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6/17/2013
1
Getting to the
Heart of the Matter
Albert Riddle, MD, CMD
Riddle Medical Group
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CARDIAC ANATOMY
Getting to the Heart of the Matter
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Cardiac Anatomy
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Cardiac Anatomy
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PHYSIOLOGY
Getting to the Heart of the Matter
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Normal Electrical Conduction
• Initiated in SA node.
• Impulse travels to LA and RA
leading to contraction in both.
• Impulse travels to the AV node.
• Bundle of His.
• Right and Left Bundle Branches.
• Purkinje System.
• Ventricular Contraction.
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Normal Heartbeat
• P wave: atrial depolarization.
• PR interval: Time for impulse to
travel from SA node to AV node.
• QRS interval: Time it takes for
ventricles to depolarize.
• T wave: Ventricular
repolarization.
• QT interval: Time needed for the
ventricles to repolarize.
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CARDIOVASCULAR CHANGES WITH
PHYSIOLOGIC AGING VERSES DISEASE
Getting to the Heart of the Matter
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Functional Areas of Concern
• Heart Rate
• Cardiac Rhythm
• Systolic Function
• Diastolic Function
• Valvular Changes
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Rate• Resting heart rate is not affected by aging
– Daytime bradycardia with heart rates < 40 bpm and sinus
pauses of over 3 seconds are not seen with healthy aging.
• Decreased heart rate in response to exercise and
stress is characteristic of healthy aging.
• Consequences
– Maximum heart rate on a treadmill is decreased.
– Heart rate response to fever, hypovolemia, and postural
stress is decreased with healthy aging.10
Rhythm
• Time for conduction through the AV node is increased
with healthy aging (P-R interval increases with healthy
aging).
• 2nd and 3rd degree AV block are not normal
consequences of aging.
• Isolated RBBB has not been linked to increased risk for
advanced conduction abnormalities.
• Isolated Left Anterior Hemiblock is not a predictor of
cardiovascular morbidity or mortality.11
Rhythm
• Left fascicular hemiblock in combination with
RBBB is associated with cardiovascular
disease in 75% of older patients.
• Isolated LBBB is not associated with normal
aging and is associated with increased risk for
cardiac events.
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Rhythm
• Atrial premature contractions increase with
age and are frequent in 95% of older healthy
people at rest and during exercise.
• Atrial Fibrillation is usually associated with
coronary, hypertensive, valvular, sinus node
disease, or thyrotoxicosis but can occur in the
absence of detectable cardiac disease.13
Rhythm
• Prevalence of atrial fibrillation presence in
absence of detectable cardiac disease:
– Older Males: 1/5
– Older Females: 1/20
• Isolated and/or multiform ventricular ectopy has
been reported in up to 80% of older men and
women without detectable cardiac disease. 14
Systolic Function
• Resting left ventricular systolic function
(ejection fraction and/or stroke volume) is not
altered by aging.
• A few studies report declines of stroke volume
with sedentary older populations.
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Systolic Function
• Cardiac output may be reduced with exercise due
to decrease in maximum heart rate and limited
ability for the heart to increase contractility.
• Result = an age-related decline in exercise
capacity.
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Cardiac Output = Stroke Volume X Heart Rate
Diastolic Function
• During Diastole the heart relaxes and gives the
ventricles time to fill.
• This time is prolonged with normal aging.
– Reasons: increased ventricular mass, collagen
infiltration, altered myocardial calcium metabolism.
– Result: Prolonged filling times may limit cardiac
output with increased heart rates, but does not lead
to congestive failure.17
Valvular Changes
• Degenerative calcification leading to sclerosis
that is normal with aging.
– Effect: Aortic and Mitral Regurgitation
• Primary valve changes that occur with
congenital and rheumatic disease are not a
normal part of aging.
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Change Comparison
Age-Related Changes Cardiovascular Disease
Decreased heart rate response Sinus Pauses
Longer P-R intervals 2nd and 3rd degree AV block
Right Bundle Branch Block Left Bundle Branch Block
Increased Atrial Ectopy Atrial Fibrillation
Increased Ventricular Ectopy Sustained Ventricular Tachycardia
Altered Diastolic Function Decreased Systolic Function
(Ejection Fraction)
Aortic Sclerosis Aortic Stenosis, Aortic Regurgitation
Annular Mitral Calcification Mitral regurgitation, Stenosis Systolic
Hypertension, Diastolic Hypertension
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BASIC CARDIAC EXAM OF THE
ELDERLY PATIENT
Getting to the Heart of the Matter
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Skin Exam
• Look for maculopapular
skin lesions on the
upper extremities as
these are a signal of
end stage heart failure
known as Robertson’s
Sign.
