Common Cardiovascular Problems 2
NUR 475 – Family Nurse Practitioner III
Common Cardiovascular and Peripheral Vascular Problems – Part 1
Prevention, early identification and effective treatment significantly reduces cardiovascular morbidity and mortality
Nurse Practitioners must focus on health maintenance and disease prevention, as well as diagnosis and management of disease. This includes a focus on the foundations of health.
· A healthy diet
· Regular physical exercise (not just activity)
· Good quality and quantity of sleep
· Good hygiene
Common Chief Complaints
· Chest pain
· Palpitations
· Dizziness
· Fatigue
· Lower extremity swelling
Common Cardiovascular disorders
· HTN - Hypertension
· Hyperlipidemia
· CAD - Coronary Artery Disease
· ACS – Acute Coronary Syndrome
· MI – Myocardial Infarction
· Syncope
· AF - Atrial Fibrillation
· Cardiac valve
· Endocarditis – bacterial prophylaxis
· Cardiomyopathy
· CHF – Congestive Heart Failure
Common Peripheral Vascular disorders
· Arterial
· Venous
Coronary Artery Disease review
· Epidemiology
o #1 killer in US and world
o 37% with an acute coronary event die the same year
o Rates are declining in the US, but number will increase due to aging
· Pathogenesis
o Atherosclerotic changes
o Risk factors; age, gender, HTN, Diabetes Mellitus (DM), Left Ventricular Hypertrophy (LVH), hyperlipidemia, smoking, obesity, Metabolic Syndrome, sedentary lifestyle, abnormal lipoprotein and homocysteine levels
· Leads to coronary ischemia and/or infarction (see the following ACS and MI sections)
· Remember ABC for prevention of cardiovascular disease
o A for antiplatelet/anticoagulation
o B for blood pressure control
o C for cholesterol management
Hypertension review
· Clinical practice guidelines http://jama.jamanetwork.com/article.aspx?articleid=1791497
· Case study #1 (in class) - notes
· Case study #2 (in class) – notes
Hyperlipidemia review
· Clinical practice guidelines http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
o Review treatment of hyperlipidemia from NUR 471 and NUR 433
· Case study #3 (in class) – notes
Chest Pain
· Case study #4 (in class) – notes
First task: Determine if chest pain is a life-threatening condition?
Refer – if unable to quickly exclude life-threatening conditions or control pain
Essential Evaluation:
· Detailed symptom description and relevant history
· Vital signs
· Chest and cardiac examination
· ECG
· Cardiac biomarkers
· Symptom description key to diagnosis
o Onset and character: when did the pain start, first or recurrent episodes, feels like?
o Location and Duration: where in the chest, constant or intermittent, radiating and to where, how long, pain scale?
o Associated/Aggravating; shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, diaphoresis, dizziness, syncope, nausea, vomiting, palpitations, cough, fever, chills, weight changes, fatigue, with activities (exercise, sexual intercourse, eating, sleeping, stress, strong emotions)?
o Relieving/Treatments; rest, antacids, nitroglycerin, anxiolytic, other?
· Important history (review medical record, if available)
o Does the patient have risk factors for CAD (HTN, DM, hyperlipidemia, family history, tobacco or cocaine use)?
o Pre-existing health problems (other cardiac disease, previous surgery, medications, relevant diagnostic studies, recent immobilization, substance abuse)?
· Physical exam
o Vital signs; include bilateral upper extremity BP, pulse oximetry (if available)
o General appearance; pallor, dyspnea, diaphoresis, tracheal shift?
o Thorax; expansion with respiration, symmetry, tenderness or lesions?
o CV; JVD, pulses, bruits, heart sounds (rate, rhythm, murmurs, gallops, clicks, PMI, pericardial rub), heptojugular reflex
o Pulmonary; respirations (rate, regularity, effort), lung sounds (rales, rhonchi, wheezing, pleural rub), percuss chest
o Abdomen; distention, masses, bowel sounds, bruits, tenderness, pulsating, organomegaly?
o Extremities; color, temperature, edema, pulses, tenderness, signs of DVT or IV drug use? DVT guidelines http://www.aafp.org/afp/2007/1015/p1225.html.
§ ↑ ACS suspicion?
§ ↑ Pericarditis?
§ Normal exam?
· Diagnostic studies– what are you looking for and will it impact diagnosis/treatment?
o ECG (effective tool-not definitive)
§ Lateral wall – Leads I, aVL, V5 and V6
§ Inferior wall – Leads II, III and aVF
§ Anterior wall – V1-4
§ Posterior wall – Leads V1-3
o Cardiac biomarkers
§ MB CK (myocardial band creatine kinase) ↑ 10-25 times in first few hours of MI, returns to normal in 2-4 days, can be ↑due to trauma
§ Troponin (inhibitory protein in muscle fibers), ↑ within 4 hours and for days, more specific to cardiac muscle.
