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Clinical Log Spring Semester 2012
Emily Koch
ACNP Student
Clinical setting and preceptor: CCU, Carole Ballew
Date: December 28-29, 2011
Description of clinical experience: We began the day by attending Heart Failure rounds with Dr. Bergin. All the inpatient HF patients on 4 East and CCU were presented and discussed. Patients who were particularly interesting to me included: 1) a heart transplant patient in rejection who had become septic and required mechanical ventilation and circulatory support, 2) a patient in cardiogenic shock following acute STEMI from in stent restenosis requiring mechanical ventilation and circulatory support, 3) a patient with a myxoma in her left ventricle and resulting severe (wide open) mitral regurgitation from valve papillary muscle rupture, and 4) a patient with LVAD who had suffered multiple complications including device clot, thromboembolic stroke, and GI bleed. The DINAMITE study (see bibliography) was discussed and cited as rationale for bringing Patient #2 back as outpatient for planned ICD placement. Afterwards, Carol and I discussed some of the common topics presented during rounds with particular focus on 1) measuring cardiac output by thermodilution and Fick equation, 2) clinical utility and interpretation of venous oximetry, and 3) mechanical circulatory support options.
Major learning points:
1. Indications for pulmonary artery catheters and clinical utility of data collected.
2. Principles of venous oximetry: determinants of SvO2, clinical utility of SvO2 to guide therapy, assessment of oxygen delivery-demand balance
3. Added foci for objectives to include clinical experience reading and interpreting cardiac catheterization and echocardiogram reports.
4. Carol demonstrated NP role on Heart Failure team.
Related to Cardiology Objectives: Objective 1.1: Develop foundational skill and knowledge to care for the critically ill patient with complex cardiac condition.
Related to Course Objectives for the ACNP student: 5, 8, 9, 13, 14, 15, 16.
Annotated bibliography:
Aroesty, J. M., Jeevanandam, V., Eisen H. J. (2011). Circulatory assist devices: Cardiopulmonary assist device and short term left ventricular assist devices. In D. Cutlip (Ed.), UptoDate. Retrieved from
The authors introduce the three major types of circulatory assist devices and their indications. The devices discussed include: intraaortic balloon pump cardiopulmonary assist device, and short term ventricular assist devices. The article covers indications, contraindications, and complications of each device.
Goldenberg, I., et al. (2006). Time dependence of defibrillator benefit after coronary revascularization in the Multicenter Defibrillator Implantation Trial (MADIT-II). Journal of the American College of Cardiology, 47 (9), 1811.
The article is the landmark MADIT II, which resulted in current guidelines for ICD implanation for primary prevention to be delayed at least three months after revascularization precedure. The study demonstrates that significant life-saving benefit of ICD is greatest six months after coronary revascularization. The authors attribute this increased benefit to the increased liklihood of sudden cardiac death more than six months after coronary revascularization.
Hohnloser, S. H., et al. (2004). Prophylactic use of an implantable cardioverter-defibrilator after acute myocardial infarction. New England Journal of Medicine, 351 (24), 2481-2488.
The article presents the landmark DIMAMIT, which evaluated whether prophylactic use of an implantable cardioverter–defibrillator (ICD) improved survival in patients at high risk for ventricular arrhythmias after a recent myocardial infarction. This randomized trial found that it does not. Patients in the ICD group did have a lower rate of death due to cardiac arrhythmia, but it was offset by an increased rate of death from nonarrhythmic causes. The lack of benefit from ICD demonstrated in DINAMIT is the primary reason that current guidelines recommend that ICD implantation should be deferred until at least 40 days after a myocardial infarction.
Rivers, E. P., Otero, R., Garcia, A. J., Reinhart, K., & Suarez, A. (2009). Chapter 26: Venous oximetry. In A. Gabrielli, A. Layon, & M. Yu (Eds.), Civetta, Taylor, & Kirby’s Critical Care (pp. 296-316). Philadelphia: Lippincont Williams & Wilkins, a Wolters Kluwer Business.
This chapter provided a basic introduction to venous oximetry, techniques for measurement, and the clinical utility of mixed venous oxygen saturation in guiding patient management in critical care.
Silvestry, F. E. (2011). Pulmonary artery catheterization: Interpretation of tracings. In S. Manaker & K. Wilson (Eds.), UptoDate. Retrieved from
The article introduces the data that can be collected from pulmonary artery catheters. Additional useful information includes how to zero and reference the catheter, how to interpret the pressure waveforms, and how to calculate cardiac output.
Weinhous, G. L. (2011). Pulmonary artery catherization: Indications and complications. In P. Parsons (Ed.), UptoDate. Retrieved from
The article provides a thorough introduction to the rationale for pulmonary artery catheters, their effect on survival, indications, and contraindications.
Clinical hours: 16
Clinical setting and preceptor: Inpatient Acute Cardiology, Amanda Beirne
Date: January 6 & 10, 2012
Description of clinical experience: We started the day on 4 East, rounding on two patients awaiting transcatheter aortic valve replacement (TAVR). The inpatient ACNP is responsible for ensuring that all of the necessary pre-op orders are in and that all diagnostic results are within safe parameters to proceed with TAVR. We also attended electrophysiology (EP) interdisciplinary rounds and reviewed the day’s EP studies and procedures. Patients who were particularly interesting to me included 1) a 44 year old female who had a dual chamber pacemaker implanted at another hospital 17 years prior who had experienced pacer pocket stretching and device migration who now needed a generator change and 2) a 81 year old male who had a dual chamber pacemaker implanted three months ago who presented 2 wks post-procedure with hiccups and now is found to have lead migration and pericardial perforation with subsequent pericardial effusion. After rounds, we reviewed and discussed the above patients’ chest X-rays and CT scans with particular foci on lead placement, complications, and correlation to clinical presentation. We conducted a chart review and telephone encounter with a patient scheduled for cardiac catheterization the following day to reconcile meds, provide patient education, and to give instruction for day of procedure. Next we reviewed a presentation that Amanda will be giving at a conference on the topic of atrial fibrillation ablation. The presentation facilitated conversation about various approaches to ablating atrial fibrillation, drug loading, cardioversion and their indications.