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Neck Veins• Always examine from the
right side (gives a more
accurate estimate than the
left: straight shot from the
right jugular veins to the
right superior vena cava
and right atria).
• Have patient turn head
slightly to the left.
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Neck Veins Estimating Central Venous Pressure
• Estimate height of column
of blood in the internal and
external jugular (use the
most distended one to
calculate).
• More than 3 cm above the
clavicle with the patient at
45 degrees is abnormal.
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Interpretation of Increased JVD
• Look at changes in JVP with respiration
– Veins should collapse with inspiration.
– Veins distend with inspiration if there is a problem with right
atrial filling (Kussmaul’s sign).
– Causes
• Constrictive pericarditis
• Right Ventricular Infarction
• There should be 2 downward motions for each upward
motion representing right atrial filling (1st) and right
ventricular filling (2nd).24
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Apical Impulse
• Look for the Point of
Maximum Impulse
(PMI)
• Mid-clavicular line at 5th
intercostal space.
• Displaced down and/or
left with LVH.
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AUSCULTATION
Getting to the Heart of the Matter
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Normal Heart Sounds
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S1: Turbulence caused by closure of the Mitral and Tricuspid valves at the start of systole.
S2: Closure of the Aortic and Pulmonic valves at the end of systole..
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Aortic RegurgitationAKA Aortic Insufficiency
• Leaky aortic valve.
• As the ventricles rest in
diastole, blood flows
backward from the
aorta into the left
ventricle.
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Symptoms• Dyspnea on exertion• Orthopnea• Angina Pectoris• Congestive failureTreatment• Surgical Correction• Medical management with
ACE or ARB and Nifedipinewith or without history of hypertension
• Vasodilators such as hydralazine if the patient also has hypertension.
Aortic Stenosis
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Early
Late
Opening of the valve is narrowed.• Usually no symptoms with mild to moderate disease.• Initial presentation is usually shortness of breath on
exertion.• Patients respond by reducing activity, thus, masking
symptoms.• Subsequent symptoms of syncope, chest pain, and
sudden death.• Nitrates, ACE inhibitors, and vasodilators such as
hydralazine may worsen condition.• No treatment indicated if patient is asymptomatic.• Valve replacement has been most effective
intervention to date.• Poor response to medical interventions.
Mitral StenosisAlmost all cases due to Rheumatic Heart Disease
• Symptoms
– Heart failure
– Palpitations
– Chest Pain
– Hemoptysis
– Thromboembolism
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Treatment is not indicated in
asymptomatic patients.
Good results seen with
valvuloplasty by balloon catheter or with surgical valve
replacement.
Medical management according
to symptoms or other conditions.
• Angina: Vasodilators, B-blockers, or Calcium channel
blockers.
• Heart Failure: Lanoxin, Diuretics, Vasodilators, or ACE
inhibitors
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Pulmonic Stenosis
• Obstruction of blood flow from the right ventricle to
the pulmonary artery.
• Usually congenital.
• Can cause symptoms of right ventricular failure and
systemic cyanosis.
• Treatment: Percutaneous balloon valvuloplasty.
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S3 Gallop
• Rare extra heart sound
• Associated with congestive heart failure due to
conditions that are associated with
– Rapid ventricular filling (Mitral regurgitation)
– Poor left ventricular function (Post MI or Dilated
Cardiomyopathy)
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S4 Gallop
• Rare extra heart sound
• Caused by a forced contraction of the atria to
overcome an abnormally stiff hypertrophied
ventricle.
• Does not require treatment.
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Abnormal Breath SoundsRales
(Crackles)Rhonchi Wheezing Stridor
Small clicking,
popping, bubbling, or rattling sounds in
the lungs.
Sounds that
resemble snoring.
High pitched
sounds produced by narrowed
airways. They are heard when a
person breaths out.
Wheeze-like sound
heard when a person inhales and
exhales.
Occurs when air
opens closed air spaces. They can be
further described as moist, dry, fine, and
course.
Occur when air is
blocked or when air passage through
the large airways becomes rough.
Sign of a partially
obstructed airway.
Usually due to a
blockage of airflow in the trachea or in
the back of the throat.