o Chest x-ray (suspected aortic aneurysm, pneumonia, pneumothorax, pulmonary edema)
o CBC and ESR (suspected pericarditis)
o Amylase/lipase (pancreatitis, cholecystitis)
o Others: CMP (electrolyte imbalance), lipid profile, TSH (hypothyroidism)
o Testing in ER or hospital may include: ABGs (unless on thrombolytic therapy, suspected pulmonary conditions), D-dimer and spiral 5CT scan (suspected PE), Echocardiogram (aneurysm, pericardial effusion, valvular disease, cardiomyopathy), Stress test (CAD and angina), Endoscopy (gastric), Cardiac catheterization (MI)
· Differential Diagnosis
Causes of Chest PainCardiac / Noncardiac
Ischemic:
· Coronary artery disease (myocardial ischemia/infarction)
· Aortic stenosis
· Prinzmetal’s angina (Variant angina pectoris, usually 12 -8 am, due to arterial spasm) / Gastroesophageal:
· Esophageal perforation
· Esophageal spasm
· Reflux esophagitis
· Peptic ulcer
· Cholecystitis
· Pancreatitis
· Biliary disease
· Eating disorder
Nonischemic:
· Dissecting aortic aneurysm
· Pericarditis
· Valvular Disease-Aortic stenosis, Mitral valve prolapse
· Hypertrophic cardiomyopathy / Pulmonary:
· Pleuritis
· Spontaneous pneumothorax
· Pulmonary embolism
· Neoplasm
· Bronchitis
· Pneumonitis
· Pulmonary hypertension
· Asthma
· Chronic cough
Musculoskeletal:
· Costochondritis/Tietze’s syndrome
· Xiphoidalgia
· Rib fracture
· Myalgia
· Muscle strain/overuse syndrome
· Thoracic outlet syndrome
· Cervical or thoracic radiculitis
· Chest wall infection
· Herpes zoster
· Trauma
· Breast mass
· Monder’s syndrome (superficial thrombophlebitis of the precordial veins)
Psychogenic/Idiopathic:
· Panic disorder
· Hyperventilation
Other:
· Substance abuse (esp. cocaine)
· Hypothyroidism
· Marfan syndrome
Principle causes of Chest Pain
Life-Threatening / Non-Life Threatening
Acute Coronary Syndrome (USA [unstable angina], NSTEMI, STEMI) / Stable Angina
Aortic Dissection / GERD/esophageal spasm
Pulmonary Embolism / Musculoskeletal
Valvular Heart Disease
Hypertrophic Cardiomyopathy
Baliga, R. & Eagle, K. (2008). Practical Cardiology-Evaluation and Treatment of CommonCardiovascular Disorders, Lippincott: Philadelphia.
· Case study #5 (in class) – notes
Acute Coronary Syndromes
· What is ACS?
o Includes several conditions that have symptoms of acute myocardial ischemia
§ Angina; unstable and Non-STEMI
· See practice guidelines 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guidelines and Replacing the 2011 Focused Update) : at http://content.onlinejacc.org/article.aspx?articleid=1217906
§ Angina, chronic, stable
· See practice guidelines
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary at http://circ.ahajournals.org/content/126/25/3097.full.pdf+html
§ Infarction; ST elevation
· (See practice guidelines 2013 ACCF/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction: Executive Summary at http://circ.ahajournals.org/content/127/4/529.full.pdf+html
Presenting symptoms suggestive of ACS
Typical chest and associated symptomsSubsternal or left-sided chest pain (not related to trauma)
Chest pressure, heaviness, tightness, or squeezing in chest
Neck/throat pain or discomfort (not related to trauma)
Jaw pain or discomfort (not related to toothache or trauma)
Shoulder pain or discomfort (not related to degenerative joint disease or trauma)
Arm pain or discomfort (not related to bursitis or trauma)
Diaphoresis
Dyspnea (not related to asthma, pulmonary infection, preexisting pulmonary problem, or renal failure)
Atypical chest and associated symptoms
Chest pain in other location
Numbness, tingling, pricking, or stabbing in chest
Fullness or burning in chest
Epigastric/indigestion-like/gas-like pain or discomfort (not related to gastrointestinal problem)
Nausea or vomiting (not related to gastrointestinal problem)
Upper extremity numbness or tingling (not related to stroke or carpal tunnel problem)
Mid-back (between shoulder blades) pain (not related to degenerative joint disease or trauma)
Pain/discomfort with deep breath or cough (not related to asthma or pulmonary infection, preexisting pulmonary problem)
Dizziness, lightheadedness, or syncope (not related to stroke, neurologic problem, or hypertension)
Fatigue or weakness (not related to stroke, neurologic problem, or hypertension)
Palpitations (new onset, no history of arrhythmias)
From: Milner, K.A., Funk, M., Arnold, A., & Vaccarino, V. (2002). Typical symptoms are predictive of acute coronary syndromes in women. Am Heart J 143(2):283-288.
