NR 603 Week 3 Case Study LATEST UPDATE, Exams of Nursing

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NR603 Week 3 Case Study

Three Months Ago:

AIC 6.4%

Fasting glucose 135mgs/dl

Total Cholesterol: 230 (200-239; borderline high) >240 very high

Triglycerides 180mgs/dl (less than 150) 150-199 is borderline high

Ldl 180 (<100 is normal) 130-159 is borderline high; 160-189 is very high

Hdl 38 (40-59 is normal but higher is better) <40 is at increased risk of cardiac disease

5'8" weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random glucose finger stick in office: 130mgs/dl

Less than 70 for LDL

There’s no abnormal physical findings in the respiratory system to suggest early heart failure. But mild JVD present with trace edema in lower extremities.

Eats out a lot - processed food, social drinking, occasional cigarette weekly; stopped Lisinopril one month ago, refuses HLD medication, will control with diet and exercise, allergy to METFORMIN

1. What Leads Demonstrate the ST Depression?
2. Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA guidelines to JNC 8 guidelines and discuss what treatment you recommend for her BP and why.
3. What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10 codes (no differentials)
4. What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)
5. Design a treatment plan and discuss how each intervention is applicable to Lorene's case. Consider the following interventions: ○ Labs ○ Durable Medical Equipment Diagnostic tests- discuss the goal/purpose ○ Any consultation with outside providers/services ○ Medications- discuss why you chose each specific medication
6. Referrals- who and why
7. Follow up- why and when
8. Education- specific and measureable
9. Lifestyle Changes- specific to her cultural preferences, values and beliefs

Dr. Deering and class,

1. Leads I, II, and V2 to V6 demonstrate ST depression.
2. Lorene’s elevated blood pressure of 146/90 places her at stage 2 hypertension based on the American College of Cardiology (ACC) 2017 guidelines. Essential (primary) hypertension (ICD I10) would be one of Lorene’s secondary diagnoses. The ACC 2017 guidelines differ from the Eight Joint National Commision (JNC 8) guidelines in the blood pressure classification, as well as blood pressure goal targets based on age and comorbidities. Regardless of age and whether the patient has diabetes and/or chronic kidney disease (CKD), the ACC 2017 guidelines recommend a blood pressure goal of less than 130/90. For patients 60 years and older, JNC 8 guidelines recommend pharmacologic treatment for blood pressure goal of less than 150/90 (Armstrong, 2014). For patients younger than 60 years old, JNC 8 guidelines recommend a blood pressure goal of less than 140/90. The blood pressure goal of less than 140/90 is also recommended for patients who have CKD or diabetes (Armstrong, 2014). While primary hypertension is often asymptomatic, long term hypertension increases the risk of developing a host of health complications, including coronary artery disease, heart failure, stroke, peripheral vascular disease, and vision loss (Woo & Robinson, 2016). The initial pharmacologic treatment for both guidelines is similar, which includes thiazide diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB) (Armstrong, 2014).

While the use of ACEI is considered first line, studies have shown that adverse effects of ACEI, such as cough and angioedema, are more prevalent in the African American population (Messerli, Bangalore, Bavishi, & Rimoldi, 2018). Angioedema, a rapid swelling under the skin, occurs in less than 1% of patients who take ACEI, but it occurs more frequently in African Americans. Since angioedema can be life-threatening as it may impair breathing with tongue or throat swelling, a thiazide diuretic is an appropriate substitute to help lower blood pressure (Messerli et al., 2018). Even though Lorene’s hemoglobin a1C is at the higher end of pre-diabetes, I would consider and treat Lorene as a diabetic especially with an elevated fasting blood glucose. The risk of developing type 2 DM is increased with a prediabetes diagnosis, especially if appropriate measures are not taken to optimize glycemic control. Currently, the JNC 8 guidelines recommend a thiazide diuretic or calcium channel blocker for African American patients with diabetes (Armstrong, 2014). Calcium channel blockers have demonstrated effectiveness in the management of hypertension in the African American population (Prendergast et al., 2014). There have been recent studies that show lower responsiveness in maintaining optimal blood pressure control with the use of ACE inhibitors in the African American population (Prendergast et al., 2014). With Lorene’s history of prediabetes, hypertension, hyperlipidemia, obesity, and ethnicity, I would prescribe Lorene a thiazide diuretic such as hydrochlorothiazide 12.5 mg orally once daily, and a calcium channel blocker, such as amlodipine 5 mg orally once a day. The only durable medical equipment I would recommend for hypertension is a blood pressure machine. Lorene should be encouraged to keep a daily log and record her blood pressure readings. She should bring the log at the next follow-up appointment in three months to

evaluate how her blood pressure responded to the medication. There is no consultation for hypertension at this time.

