Presentation on theme: "ADULT CARDIOLOGY IN PRIMARY CARE"— Presentation transcript:
1 ADULT CARDIOLOGY IN PRIMARY CARE Mary I. Jones, FNP-C, MSN, MHSAPiedmont Heart Institute
2 OUTLINE Adult heart murmurs and abnormal heart sounds Primary prevention of cardiovascular diseaseEvaluation and management of the patient with anginaPathophysiology of unstable plaqueEvaluation and management of the patient with heart failureSecondary prevention of cardiovascular diseaseEvaluation and management of the patient with Atrial Fibrillation
3 Recommendations and Level of Evidence: Definitions Classification of RecommendationsClass I: Conditions for which there isevidence for and/or general agreementthat treatment is beneficial, useful, andeffectiveClass II: Conditions for which there isconflicting evidence and/or a divergence ofopinion about the efficacy of a treatmentClass IIa: Weight of evidence/opinionfavors usefulness/efficacyClass IIb: Usefulness/efficacy is less wellestablished by evidence/opinionClass III: Conditions for which there is evidenceand/or general agreement that a treatment isnot useful/effective and in some cases may beharmfulLevel of EvidenceA: Data derived from multiplerandomized clinical trialsor meta-analysesB: Data derived from a singlerandomized trial or fromnonrandomized studiesC: Only consensus opinion ofexperts, case studies, orstandard of care
4 Adult Heart Murmurs and Abnormal Heart Sounds: The Basics
11 Heart Sounds: Normal S1 Closure of AV (mitral and tricuspid) valves Onset of systole/ventricular emptyingS2 Closure of semilunar (aortic and pulmonic)valvesOnset of diastole/ventricular filling
12 Heart Sounds: Abnormal S3 Low pitched (best heard with bell)Occurs in association with (after) S2Sign of heart failureS4 Low pitched (best heard with bell)Occurs in association with (before) S1Sign 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.
14 Prevention of Coronary Heart Disease (CHD) Campaigns and Statements National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) IIILDL goals, CHD risk equivalent, metabolic syndromeJoint National Committee (JNC)-7Hypertension managementWorld Heart Federation (WHF), World Health Organization (WHO)Cigarette smokingNational Heart, Lung, and Blood Institute (NHLBI), Food and Drug Administration (FDA), Centers for Disease Control (CDC)ObesityAHA/NHLBI Go Red for Women, AHA Guidelines on Prevention of Cardiovascular Disease (CVD) in WomenWomen and CVDSTEMI: ACC/AHA guidelines at
15 Evaluation and Management of the Patient with Ischemic Heart Disease
16 DefinitionsNew-onset angina – recently developed symptoms of less than 3 months durationChronic stable angina – a predictable pattern and presentation of symptoms (sustained > 3 months) that occurs with activity and is relieved quickly by rest and/or NTGUnstable angina – Sustained pain (20-30 minutes) or pain with occurs with increased frequency or duration and/or with lesser exertionAnginal equivalents – angina surrogates such as dyspnea, fatigue, abdominal pain, syncope, and diaphoresisSyndrome X or microvascular angina – angina with normal coronary arteriesPrinzmetal/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 UANQMISTE-MIPlaque Disruption/Fissure/ErosionThrombus FormationNon-ST-Segment Elevation Acute Coronary Syndrome (ACS)ST-Segment Elevation Acute Coronary Syndrome (ACS)OldTerminology:NewIt is now recognized that unstable angina (UA), non-Q-wave myocardial infarction (NQMI), and ST-segment elevation myocardial infarction (STE-MI) are all parts of the spectrum of clinical manifestations of acute coronary syndrome (ACS). The older terminology has now been replaced with terminology that divides ACS into non-ST-elevation ACS (NSTE-ACS) and ST-segment-elevation. All the slides in this teaching set deal with NSTE-ACS.
19 Thin, vulnerable, fibrous cap The Vulnerable PlaqueThin, vulnerable, fibrous capLarge lipid coreA cross-section of a coronary artery demonstrating the vulnerable plaque, with its large lipid core and thin fibrous capReproduced with permission from Falk E, et al. Circulation. 1998;92:
20 Ruptured Plaque with Occlusive Thrombus Formation Cross-section of a coronary artery showing the site of plaque rupture (yellow arrow) and thrombus formation, outlined in white, occluding the coronary artery.Plaque ruptureReproduced with permission from Falk E, et al. Circulation. 1998;92:
22 Pathogenesis of Acute Coronary Syndromes: The integral role of platelets PlaqueFissure or RupturePlateletAdhesionPlateletActivationPlateletAggregationPlatelets are recognized to play an integral role in acute coronary syndromes and arterial thrombosis. After plaque fissure or rupture, there is platelet adhesion and activation. This leads to platelet aggregation within the coronary artery, and ultimately partial or complete occlusion of the coronary artery.ThromboticOcclusion