· Differential Diagnosis;
o See Chest pain section
o 2 classifications by ECG
§ Non-ST segment elevation (Unstable angina-UA, Non-ST segment MI-NSTEMI)
§ ST segment elevation (STEMI)
o 10% of ACS with HF
· Physical Examination; see Chest pain section
o Pallor, diaphoresis
o Tachycardia, S4, with CHF rales and S3
· Diagnostic testing
o See Chest pain section
o ECG
§ MI – ST elevation→ T-wave inversion → Q-wave development
§ USA – ST depression and/or T-wave inversion, no Q-wave development
· Treatment for ACS (see next section for MI)
o Hospitalize
o Anticoagulation and Antiplatelet therapy
§ Aspirin 81mg
§ Clopidogrel 300 mg loading dose, 75 mg daily for 9-12 months
§ Low-molecular-weight heparin also used
o Nitroglycerin sublingual or oral
o Beta-blockers unless has HF
o CCBs are 3rd line therapy
o Statins
Myocardial Infarction
· Pathogenesis
o Damaged myocardial muscle
o STEMI
o NSTEMI
· Symptoms (also see chest pain section)
o Typical; chest pain (intense and persistent; substernal pressure, tightness, heaviness, aching); unexplained indigestion/belching/epigastric pain; radiating to neck, jaw, shoulder, back, one or both arms; dyspnea, nausea, diaphoresis, apprehension
§ Atypical; no or unnoticed symptoms by the patient (25%) and women (GI distress, less often diagnosed and more likely to be fatal)
· Signs (also see chest pain section)
o Pale, diaphoretic
o Tachycardia, S4, JVD in right ventricular infarct
· Differential Diagnosis; as in chest pain
· Diagnostic testing; as in chest pain
o Exercise stress testing if cardiac catheterization not done
· Initial Treatment
o Nitroglycerin spray or sublingual tablet; IV at the hospital
o Supplemental oxygen in respiratory distress or SaO2 <90
o IV morphine sulfate for pain control
o β blocker (if not contraindicated), alternative ACE-I (if not contraindicated)
o Aspirin 160-325 mg (nonenteric) or clopidogrel (if allergy to aspirin)
o Fibrinolysis in STEMI (if meets criteria)
o Revascularization (coronary angioplasty, stenting, bypass grafts)
· Referral – hospitalize for acute MI symptoms or unstable angina
· Secondary prevention
o β-blocker for 2 > years
o Aspirin or Clopidogrel
o ACE-I or ARB with LVEF ≤ 40%
o Modify risk factors
§ Control HTN, DM, lipids
§ Smoking cessation
§ Exercise program
Syncope
· Case study #6 (in class) – notes
· See Article on Syncope in the Elderly at http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=165984
· Epidemiology
o 3-5% of ER visits
o 1-6% of hospital admissions
· Pathogenesis
o Transient loss of consciousness and postural tone with prompt recovery
o Different than dizziness, vertigo or pre-syncope
· Symptom description key to diagnosis
o Remember OLDCART
§ Prolonged clonic/myoclonic jerks, incontinent, sleepy for hours after the event?
§ Emotional state (fear, panic) before event?
§ Change in position (sitting to standing), prolonged standing?
§ Headache, vertigo, dysarthria, diploplia?
§ Occurs immediately after an activity (cough, urinating, defecating)?
· Differential Diagnosis – algorithm Faci pg. 208
o Neurocardiogenic – vasovagal (usually benign), situational
o Orthostatic hypotension – peripheral or central (MSA), congenital, delayed, postural tachycardia syndrome (POTS) and Baroreflex failure
§ Always check orthostatic blood pressure (20 mmHg systolic drop lying to standing), consider dehydration (vomiting, diarrhea)
o Cardiovascular - structure or dysrhythmia
o Neurological – migraine, seizure, stroke, TIA, vertebrobasilar disease
o Psychiatric – anxiety, panic, somatic
o Metabolic - hypoglycemia
o Drug-related – diuretics, tricyclic, β-blockers, ACE-I, CCB, nitrates
· Physical Examination based in differential diagnosis
· Diagnostic testing (yield)
o ECG (50%)
§ Must identify patients with risk for dysrhythmias and sudden cardiac death (history of ventricular dysrhythmias or heart failure, abnormal ECG, > 45 years-old)
o In selected cases
§ Neurological signs - EEG, CT, Doppler ultrasound (2-6%)
§ Known/suspected cardiac disease – stress testing, echocardiogram, holter monitor, electrophysiology study (5-35%)
§ Recurrent, non-cardiac – tilt table (≤ 60%)
§ Psychiatric disorders (25%)
o Tilt table testing
o When suspect neurocardiogenic syncope if do not suspect cardiac cause and unclear if events are due to vasovagal syncope
o History of recurrent episodes, high-risk activities, or significant injury
· Treatment – based on underlying cause
o Life style changes – adequate fluid and salt intake, changing positions slowly, improved venous return (isometric contractions of lower extremities, support stockings)
o Drug therapy – change dose or drug to reduce dehydration or increase blood pressure
o Permanent cardiac pacemaker for selected dysrhythmias or refractory vasovagal syndrome
o AICD for recurrent VT
· Referral
o Hospitalize for high risk cardiac syncope or acute neurological signs
· Case study #7 (in class) – notes