Valve disease, heart failure, cardiomyopathy, pacemaker and ICD

1Definitions

• Valvular heart disease: a heart valve that does not open fully (stenosis) or does not close fully (regurgitation).
• Rheumatic heart disease (RHD): permanent valve damage after rheumatic fever, which follows untreated streptococcal throat infection. Still common in India; the mitral valve is most often affected.
• Heart failure: a condition in which the heart cannot pump enough blood for the body's needs, or can do so only at high filling pressures, causing breathlessness, fatigue and fluid retention.
• Cardiomyopathy: disease of the heart muscle itself (dilated, hypertrophic or restrictive).
• Pacemaker: a device that sends electrical impulses to keep the heart rate from going too low. ICD (implantable cardioverter-defibrillator): a device that detects dangerous fast rhythms and treats them with pacing or a shock.

2Classification and grading

Heart failure by ejection fraction (universal definition 2021)

• Reduced EF: 40% or less.
• Mildly reduced EF: 41–49%.
• Preserved EF: 50% or more (stiff ventricle that fills poorly).

NYHA functional classes (3 marks in S21)

Valve lesions and their murmurs

3Causes and risk factors

• Valve disease: rheumatic fever (poverty, crowding, untreated sore throats), age-related calcification (aortic stenosis), infective endocarditis, congenital (bicuspid aortic valve), heart attack damaging the mitral support.
• Heart failure: coronary disease and MI, hypertension, valve disease, cardiomyopathy, arrhythmias, diabetes, alcohol, some chemotherapy.
• Cardiomyopathy: genetic, viral myocarditis, alcohol, pregnancy (peripartum), unknown.
• Pacemaker: slow heart rhythms (heart block, sick sinus syndrome). ICD: survivors of cardiac arrest, or people at high risk (for example EF 35% or less with heart failure symptoms despite treatment).

Rheumatic fever (Jones criteria): major features are carditis, migrating polyarthritis, chorea, a ring-shaped rash (erythema marginatum) and nodules under the skin; minor features are joint pain, fever, raised inflammatory markers and a prolonged PR interval.

4Pathophysiology to impairments

1. The weak or overloaded heart cannot raise its output with exercise, so muscles get less oxygen: fatigue and low exercise tolerance.
2. Back-pressure into the lungs causes breathlessness, worse lying flat (orthopnoea) and at night; back-pressure into the body causes leg oedema and an enlarged liver.
3. The body retains salt and water to compensate, which worsens congestion.
4. Skeletal muscles weaken and change (fewer mitochondria), so even daily tasks become hard: the main target of exercise training.
5. Arrhythmias (AF, ventricular tachycardia) cause palpitations, stroke risk and sudden death.

5Clinical features

• Breathlessness on exertion, orthopnoea, waking breathless at night; fatigue; ankle swelling; weight gain from fluid.
• Fast pulse, low BP in advanced disease, raised neck veins, basal crackles, third heart sound.
• Valve disease: murmurs, palpitations (AF), fainting on exertion (aortic stenosis), coughing blood (mitral stenosis).

6Investigations

• Echocardiogram: EF, valve area and gradients, chamber size (the key test).
• ECG: rhythm (AF), conduction blocks, ventricular hypertrophy; Holter monitoring.
• Chest X-ray: large heart, pulmonary congestion, effusions; mitral stenosis shows a large left atrium.
• BNP or NT-proBNP: raised in heart failure.
• Exercise test or CPET: peak oxygen uptake, safe exercise range (not in symptomatic severe aortic stenosis).
• INR for patients on warfarin (mechanical valves, AF).

7Medical and surgical management

• Heart failure with reduced EF: four main drug groups (ACE inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid antagonist, SGLT2 inhibitor), diuretics for congestion; devices (ICD, cardiac resynchronisation therapy); exercise training.
• Rheumatic heart disease: regular benzathine penicillin injections to prevent recurrence; balloon mitral valvotomy; valve repair or replacement.
• Valve replacement: mechanical (lifelong warfarin) or tissue valve; open surgery via sternotomy or catheter valve (TAVI for aortic stenosis).
• Pacemaker or ICD: implanted under the skin below the collarbone (usually left), with leads passed through a vein into the heart.

8Complications

• Acute pulmonary oedema, arrhythmias, stroke (AF), sudden death, kidney impairment.
• Valve: infective endocarditis, valve thrombosis, bleeding on warfarin.
• Device: lead displacement (early, from arm movement), pocket haematoma or infection, pneumothorax at insertion, inappropriate ICD shocks, anxiety after shocks.

9PT assessment

• Diagnosis, EF, NYHA class, medicines, device type and settings (pacing mode, rate-response, ICD detection rate), recent shocks.
• Symptoms at rest and on exertion; daily weight trend; oedema; orthopnoea.
• HR and rhythm, BP, SpO₂, RR at rest and with activity; auscultation for crackles.
• Wound and shoulder range on the device side.
• Exercise capacity (6MWT with Borg), muscle strength, function.
• Outcome measures: 6MWT, NYHA class, Minnesota Living with Heart Failure or Kansas City Cardiomyopathy Questionnaire, HADS.