On the second day we began the day in the Short Stay Unit (SSU), where we rounded on an EP patient who had an ablation the previous day. We discharged the patient, which provided the opportunity for writing a progress note and a discharge summary in EPIC. We were also able to evaluate the patient’s response to the ablation, reconcile medications, perform discharge teaching, and set up a follow-up plan to ensure a smooth transition of care. The type of ablation that the patient had was unfamiliar to me – left ventricular outflow tract (LVOT) premature ventricular contraction (PVC) ablation, which allowed for some teaching conversations with the Interventional Cardiology fellows about the different locations from which PVCs can originate. Finally, one interesting set of details about the above patient is that his wife had been treated on 4 East and in the CCU for cardiogenic shock and severe heart failure after a massive MI. The patient’s wife had been hospitalized at UVA from June 2011 – January 2012, at which time she passed away as a result of major complications related to LVAD therapy. As a bedside nurse, I cared for the patient’s wife on 4 East. Then she was one of the patients discussed when I was participating in CCU heart failure rounds with Carole Ballew and Dr. Bergin in my first clinical experience described in this log. So, seeing this patient in the SSU provided a unique opportunity to express condolence and to really appreciate 1) the continuum of nursing and medical care for patients and their family members and 2) the full spectrum of cardiac disease from episodic dysrhythmia to end stage heart failure.
Major learning points:
1. Chest X-ray and CT scan review post device implantation: differentiating between normal variation and complications.
2. Classification of atrial fibrillation into paroxysmal, persistent, and permanent.
3. Indications for ablation, cardioversion, drug loading, rate control, and anticoagulation in the setting of atrial fibrillation.
4. Long term sequelae of atrial fibrillation, mitral valve disease, and atrial remodeling.
5. General guidelines for patient management before and after valve replacement (mechanical and tissue).
6. Pradaxa: 1) dosing and 2) as an alternative to warfarin
7. Alcohol septal ablation for hypertrophic cardiomyopathy (actually is not ablation).
8. ECG findings in pericarditis.
9. General ECG review on UVA’s REALM website and on ECG Wave-Maven website.
10. LVOT v. RVOT PVCs
11. General guidelines for heart failure management and device placement.
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology.
Related to Course Objectives for the ACNP student: 1, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14, 16.
Annotated bibliography:
Allessie, M. A., et al. (2001). Pathophysiology and prevention of atrial fibrillation. Circulation, 103 (5),769-77.
The authors provide a thorough introduction into the classification of atrial fibrillation (AF) into paroxysmal, persistent, and permanent categories, explain risk factors that predispose patients to AF, and provide a solid explanation of principles of pathophysiology and prevention (primary and secondary) of AF.
Cabrera, J. A., Pizarro, G., & Sanchez-Quintana, D. (2010). Transmural ablation of all the pulmonary veins: Is it the Holy Grail for cure of atrial fibrillation? European Heart Journal, 31 (22), 2708-2711.
The authors review the multiple trigger mechanisms for atrial fibrillation (AF) and the evolution of catheter ablation strategies and techniques to correct AF. The authors conclude that although electrical isolation of all right and left pulmonary veins is the cornerstone in catheter and surgical strategies for preventing AF, the non-uniform regional distribution of cardiac nerves and differing patterns of innervation in human hearts causea wide array of atrial regions to contribute to the fibrillatroy process. Thus, the authors proclaim it is reasonable to expect a median of two AF ablation procedures to produece a successful outcome.
Camm, A. J., et al. (2010). Guidelines for the management for atrial fibrillation. European Heart Journal, 31 (19), 2369-2429.
These guidelines were developed by a task force of the European Society of Cardiology. The task force provides an introduction to the epidemiology and mechanisms of atrial fibrillation, as well as information about detection, natural history, and acute management. Also included are guidelines for managing anticoagulation, rate, rhythm, permanent atrial fibrillation, and its sequelae. At the end of the guidelines is information about atrial fibrillation in special populations, including athletes, pregnancy, post operative, pulmonary disease, and others.
Caulkins, H., et al. (2007). News from the heart rhythm society. Heart Rhythm, 4( 6), 816-861.
The purpose of this consensus statement is to provide a state-of-the-art review of the field of cather and surgical ablation of atrical fibrillation (AF) and report findings of a task force convened by the Heart Rhythm Society and charged with defining the indications, techniques, and outcomes of the procedure. The task force was coposed of experts representing six organizations: American College of Cardiology (ACC), the American Heart Association (AHA), the European Cardiac Arrhythmia Society (ECAS), The European Heart Rhythm Association (EHRA), the Society of Thoracic Surgeons (STS), and the Heart Rhythm Society (HRS).
Friberg, L, Hammar, N., & Rosenqvist, M. (2010) Stroke in paroxysmal atrial fibrillation: Report from the Stockholm Cohort of Atrial Fibrillation. European Heart Journal, 31 (8), 967-975.
The authors of this study investigate whether there are differences in stroke risk between paroxysmal atrial fibrillation and permanent atrial fibrillation. They found that ischemic stroke is as common in the setting of paroxysmal atrial fibrillation as in permanent atrial fibrillation. The study demonstrates the importance of anticoagulation patients who have paroxysmal atrial fibrillation with the same rigor as patients with permanent atrial fibrillation.
Fuster, V. et al. (2006). ACC/AHA/ESC practice guidelines: ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. Circulation, 114 (7), e257-e354.
The guidelines published here were developed by a task forces made up of members of The American College of Cardiology Foundation, the American Heart Association, and the European Society of Cardiology. The task force performed literature reviews, weighed the strength of evidence for or against a particular treatment or procedure, and included estimates of expected patient outcomes. Patient specific modifiers, comorbidities, patient preference, required follow-up, and cost-effectiveness are considered. The guidelines are intended to assist providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of atrial fibrillation and reflect a consensus of expert opinion and current scientific evidence.
Jacobs, A. K., et al. (2011). 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 123 (1), 104-123.
This is an update to the 2006 published guidelines. The guideline update focuses on areas in which new data have become available, including a) recommendations for strict v. lenient heart rate control, b) combined use of antiplatelet and anticoagulant therapy, c) use of dronedarone. Therapies still under investigation at the time of the release of these guidelines include the new antithrombotic agent dabigatran and the Watchman device for occlusion of the left atrial appendage, both of which were awaiting FDA approval.
