCM patients died within 5 years after symptoms appeared. When the myocardial wall becomes thinner and the myocardial function declines, the prognosis will further deteriorate. The existence of arrhythmia makes the prognosis worse. Generally speaking, the survival time of male patients is only half that of female patients, while that of black patients is only half that of white patients. About 50% of patients died suddenly, presumably due to severe arrhythmia.

Treating special reasons such as alcoholism and infection can prolong life. If alcoholism is the cause of cardiomyopathy, patients should give up drinking; If the patient's cardiomyopathy is caused by infection, antibiotics should be used.

In patients with coronary heart disease, myocardial ischemia can lead to angina pectoris (a kind of chest pain caused by heart disease). It can be treated with nitrate preparations, beta blockers and calcium channel blockers. The latter two drugs can reduce the contractility of the heart. Adequate rest and sleep to avoid nervousness can reduce the oxygen consumption of the heart.

Thrombosis can form on the myocardial wall of an enlarged heart, so anticoagulants are often used to prevent thrombosis. Because most drugs for controlling arrhythmia have side effects of inhibiting myocardial contractility to varying degrees, it is often suggested to start with a small dose and then increase the dose carefully according to the curative effect. Angiotensin converting enzyme inhibitors are often used in the treatment of heart failure, and some diuretics are usually used at the same time. However, unless there are special reasons, the prognosis of heart failure in DCM patients is not ideal. It is precisely because of this poor prognosis that most heart transplant operations today are aimed at DCM.

[Edit this paragraph] Complications

Common complications of cardiomyopathy include arrhythmia, heart failure, embolism, infective endocarditis and sudden death:

(1) Infective endocarditis and sudden death mostly occurred in patients with myocardial hypertrophy;

(2) Embolism mostly occurs in patients with myocardial fibrosis, decreased contractility, atrial fibrillation, long-term lying still or taking diuretics.

(3) Sudden death is a common fatal complication.

[Edit this paragraph] Nursing knowledge

(1) Psychological care: Patients with cardiomyopathy are mostly young, with long course, complicated condition and poor prognosis, so they often have nervousness, anxiety, fear and even pessimism about treatment, which leads to increased myocardial oxygen consumption and aggravated illness. Therefore, in nursing, we should be considerate of patients, encourage and comfort them frequently, help them eliminate pessimism and enhance their confidence in treatment. In addition, pay attention to keep the rest environment quiet, tidy and comfortable to avoid bad stimulation. Give sedatives to insomnia as appropriate.

(2) Rest: Patients with no obvious symptoms in the early stage can do light work to avoid stress and fatigue. Patients with heart failure can exercise slightly after their symptoms are relieved by drug treatment. Nurses should help patients arrange beneficial activities according to their illness, but should avoid strenuous exercise. Patients with severe heart failure, arrhythmia and paroxysmal syncope should stay in bed to reduce heart load and myocardial oxygen consumption. Nurses should assist in life care, pay attention to clean and dry skin, and turn over and prevent bedsores for patients who have been bedridden and edematous for a long time.

(3) Diet: Give a digestible diet with low fat, high protein and vitamins to avoid irritating food. Every meal should not be too full, so as not to increase the burden on the heart. People with cardiac insufficiency should eat a low-salt diet. At the same time, patiently explain the importance of diet therapy to patients in order to obtain their cooperation. In addition, we should give up smoking and alcohol.

(4) Closely observe the condition, and monitor the blood pressure, heart rate and heart rhythm of critically ill patients. When there is a high degree of atrioventricular block, the doctor should be informed immediately, and emergency supplies, drugs and preparations before cardiac pacing treatment should be prepared as soon as possible. Close observation of vital signs to prevent sudden death.

(5) Patients with dyspnea should take a semi-recumbent position, continue to take oxygen, and adjust the oxygen flow according to the condition. Replace the nasal catheter or nasal obstruction every 12 ~ 24 hours. Blood gas analysis can be carried out on patients with heart failure to understand the therapeutic effect.

(6) For those complicated with edema and heart failure, the 24-hour fluid intake and output should be accurately recorded, the excessive fluid intake should be restricted, and the body weight should be measured every day. In the course of diuretic treatment, we should observe whether the patients have fatigue, limb spasm and dehydration, regularly check the blood electrolyte concentration, be alert to hypokalemia, and supplement potassium when necessary. For a large number of patients with hydrothorax and ascites, doctors should be assisted to puncture and draw fluid to relieve the symptoms of oppression.

(7) Respiratory tract infection is an important cause of heart failure in patients with cardiomyopathy. Therefore, attention should be paid to prevent respiratory tract infection in nursing, especially when the seasons change and the temperature changes suddenly. Those who stay in bed for a long time should turn over and pat their backs regularly to promote expectoration. In addition, prophylactic antibiotics should be given before and after invasive examinations such as cardiac catheterization to prevent infective endocarditis.

(8) Keep defecation unobstructed.

(9) Patients with cardiomyopathy, especially patients with dilated cardiomyopathy and restrictive cardiomyopathy, should closely observe the embolism of brain, lung, kidney and other organs and peripheral arteries, and give long-term anticoagulation treatment when necessary. For the nursing care of anticoagulants, please refer to relevant chapters.