10PT diagnosis by ICF

Worked example from a real paper (S22, 15 marks)

"A 34 year old female school teacher is proposed for pacemaker and intracardiac defibrillator following cardiomyopathy. What would be pre-operative and post-implantation assessment and physiotherapy management?"

11Goals

• Short-term (first 4–6 weeks): wound healed; no lead displacement; shoulder kept mobile below shoulder height; walking daily; knows device precautions and shock plan.
• Long-term (3 months): full shoulder range; better 6MWT and NYHA class; regular exercise below the ICD detection rate; back to teaching.

12PT management

Pre-implantation

• Assessment as in section 9; baseline shoulder range and 6MWT if stable.
• Education: what the device does, arm precautions after implantation, what to do if the ICD shocks.
• Breathing exercises and early mobilisation plan; reduce anxiety.

Post-implantation

• First 4–6 weeks: no lifting of the device-side arm above shoulder height and no heavy lifting with that arm, so the leads can fix in place. Gentle active movement of the shoulder below shoulder height, elbow, wrist and hand from day 1 to prevent a stiff shoulder.
• Early walking from the day after implantation; breathing exercises.
• After 4–6 weeks: restore full shoulder range; start structured exercise training.

Exercise training in heart failure and cardiomyopathy

• Exercise training is recommended for all stable heart failure patients who can exercise (ESC 2021, Class I): it improves exercise capacity and quality of life and reduces hospital admissions.
• Aerobic: walking or cycling, 3–5 days a week, building to 20–60 minutes; start low (RPE 11–13), progress slowly; interval training suits low-fitness patients.
• Resistance: light loads, 2–3 days a week, 10–15 repetitions, breathe out on effort.
• Inspiratory muscle training for weak breathing muscles.
• With an ICD: keep training heart rate at least 10 beats below the ICD's programmed detection rate (ask the device clinic for the setting).
• With a pacemaker: if the heart rate cannot rise (chronotropic incompetence) or the device is fixed-rate, use RPE and BP to guide intensity.
• Valve disease: moderate exercise in mild to moderate lesions; no exercise training in symptomatic severe aortic stenosis until it is treated; after valve surgery follow the CABG sternotomy plan.

Cardiac rehab after valve replacement (7 marks in W21)

Valve surgery is usually through a median sternotomy, so Phase I follows the CABG plan (sternal precautions, breathing exercises, early walking). Add these valve-specific points:

• Mechanical valve: lifelong warfarin with regular INR checks. Bruising and bleeding are easy, so handle gently, prevent falls, avoid contact sports and vigorous percussion, and report any bleeding.
• Infective endocarditis: keep teeth and skin healthy; report fever, night sweats or new breathlessness early.
• Mitral valve disease often leaves pulmonary hypertension and atrial fibrillation: progress more slowly.
• Transcatheter valve (TAVI): no sternotomy, so no sternal precautions; older, frailer patients; groin-puncture care; walk within a day and follow the same Phase 2 plan.

If the ICD shocks

• Stop, sit or lie down.
• One shock and feeling well: inform the device clinic.
• More than one shock, or feeling unwell (chest pain, breathlessness, fainting): call emergency services.

13Precautions and contraindications

• Warfarin: gentle handling; avoid vigorous manual techniques.
• Hypertrophic cardiomyopathy: avoid dehydration and very heavy straining; exercise plans are individual.

14Education

• Weigh yourself every morning; report a sudden gain.
• Follow salt and fluid advice; take medicines regularly.
• Keep active every day within your plan.
• Rheumatic heart disease: never miss penicillin injections; keep teeth healthy.
• Device: carry the device card; keep mobile phones away from the device pocket; tell staff before any procedure; follow driving rules after ICD implantation.

15Prognosis

Modern drugs and devices have greatly improved survival in heart failure. Exercise training improves symptoms and quality of life. Valve disease has a good outlook when treated before the heart muscle is damaged.

16Exam corner

• S22 Q4(a), 15 marksThe worked example in section 10.
• S21 Q1(f), 3 marksGrades of NYHA scale.
• W21 Q2(d), 7 marksPhase 1 and 2 of cardiac rehabilitation after valve replacement (see section 12).
• RelatedS20 Q4(a): stable angina with EF 25% (see the IHD page).

Technique cards for this topic: exercise testing, scales, exercise physiology, cardiac rehabilitation, cardiac drugs.

Keywords to underline

NYHA I–IV EF 40% or less exercise training Class I interval training 4–6 weeks arm restriction 10 beats below ICD detection rate no diathermy daily weights severe aortic stenosis