Oral, H. & Morady, F. (2006). How to select patients for atrial fibrillation ablation. Heart Rhythm, 3 (5), 615-618.
The procedure for catheter ablation of atrial fibrillation (AF) is complicated, technically challenging, and lengthy. The criteria used to select patients for catheter ablation should be individualized since the genesis of AF is multifactoral, patients are heterogeneous, and ablation strategies and outcomes vary among centers and interventionalists. The author provide specific considerations and recommendations on how to select patients with AF for catheter ablation.
Clinical hours: 40
Clinical setting and preceptor: Interventional Cardiology, Amanda Beirne
Date: January 19 & 26, 2012
Description of clinical experience: We started the day in the Cardiology Transition Unit (CTU), preparing patients for cardiac catheterization by reconciling medications, ensuring that laboratory parameters (electrolytes, coags, renal function) were safe for patients to proceed with procedure, and performing focused history, ROS, and physical assessments. In one case we picked up on a significant drop in a patient’s hemoglobin and hematocrit that prevented him from having his cardiac catheterization and caused him to be admitted for an anemia work-up. This finding was slightly frustrating and illuminated a systematic omission, because as we looked back over previous labs, we saw that the blood counts had been dropping over several weeks and had gone unaddressed.
We also discharged patients that had uncomplicated procedures from the previous day, and in the afternoon we discharged patients who had uncomplicated procedures that same morning. At discharge, we reconciled medications again, wrote discharge instructions, progress notes, created safe discharge plans for follow-up, and educated patients on how to care for themselves after procedure. Toward the end of the day, we conducted several telephone encounters with patients to prepare them for the following day’s procedure schedule. We provided instruction on which medications to take/hold, instructions on eating and drinking the day of procedure, when to arrive and what to expect. Then we documented the telephone encounters in EPIC and ordered the necessary labs, medications, and ECGs on patients as necessary. This preparation the day before is essential to organized flow and expeditious patient progress through procedure the following day.
On the second day in the CTU, I performed an Allen test during a pre-op work up on a patient who would later undergo cardiac catheterization by way of the radial artery. The patient later complimented me on my bedside manner and approach. I also had the opportunity to observe a rare procedure, rotational atherectomy combined with coronary angioplasty and stent placement. Otherwise, I gained more practice with target assessment, writing progress notes, writing discharge summaries, corresponding with primary care providers, and core measures/ guidelines.
An interesting practice discussion that surfaced on the second day of this clinical experience was the question of who is responsible for optimizing a patient’s medications when the patient is seen by the nurse practitioner for an ambulatory procedure. A patient who was treated for unstable angina on the NP service received a coronary stent and was discharged on aspirin and plavix, but not on a statin or beta-blocker. The patient chart was then audited for compliance with core measures, and the NP was questioned. Since the patient’s admitting diagnosis was unstable angina, the NP felt there were no indications for starting a statin and beta-blocker. The NP felt it was the responsibility to the patient’s PCP to optimize the patient’s medication regimen at a follow-up appointment. It was unclear which core measures should apply to such a scenario. However, after careful review the 2007 AHA/ACC guidelines for management of unstable angina and NSTEMI, it seems clear that the NP should have started a beta blocker at discharge and recommended follow-up with PCP to discuss initiation of a statin, since a lipid profile and baseline LFTs would guide the decision.
Major learning points:
1. Reviewed the approach to the patient presenting with anemia of unknown etiology: systematic approach to ordering labs and diagnostics.
2. Providing discharge instructions and patient education in a manner that is meaningful to the patient, i.e. speaking your patient’s language.
3. Utilizing order sets and note writing tools in EPIC.
4. Assessment pearl: Arcus Senilis – appears as a white or gray ring in the corneal margin or white ring around the iris resulting from cholesterol deposits and persistent hyperlipidemia.
5. Approach to the patient with history of ETOH abuse who presents for routine procedure and is unexpectly admitted: cover your bases.
6. Telephone encountering.
7. How to perform an Allen test on patients requiring radial artery approach for catheter.
a. The hand is elevated and the patient/person is asked to make a fist for about 30 seconds.
b. Pressure is applied over the ulnar and the radial (thumb side) arteries so as to occlude both of them.
c. Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails).
d. Ulnar pressure is released and the color should return in 7 seconds. (Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial)
e. If color does not return or returns after 7–10 seconds, the test is considered negative and the ulnar artery supply to the hand is not sufficient. The radial artery therefore cannot be safely pricked/cannulated.
8. Omnipaque v. Visipaque: how to select contrast medium based on comorbidities and renal function.
9. Unstable angina/NSTEMI core measures
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, cardiac dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology. Objective 3. Acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting.
Related to Course Objectives for the ACNP student: 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16
Annotated bibliography:
Anderson, J. L., et al. (2007). ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. Journal of the American College of Cardiology, 50 (7), e1-157.
This is an invaluable clinical tool for providers who manage patients with known or suspected cardiovascular disease. It presents guidelines for risk stratefication, immediate management, early and late hospital care, special populations, as wells as variants of cardiovascular disease, such as prinzmetal’s and takotsubo cardiomyopathy. It was useful in settling a clinical discussion about whether or not a beta-blocker and statin should be started at discharge for a patient with unstable angina.
Beirne, A. (2012). Atrial Fibrillation Ablation: Is Your Patient a Candidate? Presented at Medtronic Allied Health Professionals Forum, Orlando, FL.
This presentation describes the pathophysiology of atrial fibrillation (AF) and the rationale for various ablation techniques in relation to existing knowledge of the pathophysiology of AF. The presenter also discusses patient selection criteria for AF ablation and alternative therapies for patients who are not ideal candidates for ablation.
Beirne, A. (2011). Atrial Fibrillation: New Treatment Guidelines, Therapy Options and Anticoagulation Alternatives. Presented at Heart Rhythm Society EP and Device Therapy for Allied Professionals: Applying Knowledge to Clinical Practice, Charlottesville, VA.
This succinct powerpoint presentation was created by an nurse practitioner. It covers the classifications of atrial fibrillation (AF), and the corresponding treatment considerations and strategies. The presenter also covers new and emerging anti-thrombotics and their role in the treatment of AF.