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Absence of breath sounds where sounds are expected may indicate an effusion,
consolidation (as can be seen with pneumonia), or compression of the lung.Pleural rub occurs with friction between the pleural membranes due to inflammation.
THE HEART OF THE MATTER
Q&A Session #1
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ATRIAL FIBRILLATION
The Heart of the Matter
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Atrial Fibrillation
• 0.4% prevalence in those aged less than 65.
• 10% prevalence in those greater than 75.
• Prevalence projected to rise two to three fold
by the year 2050, largely due to increased life
expectancy.
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Atrial Fibrillation
• Present in 9.4% of patients with CVD and
1.6% of patients without CVD.
• Condition associated with valvular heart
disease, hypertension, heart failure, and
advancing age.
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PATHOPHYSIOLOGY
Atrial Fibrillation
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Atrial Fibrillation
• Rapid and disorganized
electrical activity in the atria.
• Areas other than the SA node
in the atria depolarize rapidly
and irregularly resulting in
chaotic atrial activity.
• The AV node attempts to
block as much choatic activity
as possible to slow down
ventricular rate.40
Atrial Fibrillation
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Remodeling with Atrial Fibrillation
• Atria gradually dilate and stretch.
– The hypertrophied atria then becomes more
vulnerable to abnormal electrical impulses.
• Progressive loss of ability of the AV node to block
impulses .
– More ventricular beats in response to ectopic signals
from the atria.
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A resident who is on Lanoxin 0.125 mg daily is
comfortable and in no distress. She has a heart rate of 82 per minute and her pulse is irregularly
irregular.
A lab report shows that her digoxin level is
slightly below normal.
What would you do next?
Types of Atrial Fibrillation
Type Ventricular Rate
Rapid Ventricular Response > 120 BPM
Controlled Ventricular Response 60 – 110 BPM
Slow Ventricular Response < 60 BPM
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Digoxin
• Indications
– CHF: 0.125 – 0.5 mg PO QD
– Atrial Fibrillation/Flutter: 0.125 – 0.5 mg PO QD
– PSVT conversion: 0.125 – 0.5 mg PO QD
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Digoxin
Serious Reactions
• AV block
• Severe bradycardia
• Thrombocytopenia
• Hallucinations
• Intestinal Ischemia
• Ventricular Arrhythmias
• Hemorrhagic intestinal
necrosis
Common Reactions
• Nausea/ vomiting
• Abdominal pain
• Weakness
• Bradycardia or Tachycardia
• Anorexia
• Confusion
• Depression/ Anxiety
• Mental disturbance46
IMPACT ON ADL’S
Atrial Fibrillation
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Impact on ADL’s
• Can cause a 5% - 40% drop in cardiac output
• Can lead to Cardiomyopathy that is reversible
if heart rate is controlled
• Stasis of blood in the atria increases risk of
thrombus formation that can lead to CVAs
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ASSESSMENT AND
MANAGEMENT
Atrial Fibrillation
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Causes of Atrial Fibrillation
• 3 main categories
– Primary arrhythmia in the absence of structural heart
disease or other precipitating cause.
– Secondary arrhythmia associated with a variety of
cardiovascular diseases.
– Secondary arrhythmia where there is no heart
disease but there is a condition that precipitates the
arrhythmia.50
Primary Causes of Atrial Fibrillation
• Isolated condition with no known
precipitating cause.
– Seen most commonly in patients < 65 years old
– Characterized by paroxysmal onset and
termination
– Frequently recurs
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Secondary Causes of Atrial Fibrillation
Cardiac Causes
• Hypertension
• Rheumatic heart disease
• Mitral valve disease
• Cardiomyopathy
• CHF
• Sick Sinus Syndrome
• Pericarditis
• Cardiac Surgery
Non-Cardiac Causes
• Hyperthyroidism
• Non-Cardiac surgery
• Non-cardiac diagnostic
procedure
• COPD
• Pulmonary Embolism
• Herbs (ephedra/ ginseng)
• Alcohol and drug use
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Assessment of Patient
• Symptoms
– Palpitations
– Hypotension
– Fatigue
– Dizziness
– Reduced exercise
tolerance
– Shortness of breath
– Worsening CHF
– Chest pain
– Syncope
– Near Syncope
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Assessment of Patient
• Paroxysmal Atrial fibrillation may lead to
unpredictable patterns that cause:
– Loss of feeling of control
– Fright
– Curtail usual activity to prevent recurrence
– Depression and a sense of helplessness
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Assessment of Patient
• Physical Assessment
– Blood Pressure
• Variable pulse pressure (due to variable ventricular filling
caused by irregular conduction)
• Hypotension
• Blood pressure can vary widely whether or not ventricular
rate is controlled (may need to take several blood pressure
and take an average to get a true sense of blood pressure
level)55
Assessment of Patient
• Physical Assessment
– Heart Sounds
• Rapid
• Irregularly irregular
• Variable loudness of S1
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Assessment of Patient
• Physical Assessment
– Other Findings
• Signs of CHF
– Decreased oxygen saturation
– Rales or crackles in lung fields
• Signs of poor peripheral perfusion
– Diminished distal pulses
– Impaired capillary filling
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Testing Capillary Filling Time
• Compress nail bed for 5
seconds.
