Cardiovascular Disease in Primary Care, external

Cardiovascular Diseases in Primary Care: 

Cardiovascular Diseases in Primary Care Hypertension, Heart Failure, Dyslipidemia, and Atrial Fibrillation Christine de Belen-Wilson, FNP 1

Hypertension in the Primary Care Setting by Christine de Belen-Wilson, FNP: 

Hypertension in the Primary Care Setting by Christine de Belen-Wilson, FNP Goals Who, what, why, and how of hypertension Case Scenarios 2

Hypertension- Case Scenario: 

Hypertension- Case Scenario Case #1 : M.A. is a 53 y/o male who was told @ a heatlh fair that his b/p was 150/90. At his 2 nd clinic visit, b/p was 143/92, his 3 rd visit, 162/93. How will you manage this patient? What healthcare maintenance will he need, if he has not had any? Case #2 : O.F. is a 62 y/o female diabetic and hypertensive patient. She’s on HCTZ (hydrochlorothiazide) 25 mg tab daily and lisinopril 20 mg daily. She comes to see you for a same day visit because she had severe toe pain. Case#3: R.N. is a 16 y/o female who is obese (BMI of 34). For a year of monitoring her blood pressures, it has always been 120-130/high 80s. After 3 separate b/p readings of 140s/90s, you diagnose her with hypertension. What is your first step in managing this young patient? 3

Hypertension- What is it?: 

Hypertension- What is it? The force per unit exerted on the wall of a blood vessel by its contained blood (expressed in mm HG). Simply put, the blood pressure is, “the pumping action of the heart generating blood flow and the pressure results when flow is opposed by resistance.” Main factors that influence blood pressure are cardiac output, peripheral resistance, and blood volume BLOOD PRESSURE= Cardiac Output X Peripheral Resistance How do we define hypertension? Norma l is less than 120/80 Pre-HTN 120-139 &/or 80-89 Stage 1 140-159 &/or 90-99 Stage 2 ≥ 160 &/ or ≥100 Exceptions : one episode >220/125, asymptomatic HTN emergency & end organ damage What is blood pressure?

Hypertension- What are the END-ORGAN consequences in the body?: 

Hypertension- What are the END-ORGAN consequences in the body? Stroke Retinopathy Heart Failure, aortic dissection Kidney disease 5

Hypertension- Who & Why?: 

Hypertension- Who & Why? Who does it affect? 66 million Americans have elevated blood pressures (Systolic ≥140 or diastolic ≥90) The prevalence of hypertension increases with age. Why is it important? Hypertension plays a major role in causing heart failure and end stage kidney disease. The consequences of hypertension is the leading cause of death in the world It is the most easily recognized, treatable risk factor for Stroke/MI/Heart Failure/Aortic Dissection Atrial Fibrillation, and End Stage Kidney Disease 6

Hypertension- What are the challenges?: 

Hypertension- What are the challenges? Asymptomatic Cannot be cured Treatment itself may be problematic Necessary active patient involvement 7

Benefits of Lowering BP: 

Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% 8

Hypertension- Primary vs. Secondary: 

Hypertension- Primary vs. Secondary Primary 95% of hypertensive patients Single cause cannot be identified However, identifiable behaviors, genetics, and environmental factors play a role. Onset usually between ages 25 and 55 years. (Uncommon before age 20 years). Secondary 5% of hypertensive patients Identifiable cause- neural, hormonal, and vascular mechanisms Most common cause of Chronic Kidney Disease (CKD). Onset early age (before 25 years), consider in patients w/ refractory HTN 9

Identifiable Causes of Hypertension: 

Identifiable Causes of Hypertension Sleep apnea Drug-induced or related causes Chronic kidney disease Primary hyperaldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease 10

Hypertension: What are some tests to consider?: 

Hypertension: What are some tests to consider? Cause Initial diagnostic tests or findings Sleep Apnea Sleep study Chronic Kidney Disease, Renal Vascular Disease Renal function panel, Renal ultrasound or CT or MRA (to r/o renal artery stenosis) Primary Hyperaldosteronism : ** (Suspect w/ resistant HTN, & ↓K+ (not on diuretic or ↓↓ ↓K+ (on a diuretic).** PRA (plasma renin activity), renin:angiotensin ratio (HOLD diuretics, ACE-I, ARB, Bblockers , clonidine a week before blood tests). Use CCB instead CT or MRI- adrenals Cushing s Syndrome Dexamethasone suppression test Thyroid or parathyroid disease TSH, ionized calcium, PTH Coarctation of the Aorta Echocardiogram, or CT or MRI Pheochromocytoma ED or 911 STAT! 11

Hypertension-How to diagnose it?: 