Fernandez, A. B., et al. (2009). Relation of corneal arcus to cardiovascular disease (from the Framingham heart study data set). American Journal of Cardiology, 1 (1), 64-66.
The authors revisit data from the Framingham Heart Study to determine if arcus senilis is an independent risk factor for cardiovascular disease and coronary artery disease. They concluded that arcus senilis predicted CVD and CAD in the Framingham Study cohort because of the strong association of arcus senilis and cardiac disease with increasing age.
Leichtle, S. W., Mouawad, N. J., & Bander, J. J. (2011). Anemia and transfusions in surgical patients: Current concepts and future directions. Journal of Blood Disorders & Transfusions. Retrieved from
Anemia is frequently discovered immediately preoperatively and corrected with blood transfusion to prevent evidence-based negative peri- and post-operative outcomes. The authors argue that preoperative anemia represents a challenge that is underappreciated in both incidence and potential for harm. Current guidelines propose blood conservation strategies and suggest that blood transfusions should not be considered a viable, routine treatment strategy for anemia. Alternatively, the authors lobby for preoperative optimization of elective surgical patients and utilization of blood saving techniques.
Clinical hours: 60
Clinical setting and preceptor: Electrophysiology Clinic, Donna Charlebois
Date: January 27 & February 3, 2012
Description of clinical experience: For the first day of this clinical experience, I was assigned two patients to work up and present. The first was an 86 year-old male who was being seen in the clinic for his follow-up appointment one year after receiving a DDDR pacemaker for sick sinus syndrome. The second was a 21 year-old female with the diagnosis of postural orthostatic tachycardia syndrome (POTS) who was being seen in clinic for follow-up after being started on citalopram three months ago for her symptoms. I felt prepared for this assignment and was able to confidently perform and document the episodic ROS and physical exam on each patient and create an appropriate management plan. I felt that I was able to spend most of my time applying my knowledge and skill to my patient assignments and less time asking questions about the minutia of patient management. I think this was confidence building and needed, as the past several clinical experiences really left me feeling overwhelmed by how much more I still need to learn.
On the second day of this clinical experience, I was assigned two patients to work-up and present: 1) 75 y.o. male with a history of atrial flutter and DDDR pacemaker for annual follow-up appointment, and 2) 74 y.o. female with history of atrial fibrillation ablation for follow-up. I demonstrated increased independence during the second clinical day, taking the lead in my patient’s clinic visit. I performed the medication reconciliation, interview, focused ROS and physical exam on my assigned patients without guidance. One of my patients required a slightly more extensive work-up, management plan, and consultation with the physician for dizziness, increased DOE, and right hand coldness. I presented the patient to the physician and made some recommendations for medication changes and further diagnostics, and felt quite validated when we then went back into the patient’s room together and the physician presented the plan exactly as I had suggested and even gave me credit in front of the patient. I also wrote the progress note, after visit review, and forwarded letters to my patients’ PCPs. When I requested critique from Donna, she said, “The feedback is try to go faster. We really have about 15 minutes with each patient.”
Major learning points:
1. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities
2. POTS
3. Heart Rhythm Society website has great resources for clinical guidance
4. Donna and Dr. Pamela Mason role-modeled respectful and effective collaborative practice
5. General pacemaker guidelines
6. Device interrogation reports, what device settings can be adjusted to improve clinical symptoms of dizziness and DOE
7. Wolff-Parkinson-White syndrome, clinical findings and ECG findings
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, cardiac dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology. Objective 3. Objectives to acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting.
Related to Course Objectives for the ACNP student: 1, 4, 5, 7, 9, 10, 11, 13, 14, 15
Annotated bibliography:
Connolly, S. J., et al. (2009). Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine, 361 (12), 1139-1151.
Warfarin reduces risk of stroke in patients with atrial fibrillation (AF) but increases the risk of bleeding and is difficult to maintain at a steady state in the patient’s body. Dabigatran is a new oral direct thrombin inhibitor. The purpose of this study was to test doses (110 mg and 150 mg) of dabigatran for effective prevention of stroke. The investigators found that the 110 mg dose was superior to warfarin with respect to bleeding but was associated with similar rates of stroke and systemic embolism, and the 150 mg dose was superior with respect to stroke or systemic embolism but associated with similar rates of major hemorrhage.
Epstein, A. E. (2008). ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm, 5 (6), e1-62.
This revision to the 2002 version covers major studies on bradyarrhythmias and tachyarrhythmias, which may be optimally treated with device therapy, as well as recent changes in the management of heart failure that involve drug and device therapy. The review also highlights advances in device technology. The guidelines and recommendations contained here have major impact on third party payers and the Centers for Medicare and Medicaid Services, and as such are important for any clinician who may refer a patient for device therapy.
Lip, G. Y. & Halperin, J. L. (2010). Improving stroke risk stratification in atrial fibrillation. The American Journal of Medicine, 123 (), 484-488.
The authors review the risk factors for stroke and thromboembolism in patients with atrial fibrillation. The most commonly used schema for risk stratification is the Cardiac failure, Hypertension, Age, Diabetes, Stroke doubled (CHADS-2) score, but the authors suggest that the addition of other risk factors may improve risk stratification. The CHA2DS2-VASc score denotes Cardiac failure or dysfunction, HTN, Age >74 doubled, Diabetes, Stroke doubled, Vascular disease, Age 65-74, and Sex (female), where 2 points are assigned for history of stroke or age greater than 74, and 1 point each for age 65-74, history of HTN, diabetes, cardiac failure, and vascular disease. Patients with a CHA2DS2-VASc score of 1 should be considered for oral anticoagulation, but patients with a score of 0 are truly low risk and do not require antithrombotic therapy.
Obeyesekere, M., Gula, L. J., Skanes, A. C., Leong-Sit, P., & Klein, G. j. (2012). The risk of sudden death in Wolff-Parkinson-White syndrome: how high is the risk? Circulation. Retrieved from
Wolff-Parkinson-White (WPW) syndrome has been associated with sudden cardiac death related to atrial fibrillation conducting rapidly over accessory pathways and deteriorating into ventricular fibrillation. The incidence of sudden cardiac death in WPW patients is small, about 3-4% over a lifetime. The authors review a recent study and suggest that even in symptomatic patients, it is as reasonable to choose no medical therapy as it is to choose medical therapy. The well-informed patient balances a very small immediate risk of ablation with a very small longer-term risk without ablation.