3. Lorene complains of shoulder discomfort, shortness of breath, nausea, and sweating while exercising at a dance class three days ago. Lorene stated that her symptoms disappeared after she stopped exercising. Based on Lorene’s clinical presentation, the primary diagnosis that is causing her chest pain is stable angina pectoris (ICD I20.9). Substernal chest pain or discomfort occurs when the heart is not receiving enough oxygen supply, which results in myocardial ischemia (Cayley, 2014). Lorene is experiencing stable angina, which is chest discomfort that most often occurs with activity but disappears with rest (Arnett et al., 2019). This is due to poor blood flow through the blood vessels in the heart. The most common etiology of stable angina is ischemic heart disease, or coronary artery disease (Cayley, 2014). CAD occurs when cholesterol blocks the coronary arteries and cause narrowing of the arteries. Narrow coronary arteries lead to blood flow restriction and ultimately damages the arteries (Cayley, 2014). To compensate for this restriction, the heart works harder to efficiently pump the blood and ultimately cause more damage to the cardiovascular system (Sharma, Patel, Krishnamurthy, & Snyder, 2018). Positive pertinent findings of stable angina in this case study include: nausea, diaphoresis, shortness of breath, pain radiating to shoulder, and fatigue. Lorene also has risk factors that increase her risk of CAD. These include hypertension, tobacco use, and lipid disorders.

An electrocardiogram (EKG) of patients with stable angina, or angina pectoris, can provide information for both diagnosis and prognosis, especially when it is obtained during episodes of chest pain (Cayley, 2014). The earliest electrocardiographic change often associated with ischemia is ST-segment depression, which is shown in Lorene’s recent EKG. Initially, I would refer Lorene to a cardiologist. At this time, Lorene is asymptomatic and denies chest pain during this visitation. She is hemodynamically stable and presents no signs of respiratory distress. However, I have to take into consideration that Lorene lives in a rural area, where access to quality health care services may be limited. A small population with shortages of physicians and specialists makes me concerned that Lorene may not be able to make an appointment with a cardiologist within a month. I prefer that Lorene sees a cardiologist sooner rather than later.

If she is unable to secure an appointment with a cardiologist within four weeks, I would refer Lorene to the emergency room for further evaluation because I am concerned for ischemic changes. Lorene certainly requires additional testing with continuous monitoring in an appropriate setting. In the emergency room, she will have another EKG performed to detect any ischemic changes, as well as serial troponin tests, which measure the level of cardiac markers indicative of heart injury (Cayley, 2014). Significantly raised levels of troponin (greater than 0. ng/ml) or small increment increases over a series of hours are a strong indication of heart injury (Arnett et al., 2019). Determining Lorene’s risk of acute ischemia in an emergency room setting will avoid delay in treatment for reperfusion. A

cardiologist will also see Lorene in the emergency room and evaluate whether she will need immediate cardiac catheterization, a procedure used to diagnose and treat cardiovascular conditions. Before Lorene goes to the emergency room, I would encourage Lorene to make a follow-up appointment with the cardiologist if she is evaluated as stable. She will then be able to undergo additional testing, such as an echocardiogram (ECHO) to better visualize the chambers of the heart, and an exercise stress test, which monitors how the blood vessels in the heart works during physical activity (Cayley, 2014). Exercise EKG is more sensitive and specific than the resting EKG in detecting myocardial ischemia (Cayley, 2014). The goal of these tests is to detect possible heart-related cause of Lorene’s symptoms such as shortness of breath, chest pain, diaphoresis, and lightheadedness.

At this time, I would also prescribe Lorene a nitrate, such as nitroglycerin 1 sublingual at onset of acute angina pain, which is the most effective therapy for acute angina by relaxing vascular smooth muscle (Cayley, 2014). Nitroglycerin sublingual can be repeated every 5 minutes up to 15 minutes. If the pain is unrelieved after 15 minutes, Lorene must be instructed to go to the emergency room. Lastly, I would prescribe a low dose aspirin 81 mg orally once daily for atherosclerotic cardiovascular disease (ASCVD) prevention (Arnett et al., 2019). Aspirin helps prevent platelet aggregation, reduces the risk of clot build-up and prevent blood blockage. Lastly, if Lorene is able to see a cardiologist within a month, I would strongly encourage her to seek emergency treatment if she develops more frequent episodes of shortness of breath and chest pain at rest.

