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Cardiology Clinical CasesTeri Diederich, APRN-NPOctober 2, 2020

DisclosuresI have nothing to disclose

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Objectives 1. Verbalize hypertension and hyperlipidemia management guidelines 2. Describe management of atrial arrhythmias and use of CHADS-2-VASC3. Review diagnostic tools for dyspnea and exertional chest pain evaluation 4. Verbalize treatment options for heart failure patients

Case Study Mr Smith is a 58-year-old Caucasian male establishing care at your clinic as his employer now offices discounts with yearly exams. He has no past medical history and takes no meds. He quit smoking 3 years ago and smoked 1 ppd for 30 years.

Vitals –HR – 78, BP – 148/88, RR – 18, O2 – 99%

Labs –HgbA1C – 5.9 BMP – WNL TC – 187 mg/dLTG – 157 mg/dLHDL – 43 mg/dLLDL – 113 mg/dL

BMI – 41

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Questions What medical conditions does this patient have? What medications should this patient start taking?

Hypertension Categories Persistently elevated pressures in the vessels

ACC/AHA 2017 Guidelines

Hypertensive emergency BP > 180/110 with signs of end-organ damage

Hypertensive urgency elevated blood pressure without end-organ damage

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Secondary causes of hypertension

Endocrine Adrenal Renal Cardiovascular Drugs

• Cushing's syndrome

• Acromegaly• Thyroid 

disease• Hyperpara‐

thyroid disease

• Conn's syndrome

• Adrenal hyperplasia

• Pheochromocytoma

• Diabetic nephropathy

• Chronic glomerulonephritis

• Adult polycystic kidney disease

• Renovascular disease

• Aortic coarctation

• Sleep apnea syndrome

• NSAIDs• Oral 

contraceptive• Steroids• Carbenozalone• Licorice• Sympathomimet

ics• Vasopressin• Monoamine 

oxidase inhibitors

• Chemotherapy agents

ACC/AHA 2017 Guidelines

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ASCVD Risk Calculator Age (years)GenderRaceTotal Cholesterol HDLSystolic blood pressureDiastolic blood pressureTreated for high blood pressure: no/yesDiabetes: no/yesSmoker: no/yes

cvriskcalculator.com

Oral AntihypertensivesPrimary agents • Thiazide or thiazide type

diuretics • ACE inhibitors • ARBs• Calcium Channel

Blockers (CCB)

Secondary Agents • Diuretics • Beta Blockers • Direct Renin Inhibitors • Alpha-1 Blockers• Central Alpha2 Agonists• Direct Vasodilators

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Back to our caseBP recheck 144/82ASCVD risk calculator 9.8%Mr Smith has hypertension and should be started on medications • Hydrochlorothiazide 25 mg daily• Lisinopril 5 mg daily • Losartan 25 mg daily• Amlodipine 5 mg daily

• What about his cholesterol

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Statins Block HMG-CoA reductase which inhibits the synthesis of cholesterol in the liver

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Finishing our caseASCVD risk 9.8%“Intermediate Risk”No ASCVD risk enhancers

Mr Smith does not meet criteria for statin therapy. Lipids should be checked again in 6-12 months.

His blood pressure should be monitored in clinic in 1-2 months.

Case 2Mrs Jones is a 72-year-old hispanic female who presents to clinic with complaints of her heart racing and dizziness. She has history of hypertension, hyperlipidemia and coronary artery disease.Vitals

HR – 103BP – 128/72RR – 18O2 – 98%

Meds: • Lisinopril 10 mg daily• Aspirin 81 mg daily• Atorvastatin 80 mg daily• Metoprolol tartrate 50 mg

bidLabs: • NA – 134• BUN – 34• Creatinine – 1.4 • CBC – WNL

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Thoughts

Differential diagnosis • Atrial fibrillation • Atrial flutter• AVNRT • AVRT• Atrial tachycardia• Sinus tachycardia with PACs• Multifocal atrial tachycardia

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Atrial fibrillation • Presence or absence of

clear P waves associated with each QRS

• Regular versus irregular • Normal QRS complex

Atrial fibrillation • Paroxysmal: terminates in <7 days

• Persistent: fails to terminate within 7 days OR intervention necessary to terminate (Ex. DCCV)

• Longstanding persistent: Continue AF duration > 12 months but goal is still rhythm control

• Permanent: Joint decision between patient and clinician not to pursue rhythm control treatment

Most frequent atrial arrhythmia

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Atrial fibrillation management• Resting HR < 80 bpm• 24 hour HR average< 100 bpm• HR < 110 bpm on 6 minute walk• Elevated rates can cause ischemia, hypotension, Type 2 MI, long

term tachycardia can lead to heart failure• Medications

• Beta blockers: oral and IV

• Diltiazem: oral and IV

• Verapamil: oral

• Digoxin: for hypotensive patients

• Amiodarone: rate and rhythm benefit

Rate control

Atrial fibrillation management• Preferred for first diagnosis of afib• Rhytm control options are DCCV, antiarrhythmics, and

ablations• Synchronized DC cardioverstion – emergenices, greater

efficacy than medications• Pharmacoligical cardioversion

• < 7 days atrial fibrillation – dofetilide, sotalol, flecainide, propafenone, amiodarone