Pappone, C., et al. (2012). Risk of malignant arrhythmias in initially symptomatic patients with WPW syndrome: results of a prospective long-term electrophysiological follow-up study. Circulation. Retrieved from
This study looks at predictors of malignant arrhythmia in WPW patients in order to compare outcomes of patients who declined catheter ablation with those who chose ablation. The investigators found that the outcomes of both groups were comparable. Symptomatic patients with WPW generally have good outcomes and predictors of malignant arrythmias are similar to asymptomatic patients. Previous to this study, guidelines recommended that all symptomatic patients undergo catheter ablation for WPW, but this study implies that catheter ablation does not necessarily improve outcomes for WPW patients.
Raj, S. R., et al. (2009) Propranolol decreases tachycardia and improves symptoms in the postural tachycardia syndrome: Less is more. Circulation, 120 (9), 725.
Beta blockers are appealing in the treatment of postural tachycardia syndrome (POTS) because of the disabling chronic orthostatic increase in heart rate. This study finds that low dose propranolol significantly improved symptoms in patients with POTS, while higher doses actually worsened symptoms.
Shilling, R. J. (2010). Cardioversion of atrial fibrillation: the use of antiarrhythmic drugs. Heart, 96 (5), 333-338.
This is a great review of the literature on the randomized trials on rhythm control and rate control management of atrial fibrillation. The literature proposes that attempts to cardiovert atrial fibrillation (AF) should be reserved for patients who are symptomatic despite rate control. For recent onset of AF < 24 hours the use of flecainide can successfully pharmacologically cardiovert AF but should be used with caution in patients who have CAD or structural disease. Due to the high recurrence of AF after cardioversion, antiarrythmic drugs are recommended. Amiodarone should be used for short courses (8 weeks – 6 months). In patients for whom long-term drug treatment is required, flecainide (in combination with a beta blocker or calcium channel blocker) or sotalol are probably equally effective but should not be used is patients at risk for proarrhythmia (such as CAD or structural heart disease). Patients with structural heart disease should be offered an ARB.
Clinical hours: 76
Reading Hours: Literature related to ACNP role and outcomes in general and in cardiology
Date: February 6 & 8, 2012
Description of clinical work: I spend several hours reviewing the literature related to ACNP outcomes and quality indicators. I also conducted informal interviews in person and by email with several ACNPs at UVA to inquire about ACNP outcomes and quality tracking at UVAHS.
Major learning points:
1. The following measurable outcomes are tracked by Sue Waters on the inpatient cardiology ACNP service:
a. Press Ganey patient satisfaction scores
b. Productivity and w-RVU's (relative work value units) - clinics and inpt service
c. Documentation compliance with coding
d. Physician satisfaction (informally)
e. LOS (length of stay) for inpt service
f. Pt acuity (inpt service)
g. Compliance with core measures for AMI and heart failure
h. Looking at compliance with HRS compliance with device peri-procedural guidelines
i. Donna Charlebois is working on a pt education study in EP clinics
j. Incident reports/pt safety
2. There is a wealth of literature that supports ACNP patient management as equivalent to that of physician colleagues.
3. There is also a moderate amount of literature to suggest that ACNP patient management models improve patient outcomes and decrease resource utilization. The literature suggests that this is part due to ACNPs’ rigorous adherence to evidence based practice guidelines.
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, cardiac arrhythmias, valve disease, hypertensive crisis, and myocardial infarction; Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology; Objectives 3.1 Acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting; Objective 4.1 Acquire skill and knowledge to care for and manage patients with heart failure.
Related to Course Objectives for the ACNP student: 5, 9, 12, 15, 16
Annotated bibliography:
Case, R., Haynes, D., Holaday, B., & Parker, V. (2010). Evidence-based nursing: The role of the advanced practice registered nurse in the management of heart failure patients in the outpatient setting.
Heart failure (HF) remains a challenge for healthcare providers, because there is a delicate balance between optimizing patient functioning and minimizing healthcare expenditures. Goals in the management of HF are to slow disease progression, decrease symptom acuity, and prevent exacerbation that lead to hospitalization. This comprehensive literature review confirmed the need for specialized outpatient management programs for HF patients based on evidence-based practice and confirmed the APRN value of cost effective patient management. Current literature demonstrates a need for the unique ability of APRNs to provide holistic care to patients with chronic disease.
Cowen, M.J., Shapiro, M., Hays, R., Afifi, A., Vaziraini, S., Ward, C.R., & Ettner, S. (2006). The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. Journal of Nursing Administration, 36 (2), 79-85.
This study compared collaborative nurse practitioner (NP) and physician team mangagement of hospitalized patient care to patient care managed just by physicians. The investigators measured length of stay, hospital costs, mortality and readmissions within 4 months. They concluded that collaborative NP and physican care management reduced length of stay and improved hospital profit without altering readmissions or mortality.
Kleinpell, R. M. (2005). Acute care nurse practitioner practice: Results of a 5 year longitudinal study. American Journal of Critical Care, 14, 211-219.
This longitudinal study provides information on aspects of ACNP practice and role development from a national perspective. The data was provided by more than 200 ACNPs during a 5 year study period. In 2005 this was the largest study of ACNP practice. At the time of the study, most ACNPs practiced in tertiary care practice settings with about half listing a setting other than ICU or acute practice sites, indicating expansion of the ACNP role. Respondents emphasized the importance of negotiating for salary and benefits. Among those unfamiliar with the role, a common misconception is that the focus of ACNP practice is work involving invasive skills. Primary responsibilities remain those related to direct management of patient care, including physical assessment, obtaining medical histories, writing orders, conducting rounds, consulting, and discharge planning.
Lowery, J., et al. (2012). Evaluation of a nurse practitioner disease management model for chronic heart failure: A multi-site implementation study. Congestive Heart Failure, 18 (1), 64-71.
