NR 603 Week 3 Case Discussion: Cardiovascular{100%}(LATEST UPDATE)

1 Cardiac Case Discussion Week 3 Discussion Questions: 1. What Leads Demonstrate the ST Depression? ST depression is indicative of acute myocardial ischema and hypoxia. Heart failure may cause ST depression and this ...

1 Cardiac Case Discussion Week 3 Discussion Questions: 1. What Leads Demonstrate the ST Depression? ST depression is indicative of acute myocardial ischema and hypoxia. Heart failure may cause ST depression and this is seen in leads V2, V3, V4, V5, and V6 (Klabunde, 2016; Harhash et al 2017). These depressions are horizontal or downsloping. 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. Lorene’s blood pressure is 146/90, she is a 60 year old African American female with a history of hypertension, dyslipidemia, gestational diabetes x 3, and metabolic syndrome. Yes Lorene is hypertensive based on the ACC/AHA guidelines since her BP is greater than 130/80 and she has a high cardiovascular disease risk (Mutner et al, 2017). Compared with the JNC 8 guideline, the 2017 ACC/AHA guideline recommends using lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels to define hypertension which means systolic less than 130 mm Hg and diastolic less than 80 mm Hg (Mutner et al, 2017). The JNC 8 guidelines establish treatment for persons aged 60 years and older with a BP goal of less than 150/90 mm Hg (James et al, 2014). For persons 30 years through 59 years old should maintain a diastolic goal of less than 90 mm Hg and a goal of 140/90 mm Hg based on their physcian’s expert opinion (James et al, 2014). This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 2 The 2017 ACC/AHA guidelines recommend combination therapy for all patients in stage 2 hypertension like Lorene. A recent study in Hypertension (Jaejin et al, 2021) found that a higher percentage of patients on combination therapy including an ACEI-thiazide diuretic compared with patients on monotherapy reached their blood pressure goals and achieved BP control. Participants on combination ACEI-thiazide diuretics also had better medication adherence, reduced treatment inertia, and lower cardiovascular events compared to monotherapy participants. Lorene will start combination therapy to meet the ACC/AHA guidelines with one generic combination pill Lisinopril/hydrochlorothiazide 12.5 mg/10 mg to start and continue diet and exercise. 3. What is the Primary diagnosis causing Lorene's chest pain? Include ICD 10 codes (no differentials) Angina pectoris, unspecified (ICD-10 code I20.9)- Disease can be diagnosed based on an ECG, clinical exam, or cardiac imaging (Thadani, 2016). 4. What other secondary diagnoses does Lorene have that should be addressed? (Include the rationale and a reference for your diagnoses)  Hypertension (ICD-10 code I10)- Lorene’s BP is 146/90 and pulse is 70 and she has an increased risk of CVD along with lower extremity edema so she meets both guidelines by the ACC/AHA and JNC 8. All adults recommended by the JNC 8 for hypertensive medication is also recommended by the ACC/AHA guidelines and considered to have hypertension. Adults with a high CVD risk or 65 years old and older with SBP of 130- 139 mm Hg or DBP of 80-89 mm Hg are recommended for taking antihypertensive This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 3 medication (Muntner et al, 2018). The ACC/AHA guideline is treating SBP/DBP to a goal of <130/80 mm Hg (Munter et al, 2018)  Hyperlipidemia, unspecified (ICD-10 code E78.5)- Lorene’s total cholesterol is 230 mg/dL (120-240 mg/dL normal range), triglycerides 180 mg/dL (0-200 mg/dL normal), LDL 180 mg/dL (62-130 mg/dL normal), and HDL 38 mg/dL (35-135 mg/dL normal). Total cholesterol, LDL (bad cholesterol), and HDL (good cholesterol) will be assessed along with the triglyceride level in some cases and a diagnosis will be made ( NIH, 2018). Lorene’s bad cholesterol (LDL) is elevated at 180 mg/dL and the HDL, triglycerides, and cholesterol are all boarderline. Based on a lipid profile screening for women every 1-2 years the cholesterol levels will be assessed along with a medical and family history and physical exam to diagnose hyperlipidemia. Lorene’s mother died of a stroke due to complications of type 2 diabetes and siblings also have metabolic syndrome.  