Hypertension-How to diagnose it? Elevated blood pressure readings on 3 separate occasions within 6 months. (SBP≥ 140 &/or DBP ≥90) Major exception (one episode): Patient with severe hypertension and target organ damage (hypertensive emergency), or hypertensive urgency (>220/125, no target-organ damage). 50% of Pre-hypertensive patients will develop hypertension in 4 years- Monitor annually. 12

Office BP Measurement: 

Office BP Measurement Use auscultatory method with a properly calibrated and validated instrument. Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. Appropriate-sized cuff should be used to ensure accuracy. At least two measurements should be made. Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals. 13

Hypertension-What are possible signs/symptoms (mild/moderate vs. severe)?: 

Hypertension- What are possible signs/symptoms (mild/moderate vs. severe)? 14

Hypertension-What areas of the Physical Exam do you want to focus on?: 

Hypertension- What areas of the Physical Exam do you want to focus on? VITAL SIGNS: blood pressure, pulse, respirations HEENT : funduscopic (A/V nicking, exudate, cotton wool spots= retinopathy), neck veins (JVP=CHF), carotid arteries (bruits=stenosis), thyroid CARDIOVASCULAR : S4 & displaced PMI (LVH), S3 gallop (CHF) RESPIRATORY: crackles (CHF) ABDOMEN: bruits (aneurysm or renal artery stenosis), widened aortic pulsation (AAA) EXTREMITIES : peripheral edema (CHF), peripheral pulses ( diminshed = PAD), (radial-femoral delay pulses= coarctation of aorta ) NEUROLOGICAL: unilateral weakness, facial droop, slurred speech (signs of TIA, CVA), mental status change ( htn encephalopathy) → HYPERTENSIVE EMERGENCY 15

Hypertension- Retinopathy: 

Hypertension- Retinopathy 16

Hypertension-What laboratory & diagnostic studies to consider?: 

Hypertension- What laboratory & diagnostic studies to consider? Laboratory Urinanalysis (for hematuria, proteinuria, or casts=CKD), urine microalbumin (early signs of CKD) Hemoglobin Electrolytes, uric acid Glucose level Lipid panel Diagnostic EKG -highly specific (true -) but not sensitive (true +) for LVH Echocardiogram - consider when symptomatic, concern for CHF, or valvular disorder Other diagnostic tests -urine cortisol, plasma metanephrines , aldosterone/renin ratio, renal u/s or ct , or renal arteriography. Consider when thinking seconday htn , or resistant htn (At this point you are consulting with your collaborating physician, or refer to a cardiologist) 17

Treatment Overview: 

Treatment Overview Goals of therapy- Reduce CVD and renal morbidity and mortality Treat to <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease Achieve SBP goal especially in persons > 50 years of age Lifestyle modification Pharmacologic treatment Followup and monitoring 18

Hypertension- What treatments are available?: 

Hypertension- What treatments are available? INITIAL TREATMENT Diuretics ( thiazide, hctz ,/ loop, furosemide) Beta Blocker ( carvdilol , metoprolol ) Ace Inhibitor ( lisinopril , benazepril) ARB (angiotensin receptor blocker) (valsartan, losartan) Calcium Channel Blockers diyhydropyridine amlodopine / non- dyhydropyridine , dilitiazem , verapamil) ADDITIONALTREATMENT Aldosterone Antagonist ( K+ sparing diuretic , spironolactone ) Alpha-Blockers (terazosin, doxasosin ) Central Sympathomimetics (clonidine, methyldopa) Direct Vasodilators (hydralazine, minoxidil ) 19

Algorithm for Treatment of Hypertension: 

Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP > 160 or DBP > 100 m mHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. 20

Hypertension-Which drug to use based on patient’s medical condition?: 

Hypertension- Which drug to use based on patient’s medical condition? Medical Condition Diuretic BB Blocker ACE-I ARB CCB Aldosterone Antagonist Heart Failure X X X X X Post MI X X X CAD risk X X X X Diabetes X X X X X Chronic Kidney Disease X X Stroke Prevention X X 21

Hypertension- How do the Medications work? What are treatment considerations?: 