The objective of this study was to translate evidence from randomized controlled trials (RCTs) into practice by implementing a disease management program for patients with heart failure. The heart failure (HF) management program that was implemented incorporated components of RCTs that have been shown to be effective, including specialized cardiovascular nurses practitioners (NPs) as the primary providers who followed patients as outpatients in clinic, followed algorithms for medication management, and made referrals as necessary. This HF management program was implemented for all HF patients in a specified range of tertiary and primary care Veterans Affairs (VA) medical centers. This study compared HF outcomes for patients managed in the traditional way with patients managed by NPs. The investigators found that NPs improved health outcomes, decreased resource utilization, including readmissions, bed days of care, and outpatient visits, and decreased mortality. What was most impressive about this study was the large sample size compared with most RCTs, and secondly the participation rate was very high. Additionally impressive was that the NP management model was initiated simultaneously at multiple sites with variable access to specialty resources. An important limitation of most of the previous research has been the use of a single highly motivated specialist team, which is difficult to replicate. This study, however, overcame this limitation and demonstrated that the NP management model can be translated into real-world practice without dedicated resources often utilized in RCTs. The NP management model used in this study is less expensive than physician directed care, and medical centers, including those in rural areas, can potentially improve HF outcomes by investing in HF NPs to assume primary responsibility for the care of HF patients.
Manning, S., Wendler, M. C., & Baur, K. (2010). An innovative approach to standardizing heart failure care: The heart failure support team. Journal of the American Academy of Nurse Practitioners, 22, 417-423.
The purpose of this study was to determine if a comprehensive program of heart failure support led by an ACNP improves outcomes. The goals of the program were to implement Centers for Medicare and Medicaid Services (CMS) recommendations for all patients with heart failure, reduce variation, and increase quality of care. Once the program was implemented, the ACNP-led heart failure support team achieved near-perfect CMS scores and adherence to Joint Commission recommendations. Collaboration between and among physicians, nurses, case managers, personnel from admitting, and laboratory and information technology resulted in timely identification of heart failure, daily monitoring of quality indicators, and high quality patient care. This ACNP-led heart failure support team promises to be an important and innovative model to improve patient outcomes, quality of life and organizational outcomes for heart failure patients.
Mundinger, M., et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. Journal of the American Medical Association, 283 (1), 59-68.
This was a landmark study supporting nurse practitioner practice and positive patient outcomes. The objective of the randomized trial was to compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. In an ambulatory care setting where nurse practitioners had the same authority, responsibilities, productivity, administration requirements, and patient population as primary care physicians, patient outcomes were comparable.
Newhouse, R.P., et al. (2011). Advanced practice nurse outcomes 1990-2008: A systematic Review. Nursing Economics, 29(5) 1-22.
The purpose of this systematic review was to investigate whether APRN patient outcomes are similar compared with other providers. This systematic review of published literature between 1990-2008 on care provided by APRNs indicates that patient outcomes of care provided by NPs in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the same patient population. The results extend what is previously known about APRN outcomes and indicate that APRNs provide effective, high-quality patient care, have an important role in improving quality of patient care, and address concerns about whether are provided by APRNs can safely augment physician supply to expand access to care.
Clinical hours: 84
Clinical setting and preceptor: Heart Transplant/LVAD Clinic, Beth Fallin and Kelly Godsey
Date: February 15 & 22, 2012
Description of clinical experience: This was a unique clinical experience in that on the first day, I functioned more as a learner and observer than in most of my previous clinical experiences. I entered the clinical setting with the understanding of heart transplant is very minimal and my primary goals were: 1) to acquire foundational knowledge of transplant medications and transplant surveillance and 2) to observe the collaboration between physicians and nurse practitioners to understand the clinic’s model for patient care.
I came away from my first day feeling a little overwhelmed by how specialized is the care of heart transplant patients. Even within the specialties of transplant and heart failure, heart transplant is a sub-specialty. But I also came away armed with a list of resources, including websites, guidelines, policies, and schedules that will provide me with most of the information I will ever need to manage a patient with a complex cardiac condition or requiring a cardiac procedure before or after transplant. Nonetheless, there are not many clinical scenarios I can imagine where I would not or could not consult with the heart transplant physician specialist in managing a heart transplant patient.
One aspect that I found noteworthy about this clinical experience was how underutilized the NPs were in this clinic. The NPs only performed medication reconciliation and review of systems and entered a few orders as instructed by physicians, but they did not assess the patients, write notes, or develop management plans. Prescription writing seemed primarily to be in response to physician request and as physician instructed, as opposed to prescriptive authority as a function of the NP’s critical analysis and decision-making. I am not sure whether this model of NP-physician collaboration results from the complexity of heart transplant patients or the personality mix and comfort level of the individuals in this arrangement. As an outsider, it seems like patient flow could be made more efficient if the NPs saw routine follow-up patients and the physicians saw patients presenting with new problems.
The second day in transplant clinic was much more hands-on for me. One of the NPs was out sick, so Beth and Kelly seemed to be relieved to have me there to assist with seeing patients and presenting to the attending physicians. I saw four patients on my own, performed med reconciliation, review of systems, and focused health histories. Then I presented my patients to the attending physician and gave general assessment of how I felt the patient was doing and what the patient needed regarding medical management. I documented my work in EPIC, and the physicians used my ROS in their progress notes. I feel my skills and knowledge were received well, and I think I functioned relatively effectively in the role of the NP in this setting. I continued to learn a lot about transplant surveillance and medication regimens, building on what I had learned the previous clinical day.
It was really nice to interface with this group of physicians and fellows in the clinic setting, because they previously have only known me as a bedside nurse. I think my professional colleagues are starting to realize that I have more to offer and that my skills and knowledge are more developed than may be apparent when I am functioning in the role of the bedside nurse. I also felt that I had more opportunity for casual conversations to allow me to get to know some of my colleagues with whom I have been working for years but do not really know outside of their professional roles.
Major learning points:
1. Recommended and organizational guidelines for heart transplant surveillance
2. Side effect profiles of heart transplant medications
3. Description, objectives, and benefits of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS)
4. Clinical utility, indications, contraindications, and interpretation of AlloMap testing
5. New onset AFib can be a signal of rejection.
Related to Cardiology Objective: Objective 1.1: Develop foundational skill and knowledge to care for the critically ill patient with a complex cardiac condition. Objective 3.1: Acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting. Objective 4.1: Acquire skill and knowledge to care for and manage patients with heart failure.