Metabolic Syndrome (ICD-10 code E88.81)- The NIH (n.d) defines metabolic syndrome as having 3 of the 5 following risk factors: large waistline of 35 inches or more for women (apple shaped body type), high triglyceride level of 150 mg/dL or higher, low HDL level of less than 40 mg/dL, high blood pressure of over 130/85 mm Hg, and a fasting glucose level of 100 mg/dL or higher (normal is less than 100 mg/dL). Lorene has BMI of 33.5, hypertension, triglyceride level of 180 mg/dL, HDL level is less than 40 mg/dL, and a fasting glucose of over 100 mg/dL which was 135 mg/dL so she is positive for metabolic syndrome. Her siblings also have metabolic syndrome. 5. Design a treatment plan and discuss how each intervention is applicable to Lorene's case. Consider the following interventions: This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 4  Labs- Order lipid panel (repeat in 2- 4 weeks and ensure patient is fasting), HA1C (redraw in 3 months), fasting glucose, fructosamine, renal panel (includes glucose, phosphorus, Ca, creatinine, BUN, bicarbonate, albumin, K, Na, Cl, CO2, anion gap, eGFR, total protein, and BUN: Cr ratio) and liver panel (ALT, ALP, AST, bilirubin, and total protein) (NIH, n.d.: NIH, 2018).  Durable Medical Equipment Diagnostic tests- Repeat ECG each year and a take home sphymomanometry to measure BP daily and record for review at the next appointment.  Consult with endocrinologist on metabolic syndrome plan with using pioglitazone and not using metformin.  Medications (allergic to Metformin- GI upset):  RX: Aspirin 81 mg- Antiplatelet prophylactically (Vallerand & Sanoski, 2021).  Sig: Take 1 chewable tablet PO once a day  Dispense: OTC no script needed  RX: Nitroglycerin 0.3 mg- Nitrate that relaxes the blood vessels and increases the blood supply to the heart and also reduces the hearts workload (Vallerand & Sanoski, 2021).  Sig: Take 1 tablet sublingual every 5 minutes for chest pain up to a max of 3 doses  Dispense: 30  Refills: 3  RX: Rosuvastatin 10 mg- Statins have proven to lower the bad cholesterol (LDL) and therefore lower the risk of heart attach and stroke in people with high levels of LDL (NIH, 2018). Recheck lipids 2-4 weeks after initiation for titration (Vallerand & Sanoski, 2021).  Sig: Take 1 tablet PO once a day This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 5  Dispense: 30  Refills: 3  RX: Pioglitazone 15 mg- Metformin caused GI upset so pioglitazone is used as an antihyperglycemic when patients with type 2 diabetes has endogenous insulin. Using pioglitazone as a monotherapy or in combination with other antihypertensive medications is proven to have sustained positive results in patients with metabolic syndrome (Rajagopalan et al, 2005). It reduces resistance to insulin (Vallerand & Sanoski, 2021).  Sig: Take 1 tablet PO once a day  Dispense: 30  Refills: 3  Referrals- Lorene is referred to the following: Cardiologist for further assessment of angina pectoralis. Dietician consult for metabolic syndrome and DASH diet plan. Exercise physiologist for specialized training for weight loss. Consult with endocrinology on metabolic syndrome.  Follow up- Follow up with cardiology within the next few weeks and follow up with me in 2- 4 weeks to assess improvement.  Education- Education on measuring blood pressure in the moring and record them to share with HCP at next office visit. Educate on healthy eating for lowering cholesterol by utilizing the DASH eating plans (NIH, 2018), limiting alcohol consumption and cigarette smoking, increase physical activity to promote weight loss, manage stress, and get enough quality sleep.  