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 Home > Journal of Nursing > The Signs and Symptoms’ of Cardiomyopathy: The Awareness and Actions of the Registered Nurse
 
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Sudden Cardiac Death - 

  • Sudden cardiac death has the highest incidence in adolescent children but not excluding younger adults, and is typically associated with sports or vigorous exertion.  
  • The arrhythmia that causes sudden death is usually but not exclusive alone to, ventricular fibrillation. 
  • A pathophysiology and epidemiology report have shown in more than 80% of patients with HCM and with known congenital heart disease brings a higher risk for sudden cardiac death. 19 
  • For many patients with HCM develop over time, ventricular fibrillation (VFib) following atrial fibrillation (AFib), also atrial flutter (AF), and supraventricular tachycardia (SVT’s) associated with Wolff-Parkinson-White (WPW) syndrome. Commonly found in documented findings, there ventricular tachycardia (VT) with low-cardiac-output, associated with hemodynamic collapse. 20 
  • Early diagnosis is of prime importance, if death is to be prevented by prescription of an appropriate levels of safe activity, medications, surgery (e.g., electrophysiology invasive procedures), and/or an implantable cardioverter defibrillator may be in order.  
  • Remember, that because this is an autosomal (i.e., genetic disorder) dominantly inherited disease, an investigation with screening of first-degree relatives, which should include a physical examination, and an electrocardiography (ECG) screening, with a transthoracic 2D- echocardiography, with color flow mapping, which will be useful to identify additional family members with possible cardiomyopathy (CM) before the onset of significant symptoms or sudden death occur.   

Physical Examination Findings –   

    Most patients with HCM or cardiomyopathy (CM), excluding the pediatric patients with known congenital heart disease, do not have outflow tract obstruction and may show completely normal during the physical examination findings.  Therefore, it is important that the nurse investigates further, using her skills in evidence-based practice towards listening to heart sounds, cardiac impulse, murmur, and other findings: 

  • The first heart sound (S₁) is influenced by the position of the mitral leaflets at the onset of ventricular systole.  The amount of tissue, air, or fluid between the heart and the stethoscope may be louder if diastole is shortened because of tachycardia.  Also, in a prolonged P-R interval, or with an imperfect closure due to reduced valve substance in the mitral regurgitation S₁ sound may appear soft. 
  • The second heart sound will appear to sound “split”.  Splitting in S₂ that persists with expiration from the pulmonic area or left sternal border may be due to many causes, including patients with chronic pulmonary hypertension.  The oxygen partial pressure (P₀₂) may appear loud and also, patients with HCM/CM will split paradoxically. 
  • The third heard sound (S₃) is a low-pitched sound produced in the ventricle after the closing sound of the aortic valve (A₂), at the termination of rapid filling.  In younger patients with CM a sound or “gallop” may appear but does not have the same ominous significance as in patients with valvular aortic stenosis (VAS) or in older adults. 21  Place the stethoscope at the left ventricular apex during expiration and with the patient in the left lateral position. 
  • The fourth heart sound (S₄) is frequently heard in patients with HCM, and is due to atrial systole against a highly non-compliant LV wall.  It is usually loudest at the left ventricular apex, when the patient is in the left lateral position.  The right-sided (S₄) sound is present in patients with right ventricular hypertrophy, secondary to either pulmonic stenosis or pulmonary hypertension. 22 

Cardiac Impulse – 

  • The apical precordial impulse is frequently laterally displaced and is usually abnormally forceful and enlarged in patients with HCM. 
  • Double apical impulse resulting from a forceful left atrial contraction against a highly non-compliant LV and occurs in young children plus, a variance within younger adults with HCM. 23  
  • A triple apical impulse are rarely but does accrue from a belated systolic bulge (e.g., sudden increase sound) that appears when the heart is almost empty and is performing near-isometric contraction. 24ʹ25 

Murmurs -   

  • Systolic ejection murmurs are often “crescendo-decrescendo” in shape when blood is ejected across the aortic or pulmonic outflow tracts. 26 Place your stethoscope between the apex and the left sternal border; it radiates to the suprasternal notch but not to the carotid arteries or neck.  The murmur may vary with the subaortic gradient across the LV outflow tract. 
  • The systolic or holosystolic (pansystolic) murmurs are generated when there is flow between two chambers that have widely different pressures throughout systole.  The holosystolic murmur of the mitral regurgitation is heard at the apex and left axilla in patients with systolic anterior motion of the mitral valve and significant LV outflow tract. 27 
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