Related to Course Objectives for the ACNP student: 4, 5, 6, 7, 9, 10, 11, 13, 14, 15
Annotated bibliography:
Cardiac Transplant Team. (2012). The Cardiac Transplantation Cookbook. Retrieved from University of Virginia Heath System intranet.
This manual is intended for use by physicians and nurses in the immediate pre-operative phase, OR phase, and immediate post transplantation phase of hospitalization. It specifically instructs steps for medication administration and titration for various conditions, immunosuppression, and cardiovascular support.
Colucci, W. S. & Pina, I. L. (2011). Indications and contraindications for cardiac transplantation. In S. Hunt (Ed.), UptoDate. Retrieved from
Cardiac transplantation is the treatment of choice for many patients with end-stage heart failure who remain symptomatic despite optimal medical therapy, but the primary indications, specific inclusion criteria, and exclusion criteria determine recipient selection. The recipient selection process involves both clinical and ethical issues because of the shortage of organs available to treat all patients who qualify for this treatment. The authors provide a summary and overview of the considerations, criteria for transplantation, criteria for exclusion, and options for bridging to transplantation. Finally the extensive reference list is invaluable for investigating these issues on a deeper level.
Fallin, B. (2011). Cardiac Transplant: Immune Response, Rejection, and Immunosuppressive Medications. Presented at 4 East Staff Meeting, UVA Health System, Charlottesville, VA.
This presentation reviews the classifications of rejection and the mechanism of rejection. Also reviewed, are the most common immunosuppressive medications used in heart transplant population and nursing considerations for their administration and patient monitoring.
Fallin, B. (2007). Allomap Molecular Expression Testing. Presented in CTU Staff Meeting, UVA Health System, Charlottesville, VA.
The presentation provides an overview of current recommendations for surveillance regarding heart biopsies and the role of a new method of surveillance called Allomap. Allomap can potentially reduce the number of invasive procedures for transplant patients, but selection criteria is important to understand as not every transplant patient is a good candidate for Allomap.
International Society for Heart & Lung Transplantation. (2010). Guidelines. Retrieved from http:/publications/guidelines.asp.
This website is the single best resource for international evidence based guidelines on the care of heart transplant recipients peri-operatively, during various phases of immunosuppression and rejection, and long-term management. It also provides guidelines for grading and managing heart failure and cardiac allograft vasculopathy in the transplanted patient.
Pham, M. X. & Valentine, H. A. (2011). Induction and maintenance of immunosuppressive therapy in cardiac transplantation. In S. Hunt (Ed.), UptoDate. Retrieved from
The goal of immunosuppression is to prevent and/or treat cardiac allograft rejection while minimizing drug toxicity and sequelae of immune suppression. The authors discuss immunosuppressive regimens and general principles for induction and maintenance to prevent both acute and chronic rejection. The treatment of rejection is not discussed. The article provides a thorough introduction to classifications of immunosuppressive medications, as well as trends and special considerations for their use. A useful table covers drug, dosing, target levels, and major toxicities. The reference list is extensive.
Teaster, R. E., Bergin, J. D., & Kern, J. A. (2010). Transplant Services Policy No. 5.5: Post Transplant Outpatient Process – Heart. Retrieved from University of Virginia Heath System intranet.
This policy describes care of the post transplant patient, including overview of post transplant care coordination, frequency of laboratory studies, recommended schedule and method of transplant rejection surveillance, and recommended schedule for follow-up clinic visits. The policy also discusses rejection therapy and immunosuppressant medication management, and their corresponding titration schedules. The policy describes general medication management of hypertension, hyperlipidemia, fluid volume overload, electrolyte imbalances, sinusitis, allergies, dental prophylaxis, constipation, nausea, and muscle spasm in the post heart transplant patient. Finally, the policy outlines the ACNP scope of practice in caring for the outpatient heart transplant patient.
Clinical hours: 100
Clinical setting: Heart Failure Symposium at UVA SON McLeod Hall
Date: February 25, 2012
Description of clinical experience: The Heart Failure Symposium consisted of a series of lectures on the following topics: 1) Heart Failure Guidelines and Resources, 2) Joint Commission Disease Specific Certification, 3) Heart Failure Patient Education Documentation, 4) Pacemaker/ICD Basics, and 5) Clinical Trials in Heart Failure at UVA. Also presented were some case studies and discussion about patient management. The purpose of the symposium was to offer the most up to date information in the field of heart failure with the goal of improving outcomes for heart failure patients.
Major learning points:
1. Cardiorenal syndrome – the role of nesiritide in this population.
2. Pacemaker device settings optimization: case study of pacemaker induced severe mitral regurgitation
3. Disease specific certification: where does UVA stand.
Related to Cardiology Objective: Objective 4.1: To acquire skill and knowledge to care for and manage patients with heart failure.
Related to Course Objectives for the ACNP student: 5, 6, 7, 9, 12, 15, 16
Annotated bibliography:
Bock, J. S. & Gottlieb, S. S. (2010). Cardiorenal syndrome: new perspectives. Circulation, 121, 2592-2600.
The authors provide a succinct overview of past and current perspectives on cardiorenal syndrome and the important relationship between renal dysfunction and heart failure. They emphasize the importance of understanding the risk-benefit analysis of certain medications, particularly loop diuretics and ACE-inhibitors. Review of current evidence suggests that some increase in creatinine should be tolerated with use of ACE-inhibitors even if it means decreasing diuretics or using inotropes to enhance diuresis, because the advantage of ACE inhibitors in delaying progression and death in heart failure is undeniable. The article also discusses current dialogue about the role of nesiritide in this patient population.
Heart Failure Society of America. (2010). Execute summary: HFSA 2010 comprehensive heart failure practice guidelines. Journal of Cardiac Failure, 16 (6), 475-539.
Knowledge about heart failure (HF) accumulates so rapidly that individual providers and clinicians may be unable to readily and adequately synthesize new information from trial data into effective strategies for patient management. Thus the Heart Failure Society of American finds it necessary and critical to publish comprehensive practice guidelines to address the full range of evaluation, care, and management of HF patients.