• Upon release the blood
flow to the area should
be restored within 3
seconds.
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Lab & Diagnostic Testing
• Serial Cardiac Enzymes to assess for possible
acute MI
• Arterial Blood Gas to assess for hypoxia
• Thyroid Function Tests to rule out
hypothyroidism
• Electrolytes and Magnesium Level
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Lab & Diagnostic Testing
• Chest X-Ray to rule out CHF, Pulmonary
Disease, or Pneumonia
• Echocardiogram to assess cardiac valve
function and determine LV function
• Trans-esophageal Echo to assess for presence
of clots in the atria
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Lab & Diagnostic Testing
• 12 lead ECG
• Continuous ambulatory ECG may be
indicated if there are symptoms of atrial
fibrillation but the ECG is normal
• Nuclear medicine cardiac studies may be
indicated
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GOALS OF THERAPY
Atrial Fibrillation
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Appropriate Goals of Therapy
• Paroxysmal Atrial Fibrillation
– Use of antiarrhythmic therapy may not be needed
for patients that are asymptomatic.
– Antiarrhythmic therapy is indicated for those that
experience severe symptoms.
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Appropriate Goals of Therapy
• Recurrence after electrical or pharmacologic
cardioversion
– Long term rate control
– Ablation may be required for severely
symptomatic patients
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Appropriate Goals of Therapy
• Persistent (Permanent) Atrial Fibrillation
– Long term rate control
65
Appropriate Goals of Therapy
• Persistent Signs of Decreased Cardiac Output
during episodes of atrial fibrillation
– Restoration of normal sinus rhythm
–Maintenance of normal sinus rhythm is the goal
for persons who spontaneously convert from
atrial fibrillation to sinus rhythm
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MANAGEMENT
Atrial Fibrillation
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Pharmacologic Therapy
Antiarrhythmics
Class Actions Agents
Ia Slows conduction velocity Quinidine
ProcainamideDisopyramide
Ib Used only for Ventricular arrhythmias Lidocaine
Mexiletine
Ic Slows conduction velocity Flecainide
Propafenone
II Slows AV node conduction
Slows sinus rateDecreases myocardial oxygen consumption
Metoprolol
AcebutololPropranolol
Esmolol
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Pharmacologic Therapy
Antiarrhythmics
Class Actions Agents
IV Blocks outward movement of potassium
Prolongs cardiac refractory period
Amiodorone
SotalolDofetilide
Ibutilide
V Blocks calcium channels
Slows conduction through SA and AV NodesProlongs AV node refractory period
Verapamil
Diltiazem
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Acute Rate Control
Agent Action Route Time
Diltiazem Calcium Channel
Blocker
IV bolus Onset in 3 – 7
minutes
Verapamil Calcium Channel
Blocker
IV Loading
dose
Onset in 3 to 5
minutes
Esmolol B-Blocker IV Infusion
Metoprolol B-Blocker IV Loading
dose
Onset in 5 minutes
Digoxin Slows conduction
through SA and AV node
IV or oral
loading odse
Onset in 2 hours
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Oral treatment is possible with Digoxin, however, onset of action is 2 hours after administration of oral loading dose. More rapid onset of medication action would require IV therapy.