Hypertension- How do the Medications work? What are treatment considerations? Quick Mechanism of Action Treatment Considerations Diuretics: Decreases blood volume, decreases peripheral vascular resistance Electrolyte imbalances and volume depletion (especially with loop). Monitor K+ for hypokalemia, baseline uric acid (↑risk gout flare) Beta Blockers: Decrease heart rate & cardiac output Caution with asthma or COPD (choose cardio-selective BB). Possible fatigue, lethargy & erectile dysfunction. Good with CHF patients. Good w/ CAD patients. Avoid abrupt withdrawal. ACE: Angiotensin Converting Enzyme Inhibitors : Inhibits the RAAS system Special populations : In blacks, elderly, pts w/ predominantly ↑SBP = less effective as monotherapy . Better w/combo therapy. In childbearing women, ensure proper birth control. Cat. D- poss. Teratogenecity ! Contraindicated in renal artery stenosis and hypovolemia . Monitor Cr & K+, dry cough, angioedema. ARB:Angiotensin II receptor blockers: similar process as ACE-I Contraindicated in renal artery stenosis and hypovolemia . Monitor Cr & K+, When combined w/ ACE-I, better control, and protect heart & kidneys. Calcium channel blockers: acts as an anti-arrhythmic, anti- anginal , and anti- htn Dihydropyridines can cause LE edema. Non- dyhropyridines increases contractility- use cautiously w/ beta blockers. CVA protective. Aldosterone antagonists: ( spironalactone , K+ sparing diuretic) decreases blood volume Not neccesarily 1 st line tx , but good as adjunct. Can cause breast pain or gynecomastia in men. Montor Cr & K+ for hyperkalemia. Other Treatments Review CURRENT 2012 for details, consider 2° causes, consult with collaborating MD or refer to cardiologist. 22

Hypertension- How will you manage this?: 

Hypertension- How will you manage this? Case #1 : M.A. is newly diagnosed with hypertension. What medication will you start him on? What baseline labs would you order? What healthcare maintenance is due? Case #2 : O.F. has diabetes & hypertension (on HCTZ & lisinopril ), has toe pain. What should you consider? What are other possible medications to treat her hypertension? What healthcare maintenance is due ? Case#3: R.N. is a 16 y/o female with newly diagnosed hypertension. What is your first step in managing this young patient? 23

Hypertension-When to Consult &/or Refer?: 

Hypertension-When to Consult &/or Refer? Patients with severe, resistant, or early onset of hypertension. When you are considering that the elevated blood pressure is likely a secondary hypertension. Severe hypertension or hypertension emergency or with possible target organ damage (symptomatic patients). Of course, consult with your collaborating physician when in doubt! 24

Hypertension-Things to Consider: 

Hypertension- Things to Consider Non-adherence to B/P meds is common. Usually cause of resistant HTN. Need patient “buy-in”. Education is paramount. Six months is a good trial period for patients reluctant to initiate Rx, and want to try lifestyle modification . Refractory or Resistant hypertension likely a result of medication non-adherence. If patient is compliant, consider secondary causes. Many patients will require 2-3 agents for good B/P control. Recheck B/P in a month after Rx changes. Any B/P ↑ from a pregnant woman’s pre-pregnancy baseline warrants timely evaluation/consultation. ACE-I/ARBs is a Category D- women of childbearing age need to be on a reliable form of birth control or change the med. Use the Framingham Scoring System to assess risk for coronary artery disease. 25

Hypertension-Wrap Up: 

Hypertension-Wrap Up Diagnose with 3 isolated elevated blood pressures readings ≥140/90 for diagnosis of hypertension within 6 months. Monitor pre-hypertensive patients yearly- they have 50% chance of devloping hypertension within 4 years. Treat to prevent target-organ damage - to brain, eyes, heart, kidneys. Remember to review potential side effects and do routine surveillance labs. * Always check for potential drug-drug interactions !!* Consider work up of secondary hypertension & refer to cardiology When in doubt consult &/or refer 26

References:: 

References: www.nhlbi.nih.gov/guidelines/hypertension/jnc7 Current 2012 : Mcphee & Papadakis Primary Care: The Art & Science of Advance Practice Nursing : Dunphy , Winland -Brown, Porter, & Thomas Cecil Medicine 23 rd edition: Goldman & Ausiello Pathophysiology 23 rd edition: McCance & Huether Human Anatomy/Physiology 3 rd edition: Marieb Extremely Elevated Blood Pressures: An update on hypertensive urgencies & emergencies: Consultant, Wright, Adams, Varela, Nesmith, & Rutecki Prescriber’s letter-2011 27

Dyslipidemia in the Primary Care Setting by Christine de Belen-Wilson, FNP: 

Dyslipidemia in the Primary Care Setting by Christine de Belen-Wilson, FNP Goals Who, what, why, and how Case Scenarios 28

PowerPoint Presentation: 

29 1 out of 3 women will die of heart disease WHAT IS YOUR ROLE?