4. Lorene has several secondary diagnoses to be addressed during this visit. The treatment plan for each secondary diagnosis is as follows:

Impaired fasting glucose (R73.01) In this case study, it is unclear whether Lorene was previously diagnosed with type 2 DM since she mentioned having gastrointestinal side effects from Metformin. She also reports only taking insulin for gestational diabetes with her three pregnancies. However, based on the lab work from three months ago, Lorene’s hemoglobin A1c is 6.4%, which places her in the prediabetes category. Three months ago, her fasting blood glucose was 135 mgs/dl, which is higher than the normal range (greater than 100 mgs/dl). According to the American Diabetes Association (ADA, 2018) guidelines, a repeat hg A1c or a fasting plasma glucose (FPG) and a 2-hour plasma glucose (PG) should be obtained to confirm a type 2 DM diagnosis. If two different tests (such as A1C and FPG) are both above the diagnostic threshold, the diagnosis of type 2 DM is confirmed. Therefore, I would repeat a hb A1c and fasting plasma glucose on Lorene today as a follow up to her three month lab results. A high fasting blood sugar is only accurate at the moment, whereas a hemoglobin A1c measures overall blood sugar control in the past two to three months (Crawford, 2017). If the results are indicative of type 2 DM, I would prescribe Metformin ER 500 mg tablets by mouth twice daily because biguanides are the first line drug therapy for type 2 DM (ADA, 2018). I would educate Lorene about the potential side effects of Metformin, which include nausea, vomiting, bloating, gas, and abdominal pain (Irons & Minze, 2014). Lorene must understand that the gastrointestinal symptoms she was experiencing when she took Metformin in the past

are common side effects and not considered a true allergy. If she experiences a serious allergic reaction to Metformin, such as difficulty breathing, severe dizziness, rash, or itching/swelling of the face or throat, she should be advised to go to the nearest emergency room (Irons & Minze, 2014). The ADA (2018) guidelines also states there are many risk factors that significantly contribute to the development of type 2 DM, including age, race/ethnicity, obesity, positive family history, hyperlipidemia, smoking, and physical inactivity. Based on the information given, Lorene has some risk factors including her age, ethnicity, obesity, and hyperlipidemia. Lorene’s body mass index (BMI) is considered obese at 33.5. Type 2 diabetes is most common in overweight or obese individuals because excess weight causes insulin resistance (ADA, 2018). Lastly, there are no durable medical equipment or consultations needed for this secondary diagnosis at this time.

Mixed Hyperlipidemia (E78.2) : Mixed hyperlipidemia is another secondary diagnosis that requires attention during this visitation. Hyperlipidemia, also referred to as dyslipidemia, is a general term for high levels of lipids in the plasma (Jellinger et al., 2017). Increased circulating lipids in the blood vessels build up and create plaque, which narrows the blood vessels and cause blood blockage (Jellinger et al., 2017). Hyperlipidemia is most commonly caused by the consumption of foods high in saturated or trans fats, obesity, smoking, diabetes, and a sedentary lifestyle. Patients with hyperlipidemia are often asymptomatic until the disorder progresses to the point where it has caused atherosclerosis. Typically, patients may have symptoms associated with other problems such as CAD and hypertension. The most common symptoms include weakness, fatigue, nausea, and shortness of breath (Jellinger et al., 2017). Lorene has a history of dyslipidemia, but chose to initiate lifestyle changes instead of taking hyperlipidemia medications. During this visit, Lorene has positive pertinent findings within her laboratory results. Her elevated lipid panel is indicative of hyperlipidemia with total cholesterol 230 mg/dl (normal is less than 200 mg/dl), LDL 180 mg/dl (normal is less than 100 mg/dl), HDL 38 mg/dl (normal is greater than 40 mg/dl), and triglycerides 180 mg/dl (normal is less than 150 mg/dl) (Jellinger et al., 2017). While Lorene has tried lifestyle management through diet and exercise, her elevated lipid panel and obesity status still warrants the treatment of lowering her lipids. Abnormal lipid profile requires early management and assessment of risk for ASCVD. Studies have shown that early management of hyperlipidemia reduces the risk of cardiovascular disease and decrease mortality and disease progression among patients with clinical ASCVD (Jellinger et al., 2017). Since most patients with hyperlipidemia are asymptomatic, it is important to understand the significant role of screening in the treatment and prevention of both hyperlipidemia and cardiovascular disease.