Long Term Rate Control
Agent Action Route ER Formulation
Diltiazem Calcium Channel
Blocker
120 – 360 mg per
day (divided doses)
SR: 60 – 120 BID
ER: 120 – 240 QD
Verapamil Calcium Channel
Blocker
120 – 360 mg per
day (divided doses)
ER 120 – 360 QD
IR 240 – 480 TID or QID
Lanoxin Slows SA/AV
conduction
0.125 – 0.375 mg
daily
Metoprolol B-Blocker 25 – 100 mg daily in
divided doses
Daily ER formulations
Propranolol B-Blocker 120 – 240 mg daily
in divided doses
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PREVENTING STROKE
Atrial Fibrillation
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Atrial Fibrillation & Stroke Risk
• Results from Framingham study in the 1970’s
provided the first population data to show a
fivefold increased risk of stroke with AF.
• The typical natural history is to go from
paroxysmal to persistent to permanent
usually over the course of many years.
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Atrial Fibrillation & Stroke Risk
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Percentage of stroke attributed to Atrial Fibrillation is 15% for all age groups and increases with advancing age.
Atrial Fibrillation & Stroke Risk• Increased risk for stroke with chronic, persistent, or
frequent episodes of atrial fibrillation.
• Reasons
– Heart’s atria doesn’t squeeze effectively
– Blood pools in the atria
– The pooled blood forms clots
– Clots eventually can break loose
– Loose clots can travel to the arteries to the brain
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CHADS2 Score
• Increased risk for stroke is
dependent upon age, and
on other medical conditions
that are present.
• CHADS2 assigns a number
from 0-6 to help decide
whether anticoagulation
therapy is warranted.
Medical Condition Points
Prior Stroke 2
CHF 1
Hypertension 1
Diabetes 1
Age 75 or older 1
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Developed by researchers from the Washington University School of Medicine in St. Louis, Missouri
Stroke Estimates Using CHADS2
• The CHADS2 model was
developed by studying
records of 1,733 Medicare
Beneficiaries aged 65 to 95.
• Cautions: not a proven
predictor for patients < 65
years old and not found to
be a valid predictor in
patients with mitral
stenosis.
CHADS Score
Yearly Stroke Risk
0 1.9%
1 2.8%
2 4.0%
3 5.9%
4 8.5%
5 12.5%
6 18.2%
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CHADS2VASc ScoreRisk Factors for Stroke and Thromboembolism in non-valvular AF
Major Risk Factors Clinically Relevant non-major Risk
Factors
Previous stroke, TIA, Systemic Embolism,
and Age > 75.
Heart failure or moderate to severe LV
dysfunction (LVEF < 40%), Hypertension, Diabetes, Female, Age 65 – 74, and
Vascular Disease
Point Based Scoring System
Congestive Failure or LV Dysfunction 1
Hypertension 1
Age 75 or greater 2
Diabetes Mellitus 1
Stroke, TIA, thromb0-embolism 2
Vascular disease 1
Age 65-74 1
Sex category (i.e. female sex) 1
Maximum score 9 78
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Plan of Care Using CHADS2VAScRisk Category CHADS2VASc
Score
Recommended Antithrombotic
Therapy
One major risk factor or 2
or more clinically relevantnon-major risk factors
2 or more Oral anticoagulation therapy (OAC)
One clinically relevant risk
factor
1 Either OAC or Aspirin 75 – 325 mg daily
Preferred: OAC rather than aspirin
No risk factors 0 Either aspirin 75 – 325 mg daily or no
antithrombotic therapy.
Preferred = No antithrombotic therapy rather than aspirin.
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Major : Previous stroke, TIA, Systemic Embolism, and Age > 75.
Non-Major: Heart failure or moderate to severe LV dysfunction (LVEF < 40%),
Hypertension, Diabetes, Female, Age 65 – 74, and Vascular Disease.
HAS BLED Bleeding Risk Score
Letter Clinical Characteristics Points Awarded
H Hypertension 1
A Abnormal renal and liver function (1 point each) 1 0r 2
S Stroke 1
B Bleeding 1
L Labile INR’s 1
E Elderly (> 65 years of age) 1
D Drugs or alcohol (1 point each) 1 or 2
Maximum 9 Pts
80
High Risk: Score > 3
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Atrial Fibrillation Summary
• Atrial Fibrillation is a prevalent condition in the elderly that
can negatively impact ADL’s and quality of life.
• A. Fib can result from a large number of other chronic
medical conditions.
• Patients with atrial fibrillation are at increased risk fro
ischemic stroke.
• Appropriate management of anticoagulation is important.