Dyslipidemia- Case Scenarios: 

Dyslipidemia- Case Scenarios Case # 1: M.A. 53 y/o ( htn pt ), non-smoker, no family history of significant CHD (coronary heart disease), BMI=32. You ordered baseline lipid panel. These are his numbers: Total Chol:232, LDL:130, HDL:36, B/P:138/86. Will you start a lipid-lowering agent? Case # 2: O.F. 62 y/o ( dm pt ), non-smoker, no family history of significant CHD, BMI=28. You ordered lipid panel: These are her numbers: Total Chol:156, LDL:147, HDL:45, B/P:142/88. Will you start a lipid lowering agent? Case #3 : M.M. is 38 y/o female, otherwise healthy, non-smoker, no family history of CHD, BMI=37. You ordered lipid panel: There are her numbers: Total Chol:268, LDL:127, HDL:35, B/P:118/60 . Will you start a lipid lowering agent? 30

Dyslipidemia- What are lipids?: 

Dyslipidemia- What are lipids ? LIPIDS-help manufacture & repair plasma membranes, produce steroid hormones LIPOPROTEINS-lipids, cholesterol, triglyceride. HDL is cardioprotective Low HDL in women is an important risk factor for CHD, than High LDL LDL is associated with CHD TRIGLYCERIDES- fatty substances in the blood. Role of isolated hypertriglyceridemia (normal cholesterol, but ↑ triglycerides) is unclear. May be a marker for insulin resistance (risk of DM) 31

Dyslipidemia- What does it to the body?: 

Dyslipidemia- What does it to the body? 32

Dyslipidemia- Who & Why?: 

Dyslipidemia- Who & Why? Who does it affect? Primary Cause: Genetic Secondary Causes: Obesity Lifestyle Sedentary Alcohol use Diseases DM, Kidney dz , Hypo/hyper thyroidism , Liver dz , Cushings dz Drugs Diuretics, Bblockers , OCPs, antipsychotics Why is it important? Major risk factor for CHD → Heart attack (MI) or Stroke (CVA) 33

ATP III - Major Risk Factors for CHD or CVA : 

ATP III - Major Risk Factors for CHD or CVA Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/ dL ) † Family history of premature CHD CHD in male first degree relative <55 years CHD in female first degree relative <65 years Age > 45 y/o for men / > 55 y/o for women † HDL cholesterol 60 mg/ dL counts as a “negative” risk factor; its presence removes one risk factor from the total count. 34

ATP III- CHD Risk Equivalents: 

ATP III- CHD Risk Equivalents Diabetes is considered a CHD risk equivalent Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease ) Multiple risk factors that confer a 10-year risk for CHD ≥20 % 35

ATP III- Risk Assessment- Use Framingham Scoring System to calculate CHD risk: 

ATP III- Risk Assessment- Use Framingham Scoring System to calculate CHD risk Count major risk factors For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 0–1 risk factor 10 year risk assessment not required Most patients have 10-year risk <10% 36

PowerPoint Presentation: 

37 FRAMINGHAM RISK ASSESSMENT : MEN/WOMEN

PowerPoint Presentation: 

38 Framingham Score Sheet for Women

PowerPoint Presentation: 

39

Dyslipidemia- What will we see on physical exam?: 

Dyslipidemia- What will we see on physical exam? Likely asymptomatic and no clinical signs on exam. However, may see xanthomas . 40

Dyslipidemia-How to diagnose it?: 

Dyslipidemia- How to diagnose it? ATP III New Recommendation for Screening/Detection Complete lipoprotein profile preferred Fasting total cholesterol, LDL, HDL, triglycerides Secondary option Non-fasting total cholesterol and HDL Proceed to lipoprotein profile if TC  200 mg/ dL or HDL <40 mg/ dL 41

Dyslipidemia- How do we treat it?: 

Dyslipidemia- How do we treat it? Non-Pharmacological Tx Lifestyle Modification s moking cessation ↓ weight ↓ dietary cholesterol <200 ↓ saturated fat ↑ soluble fiber (bran, oat bran, psyllium ) Medication Tx Statins - atorvastatin, simvastatin Niacin -niacin otc , or niaspan Fibric Acid derivatives - gemfibrozil Ezetmibe -Zetia Bile Acid Binding Resins - cholestyramine , colesevelam ( welchol ) 42

Dyslipidemia- How do the Medications work? What are treatment considerations?: 

