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ADULT CARDIOLOGY IN PRIMARY CARE Mary I. Jones, FNP-C, MSN, MHSA Piedmont Heart Institute.

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Presentation on theme: "ADULT CARDIOLOGY IN PRIMARY CARE Mary I. Jones, FNP-C, MSN, MHSA Piedmont Heart Institute."— Presentation transcript:

1 ADULT CARDIOLOGY IN PRIMARY CARE Mary I. Jones, FNP-C, MSN, MHSA Piedmont Heart Institute

2 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

3 Recommendations and Level of Evidence: Definitions Classification 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

4 Adult Heart Murmurs and Abnormal Heart Sounds: The Basics

5 Location of Heart Murmurs

6 Aortic Pulmonic Erbs Triscupic Mitral All People Eventually Take Money

7 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.

8 Timing of Heart Murmurs: Systolic Murmurs Mr. Pass MVP Mitral Regurgitation Physiologic (functional) Aortic Stenosis Systolic Mitral Valve Prolapse

9 Timing of Heart Murmurs: Diastolic Murmurs Ms. Ard Mitral Stenosis Aortic Regurgitation Diastolic

10 Heart Sounds Normal heart sounds: S 1 S 2 Abnormal heart sounds: S 3 S 4

11 Heart Sounds: Normal S 1 Closure of AV (mitral and tricuspid) valves Onset of systole/ventricular emptying S 2 Closure of semilunar (aortic and pulmonic) valves Onset of diastole/ventricular filling

12 Heart Sounds: Abnormal S 3 Low pitched (best heard with bell) Occurs in association with (after) S 2 Sign of heart failure S 4 Low pitched (best heard with bell) Occurs in association with (before) S 1 Sign of hypertension or acute MI S1 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.

13 Primary Prevention of Cardiovascular Disease

14 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

15 Evaluation and Management of the Patient with Ischemic Heart Disease

16 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

17 More Definitions Acute 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)

18 Thrombus Formation and ACS UANQMI 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: New Terminology:

19 The Vulnerable Plaque Reproduced with permission from Falk E, et al. Circulation. 1998;92: Thin, vulnerable, fibrous cap Large lipid core

20 Ruptured Plaque with Occlusive Thrombus Formation Reproduced with permission from Falk E, et al. Circulation. 1998;92: Thrombus formation Plaque rupture

21 Ruptured Plaque & Occlusive Thrombus Ruptured PlaqueOcclusive Thrombus

22 Pathogenesis of Acute Coronary Syndromes: The integral role of platelets Plaque Fissure or Rupture Platelet Aggregation Platelet Activation Platelet Adhesion Thrombotic Occlusion


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