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THE HEART OF THE MATTER
Q&A Session #2
83
CONGESTIVE HEART FAILURE
The Heart of the Matter
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Heart Failure Zones
• Everyday
– Weight before breakfast
– Take prescribed
medications
– Check for swelling in
ankles, feet, legs, and
stomach
– Low salt food
– Balance activity with rest
periods86
Heart Failure Zones
• All Clear: Green Zone
– No shortness of breath
– No weight gain more
than 2 pounds
– No edema
– No chest pain
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Heart Failure Zones
• Caution
– Weight gain of 3 pounds
over a day or 5 pounds
over a week
– Shortness of breath
– More edema
– More tired/ no energy
– Dry/ Hacky Cough
– Dizziness
– SOB when lying down88
Heart Failure Zones
• Emergency
– Struggling to breath
– Shortness of breath
while sitting still
– Chest pain
– Having confusion or
difficulty thinking clearly
89
Weight (If 8 ounce glasses)?
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Weight (If 8 ounce glasses)?
Answer = 1 Pound
91
Weight QOD: 2 Days Later
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1 Quart
Weekly Weights8 pounds (1 Gallon) a Week Later
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Visualizing Daily Weights
1 gallon of water weighs 8.34 pounds
1 pound of water = 0.119 gallons
8 ounces of water is 1/16th of a gallon
8 ounces of water = 0.0625 gallons
16 ounces of water = 1 pound
2 glasses of water = 1 pound
30 cc in one ounce94
STAGES IN THE EVOLUTION OF
HEART FAILURE
Getting to the Heart of the Matter
95
Stages in the Evolution of HF
Category Stage Characteristics
At Risk for Heart Failure
A • No structural heart disease.• No symptoms of Heart Failure.
At Risk for Heart Failure
B • Structural heart disease• No symptoms of heart failure
Heart Failure
C • Structural heart disease• Prior or current symptoms of HF
Heart Failure
D • Refractory heart failure requiring specialized interventions
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Stage A
• Definition: High risk for
heart failure but without
structural heart disease or
symptoms of HF.
• Examples: patients with
HTN, ASHD, DM, Obesity,
Metabolic syndrome, or
using cardiotoxins.
• Therapy Goals
– Optimal control of DM, HTN,
and lipid disorders
– Smoke cessation
– Regular exercise
– Discontinue excessive alcohol
intake or elicit drug use
• Treatment: ACE/ARB in
appropriate patients for DM,
HTN.
97
Stage B
• Definition: Structural heart
disease without symptoms
of heart failure.
• Examples: patients with
Previous MI, LV remodeling
other than LVH, or
asymptomatic valvular
disease.
• Therapy Goals (Same as A)
– Optimal control of DM, HTN,
and lipid disorders
– Smoke cessation
– Regular exercise
– Discontinue excessive alcohol
intake or elicit drug use
• Treatment:
– ACE/ARB in appropriate
patients for DM, HTN
– B-blockers
98
Stage C
• Definition: Structural heart
disease with prior or current
symptoms of heart failure.
• Examples: patients with
known structural heart
disease and shortness of
breath, fatigue, and reduced
exercise tolerance.
• Therapy Goals (Same as A)
– Same as under A & B
– Dietary salt restriction
• Treatment:
– Diuretics for fluid retention
– ACE/ARB where appropriate
– B-blockers
– Hydralazine/ Nitrates
– Digitalis where appropriate
• Devices
– Pacemaker
– Implantable difibrillator99
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Stage D
• Definition: Refractory heart failure
requiring specialized interventions.
• Examples: Patients with marked
symptoms at rest despite
maximum medical therapy
(recurrent hospitalizations or
cannot be safely discharged from
the hospital without specialized
interventions)
• Therapy Goals (Same as A)
– Same as under A , B, and C
• Options:
– Compassionate end of life care
– Hospice
• Extraordinary Measures
– Heart transplant
– Chronic inotropes
– Permanent mechanical support
– Experimental drugs
– Experimental surgery 100
Management of Chronic CHF
• General Measures
– Control systolic and diastolic blood pressure
– Treat lipid disorders
– Control blood sugar
– Treat thyroid disorders
– Use or consider ASA 50 – 325 mg daily
– Assess Left Ventricular Function101
If LVEF > 40%
• Goal: Preserve function
• Treat volume overload with short term loop
diuretics until signs of overload resolve.
• Aggressively treat underlying disease such as
myocardial ischemia, hypertension, or atrial
fibrillation.
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If LVEF at or under 40%
• No signs or symptoms of congestion
– Initiate treatment with ACE followed by initiation
and titration of a B-blocker to target dose.