Dyslipidemia- How do the Medications work? What are treatment considerations? Quick Mechanism of Action Treatment Considerations Statins - helps ↓ cholesterol synthesis in the liver (simvastatin, pravastatin) ↓ MI and ↓CVA , good for 2° prevention, ↑ HDL, ↓ triglycerides. S/ fx : myalgias , mild GI sx . Serious s/ fx : are rhabdomyolysis , liver failure. Consider LFT, CPK. Niacin (nicotinic acid)- ↓ VLDL particles ( niaspan ) ↑ HDL, ↓ triglycerides. Full dose needed to affect LDL, but some cannot tolerate the flushing s/ fx . Aspirin 8- 325mg may help with this. May exacerbate gout or PUD (peptic ulcer dz ) Fibric Acid derivatives- ( gemfibrozil ) ↑ HDL, ↓ triglycerides. S/ fx : cholelithiasis , hepatitis, myositis (caution with rhabdomyolysis esp. when using combo) Ezetimibe - ↓ dietary & biliary cholesterol by blocking a cholesterol transporter. Can combine well with statin to help reach LDL goal. Long-term safety unknown. Bile Acid-binding Resins - Binds bile acids in the intestine ( welchol ) ↓ coronary event, but no effect on total mortality. Don’t use in ≥ 500 triglycerides. S/ fx : Gi related gas & constipation 43 See CURRENT 2012, p.1223-Table 28-4: on effects on LDL, HDL, triglycerides, dosing, & price of medication

ATP III- LDL Goals Therapeutic Lifestyle Changes (TLC) and Drug Treatment in Different Risk Categories: 

ATP III- LDL Goals Therapeutic Lifestyle Changes (TLC) and Drug Treatment in Different Risk Categories Risk Category LDL Goal (mg/ dL ) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Level at Which to Consider Drug Therapy (mg/dL) CHD or CHD Risk Equivalents (10-year risk >20%) <100 100 130 (100–129: drug optional) 2+ Risk Factors (10-year risk 20%) <130 130 10-year risk 10–20%: 130 10-year risk <10%: 160 0–1 Risk Factor <160 160 190 (160–189: LDL-lowering drug optional)

Dyslipidemia-When to Refer?: 

Dyslipidemia-When to Refer? Patients with known genetic lipid disorders Failing standard treatment (not reaching target goals) despite patient compliance to medications When in doubt consult with collaborating physician &/ or refer 45

Dyslipidemia- Things to consider: 

Dyslipidemia- Things to consider Start with a statin , but remember to look @ safety monitoring/contraindications/side-effects, avoid use with fibrates ( gemfibrozil ), & avoid at high doses due to higher risk of rhabdomyolysis . Extremely ↑ triglycerides ≥ 1000 , can cause pancreatitis. ↑ triglycerides can clue us to uncontrolled diabetes, hypothyroidism. Fish oils may be a good adjunct treatment with patients with very elevated triglycerides (anti-inflammatory properties) Rhabdomyolysis is rare, however, may occur with concurrent drugs (other lipid lowering drugs, oral anti-fungal, certain antibiotics). Therefore, important to check drug-drug interactions ! 46

Dyslipidemia-Wrap up: 

Dyslipidemia-Wrap up Review ATP III guidelines- see link Always risk stratify patients with Framingham Score System to determine their risk for Coronary Artery Event Diabetes, PAD (Peripheral Artery Disease) are CHD risk equivalents . Really should be on a lipid-lowering agent (plus, aspirin if no contraindication ). Get to know one type of medication in each class of lipid lowering agents. Remember, even with high cholesterol levels, not everyone needs a statin or lipid-lowering agent automatically. 47

References: 

References www.nhlbi.nih.gov/guidelines/cholesterol/atpIII Current 2012 : Mcphee & Papadakis Primary Care: The Art & Science of Advance Practice Nursing : Dunphy , Winland -Brown, Porter, & Thomas Cecil Medicine 23 rd edition: Goldman & Ausiello Pathophysiology 23 rd edition: McCance & Huether Human Anatomy/Physiology 3 rd edition: Marieb 48

Congestive Heart Failure in the Primary Care Setting by Christine de Belen-Wilson, FNP: 

Congestive Heart Failure in the Primary Care Setting by Christine de Belen-Wilson, FNP Goals Who, what, why, and how Case Scenario 49

CHF-Case Scenario: 

CHF-Case Scenario Case #1 : L.T. is a 57 y/o female, new to your clinic. She has a history of hypertension, coronary artery disease, and COPD. She comes to your clinic with complaints of increasing shortness of breath with activity and noticeable swelling in her legs. What other questions do you want to ask her in the Subjective component? What part of the physical is important to assess? What labs/diagnostics are you thinking of ordering? What medications/treatments are you going to start? Why? What will you educate her on? When do you want her to follow-up with you? 50

CHF - What is it?: 

CHF - What is it? Heart Failure is the heart pump failing to pump efficiently → low cardiac output → low blood circulation → can’t meet body’s needs . Progressive, worsening condition 51

CHF- What does it do to the body?: 