Therefore, I would prescribe atorvastatin 40 mg by mouth at bedtime because statins are the primary drugs to reduce LDL levels (Jellinger et al., 2014. The decision to treat hyperlipidemia is based on the patient’s risk of atherosclerosis, which includes the patient’s lipid levels as well as other risk factors for developing atherosclerosis. Targeted LDL levels should be less than 100 mg/dL for patients with 2 or more risk factors and a 10-year risk of heart disease of 10-20% (Jellinget et al., 2017). Statin therapy can reduce LDL by 50% in diabetic patients who are 40 years of age (ADA, 2018). Lorene

has a few risk factors, including advanced age, increased lipid levels, and obesity. Therefore, she would benefit from statin therapy, which significantly reduces cardiovascular events in patients with diabetes (ADA, 2018).

Since Lorene’s latest lipid profile is from three months ago, I would order a follow-up lipid profile during this visit to see if her results have changed based on her dietary modifications. If the lipid profile results remain elevated, a prescription for atorvastatin 40 mg orally once a day will be beneficial for Lorene. At this time, she does not require any medical equipment or additional consultations for this secondary diagnosis.

Obesity (E66.9): Obesity is another secondary diagnosis that requires Lorene’s attention. Obesity is a disorder that involves excessive adipose tissue that increases the risk of health problems. It is often defined by a BMI of 30 kg/m2 or weight above the 95th percentile on the growth chart (Ankuda et al., 2017). The cause of obesity is primarily due to calorie intake that extends beyond the body’s metabolic needs. Lorene is considered obese since her current BMI is 33.5 kg/m2. Obesity results from a combination of causes and contributing factors, such as genetics, dietary patterns, physical inactivity, and medication use (Ankuda et al., 2017). Even though Lorene has tried to make some dietary changes, she admits eating processed foods whenever she is with her clients. She also states that it is difficult for her to prepare healthy foods since food is a large part of her culture. At this time, I would not consider any medications for obesity. The mainstay treatment for obesity is lifestyle changes such as diet and exercise. There is no additional diagnostic testing for obesity at this visit. Her BMI measurement is based on Lorene’s height and weight, which can be obtained with a scale. Lorene has been going to the gym with her daughter twice a week and has lost 2 inches around the abdomen. Since she has taken initiatives to promote weight loss, I do not feel the need to encourage any consultation unless she is interested in seeing a registered dietician. A registered dietician can help improve and promote proper nutrition therapy for patients who want to lose weight (Ankuda et al., 2017). A registered dietician can help discuss various ways to lose weight through simplified meal plans, behavior strategies, carbohydrate counting, and nutrition education (Ankuda et al., 2017). They can also provide therapeutic and counseling services to help Lorene manage her health conditions. Portion control and choosing nutritious food items can help control blood glucose levels and improve cholesterol levels.

5. Referrals

As I had mentioned previously, I would refer Lorene to a cardiologist so that she may have additional tests for her new onset angina. A cardiologist is a specialist who can evaluate whether Lorene needs immediate intervention and interpret results from diagnostic testing, such as an exercise stress test or coronary angiography (Buch et al., 2018). Lorene has many risk factors, such as ethnicity, obesity, prediabetes, hyperlipidemia, hypertension, and tobacco use, that predispose her to cardiovascular events. Aggressive management of these cardiovascular risk factors is essential (Buch et al., 2018). Therefore, recommendations from cardiologists will benefit Lorene in managing her many secondary diagnoses.

6. Follow Up

Since I am starting Lorene on new prescription medication, I would follow-up with Lorene’s medical therapy in 4 weeks. At that time, I would like to re-evaluate Lorene’s blood pressure, as well as assess the frequency and severity of her symptoms (Buch et al., 2018). I would like to know if she is still experiencing shoulder discomfort and shortness of breath during physical activity, and re-assess her fatigue symptoms. Even though patients with stable angina should be clinically assessed every 4-6 months for the first year, it is important to always assess change in symptoms (Buch et al., 2018). It is also important to evaluate whether Lorene followed up with a cardiologist. Effective communication and interdisciplinary management between primary care providers and specialists are associated with better clinical outcomes (Buch et al., 2018). In regards to Lorene’s many secondary diagnoses, I would like to follow-up with hg A1c and lipid profile in three months. If her results are not decreasing, I would need to modify the dosage on her current medications. Lastly, I would like to follow up on whether Lorene has continued to adhere to lifestyle modifications in regards to diet and exercise.