– Continue to monitor for onset of signs or
symptoms of congestion
• At onset add loop diuretic followed by digoxin then
aldosterone receptor antagonist and finally
spironolactone.103
If LVEF at or under 40%
• With signs or symptoms of congestion
– Initiate ACE with a loop diuretic
– Titrate ACE to target dose
• Once symptoms resolve
– Initiate and titrate B-blocker
– If symptoms develop
• Titrate diuretic and consider addition of Zaroxolyn104
BRAIN NATRIURETIC PEPTIDE
Getting to the Heart of the Matter
105
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BNP
• Brain Natriuretic Peptide Hormone.
• Made in the heart.
• Normally only a small amount if found in blood.
• If the heart has to work harder than usual over a long
period of time (heart failure) it releases more BNP.
• With response to treatment for heart failure the BNP
levels fall.
106
BNP
• Function
– Regulates Circulation
• Dilate blood vessels
• Stimulate the kidneys to excrete more salt and water
• Lower blood pressure
• Reduce the workload and stress on the heart
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BNP
• Information obtained from the test
– Confirms presence of heart failure in those with
symptoms (example: trouble breathing, edema)
– Indicates how severe heart failure is
–Measures the response to treatment for heart
failure
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BNP
• Interpretation of Results
– < 100 pg/mL rules out heart failure
– 100 – 400 warrant further diagnostic investigation
– > 400 pg/mL indicates a 95% likelihood of heart
failure
– The higher the BNP, the more severe the heart failure
with levels sometimes reaching into the thousands
109PG = Picograms
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A 76-year-old female, Doris Smith, is admitted to your facility after a 4 day hospitalization for decompensated congestive heart failure. She was treated aggressively with diuretics and stabilized in the hospital but is not strong enough to go home. You are accepting her to provide a brief course of rehabilitation so that she can eventually return to her home. She weighs 124 pounds.
History: Diabetes, Hypertension, and CHF
MedicationsLasix 40 mg daily with potassium supplementationLanoxin o.125 mg dailyInsulin (Long and Short Acting with SSI Coverage
ECG: Old anterior wall MI and PVC’s
She ambulates about 100 feet without SOB, eats meals without assistance, and is able to toilet herself without assistance.
CHF Care Plan
• Goals
– Body weight will remain stable
– Sodium restricted diet
– Maintain optimal level of physical activity
– Staff will monitor for early signs of fluid overload
– Maintain optimal cardiac output
– Maintain optimal fluid volume
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CHF Care Plan
• Interventions
–Weight resident in the same clothing type and at
the same time of day in the morning.
–Maintain a record of weights.
– Teach resident and family about maintaining a
daily weight log.
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CHF Care Plan
• Interventions
– Provide sodium restricted diet along with other
appropriate dietary restrictions.
– Teach the resident about restricting sodium.
– Teach family about appropriate food and snacks.
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CHF Care Plan
• Interventions
– Establish the baseline level of physical activity (the level at
time of hospital discharge).
– Increase activity gradually.
– Utilize measurements (V.S., “Talk Test) and coordinate
with Physical Therapy.
– Observe for complications (dyspnea, fatigue, and pain)
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CHF Care Plan
• Interventions
– Observe for the following
• Edema of extremities
• Coughing
• # of pillows used or resident wanting to sleep in chair
• Shortness of breath with usual acitivity
• Increasing weight
– Provide emotional support
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CHF Care Plan
• Interventions
– Check vital signs, breath sounds, and breathing
patterns
– Observe for s/s of decreased cardiac output
• Chest pain, dyspnea, edema, JVD, or change in mental
status
– Check lab values as ordered
– Monitor pacemaker and other related devices116
CHF Care Plan
• Interventions
– Administer cardiac medications, anticoagulants, and
diuretics as per medical orders.
– Administer oxygen as needed.
– Elevate head of bed as needed.
– Monitor I’s and O’s.
– Check appetite and monitor for s/s of malnutrition.117
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During her second night in the facility Mrs. Smith asked to C.N.A. if she could have an additional pillow to sleep on. It was provided, but as the C.N.A. was helping her get comfortable, she noticed that Mrs. Smith had a cough that she did not hear the previous night.
During the next morning, Mrs. Smith appetite was poor and she seemed slightly confused. She had not been confused at all one day earlier.
