1. CARDIOVASCULAR CARE of the OUTPATIENT Diane M. Enzweiler, MSN, ANP-BC St. Elizabeth Physicians: Heart and Vascular

2. Case Study J.B. is a 52 year old Caucasian male who recently presented with complaints of chest pain and shortness of breath. Initial evaluation in the ER shows anterior ECG changes and elevated troponins. He was taken emergently to the cardiac cath lab and noted to have high grade LAD lesion that was stented. LV gram showed anterior hypokinesis with EF 40%. J.B. is a 52 year old Caucasian male who recently presented with complaints of chest pain and shortness of breath. Initial evaluation in the ER shows anterior ECG changes and elevated troponins. He was taken emergently to the cardiac cath lab and noted to have high grade LAD lesion that was stented. LV gram showed anterior hypokinesis with EF 40%.

3. J.B. has history of HTN, tobacco use (60 pack years), obesity (BMI 30), and family history of CAD (Father died @age 50 from MI). J.B. has history of HTN, tobacco use (60 pack years), obesity (BMI 30), and family history of CAD (Father died @age 50 from MI). Home meds: HCTZ 25 mg daily and Diltiazem 240 mg daily. Home meds: HCTZ 25 mg daily and Diltiazem 240 mg daily.

4. Being discharged today on ASA 325 mg daily, Effient 10 mg daily, Carvedilol 6.25 mg BID, Lisinopril 5 mg BID, Rosuvastatin 10 mg daily, NTG 0.4 mg SL PRN, and HCTZ 12.5 mg daily. Being discharged today on ASA 325 mg daily, Effient 10 mg daily, Carvedilol 6.25 mg BID, Lisinopril 5 mg BID, Rosuvastatin 10 mg daily, NTG 0.4 mg SL PRN, and HCTZ 12.5 mg daily. Follow-up in office in 1-2 weeks. Follow-up in office in 1-2 weeks.

5. Return Office Visit What is next? 1.Assessment (subjective and objective) 2.Review of meds a. Doses b. Indications c. Compliance/ Tolerance c. Compliance/ Tolerance 3.Education

6. Long Term Goals of Treatment To aid the patient to be able to live with fewest restrictions and without pain. To aid the patient to be able to live with fewest restrictions and without pain. Slow or reverse the degree of atherosclerosis. Slow or reverse the degree of atherosclerosis. Reduce cardiovascular risk factors Reduce cardiovascular risk factors Reduce recurrent events Reduce recurrent events

7. Medications Aspirin and Effient (Antiplatelet agents) Aspirin and Effient (Antiplatelet agents) * ASA 1 st line unless allergy or GI bleed 81-325 mgs daily * Long term use makes acute ischemic episodes less likely * Clopidogrel or Effient increase the inhibition of clot formation

8. Beta-blockers (Carvedilol) Beta-blockers (Carvedilol) * Antihypertensive * Reduce heart rate, myocardial O2 demand and lower the incidence of episodes of angina. * Report changes in glucose levels.

9. ACE-I Inhibitors (Lisinopril) ACE-I Inhibitors (Lisinopril) * Antihypertensive * Monitor Creatinine and Potassium levels * Suppression of RAAS * Decreases afterload * Stabilizes plaque * Arterial vasodilator

10. Statins (Rosuvastatin) Statins (Rosuvastatin) * Reduces LDL, total cholesterol, TG, and increases HDL * Adjunct to diet to slow atherosclerosis progression * Used in conjunction with diet and exercise * Monitor liver profile

11. Nitroglycerin Nitroglycerin * Relieve chest pain * Prevent chest pain * Educate on use (reinforce) * Avoid use with erectile dysfunction medicines

12. Diuretics (Thiazide, Loop, Potassium Sparing) Diuretics (Thiazide, Loop, Potassium Sparing) * Increases sodium and water excretion * Decreases preload * Monitor electrolytes

13. Lifestyle Modifications Smoking cessation Smoking cessation –One of the most powerful predictors for development of ASHD –Contributes to the development of ASHD, DM, lung disease, dyslipidemias, cancers. –Provide support and counseling

14. Lifestyle Modifications Exercise Exercise - Improves body’s metabolism - Conditions heart muscle, increases stamina, improves lipid levels, lowers blood pressure, and increases feeling of well being. - Minimum 45 minutes most days of the week.

15. Maintain healthy weight Maintain healthy weight Low fat diet Low fat diet Keep BP low Keep BP low Blood sugar control Blood sugar control ETOH consumption ETOH consumption

16. REINFORCE CHANGES WITH EACH VISIT REINFORCE CHANGES WITH EACH VISIT

17. QUESTIONS???