Lifestyle Changes- Lorene is doing well with diet and exercise currently by going with her daughter to the gym and by not eating processed foods. She has also lost 2 inches to This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 6 her waist line so encouraging her to continue exercising and eating a low fat DASH diet will benefit her. In social situations she needs to plan what she will eat beforehand and stick to her plan and only allow a few cheat food items occasionally. Stopping smoking cigarettes, drinking alcohol, and making smart food choices when she dines out is important for Lorene’s success. Referring Lorene to the dietician will empower her with more knowledge on how to plan out her diet. References Berlowitz. (2018). Clinical inertia and the 2017 ACA/AHA guideline. The Journal of Clinical Hypertension (Greenwich, Conn.), 20(10), 1392–1394. https://doi.org/10.1111/jch.13373 Demir, V., Ede, H., Yılmaz, S., & Dogru, M. T. (2017). Treatment of hyperlipidemia: The effects of atorvastatin and rosuvastatin treatment on endothelial dysfunction among patients with hyperlipidemia. The American Journal of Cardiology, 119(8), e38–e38. https://doi.org/10.1016/j.amjcard.2017.03.126 Harhash, Reddy, S., Huang-Tsang, J., Natarajan, B., Balakrishnan, M., Shetty, R., Hutchinson, M., & Kern, K. (2017). TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion? Journal of the American College of Cardiology, 70(18), B159–B159. https://doi.org/10.1016/j.jacc.2017.09.484 Jaejin, A., Luong, T., Qian, L., Wei, R., Liu, R., Muntner, P., Brettler, J., Jaffe, A. E., Reynolds, M., & Reynolds, K. (2021). Treatment patterns and blood pressure control with initiation of combination versus monotherapy antihypertensive regimens. Hypertension, 77, p. 103- 113. This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 7 James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C. Jr., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T. Jr, Narva, A. S., Ortiz, E. (2014). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. doi: 10.1001/jama.2013.284427. Erratum in: JAMA. 2014 May 7;311(17):1809. PMID: 24352797 Klabunde, R. E. (2017, March 9). Cardiovascular physiology concepts. Retrieved from https://www.cvphysiology.com/CAD/CAD012 Muntner, P., Carey, R. M., Gidding, S., Jones, D. W., Taler, S. J., Wright, J. T. Jr., & Whelton, P. K. (2018). Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. American Heart Association Circulation, 137(2):109-118. doi: 10.1161/CIRCULATIONAHA.117.032582. Epub 2017 Nov 13. PMID: 29133599; PMCID: PMC5873602 National Insitiute of Health: National Heart, Lung, and Blood Institute. (2018, November 14). Blood Cholesterol. Retrieved from https://www.nhlbi.nih.gov/health-topics/bloodcholesterol National Institute of Health: National Heart, Lung, and Blood Institute. (n.d.). Metabolic Syndrome. Retrieved from https://www.nhlbi.nih.gov/health-topics/metabolic-syndrome Rajagopalan, R., Iyer, S., & Khan, M. (2005). Effect of pioglitazone on metabolic syndrome risk factors: results of double-blind, multicenter, randomized clinical trials. Current Medical Research Opinion, 21(1). This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ 8 Thadani, U. (2016). Management of stable angina–current guidelines: a critical appraisal. Cardiovascular drugs and therapy, 30(4), 419-426.Thadani, U. (2016). Management of stable angina–current guidelines: a critical appraisal. Cardiovascular drugs and therapy, 30(4), 419-426. doi: 10.1007/s10557-016- 6681-2 Vallerand, A. H. & Sanoski, C. A. (2021). Davis’s drug guide for nurses (7th ed.). Philadelphia: F. A. Davis. This study source was downloaded by 100000844830524 from CourseHero.com on 10-09-2023 23:58:09 GMT -05:00 https://www.coursehero.com/file/142255819/NR-603-week-3-discussiondocx/ Powered by TCPDF (www.tcpdf.org)