She also seemed to be having more difficulty getting to the toilet, about 30 feet away from her bed, without assistance. While being assisted, she was having difficulty speaking clearly.
The C.N.A. reported her findings to the nurse manager of the unit.
Stop and Watch Early Warning Tool
S Seems different than usual
T Talks or communicates less
O Overall needs more help
P Pain – New or worsening (Less participation in activities)
A Ate less
N No bowel movement in 3 days; or diarrhea
D Drank less
W Weight change
A Agitated or nervous more than usual
T Tired, weak, confused, or drowsy
C Change in skin color or condition
H Help with walking, transferring or toileting more than usual119
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The nurse manager assessed Mrs. Smith to have the following
findings:
1. She had gained 3 pounds since admission.
2. She needed to sit upright to breath comfortably.
3. She was having difficulty talking.
4. Her nail-beds were dusky.
5. Blood pressure 145/92
6. Pulse 102
7. Respirations 26
8. Bilateral ankle edema
9. Oxygen saturation 95% on 2 liters oxygen by N/C
10. Skin cool and moist (no fever)
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SBAR – CHF
Situation• I am calling about Mrs. Smith. He/she has CHF and;
– Unrelieved or new shortness of breath at rest (no)
– Unrelieved new chest pain (no)
– Wheezing or chest tightness at rest (no)
– Inability to sleep without sitting up (Asked for another pillow)
– Inability to stand without severe dizziness or light headedness (no)
– Weight gain of > 5 pounds in 3 days (3 pounds in 2 days)
– Markedly increased edema (some edema)
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SBAR – CHF
Background• Primary diagnosis: CHF, Diabetes, Hypertension
• Medication changes during the last week: None
• Findings include
– Temp Afebrile
– Heart rate 102
– Respirations 26
– Blood Pressure 145/92
– Oxygen saturation 95% ON 2 liters per minute
– Glucose (if applicable) fingerstick 88
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SBAR – CHF
Assessment
I think the resident has signs and symptoms of
new or worsening CHF. They Do/ Do not meet
the care path criteria for management of signs
and symptoms in the nursing home.
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SBAR – CHF
Recommendations
• Manage in the nursing home
• Consider CBC, BMP, CXR
• Initiate or increase diuretic dose if indicated
• Oxygen supplementation if indicated
• Monitor VS (pulse and apical heart rate) Q4H for 24 –
72 hours
• Transfer to acute care facility
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CAREPATH for CHF
Initial Assessment Observation
Unrelieved shortness of breath or new shortness of breath.
Yes
Unrelieved new chest pain. No
Wheezing or chest tightness at rest. No
Inability to sleep without sitting up. Yes
Inability to stand without severe dizziness or light headedness.
No
Weight gain of > 5 pounds in a week. No
Worsening edema. Yes
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CAREPATH for CHF
Vital Signs Observation
Temperature > 100.5 No
Apical heart rate > 100 or < 50 Yes
Respiratory rate > 28/min or < 10/min No
BP < 90 or > 200 systolic No
Oxygen saturation < 90% No
Finger stick glucose < 70 or > 300 No
New or worsening chest pain No
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CAREPATH for CHF• Initiate Work-Up
– STAT Portable Chest X-Ray
– STAT Complete Blood Count with Differential
– STAT Basic Metabolic Panel
– EKG
– BNP level
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CAREPATH for CHF
• What to look for
– CHF or pneumonia on CXR
– Critical lab values
– EKG shows new changes suggestive of acute MI
or arrhythmia
–Worsening clinical condition
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CAREPATH for CHF• Plan of Care: Manage at Facility
–Monitor vital signs, fluid intake, and urine output
every 4 to 8 hours.
– Supplemental Oxygen.
– Initiate or increase diuretic dose.
– Initiate or modify other cardiovascular
medications.
–Monitor electrolytes and kidney function.129
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CAREPATH for CHF
• Monitoring
– Vital Signs
• Keep temperature at 100.5 or less
• Maintain apical heart rate between 50 - 99
• Maintain respiration between 10 - 28
–Worsening condition
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CHF Summary
• CHF is a serious condition that demands careful
monitoring and early recognition of signs and symptoms of
decompensation.
• A comprehensive care plan is vital.
• Aggressive monitoring of weight change is crucial.
• BNP is a powerful monitoring tool.
• Use of Interact III tools can improve care and reduce
potential risk of hospitalization.
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THE HEART OF THE MATTER
Q&A Session #3
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