7. Education

Lorene will need proper education on the management of prediabetes, hypertension, hyperlipidemia, and obesity. First, a brief education on the medical conditions is recommended. It is important for health care providers to provide education on managing these chronic conditions through healthy lifestyle habits, medication regimen, and regular physician follow-up appointments (Mundt et al., 2016). Recognizing symptoms and risk factors for these conditions are essential steps toward prevention and control. Addressing treatment goals based on lab results will help Lorene as well. For prediabetes, the treatment goal is to lower her hg A1c results from the previous one. For hyperlipidemia, the treatment goal is to lower her LDL levels to below 100 mg/dL and triglycerides levels to below 150 mg/dL (Jellinger et al., 2017). For obesity, the treatment goal is to lower her BMI to less than 25. A weight loss of 1 to 2 pounds per week is recommended (Crawford, 2017).

As far as medication is concerned, Lorene must be educated on the common side effects of nitroglycerin, aspirin, metformin, hydrochlorothiazide, amlodipine, and atorvastatin. With Lorene’s past response to metformin, it is important to educate her on taking metformin with meals to reduce gastrointestinal side effects (Woo & Robinson, 2016). Lorene should also be educated on refraining from drinking alcohol while taking her prescribed medications because of poor interactions and adverse side effects.

8. Lifestyle Changes

To manage prediabetes and hyperlipidemia, it is important to educate Lorene on maintaining a diabetic and heart healthy diet. The ADA (2018) recommends a low- calorie diet with low saturated fat. Therefore, a proper diet with appropriate amounts of whole grain, vegetables, fruit, and protein should be implemented to improve glucose tolerance and lower cholesterol (Zand, Ibrahim, & Patham, 2018). Lorene should be encouraged to list healthy ingredients whenever she goes grocery shopping and set aside time to meal prep. Meal prepping can help hold Lorene accountable and maintain

a proper diet (Zand et al., 2018). This would also help her avoid processed foods and eating at restaurants where food is often prepared with high sodium and unsaturated fats. Lorene should also reduce the amount of sweetened beverages and coffee she drinks a day. It is important for healthcare providers to understand many of these restrictions will be overwhelming for Lorene, especially since she leads a busy schedule with clients. To slowly change some of these habits, Lorene should be encouraged to set small goals. Small goals include gradually decreasing the amount of sweetened beverages or increasing the amount of vegetable servings over a certain period of time. In terms of her cultural preference, Lorene should be encouraged to continue to cook at home with family and be mindful on how much salt she uses. This type of dietary approach can help treat hypertension, and lower the risk of heart disease, stroke, and diabetes (ACC, 2017).

Even though Lorene socially smokes on a weekly basis, it is important to encourage smoking cessation because it reduces the risk of cardiovascular complications, such as stroke, asthma, and lung cancer (ACC, 2017). Lorene should be educated that smoking damages the lining of the vessels, which ultimately causes narrowing of the vessels.

Exercise is another lifestyle modification that Lorene should continue to implement to manage her secondary diagnoses. Regular physical activity of light to moderate intensity helps improve overall health and fitness (ADA, 2018). Any type of physical activity will help manage the weight, strengthen the heart and muscles, and lower stress levels. The ADA (2018) guidelines recommend a minimum of 150 minutes per week of moderate aerobic exercise or 75 minutes per week of high intensity aerobic exercise. Lorene should be encouraged to increase the amount of time she goes to the gym if she is able to tolerate it and have no symptoms of angina. She can gradually increase her workout regimen to 30 minutes for five days a week. Maintaining a rigid workout regimen, along with a proper diet, will improve her glycemic control, lower her cholesterol, and reduce her weight.

References

American College of Cardiology. (2017). 2017 Guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults. Retrieved from https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word- etc/Guidelines/2017/Guidelines_Made_Simple_2017_HBP.pdf

American Diabetes Association. (2018). American Diabetes Association: Standards of medical care in diabetes-2018. Retrieved from https://diabetesed.net/.../12/2018-ADA- Standards-of-Care.pdf

Ankuda, C.K., Harris, J., Ornstein, K., Levine, D.A., Langa, K.M., & Kelley, A.S. (2017). Caregiving for older adults with obesity in the United States. Journal of the American Geriatrics Society, 65( 9), 1939-1945.

Armstrong, C. (2014). JNC 8 guidelines for the management of hypertension in adults.

American Family Physician, 90( 7), 503-504.

Arnett, D.K., Blumenthal, R.S., Albert, M.A., Michos, E.D., Buroker, A.B., Miedema, M.D.,... Wijeysundera, D.N. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 43( 8). doi:10.1016/j.jacc.2019.03.

