adult cardiology in primary care mary i. jones, fnp-c, msn, mhsa piedmont heart institute
TRANSCRIPT
ADULT CARDIOLOGY IN PRIMARY CARE
Mary I. Jones, FNP-C, MSN, MHSA
Piedmont Heart Institute
OUTLINE• Adult heart murmurs and abnormal heart sounds• Primary prevention of cardiovascular disease• Evaluation and management of the patient with angina• Pathophysiology of unstable plaque• Evaluation and management of the patient with heart
failure• Secondary prevention of cardiovascular disease• Evaluation and management of the patient with Atrial
Fibrillation
Recommendations and Level of Evidence:
DefinitionsClassification of Recommendations Class I: Conditions for which there is evidence for and/or general agreement that treatment is beneficial, useful, and effective Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the efficacy of a treatment Class IIa: Weight of evidence/opinion favors usefulness/efficacy Class IIb: Usefulness/efficacy is less well established by evidence/opinion Class III: Conditions for which there is evidence and/or general agreement that a treatment is not useful/effective and in some cases may be harmful
Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses B: Data derived from a single randomized trial or from nonrandomized studies C: Only consensus opinion of experts, case studies, or standard of care
Adult Heart Murmurs and Abnormal Heart
Sounds: The Basics
Location of Heart Murmurs
Location of Heart Murmurs
Aortic
Pulmonic
Erbs
Triscupic
Mitral
All
People
Eventually
Take
Money
Heart Murmurs
In general, heart mumurs may be classified as: systolic or diastolic benign or pathologic
Systolic murmurs may be either benign or pathologic.All diastolic murmurs are pathologic.
Timing of Heart Murmurs:Systolic Murmurs
Mr. Pass MVP
Mitral Regurgitation
Physiologic (functional)
Aortic Stenosis
Systolic
Mitral Valve Prolapse
Timing of Heart Murmurs:Diastolic Murmurs
Ms. Ard
Mitral Stenosis
Aortic Regurgitation
Diastolic
Heart Sounds
Normal heart sounds: S1 S2
Abnormal heart sounds: S3 S4
Heart Sounds: Normal
S1 Closure of AV (mitral and tricuspid) valves
Onset of systole/ventricular emptying
S2 Closure of semilunar (aortic and pulmonic)
valves
Onset of diastole/ventricular filling
Heart Sounds: Abnormal
S3 Low pitched (best heard with bell)
Occurs in association with (after) S2
Sign of heart failure
S4 Low pitched (best heard with bell)
Occurs in association with (before) S1
Sign of hypertension or acute MIS1 and S4 occur close to each other in time.
Note: 1 and 4 are both straight line figures.
S2 and S3 occur close to each other in time.
Note: 2 and 3 are both curved line figures.
Primary Prevention of Cardiovascular Disease
Prevention of Coronary Heart Disease (CHD)Campaigns and Statements
National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III
LDL goals, CHD risk equivalent, metabolic syndrome
Joint National Committee (JNC)-7
Hypertension management
World Heart Federation (WHF), World Health Organization (WHO)
Cigarette smoking
National Heart, Lung, and Blood Institute (NHLBI), Food and Drug Administration (FDA), Centers for Disease Control (CDC)
Obesity
AHA/NHLBI Go Red for Women, AHA Guidelines on Prevention of Cardiovascular Disease (CVD) in Women
Women and CVD
STEMI: ACC/AHA guidelines at www.acc.org
Evaluation and Management of the
Patient with Ischemic Heart Disease
Definitions
New-onset angina – recently developed symptoms of less than 3 months duration
Chronic stable angina – a predictable pattern and presentation of symptoms (sustained > 3 months) that occurs with activity and is relieved quickly by rest and/or NTG
Unstable angina – Sustained pain (20-30 minutes) or pain with occurs with increased frequency or duration and/or with lesser exertion
Anginal equivalents – angina surrogates such as dyspnea, fatigue, abdominal pain, syncope, and diaphoresis
Syndrome X or microvascular angina – angina with normal coronary arteries
Prinzmetal/variant angina – symptoms related to coronary artery spasm
More DefinitionsAcute Coronary Syndromes • acute myocardial ischemia with two subtypes (unstable
angina and NSTEMI)• similar pathophysiology (severe narrowing and/or transient
occlusion of a coronary artery)Non-ST-elevation MI (NSTEMI) – chemical evidence of
myocardial necrosis without characteristic EKG changes (formerly called non-Q-wave MI)
ST-elevation MI (STEMI) – complete and prolonged occlusion of a coronary artery demonstrated by chemical and EKG evidence of necrosis (formerly called Q-wave MI)
Thrombus Formation and ACS
UA NQMI STE-MI
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Non-ST-Segment Elevation Acute Coronary Syndrome (ACS)
ST-Segment Elevation
Acute Coronary Syndrome
(ACS)
Old Terminology:
NewTerminology:
The Vulnerable Plaque
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
Thin, vulnerable, fibrous cap
Large lipid core
Ruptured Plaque with Occlusive Thrombus
Formation
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
Thrombus formation
Plaque rupture
Ruptured Plaque & Occlusive Thrombus
Ruptured Plaque Occlusive Thrombus
Pathogenesis of Acute Coronary
Syndromes:The integral
role of platelets
PlaqueFissure or Rupture
PlateletAggregation
PlateletActivation
PlateletAdhesion
ThromboticOcclusion