Module 4 (b) Flashcards
CAD
-Differentials and DX
- CAD is a dx that has to be made w/ OBJECTIVE Testing
- Positive stress test w/ follow up LHC to show obstructive vs non-obstructive dz
- Hx of CABG
- Hx of coronary stents
Chest pain
-Diagnostic Testing
- ECG
- Refer to cardiology or ER - Cardiology Dx Testing:
- Exercise stress test
- Echocardiogram w/ suspicion of CHF
- Coronary angiogram (Cardiac catheterization); Left Heart Catheterization
CAD Treatment
- Risk factor reduction
- Lifestyle modification
- Exercise
- Cardiac rehab
- Cardiology input
CAD: Medical Management
- ASA
- Plavix, Effient vs Brillenta (MUST BE ON blood thinner post stent placement
- Tight BG control w/ DM
- BB
- ACE-I or ARB
- CCB
- Follow up
- Need a statin
CAD: Medical Management
-Stent Management
- Bare metal stent recommended for 3 months
- Drug eluding stent recommended for 1 year
- Surgery needs to be done in a facility with cath lab with drug eluding stent d/t risk of clotting
CAD
-When to Refer
- New Pt w/ hx of cardiac intervention seen by Cardiologist once a year
- Condition is complicated w/ multiple co-morbidities
- Change in angina
- Hx of coronary ischemic syndrome
- Symptoms and comorbidities dz should determine frequency of visits to specialist
Heart Failure
-Definition
A complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood.
Heart Failure
-Patho
- Myocardial insult
- Myocardial dysfunction
- Reduced Organ perfusion
- Renin-Angiotensin-Aldosterone activation
- Remodeling
Heart Failure
-Treatment Goal***
ALL oral therapy to reduce morbidity and mortality is aimed at:
1. SLOWING or STOPPING the sympathetic activation in the renin-angiotensin-aldosterone system **
Heart Failure
-LVEF
Normal is >55%
1. Measures how well heart is pumping
Heart Failure
-LVEF = 40-45%?
- Heart failure w/ reduced EF is HF with EF = 40-45%
- Mid range of 45-50% you treat as HFrEF
Heart Failure
-Risk Factor for HFpEF
- HTN (with prevalence of 60-89%)
- Obesity
- DM
- A fib
- Hyperlipidemia
- Older age
HFpEF= preserved EF greater than 50%
Heart Failure
-Risk factors for HFrEF
- HTN
- Diabetes
- Metabolic syndrome
- Atherosclerotic dz
- Valve dz
- Dilated cardiomyopathy
Heart Failure
-Precipitating Event
- CAD is cause of HF in 2/3 of patients w/ systolic dysfunction
- Most patients w/ HF (70%) have systolic dysfunction HFrEF
Heart Failure
-ACC/AHA HF Stages
- A
- High Risk w/ No structural disease - B
- Structural heart DZ w/ no HF symptoms - C
- Structural heart DZ w/ Prior or current HF symptoms - D
- Refractory end-stage HF requiring special interventions
Heart Failure
-NYHA Functional Class (Talks about Symptoms)
- Class 1
- Asymptomatic - Class 2
- Symptomatic w/ moderate exertion - Class 3
- Symptomatic w/ minimal exertion - Class 4
- Symptomatic at rest
Heart Failure
-Common Symptoms
- Orthopedic
- Dyspnea at rest and on exertion
- Reduced exercise capacity
- Ascites
- Scrotal Edema (Nephrotic syndrome or HF)
- Paroxysmal Nocturnal Dyspnea PND — wake up SOB
Heart Failure
-Uncommon Symptoms
- Wheezing or cough
- Confusion/delirium
- Depression/weakness (especially elderly)
- Unexplained fatigue
- GI symptoms
- RUQ abdominal pain can be HF
Heart Failure
-Differential Dx
- MI
- Pulmonary dz
- Sleep disordered breathing
- Obesity
- Malnutrition/ anemia
Treatment of HFrEF
-Guideline Directed Medical Therapy (reduced mortality)
- ACE-I or ARB or ARNI
- Beta Blocker
- Aldosterone antagonist
- Hydralazine/isosorbide (For African Americans and those who cannot tolerate ACE-I/ARB)
- Add hydralazine/isosorbide to all the above w/ AA for significant benefit - SGLT2i**
Treatment of HFrEF
-Guideline Directed Medical Therapy (reduced symptoms**)
- Loop Diuretics
- Potassium supplements if needed for loop diuretics
- DIgoxin to reduce hospitalization
- Thiazide diuretics can be added to boost loop diuretics
These meds are for SYMPTOMS NOT MORTALITY
AFIB
-Anticoagulation w/ cardioversion
- When the rhythm has been sustained for longer than 48 hrs, anticoagulation therapy should be uninterrupted for 4 weeks before and for at least 4 wks after elective cardioversion
- TEE used to evaluate thrombosis before cardioversion
Afib
-CHA2D2-VASc Score?
- CHA2D2-VASc Score of 2 or greater in men and 3 or greater in women
- Oral anticoagulants are recommended
Afib
-Anti-coagulants (NOACs)
- Pradaxa
- Eliquis
- Xarelto
- Savaysa
No INR needed
Afib
- Refer a pacemaker to a specialist. DO not manage in clinic
PVD
-Smoking
Smokers are twice as likely to develop PVD than non-smokers
PVD Limb Pain
-Venous Pain
- Decreased w/ elevation
- Better with walking
- Pain localized at sight of vein
PVD Limb Pain
-Arterial Pain
- Relieved with rest
- Increased with elevation
- Worse with walking
- Pain in regional areas of arterial flow
PVD
-Buerger’s Dz
- Specific to young male smokers
- Can lose digits & limbs
- Resolves when smoking is stopped
PVD
-When to refer
- No pulse
2. Ankle brachial index
PVD
-AnkleBrachial Index ** Exam
- Noncompressible >1.30
- Normal = 0.91-1.30
- Mild to Moderate PAD = 0.41-0.90
- Severe PAD = 0.00-0.40
TEST
Valve Disease
-Key Diagnostics
- Cardiac Murmur
2. Symptoms (SOB, dizziness, syncope)
Valve Disease
-Aortic Stenosis
- Elderly patients can develop aortic stenosis
- Can progress to symptoms - Aortic Stenosis murmur is heard best at the Right sternal border 2nd intercostal space
- Radiate to the neck as a brui
REFER
Valve Disease
-Medical MgMt
- Manage other risk factors such as DM, HTN, Hyperlipidemia
- DO NOT start a new exercise program
- See cardiology prior to starting a new exercise program **