Buch, V., Hayley, R., Salas, J., Hauptman, P.J., Davis, D., & Scherrer, J.F. (2018). Chest pain, atherosclerotic cardiovascular risk, and cardiology referral in primary care. Journal of Primary Care & Community Health, 9. doi: 10.1177/

Cayley, W.E. (2014). Diagnosing the cause of chest pain. American Family Physician, 72( 10), 2012-2021.

Crawford, K. (2017). Review of 2017 diabetes standards of care. Nursing Clinics of North America, 52(4), 621-663. https://doi.org/10.1016/j.cnur.2017.07.

Goroll, A., & Mulley, A. (2014). Primary care medicine: Office evaluation and management of the adult patient. (7th ed.) Philadelphia, PA: Lippincott Wlliams & Wilkins

Irons, B.K., & Minze, M.G. (2014). Drug treatment of type 2 diabetes mellitus in patients for whom metformin is contraindicated. Diabetes, Metabolic Syndrome, and Obesity: Targets and Therapy, 7 , 15-24. doi:10.2147/DMSO.S

Jellinger, P. S., Handelsman, Y., Rosenblit, P. D., Bloomgarden, Z. T., Fonseca, A. V., Grunberger, G.,... Davidson, M. (2017). Guideline for the management of dyslipidemia and prevention of cardiovascular disease. American Association of Clinical Endocrinologists, 23( 3), 1-87.

Messerli, F.H., Bangalore, S., Bavishi, C., & Rimoldi, S. (2018). Angiotensin-converting enzyme inhibitors in hypertension: To use or not to use? Journal of the American College of Cardiology, 71 (13), 1474-1482. doi:10.1016/j.jacc.2018.01.

Mundt, M.P., Agneessens, F., Tuan, W., Zakletskaia, L., Kamnetz, S.S., & Gilchrist, V.J. (2016). Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study. Internal Journal of Nursing Studies, 58( 1), doi:10.1016/j.ijnurstu.2016.01.

Prendergast, H.M., Dudley, S., Brown, M., Daviglus, M., Kane, J., Bradshaw, B.E.,... & Sanyaolu, R. (2014). Antihypertensive medications and diastolic dysfunction progression in an African American population. High Blood Pressure & Cardiovascular Prevention: The Official Journal Of The Italian Society Of Hypertension, 21 (4), 269-274. doi:10.1007/s40292-014-0064-

Sharma, M., Patel, R.K., Krishnamurthy, M., & Snyder, R. (2018). Determining the role of intravenous hydration on hospital readmissions for acute congestive heart failure. Clinics & Practice, 8 (1), 1-4. doi:10.4081/cp.2018.

Woo, T & Robinson, M. (2016). Pharmacotherapeutics for the advanced practice nurse prescribers. (4th ed.) Philadelphia, PA: F. A. Davis Company

Zand, A., Ibrahim, K., & Patham, B. (2018). Prediabetes: Why should we care? Methodist Debakey Cardiovascular Journal, 14( 4), 289-297. doi:10.14797/mdcj-14-4- 289

Amy, Thank you for your post. I am wondering about your referral to cardiology. Your plan reads like you'd send the pt to ED only if she cannot get an appt with Cardio within 4 weeks. Does the patient need to be evaluated in ED today or no? And how does she have stable angina with EKG changes? Are we sure this is not an acute coronary event? I Look forward to your response.

Dr. Deering,

Thank you for your question! My initial thought process was to refer her to cardiology to get additional testing. Seeing as Lorene lives in a rural area with limited resources, the likelihood of her obtaining an appointment with a cardiologist within four weeks are slim. However, I re-evaluated the situation and I realize that even though Lorene is asymptomatic during this office visit, she has many risk factors that place her at risk of an acute coronary event. Therefore, Lorene needs to be evaluated in the emergency room today. Even though Lorene reports only one episode of shoulder discomfort and shortness of breath that was relieved with rest, it is common for women to present with atypical presentation of chest pain. Therefore, the diagnosis of acute coronary syndrome (ACS) without typical chest pain can be challenging. Patients, such as Lorene, are at increased risk for delayed or incorrect diagnosis, less aggressive treatment, and high mortality (Arnett et al., 2019). With Lorene’s extensive history of uncontrolled hypertension, hyperlipidemia, prediabetes, and obesity, Lorene is at a high risk of experiencing an acute coronary event (Arnett et al., 2019).