CHF- What does it do to the body? Causes weak myocardium Leads to: Coronary athersclerosis Persistent hypertension Multiple myocardial infarctions Cardiomyopathy (ventricles become stretched & flabby) 52

CHF- How do we define it?: 

CHF- How do we define it? Left Ventricular Failure Dyspnea on exertion Cough Fatigue Orthopnea Paroxysmal Nocturnal dyspnea Cardiac enlargement Rales /Crackles Gallop rhythm Pulmonary venous congestion Right Ventricular Failure Elevated venous pressure Hepatomegaly Dependent edema Usually due to LV failure 53

CHF- How do we define it?: 

CHF- How do we define it? Systolic Dysfunction Contractile problem Ischemic damage/dysfunction MI , or shock Hypertension C hronic pressure &/or voume overload . Valvular disease Intra-cardiac shunting Non-ischemic cardiomyopathy Diastolic Dysfunction May be difficult to differentiate with systolic dysfunction (S/ Sx : dyspnea on exertion, fatigue) Stiffness, decreased filling ↑ age Hypertension Genetic abnormalities, sarcoidosis Valvular disorders, arrhythmias Pulmonary vascular disorders Metabolic disorders, thyroid issues Chronic anemia (2° excessive blood flow requirements) 54

CHF- Why is it important?: 

CHF- Why is it important? 5 million patients in the US with HF, nearly a half-million new cases each year. It is primarily a disease of aging. However, this may be changing. Poor prognosis- 5 year mortality rates is approximately 50% (However, it varies from <5% per year w/ patients w/ no or few symptoms to >30% per year w/ severe disease). What is your role? Early detection & treatment 55

CHF- Who does it affect? Who’s at risk?: 

CHF- Who does it affect? Who’s at risk? Advancing Age Hypertension Diabetes Dyslipidemia Obesity Conditions causing myocardial necrosis, chronic pressure, or volume overload Others: cocaine, ETOH 56

CHF- What History questions do you want to ask? (Patient Symptoms) : 

CHF- What History questions do you want to ask ? (Patient Symptoms) Shortness of breath (SOB) → Dyspnea on exertion (DOE) → Orthopnea →Paroxysmal Nocturnal Dyspnea (PND) → Rest Dyspnea Chronic Non-productive Cough, worse in recumbent position (lying down) Nocturia , voiding at night from daytime fluid retention and ↑ renal perfusion in recumbent position. Fatigue/Exercise Intolerance Right HF, Signs of Fluid Retention Edema Hepatic congestion, ascites CHF exacerbations - worsening of these symptoms. 57

CHF- NYHA Classification System: 

CHF- NYHA Classification System Class 1 – Asymptomatic Class 2 – Symptomatic with moderate activity Class 3 - Symptomatic with mild activity Class 4 – Symptomatic at rest 58

CHF- What might we see on physical exam?: 

CHF- What might we see on physical exam? GEN : Maybe asymptomatic at rest or dyspneic during conversation or with minor activity Vital Signs : Maybe normal, or tachycardic , hypotensive, or hypertensive Skin: Possibly c achetic or cyanotic, cold extremities, diaphoretic HEENT : jugular venous distension, thyroid ( √ for thyroid dz as underlying cause to HF) CARDIAC : S3 gallop or S4, parasternal heave/lift, possible murmur (√ for underlying valve dz ) RESPIRATORY : Crackles/ rales /rhonchi (usually bilateral) ABDOMEN: hepatic congestion, ascites EXTREMITIES: peripheral pitting edema 59

CHF- How do we diagnose it?: 

CHF- How do we diagnose it? Laborotary Utility of BNP Helpful in acute settings (ER) Helpful in assessing response to treatment Baseline/Surveillance CBC Renal function Electrolytes Thyroid (TSH) Diagnostics EKG & Chest Xray EKG may reveal underlying arrhythmia, prior MI CXR may reveal cardiomegaly (poor prognosis) Echocardiogram Gold Standard Reveals size & function of both ventricles & the atria. 60 Be suspicious in patients with high risk factors

CHF- What are the goals of treatment?: 

CHF- What are the goals of treatment? Delay progression of disease (Stage A & B) Relief of symptoms A voidance of hospital admissions Prevent premature death 61

PowerPoint Presentation: 

62 ACC/AHA 2005 Guidelines for Evaluation & Treatment of CHF See CURRENT 2012, p. 389, Figure 10-1

CHF- Medications & Treatment considerations: 