• > 7 days atrial fibrillation – dofetilide, sotalol, amiodarone

Rhythm control

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Anticoagulation and DCCV• Atrial fibrillation < 48

hours• No anticoagulation

needed prior to DCCV• Needs oral

anticoagulation for 30 days after DCCV

• Atrial fibrillation > 48 hours

• Needs anticoagulated for 3-4 weeks before DCCV

• If patient is unstable can get TEE prior to DCCV to rule out clot

• Needs oral anticoagulation for 30 days after DCCV

AnticoagulationUse Chads2-vasc to risk stratify patients

0-1 can consider aspirin only versus oral anticoagulation

5-6 should be bridged with heparin/low molecular weight heparin if holding oral anticoagulation

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Oral anticoagulationWarfain – only medication approved for valvular atrial fibrillation, approved for patients with ESRD

Dabigatran (Pradaxa)Rivaroxaban (Xarelto) - approved for patients with ESRDApixiban (Eliquis) - approved for patients with ESRD

DOACs mechanism of action – inhibition of prothorombinasecomplex-bound and clot-associated factor Xa, resulting in a reduction of the thrombin burst during the propgatino phase of the coagulation cascade

My patient can't take anticoagulationWatchman

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Watchman• Self expanding device

that is deployed in the LAA

• FDA approved in March 2015 for patients with nonvalvular atrial fibrillation

• For patients with atrial fibrillation at high risk of stroke

• Patients at high risk of bleeding on oral anticoagulation

• Need to be able to tolerate anticoagulation for 6 weeks currently

Back to our caseMrs Jones has new onset atrial fibrillation and is unsure of when the episode started. She is hemodynamically stable and does not require inpatient admission

Treament of choice – start oral anticoagulation and refer to cardiology for DCCV

Increase metoprolol tartrate to 100 mg bid to assist in rate control

Provide education on emergency signs and symptoms

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Case 3Mr Martin is a 66-year-old African American male being seen for a hospital follow up. He was in the ER with chest pain and shortness of breath on exertion. He was observed overnight, and ACS ruled out. He continues to have SOB with activity and when doing his 1-mile walk gets SOB and pressure halfway through the walk. It resolves when he rests. He has a PMF of hypertension and hyperlipidemia.

Vitals – BP 136/66, HR 74, RR 18, O2 98% on room air

EKG – sinus rhythm, no ST depression

Medications –hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily

What would you recommend?

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Cardiac diagnostic toolsEKG – evaluates rate, rhythm, ST elevation, ST depression, Q waves

Laboratory testing – troponin, cbc, cmp, flp

Imaging – echocardiogram, cardiac CT, cardiac MRI, nuclear imaging

To know what test you want, you need to know the results it gives you

EchocardiogramUltrasound technology• Heart size• Heart function• Valve function

• Can be difficult to visualize the RV

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Cardiac CTCT technology• Accurate reconstruction

of the heart and blood vessels

• Can detect calcium build up to detect blockages

• Provides calcium score• Can produce 3D images

Nuclear TestingRadionucleotide testing• MUGA scan• Creates accurate images

of the ventricles to determine function

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Cardiac MRIUse magnetic waves and radiofrequency to create imagesAccurate assessment of• Heart size• Heart function• Myocardium• Inflammation• Scar• Right ventricle

Stress testingTo evaluate for ischemia you need to stress your patient• Exercise versus chemical stress

• Can your patient exercise and provide maximal effort?• HR target is 220-age x 85% for maximal effort

All imaging can also be ordered as a stress test

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Stress tests• Treadmill stress test• Exercise echo• Dobutamine stress echo• Nuclear stress test

•Both exercise and chemical

• CT Angiogram• Adenosine MRI

Pearls• May need to hold beta

blocker prior to test• No caffeine for 24 hours

before nuclear stress test• Cardiac CT requires HR <

65 for more accurate images

• Cardiac MRI requires contrast and is contraindicated in ESRD

Back to our caseMr Martin has DOE which may be an anginal equivalent. He has been ruled out for ACS but should have ischemic evaluation.• Echo or MRI will give cardiac function but no stress• If your patient can exercise order a test that has them

exercising to potentially reproduce symptoms• Exercise echo will provide cardiac function along with

stress images• Can also refer to cardiology for further evaluation

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Case 4Mr Jacobs is a 65-year-old African American male with PMH for severe CAD, s/p CABG in 1994, HTN, HDL, DM-II, and ischemic cardiomyopathy with last ef 15-20%. He comes to clinic for his 6 month follow up. He exhibits NHYA class III symptoms. He denies chest pain, pressure, palpitations, dizziness or lightheadedness. He has trace pedal edema which fluctuates depending on how closely he watches his salt.