Stable angina, which is often a symptom of coronary artery disease, is when an individual experiences a brief episode of chest discomfort that disappears with rest. The chest discomfort is due to poor flow through the blood vessels in the heart (Arnett et al., 2019). It is important to note that a normal resting EKG is not uncommon in patients with angina regardless of severity. However, that does not exclude the diagnosis of ischemia. In this particular case study, Lorene’s resting EKG shows ST depression in areas of the heart that are not receiving enough oxygenation. Regardless of stable or unstable coronary artery disease, ST-segment depression is associated with an increased risk of subsequent cardiac events (Barstow & Rice, 2017). Based on the leads with ST depression in Lorene’s EKG results, there may be a possible blockage of the left main coronary artery that supplies blood and oxygen to the heart. The ischemia within the inferior and anterolateral areas of the heart warrants immediate attention

(Barstow & Rice, 2017). Therefore, in Lorene’s case, she must be evaluated sooner rather than later even if she only had one episode of chest discomfort. Given her risk factors, symptoms, and EKG abnormalities, a non-ST elevation acute coronary syndrome (NSTE-ACS) is suspected but additional testing, such as cardiac biomarkers, exercise stress test, and echocardiogram, are extremely helpful in proper diagnosis (Barstow & Rice, 2017).

References

Arnett, D.K., Blumenthal, R.S., Albert, M.A., Michos, E.D., Buroker, A.B., Miedema, M.D.,... Wijeysundera, D.N. (2019). 2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 43( 8). doi:10.1016/j.jacc.2019.03.

Barstow, C., & Rice, M. (2017). Acute coronary syndrome: Diagnostic evaluation. American Family Physician, 95( 3), 170-177.

Hi Brittany,

Thank you for your informative discussion post on this week’s complex cardiovascular case study. As we know, there are many antihypertensive agents with different actions to lower blood pressure, such as decreasing cardiac output and renal blood blow, blocking sodium and chloride reabsorption in the kidneys, peripheral vasoconstriction, and affecting different receptors (Arnett et al., 2019). Choosing an appropriate agent depends on the patient's medical history, age, race, comorbidities, and renal function. Monitoring laboratory work, encouraging routine follow-up, and observing adverse effects of the drug are essential to the patient's plan of care. I agree with your treatment plan on prescribing combination doses for Lorene’s stage 2 hypertension. Given Lorene’s history of non-compliance with Lisinopril, it is important to continue education on the side effects of angiotensin-converting enzyme inhibitor (ACEI). Even though the adverse effects of ACEI, such as cough and angioedema, are more prevalent in the African American population, it is important to educate Lorene that the onset of ACEI- induced cough ranges from within hours of the first dose to a month after taking the medication (Messerli, Bangalore, Bavishi, & Rimoldi, 2018). Since Lorene reported taking the Lisinopril for only a month without a cough, it is important that she continues to take it and ensure her that she can be re-evaluated if she develops a cough.

Secondly, Lorene seems to also present early signs of possible heart failure, such as fatigue, mild bulging of the neck veins, and trace swelling of the legs. This is due to prolonged uncontrolled hypertension, which causes further damage to the vessels of the heart (Singer, Skopicki, Thode, & Peacock, 2014). Hypertension is one of the most preventable contributors to cardiovascular issues. The incidence of heart failure is greater with higher levels of blood pressure, older age, and longer duration of heart failure (Singer et al., 2014). Furthermore, Lorene’s history of metabolic syndrome is another risk factor for heart failure (Singer et al., 2014). Based on Lorene’s borderline high lipid profile, obesity, hypertension, and impaired fasting glucose, she is at an

increased risk of cardiovascular events. Although obesity-related heart failure is unknown, the concept of excessive adipose accumulation that increases circulating blood volume and cardiac work is a risk factor associated with the future risk of heart failure development (Yancy et al., 2017).

Lastly, Lorene’s calculated 10-year Framingham Risk Score for coronary artery disease is 10.7%, which is relatively high. A low-dose aspirin is beneficial for patients between 40 and 70 years old as a preventative measure of a cardiovascular event. Interestingly enough, the current 2019 ACC/AHA guidelines for primary prevention of cardiovascular disease do not recommend low-dose aspirin for patients over 70 years without prior ASCVD (Arnett et al., 2019). It is evident that recent literature has changed professional decisions since there is no strong evidence indicating that the benefits outweigh the risks (Arnett et al., 2019). Even though this is not applicable to Lorene, it is interesting to note that recent evidence.

References Arnett, D.K., Blumenthal, R.S., Albert, M.A., Michos, E.D., Buroker, A.B., Miedema, M.D.,... Wijeysundera, D.N. (2019). 2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 43( 8). doi:10.1016/j.jacc.2019.03.