CHF- Medications & Treatment considerations Mechanism of Action Treatment Considerations Diuretics ( thiazide, HCTZ, metolazone ) or Loop ( furosemide ) - ↓ preload Should be 1 st line tx (w/ ace-I). ↓↓ sx , but doesn’t improve morbidity/mortality Goal-is edema free state Cons - electrolyte imbalance (monitor Cr, K), uric acid for gout flare up risk. Start w/ thiazide for mild edema, loop with severe sx . ACE-I/ARB ( lisinopril / losartan ) - ↓ LV size Should be 1 st line if no contraindications . Contraindicated in renal artery stenosis. ↓ hosp. admissions, ↑ mortality, ↓ s/x Monitor Cr, K+, uric acid, hypotension, ace-I cough, severe hypotension (start low, go slow) Beta Blockers ( carvdilol , metoprolol )- ↑ EF, ↓LV size & mass 1 st line tx for those w/ CAD for stable pts (d/c temporarily if in chf exac ). Start low & go slow. ↑ dose 1-4 weeks. Monitor for poss. CHF exac , ↑ wt , sx . (can use w/ diuretic, ACE-I) CCB- ( Avoid verapamil, diltiazem ) 1 st gen. CCB worsened CHF. Amlodopine may be safer if needed to tx HTN. Spironolactone -↑ excretion of Na+ Monitor K+ (hyperkalemia). Can combine with loop or thiazide diuretics. However, monitor for extreme diuresis. Vasodilators (nitrates ( isosorbide ) , hydralazine )- ↓ venous return, ↓ preload & ↓ afterload Nitrates relieve SOB, but pt may develop nitrate-tolerance. Caution hypotension . Hydralazine ↑survival in blacks, ↓ hosp. admissions. s/ fx , GI probs , h/a, tachycardia, hypotension. 63

CHF-When to refer?: 

CHF-When to refer? New CHF symptoms without obvious cause Failing standard treatments For concerns/questions/issues 64

CHF- Things to Consider: 

CHF- Things to Consider Start med tx with thiazide diuretic ( hctz ), ace-I ( lisinopril ) or ARB (losartan) for mild to moderate sx . Then work your way up the ACC/AHA 2005 CHF algorithym . 1 st generation CCB (verapamil or diltiazem ), thiazolidiones ( Actos ), NSAIDS can worsen HF Consider hydralazine in black patients since it ↑ survival Education regarding excess sodium and fluid intake 65

CHF- Wrap up: 

CHF- Wrap up Always be suspicious of possible CHF in patients with high risk factors Remember, a lingering non-productive cough can be a signal pointing you to CHF in a patient w/ high risk factors When in doubt, consult with collaborating physician &/or refer to cardiologist. 66

References: 

References Current 2012 : Mcphee & Papadakis Primary Care: The Art & Science of Advance Practice Nursing : Dunphy , Winland -Brown, Porter, & Thomas Cecil Medicine 23 rd edition: Goldman & Ausiello Pathophysiology 23 rd edition: McCance & Huether Human Anatomy/Physiology 3 rd edition: Marieb 67

Atrial Fibrillation in the Primary Care Setting by Christine de Belen-Wilson, FNP: 

Atrial Fibrillation in the Primary Care Setting by Christine de Belen-Wilson, FNP Goals Who, what, why, and how Case Scenarios 68

AFib- Case Scenarios: 

AFib - Case Scenarios Case #1 : F.J. is a 68 y/o male, he hasn’t had medical care for the last decade because he’s a traveling musician. He’s establishing care with you. His only complaint is feeling fatigued. During your physical exam you notice: b/p 164/92, hr , 104 and a very irregularly irregular rhythm. What will you do next? How will you manage this patient? Case #2: L.O. is a 83 y/o female, has well-controlled hypertension. She is independent in all activities of daily life, uses a walker because of a few mechanical falls (secondary to chronic pain & associated weakness). On physical exam: b/p is 122/84, hr 86, and a very irregularly irregular rhythm. What will you do next? How will you manage this patient? 69

AFib- What is it?: 

AFib - What is it? Loss of the “atrial kick” along with rapid ventricular rate R apid & disorganized electrical signals → atria to fibrillate (quiver) AFIB► atria & ventricles don’t work together→ ↓ cardiac output→ stasis of blood, left atrium → thrombi → Stroke 70

Afib- Who does it affect? Who’s at Risk?: 

Afib - Who does it affect? Who’s at Risk? Most common chronic arrhythmia Risk Factors: Advancing Age Hypertension Congestive heart failure / cardiomyopathy Ischemia (like past MI) Hyperthyroidism Mitral valve disease Genetics Obesity Acute, Excessive alcohol & withdrawal Other: chest trauma, pericarditis, (theophylline, beta agonist inhalers, for asthma), sleep apnea 71

Afib-Why is it important?: 

