Common Cardiovascular Problems
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.
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A healthy diet
Regular physical exercise (not just activity)
Good quality and quantity of sleep
Good hygiene
Common Chief Complaints
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Chest pain
Palpitations
Dizziness
Fatigue
Lower extremity swelling
Common Cardiovascular disorders
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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
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Arterial
Venous
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Common Cardiovascular Problems
2
Coronary Artery Disease review
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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
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Clinical practice guidelines http://www.nhlbi.nih.gov/healthpro/guidelines/current/hypertension-jnc-7/index.htm
Case study #1 (in class) - notes
 Case study #2 (in class) – notes
Hyperlipidemia review
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Clinical practice guidelines http://circ.ahajournals.org/content/112/20/3184.full and
www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
o See separate document “Aggressive lipid and cardiovascular disease management
algorithm” by Julie Adkins, DNP, APN, FNP-BC (certified in lipid
management)—See next page
Case study #3 (in class) – notes
Common Cardiovascular Problems
3
Aggressive Lipid and Cardiovascular Disease Management to Decrease Morbidity and Mortality
in Primary and Secondary Prevention (by Julie Adkins, DNP, APN, FNP-BC)
Population=
*>age 19
Inclusion:
Age>/=19
TC>200 &/or
TG>150 &/or
HDL<40male or
HDL<50female
&/or
LDL >70
Lipid
Profile
Exclusions:
*=/<19
*patient refusal
*active liver disease
*nursing mothers
*pregnancy or plans
of pregnancy
Aggressive lipid
management and
CVD risk
reduction for
primary and
secondary
prevention of
CVD
TLC described in detail in the
Cholesterol Primer
* stop smoking
*blood pressure management and
control=goal<130/80-low salt
diet<4GM/day
*Diabetes control=HgbA1c<7
*Lipid control to aggressive goals as
stated
*Maintain healthy weight=BMI<25
*lose weight-Women=1800-2000
calorie diet, Men=2200-2500calorie
diet. Total fat consumption per
day=30% of daily calories
*Stress management intervention if
needed
*Exercise-goal to 30 minutes/day 5
days/week. May be separated into
three 10 minute sessions-investigate
patient preferences and abilities
*Evaluate for sleep apnea if appropriate
*Limit alcohol intake to no more than1
drink/day for women and 2 drinks per
day for men. 1 drink=12oz. beer or 4oz.
wine for example.
Evaluation and goal
attainment
Follow-up lab after
initiating lipid
lowering medication:
-6 weeks—lipid/ liver
profile
-If at goal-recheck
lipid/ liver profile in 3
months
-If remains at goalrecheck same every 6
months.
*If at any time
medication is added
or adjusted-restart
lab evaluation again
at 6 weeks, 3 months
and 6 months
pattern until optimal
goals are met
without side effects.
Medication management strategies
** STATIN therapy
-Lipitor 10-80mg daily
-Crestor 5-40mg daily
-Pravastatin 40-80mg daily
-Lovastatin 10-40mg daily
-Simvastatin 10-80mg daily
**FIBRATE therapy
-Tricor 48 or 145mg daily
-Fenofibrate 160mg daily
-Antara 160mg daily
-Trilipix 45mg-135mg daily
**NICTONIC ACID DERIVATIVES
-Niaspan 500-200mg daily
**BILE ACID SEQUESTRANTS
*Welchol-3.75mg pwd pkts daily or 625mg
tablets 6/day
*Cholestyramine 4mg pkt 2-4times/day
**COMBINATION therapies
-Vytorin 10/20mg-10/80mg daily
-Advicor 500/20mg to 1000/40mg daily
-Simcor 500/20/40-1000/20/40
**Cholesterol absorption inhibitor
-Zetia 10mg daily
Decrease
CVD
morbidity and
mortality in
primary &
secondary
prevention
Common Cardiovascular Problems
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Chest pain
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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
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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?
Common Cardiovascular Problems
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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)
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Differential Diagnosis
Causes of Chest Pain
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Cardiac
Noncardiac
Ischemic:
Gastroesophageal:
Coronary artery disease
(myocardial
ischemia/infarction)
Aortic stenosis
Prinzmetal’s angina (Variant
angina pectoris, usually 12 -8
am, due to arterial spasm)
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Esophageal perforation
Esophageal spasm
Reflux esophagitis
Peptic ulcer
Cholecystitis
Pancreatitis
Biliary disease
Eating disorder
Pulmonary:
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Pleuritis
Spontaneous pneumothorax
Pulmonary embolism
Neoplasm
Bronchitis
Pneumonitis
Pulmonary hypertension
Asthma
Nonischemic:
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Dissecting aortic aneurysm
Pericarditis
Valvular Disease-Aortic
stenosis, Mitral valve prolapse
Hypertrophic cardiomyopathy
Common Cardiovascular Problems
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Chronic cough
Musculoskeletal:
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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:
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Panic disorder
Hyperventilation
Other:
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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.
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Case study #5 (in class) – notes
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Common Cardiovascular Problems
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Acute Coronary Syndromes
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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 symptoms
Substernal 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)
Common Cardiovascular Problems
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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.
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Differential Diagnosis;
o See Chest pain section
o 2 classifications by ECG
 Non-ST segment elevation (Unstable angina-UA, Non-ST segment MINSTEMI)
 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
Common Cardiovascular Problems
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 Aspirin 81mg
 Clopidogrel 300 mg loading dose, 75 mg daily for 9-12 months
 Low-molecular-weight heparin also used
Nitroglycerin sublingual or oral
Beta-blockers unless has HF
CCBs are 3rd line therapy
Statins
Myocardial Infarction
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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
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Common Cardiovascular Problems
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Syncope
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Case study #6 (in class) – notes
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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
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Common Cardiovascular Problems
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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