Vitals – HR 78, BP – 108/76, RR – 18, BMI – 38Labs – CBC WNL, BUN 42, creatinine 1.4, HgbA1c 8.2Medications – Metoprolol succinate 100 mg daily, Lisinopril 10 mg daily, Furosemide 40 mg daily, Atorvastatin 80 mg daily, Asprin 81 mg daily, Metformin 1000 mg bid

RecommendationsHow is Mr Jacobs doing?

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Heart failure• A syndrome caused by cardiac dysfunction,

generally resulting from myocardial muscle dysfunction or loss and characterized by either LV dilation or hypertrophy or both – HFSA

• The heart is unable to pump sufficiently to need the needs of the body

• Systolic Heart Failure – syndrome characterized by signs and symptoms of HF and reduced LVEF. Commonly associated with LV dilation

• Diastolic Heart Failure or Heart failure with preserved ejection fraction – syndrome characterized by symptoms of HF and preserved LVEF. Commonly associated with nondilated LV

Causes of heart failure• Heart failure with reduced

ejection fraction• Ischemia

• Viruses

• Familial/genetic

• Tachycardia

• Thyroid disease

• Toxins

• Peripartum/postpartum

• Adult congenital heart disease

• Ischemia

• Viruses

• Familial/Genetic

• Heart failure with preserved ejection fraction

• Hypertension• Valvular disease• Constrictive disease• Infiltrative disease

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Pharmacological treatment• ACE inhibitors/ARBs/ARNI• Beta Blockers• Aldosterone antagonists• Vasodilators• Diuretics• SGLT2 inhibitors –

Approved in 2019/2020

Guideline directed medical therapy (GDMT)

SGLT2 inhibitorsMechanism of action:• Effects on glucose = ↓ reabsorption (kidneys)

• Excreted in urine

• ↓ overall glucose levels

• Excreted in urine

• ↓ overall glucose levels

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Effects of SGLT2 inhibitors

on LV function

SGLT2 inhibitor diuresis effect

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Referral to a heart failure specialistI – IV inotropesN – NYHA IIIB/IV or persistently elevated natriuretic peptidesE – End-organ dysfunction (Cr > 1.8 mg/dL or BUN > 43 mg/dL)E – Ejection fraction < 35%D – Defibrillator shocksH – Hospitalizations > 1E – Edema (or elevated PA pressure) despite escalating diureticsL – Low blood pressure, high heart rateP – Prognostic medication, progressive intolerance or down-titration of guideline directed medical therapy

INEEDHELP

Back to our caseMr Jacobs is stable but continues to exhibit class III symptoms.• Lisinopril should be switched to sacubitril/valsartan with 36

hour wash out period• Metoprolol succinate is not at target dose and can be

titrated up• Diabetes is not under control and SGLT2 inhibitor should

be added• Aldosterone antagonist should be added• Return to clinic in 2 weeks to assess medication tolerance

and fluid retention as diuretic may need adjusted

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Case 5Mrs Alberts is a 55-year-old caucasian female being seen in clinic for worsening SOB and lower extremity edema. She has a PMH of hypertension, hyperlipidemia, HFpEF with echo showing ef of 55-60% with grade III diastolic dysfunction, obesity and OSA. Over the past month she's been more SOB with any activity and has gained 10 pounds. She needs to rest on her walks but does not have PND or orthopnea.

Vitals – HR 88, BP 144/82, RR 20, BMI 42Labs – CBB WNL, BUN 38, creatinine 1.26Medications – Losartan 100 mg daily, amlodipine 5 mg daily, furosemide 80 mg daily, atorvastatin 40 mg daily, levothyroxine 112 mcg daily

Recommendations

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HFpEF

HFpEF guidelines• Treat underlying medical conditions

• Management of hypertension• Management of OSA

• Use of aldosterone antagonists• Use of ARBs

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CardioMEMSCardioMEMS remotely monitors changes in pulmonary artery (PA) pressures• Sensor is implants in the distal pulmonary artery via a right

heart catherization• Sensor daily measures pressures in the PA• Pressures are downloaded and sent remotely by patient

• Reduces heart failure hospitalizations• Lowers mortality• Improves quality of life and functional capacity

CardioMEMS

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Back to our caseMrs Alberts has signs of fluid overload related to her HFpEF• Her OSA is treated with CPAP• Blood pressures are slightly elevated• Aldosterone antagonist recommended – spironolactone 25

mg daily• Potential diuretic resistance and can be switched to

torsemide 80 mg daily• Refer to cardiology for CardioMEMS implant

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