ADULT CARDIOLOGY IN PRIMARY CARE

Mary I. Jones, FNP-C, MSN, MHSA

Piedmont Heart Institute

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

Recommendations and Level of Evidence:

DefinitionsClassification 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

Adult Heart Murmurs and Abnormal Heart

Sounds: The Basics

Location of Heart Murmurs

Location of Heart Murmurs

Aortic

Pulmonic

Erbs

Triscupic

Mitral

All

People

Eventually

Take

Money

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.

Timing of Heart Murmurs:Systolic Murmurs

Mr. Pass MVP

Mitral Regurgitation

Physiologic (functional)

Aortic Stenosis

Systolic

Mitral Valve Prolapse

Timing of Heart Murmurs:Diastolic Murmurs

Ms. Ard

Mitral Stenosis

Aortic Regurgitation

Diastolic

Heart Sounds

Normal heart sounds: S1 S2

Abnormal heart sounds: S3 S4

Heart Sounds: Normal

S1 Closure of AV (mitral and tricuspid) valves

Onset of systole/ventricular emptying

S2 Closure of semilunar (aortic and pulmonic)

valves

Onset of diastole/ventricular filling

Heart Sounds: Abnormal

S3 Low pitched (best heard with bell)

Occurs in association with (after) S2

Sign of heart failure

S4 Low pitched (best heard with bell)

Occurs in association with (before) S1

Sign 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.

Primary Prevention of Cardiovascular Disease

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 www.acc.org

Evaluation and Management of the

Patient with Ischemic Heart Disease

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

More DefinitionsAcute 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)

Thrombus Formation and ACS

UA NQMI 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:

NewTerminology:

The Vulnerable Plaque

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

Thin, vulnerable, fibrous cap

Large lipid core

Ruptured Plaque with Occlusive Thrombus

Formation

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

Thrombus formation

Plaque rupture

Ruptured Plaque & Occlusive Thrombus

Ruptured Plaque Occlusive Thrombus

Pathogenesis of Acute Coronary

Syndromes:The integral

role of platelets

PlaqueFissure or Rupture

PlateletAggregation

PlateletActivation

PlateletAdhesion

ThromboticOcclusion