Afib -Why is it important? Consequences are severe: STROKE, premature Death However, afib by itself isn’t dangerous, only when ventricular heart rate is so rapid that it becomes a problem. So what is our role? 72

AFib- What are some symptoms patients may have?: 

AFib - What are some symptoms patients may have? No symptoms (may find an irregular rhythm incidentally on physical exam) Possible mild symptomatic complaints: palpitations, dizziness, or easily fatigued with activity SEVERE : symptomatic tachycardia (HR ≥100-180), chest pain, dyspnea, signs of severe hypotension). You’ll likely not see these patients in primary care. But, if you do send to ED!! 73

AFib- What would you see on Physical Exam? : 

AFib - What would you see on Physical Exam? Cardiovascular: slow to very fast HR, very irregular 74

AFib- How would you diagnose it? : 

AFib - How would you diagnose it? EKG: no discernible p-waves, coarse or fine fibrillatory wave. 75

PowerPoint Presentation: 

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PowerPoint Presentation: 

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AFib- Types of atrial fibrillation: 

AFib - Types of atrial fibrillation New onset- Two-thirds of 1 st episode afib will spontaneously revert to sinus rhythm w/in 24 hours. Parosymal - intermittent, self-terminating atrial fibrillation. Usually lasts for 7 days, however, most will resolve within 24 hours) Persistent - If afib has been more than a week, unlikely to revert to sinus rhythm. (not a candidate for cardioversion ) Lone- usually <65 y/o, no heart disease, ……. 78

AFib- ]What’s the goal for treatment?: 

AFib - ]What’s the goal for treatment? *Remember this is for the hemodynamically stable patient with atrial fibrillation in primary care* Prevent thromboembolism (stroke) Relief of symptoms 79

AFib- What is CHADS2 Score?: 

AFib - What is CHADS2 Score? 80

AFib – What Medications work? What are treatment considerations?: 

AFib – What Medications work? What are treatment considerations? Mechanism of Action Treatment Considerations Rate Control: Target rate control : rest <80, exercise <120, basically may be based on symptoms Beta-blockers ( carvdilol , metoprolol ) Calcium channel blockers (verapamil, diltiazem ) Digoxin (used occasionally, mostly with combination tx ) Afib + HTN pts : bblocker or ccblocker Afib + CAD pts : bblocker Afib + CHF pts : bblocker & possibly add digoxin (if no relief of sx ) Anticoagulation: Caution with pts w/ high risk for intracranial bleed ( icb ) Warfarin, dabigatran , aspirin, clopidogrel ( tx is lifetime) Warfarin (INR goal 2-3)/ (w/ mech valve INR 2.5-3.5): compliance issues w/monitoring. √INR in 3 days of initiating, then weekly for 1 mo (individualized monitoring). Dabigatran : expensive, poss. less icb , caution w/ renal pts. N0 antidote. Aspirin : may not be sufficient (combo w/ clopidogrel ↑s bleed risk) 81

AFib- When to Refer?: 

AFib - When to Refer? Symptomatic stable atrial fibrillation w/ or w/o rate control Asymptomatic atrial fibrillation w/ poor rate control despite bblockers or ccblockers (& considering anti- arrhythmics ) Newly diagnosed stable atrial fibrillation that you discover should be consulted with your collaborating physician or referred to cardiologist. To The Emergency Department when …. Atrial fibrillation w/ RVR (rapid ventricular rate) & pt hemodynamically unstable (symptomatic= signs of low cardiac output) 82

AFib- Things to Consider: 

AFib - Things to Consider When considering treatment: assess patient-adherence to warfarin monitoring *this is crucial* Remember patient’s vitamin K intake in diet will affect warfarin. Warfarin can cause teratogenicity (fetal harm) Dabigatran has no antidote Always review medication contraindications & side-effects, & definitely drug-drug interaction especially with warfarin (certain meds may decrease/increase INR levels) Be cognizant of your patients @ risk of an intracranial bleed 83

AFib- Wrap up: 

AFib - Wrap up Always consider the potential for atrial fibrillation in patients with high risk factors (long standing htn , elderly, etc ) You may be the 1 st to encounter stable afib , think of treatment that consists of rate control & anticoagulation Consult with your collaborating physician or refer to the cardiologist when you are not familiar with afib management. 84

AFib- References: 

AFib - References Current 2012 : Mcphee & Papadakis Primary Care: The Art & Science of Advance Practice Nursing : Dunphy , Winland -Brown, Porter, & Thomas Cecil Medicine 23 rd edition: Goldman & Ausiello Pathophysiology 23 rd edition: McCance & Huether Human Anatomy/Physiology 3 rd edition: Marieb Saint Francis Outpatient Guide 85