Messerli, F.H., Bangalore, S., Bavishi, C., & Rimoldi, S. (2018). Angiotensin-converting enzyme inhibitors in hypertension: To use or not to use? Journal of the American College of Cardiology, 71 (13), 1474-1482. doi:10.1016/j.jacc.2018.01.

Singer, A.J., Skopicki, H., Thode, H.C., & Peacock, W.F. (2014). Hemodynamic profiles of ED patients with acute decompensated heart failure and their associated with treatment. The American Journal of Emergency Medicine, 32 (4), 302-305. doi:10.1016/j.ajem.2013.12.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. J., Colvin, M. M.,.. Westlake, C.(2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guidelines for the management of heart failure: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Failure Society of America. Journal of the American College of Cardiology, 70 (6), 776-803. doi:10.1016/j.jacc.2017.04.

Both cardiac disease and metabolic syndrome behave differently in men than in women. We have to consider if and how she needs to be treated differently than a male patient in the same situation. This is where the history of the patient makes a big difference.

Gender differences in metabolic disease

Central adiposity

● ■ Prevalence of extreme obesity is increased in women compared with men

● ■ Increased waist circumference in women increases risk of metabolic syndrome to a greater degree than in men

Dyslipidemia

● ■ Associated with a greater risk for coronary artery disease in women than in men ● ■ Elevated triglyceride levels have a greater impact on coronary artery disease risk in women than in men, especially when combined with low HDL levels

Hypertension

● ■ Congestive heart failure is more commonly seen as a consequence of hypertension in women than in men ● ■ White coat hypertension’ is more commonly reported in women than in men

Hyperglycemia

● ■ Glucose levels after a glucose load are more commonly elevated than fasting blood glucose in women; the opposite is found in men

How might your management change based on this info?

Dr. Deering,

This week’s case study was interesting because it involved a complex cardiac issue in a woman with multiple risk factors. Although heart disease is often thought of as a common issue for men, heart disease is the most common cause of death for both men and women in the United States (National Heart, Lung, and Blood Institute [NHLBI], 2019). Unfortunately, there are gender differences in cardiac disease and metabolic syndrome. As we have discussed throughout this week, women do not always have typical signs of an acute coronary event. They often present with subtle symptoms, such as fatigue, weakness, indigestion, sweating, and anxiety, that are often misdiagnosed (Kuehn, 2019). They often do not feel the more obvious crushing chest pain that men typically experience. Therefore, women tend to downplay symptoms that are associated with cardiovascular events. Research has shown that women tend to have blockages not only in their main arteries but also in the smaller arteries that supply blood and oxygen to the heart (NHLBI, 2019). This condition is known as coronary microvascular disease. Another thing to take note is that mental stress can also trigger cardiac symptoms in women.

While Lorene was hemodynamically stable (blood pressure of 146/90, heart rate of 70, and oxygen saturation of 97%) and did not present to the office with symptoms of respiratory distress (shortness of breath or tachypnea), her resting EKG results indicated signs of ischemia. With her multiple comorbidities, such as age, ethnicity, obesity, and metabolic syndrome, she is at high risk of heart failure, acute coronary syndrome, and death. Knowing that there are molecular and cellular differences between men and women in regards to cardiac disorders will help us understand the progression and treatment of these disorders (NHLBI, 2019). Therefore, healthcare providers must lean towards a more aggressive approach when treating cardiac disease

in women. Since the prevalence of extreme obesity is increased in women compared with men, it is important to educate women about the risk of developing diabetes and cardiac disease when their body mass index (BMI) begins to fall into the borderline overweight range. They need strong encouragement to alter lifestyle modifications, such as exercise and diet, to lower their central adiposity and reduce the risk of developing metabolic syndrome.

Based on these gender differences in metabolic syndrome, my treatment plan would remain the same in terms of starting the appropriate medications to treat Lorene’s hypertension, hyperlipidemia, and prediabetes. Lorene will also need a prescription for a low-dose aspirin to prevent cardiovascular events since her 10-year Framingham Risk Score for coronary artery disease is relatively high at 10.7% (Alexander et al., 2014). Education is extremely important for Lorene in terms of adhering to a diet with limited sodium and saturated fats, as well as promoting exercise, smoking cessation, and decreasing alcohol consumption (Alexander et al., 2014). Lastly, as we have already discussed, it is imperative that Lorene is referred to the emergency room for additional testing and continuous monitoring to assess for cardiovascular events.