Key Elements of Outpatient Cardiology

Mastering the 10 Facets of Outpatient Cardiology for Nurse Practitioners

By Dr. Tranise Goodlow, DNP, APRN, AGACNP-BC

Edited by: Claire Lang

 

1. Patient History

This is one of the most important pieces of information that you need from your patient. Their history includes the patient’s personal history and the patient’s family history. This combination of information is vital to identify any risk factors. For example, the likelihood of having premature coronary disease increases if someone has male family members under the age of 55 or female family members under the age of 65 with heart disease.

2. Lifestyle Modification

We often tell patients to exercise and eat a healthy diet, assuming they actually know what this entails. I’ve found it best to offer detailed suggestions. For instance, the American Heart Association recommends adults get 150 minutes of moderate exercise or 75 minutes of intense exercise per week. In regards to a diet, the American Heart Association recommends only two diets: the DASH diet or the Mediterranean diet while maintaining a low sodium intake (2300 mg per day, approximately a teaspoon). We must also address lifestyle modifications or cessation programs pertaining to tobacco use, alcohol intake, and illicit drug use.

The above are just a few examples to help your patients lead healthier lives. Conversations such as these are critical to improve individual outcomes and avoid potentially life changing events.

3. Medications

Cardiac pharmacology and prescribing medications can be quite intimidating. To get a sense, there are approximately 125 medications that can be prescribed for hypertension alone. This number is ever-expanding. Guideline recommendations are great for base knowledge and considerations for medications, but guidelines cannot substitute clinical judgement. As studies estimate that medication compliance is around 50%, it is critical that we individualize patient care to improve compliance and patient outcomes.

Another facet of prescribing medications is to consider potential side effects. Discussing these possible side effects promotes shared decision making and builds trust in the care you provide. It also offers a teaching/learning opportunity for patients to feel more comfortable with the medications you prescribe.

4. EKG Interpretation

This is certainly an expected skill to possess as a cardiology nurse practitioner. The foundation for EKG interpretation is knowing the rules and applying these rules properly. I find it extremely important to complete my own interpretation of EKGs, because the computer’s interpretation can result incorrect findings.

It is always important to have baseline EKGs for your patients. Since many people have baseline abnormal EKGs, a baseline provides comparison for future readings. If the patient has no change from their prior EKG, this is likely a stable finding (of course there are exceptions). In order to improve your interpretation skills: practice, find reliable sources, and practice some more!

5. Hypertension

The American College of Cardiology/American Heart Association (ACC/AHA) redefined Stage I hypertension as 130-139/80-89 mmHg. The AHA has named hypertension the “silent killer”.  Hence why it is very alarming to learn that approximately half of adults fall into the category of hypertensive.

As practitioners, we must appropriately manage hypertension with lifestyle modifications and pharmacological therapy, because hypertension impacts vital organs and can lead to long-term organ damage. In hard to control hypertension (e.g., the patient is on three or more anti-hypertensives), consider secondary causes. The workup of secondary hypertension often includes lab work, imaging, and additional testing.

6. Lipids

Lipid control is instrumental for successful patient outcomes and avoidance of future complications. Initiating lipid lowering medications is not as simple as: the patient’s lab results are out of range = begin therapy.

Per the ACC/AHA Guidelines, a patient’s ASCVD score needs to be calculated. This score estimates their 10-year risk of having a cerebral vascular accident or myocardial infarction. A score of 7.5% or more indicates statin therapy should be instituted.

7. Heart Failure

In simple terms, heart failure impairs the ability of the heart to pump, relax, or pump and relax. Without standard therapy implementation, patients diagnosed with heart failure have approximately a five-year mortality rate.

Loop diuretics can be helpful for HF patients to remove excess fluid and help them feel better, but they do not improve outcomes. ARNI (Entresto – sacubitril/valsartan) or ACEs/ARBs with beta blockers and Aldactone have been shown to improve patient outcomes. In the African American heart failure population, use of BiDil (isosorbide dinitrate/hydralazine) along with standard therapy markedly improves patient outcomes.

8. Chest Pain & Ischemia Evaluations

The complaint of chest pain is certainly attention grabbing. One of the most serious implications from a cardiac standpoint is ischemia and potential myocardial infarction.

As a provider, you need to obtain an appropriate history of present illness, specifically all aspects of OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and Treatment). Based on the patient presentation, recommendations for medications and diagnostics are made.

The definition of ischemia is the lack of blood flow. Therefore, ischemia evaluations are diagnostic tests to determine if the patient is getting adequate blood supply to the heart. Depending on the results of the evaluation, the patient may require medications, interventions (e.g., stenting, bypass graft surgery), and/or enhanced counter pulsation therapy.

Keep in mind, ischemia evaluations can NOT predict myocardial infarctions. Myocardial infarctions are acute events of unstable plaque rupturing and stopping the arterial blood flow to a portion of the heart.

9. Palpitations

Palpitations are a subjective complaint. Patients may experience the sensation of racing, irregular, or skipped heart beats. Other symptoms of palpitations include shortness of breath, lightheadedness, dizziness, or even syncope. Implementation of lifestyle modifications prove beneficial when exogenous triggers (e.g., caffeine or alcohol) play a role in palpitations.

Arrhythmias can also cause palpitations (anything from PVCs, atrial fibrillation, or ventricular tachycardia, to name a few). Thorough investigation of arrhythmias is necessary for proper management. This may include the patient wearing an ambulatory monitor for a period of time. Depending on the findings, cardiology may continue to manage the patient’s problem. Electrophysiology will need to follow-up if it is something more advance.

10. Staying Up to Date

This is arguably the most challenging facet in being a practicing clinician. Evidence based research, guidelines, updates, and care are ever-evolving. Therefore, staying up to date is a tall order!

Podcasts make it easier for me to stay current in the cardiology world. This is because they include new information with articles, trials, and endless references. My go-to is Cardionerds, because it’s entertaining, informative, and covers a wide range of topics. The American College of Cardiology also has a podcast entitled ACC CardiaCast. Another resource I find helpful is produced by heart.org and Medscape is This Week in Cardiology.

 

About Tranise

Tranise Goodlow, DNP, APRN, AGACNP-BC is a cardiology nurse practitioner, adjunct professor, and founder of Dr. G the NP, a nurse/nurse practitioner coaching business that teaches cholesterol/hypertension management and EKG interpretation. Visit drgthenp.com for more information!

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