(10) For the treatment and nursing of patients with heart failure, please refer to relevant chapters. It is worth mentioning that patients with heart disease often have extensive myocardial lesions, have low tolerance to digitalis and are prone to toxic reactions. Therefore, we should strictly follow the doctor's advice, accurately grasp the dosage, and pay close attention to the toxic reactions of Rehmannia glutinosa, such as nausea, vomiting, yellow-green vision, premature ventricular beats, atrioventricular block and other arrhythmia.

Patients with hypertrophic cardiomyopathy should use drugs carefully to reduce the anterior and posterior load of the heart so as not to aggravate ventricular obstruction. Digitalis can strengthen myocardial contractility, aggravate left ventricular outflow tract obstruction and further reduce cardiac output, so it should be used with caution. Nitroglycerin is prohibited in patients with angina pectoris because it can aggravate left ventricular outflow tract obstruction. ? Blockers and calcium antagonists can alleviate ventricular obstruction and relieve symptoms, and often have certain curative effects. In the first few weeks of verapamil treatment, about 20% patients have nausea and first-degree adverse reactions. Patients should be told not to stop taking the drug casually, and the symptoms can gradually disappear after continuous medication. Start with a small amount of medicine, and don't add it too quickly. Pay attention to adverse reactions such as arrhythmia and postural hypotension during nursing, and inform the doctor immediately if found.

Nursing and prevention of patients with restrictive cardiomyopathy

The prevention of restrictive cardiomyopathy is limited to avoiding complications, fatigue and infection. If you have symptoms such as dyspnea, dizziness, chest pain and edema, you should go to the hospital as soon as possible. Patients diagnosed with restrictive cardiomyopathy should avoid fatigue, prevent respiratory tract infection, quit smoking and drinking, keep a good mood, and go to the hospital for regular review to protect or improve cardiac function and improve quality of life. When you have severe dyspnea, you will sweat more when you lie down, which may be serious cardiac insufficiency. Patients should be asked to sit or semi-sit, and call the medical emergency center for help, or be sent to a nearby hospital by the safest, stable and fast means of transportation. Don't go to see a doctor without formal training after the onset, so as not to delay the illness.

[Edit this paragraph] Treatment criteria for perinatal cardiomyopathy:

Perinatal cardiomyopathy is a kind of heart disease with unknown etiology, which occurs before and after delivery in women. Cardiomyopathy becomes the basic feature, and congestive heart failure is the main manifestation.

The domestic incidence of this disease accounts for about 0.023% of parturients. The incidence of elderly, multiple births, multiple births and pregnant women with a history of pregnancy poisoning is higher. The prognosis of this disease is better than that of primary cardiomyopathy.

Treatment standard:

1. cure: the shape, structure and function of the heart completely returned to normal without any sequelae, such as embolism.

2. Improvement: The morphological structure of the heart has not completely returned to normal, and the cardiac function has returned to the second level.

3. Non-union: After treatment, the cardiac morphology and functional state did not improve significantly or showed a worsening trend.

Surgical method of dilated cardiomyopathy

(1) heart transplantation: starting from 1968. The postoperative 1 year survival rate was 83%, and the 5-year survival rate was over 70%. Due to financial constraints, lack of donors, complicated surgical procedures, and rejection, although.

(2) Myoplasty: Myoplasty or dynamic myoplasty was started in 1985, and the postoperative 1 year survival rate reached 83%.

(3) Partial resection of left ventricular myocardium: Partial resection of left ventricular myocardium (ventricular volume reduction) or Batista operation started at 1994, and the annual survival rate was 63-82%. The basic method is wedge-shaped resection of 75- 150g myocardium on the left ventricular sidewall, and then suture the ventricular wall, thus reducing the ventricular volume, reducing the traction tension of the ventricular wall, improving myocardial contraction and increasing cardiac output.

(4) Mitral valvuloplasty: Mitral valvuloplasty was started in 1994, and the postoperative 1 year survival rate was 75%. The method is to reduce the diameter of mitral valve orifice and preserve the anatomical structure of mitral valve (leaflets, chordae tendineae and papillary muscles). The new normal geometry of the left side recovered, the ejection fraction increased and the cardiac function improved. Other patients underwent "double heart valvuloplasty", namely mitral valvuloplasty and tricuspid valvuloplasty, to improve cardiac function. According to the literature, this kind of operation is still being tested because its effect is uncertain.

(5) Left ventricular assist device: This surgical method is to place both ends of the extracorporeal pump device on the left ventricular cavity tip and aorta respectively. This auxiliary device is mainly used for patients with dilated cardiomyopathy in the late stage while waiting for a heart donor. After using the device for 6 months, the left ventricle of individual patients was reduced and the cardiac function was improved, so the left ventricular assist device was evacuated. This auxiliary device is relatively heavy and is the prototype of artificial heart.

(6) Artificial heart: This method reduces the volume on the basis of the left ventricular assist device, and places it in the abdominal subcutaneous or chest cavity of patients with dilated cardiomyopathy. [ 1]