Jessup, M., et al. (2009). 2009 guideline focused update on heart failure. Circulation, 119 (14), 1977-2016.
These heart failure (HF) guidelines developed and published by a task force of members from the American College of Cardiology and the American Heart Association were created in response to late breaking clinical trials in 2005-2007. The task force also deemed in necessary to create a new section on management of hospitalized patients with HR. Finally, there is increasing government and third party payer interest in the prevention of HF hospitalizations and rehospitalizations, and so quality indicators regarding the discharge process and discharge planning for hospitalized HF patients are revisited.
Kamath, S. (2012). Clinical Trials of HF (and more) at UVa. Presented at Heart Failure Symposium, Charlottesville, VA.
The Heart Failure (HF) program at UVa seeks to achieve high penetration of evidence-based care and to reduce readmission rates. In order to improve access to care and reduce hospital admissions, the HF program hopes to conduct a study of monitoring approaches to evaluate whether remote monitoring via a home health aide or a video would improve outcomes. Another series of studies involves intracardiac devices and various physiologic sensors that would help guide medication adjustments in HF patients. Future directions for HF trials at UVa involve novel applications of existing device-based technologies, including the use of cardiac resynchronization therapy in patients with a narrow QRS.
Reigle, N. (2012). Heart Failure Guidelines: What we need to know. Presented at Heart Failure Symposium, Charlottesville, VA.
This is one of the most concise and thorough reviews of the heart failure (HF) guidelines that I have seen. It covers the epidemiology and natural history of HF, as well as the costs. The presenter also reviews the strength of evidence supporting each guideline and correlates the guidelines to the stages of the disease. Particularly informative is the step-wise approach to medication optimization. Also provided is an overview of guidelines for discharge criteria of HF patients and patient education. Finally, the presenter discusses the role of device therapy in HF.
Clinical hours: 108
Clinical setting and preceptor: Heart Failure Clinic, Nita Reigle
Date: February 27 & 28, 2012
Description of clinical experience: I spent time in two clinics during this rotation. The NP run Hospital to Home (H2H) clinic was in the morning, and the NP-MD collaborative heart failure clinic was in the afternoon each day. The goal of the H2H clinic is to see patients within 7 days of discharge from a heart failure related hospitalization and to follow patients for 30 days to prevent rehospitalization for heart failure. The NP spends up to 45 minutes with each patient reviewing medication regimen, symptom surveillance, and early intervention at the first sign of disease exacerbation. In the afternoon clinic, the NP functions to collect information from patients quickly to evaluate their responses to disease process and therapeutic interventions. Then the NP and MD collaborative formulate a management plan for the patient. The afternoon clinic visits are much shorter, and there is much less time for patient teaching and coaching.
These two clinical days flew by because these clinics are so busy. One of the days seemed to have several patients who cancelled, so I spend time reading ECGs and reviewing them with my preceptor – very helpful to do this thorough review and provided some reassurance that I am actually retaining some of what I have been taught! Heart failure in the setting of organ transplant remains distant from my clinical knowledge and skill set. Heart failure in the setting of James Bergin also remains distant from my clinical knowledge and skill set. A few of the zebras are presented below under Major learning points.
Both NPs and physicians were compassionate and sensitive to patients’ social and cultural variations and attempted to make individualized adjustments accordingly. Several patients worked night shifts or long day shifts and were citing work schedules as rationale for nonadherence to diuretic regimen. For one patient the physician suggested taking a higher dose of the diuretic when the patient would have easy access to the restroom and lower dose while on the job instead of the same dose twice daily. For the other patient, the physician suggested adding metolazone thirty minutes before the loop diuretic on the patient’s days off from work. Both adjustments were creative and demonstrated flexibility in patient management.
From a patient management standpoint, I saw 3 patients in the H2H clinic and about 7 patients in the NP/MD clinic. Preceptor and physician feedback was positive and suggestive that I am functioning effectively in the ACNP role within the scope of student practice. I feel more and more confident and continue to build my knowledge base and skill set.
Major learning points:
1. Amyloidosis
a. Generically refers to extracellular tissue deposition of low molecular weight subunits of a variety of at least 27 proteins.
b. Most common organs affected: kidney, heart, liver
c. Diagnosis confirmed only by tissue biopsy
d. Subcutaneous fat biopsy and staining with Congo red is fairly sensitive and very specific for primary and secondary amyloidosis.
e. proteinuria in 80%
2. Stem cell transplant in patients with Amyloidosis. Eligibility criteria:
a. Biopsy-proven AL amyloid
b. Symptomatic disease
c. Age ≤70 years
d. Serum troponin T 55 percent
f. Creatinine clearance ≥30 ml/minute (unless on chronic stable dialysis)
g. Performance status ≤2
h. New York Heart Association Class I or II
i. No more than two organs significantly involved
j. Serum direct bilirubin concentration ≤2.0 mg/dL
3. Creative medication adjustment to improve patient adherence
4. Short acting metoprolol is not contraindicated in patients with EF>45%, but long acting metoprolol is recommended in patients with EF< 40-45%
5. ECG review
a. LAFB: 1) rS in Leads II, III, avF; 2)qR in Leads I and avL; 3) always Left axis deviation 4) QRS duration < .12
b. LPFB: 1) . rS in Leads I and avL; 2) qR in leads II, III, and avF; 3) always Right axis deviation; 4) QRS duration < .12 sec
c. Axis in BBB: 1) RBBB can be normal or right (or left if there is also LAFB); 2) LBBB can be normal or left
d. LAFB and LPFB can occur in setting of RBBB; cannot read fascicular blocks in setting of LBBB
Related to Cardiology Objective: Objective 4.1: To acquire skill and knowledge to care for and manage patients with heart failure.
Related to Course Objectives for the ACNP student: 1, 2, 5, 7, 9, 10, 11, 13, 14, 15, 16
Annotated bibliography:
Cibeira, M. T., et al. (2011). Outcome of AL amyloidosis after high-dose melphalan and autologous stem cell transplantation: long-term results in a series of 421 patients. Blood 118 (16), 4346-4352.
The study concludes that primary amyloidosis patients treated with chemotherapy and stem cell transplant experience durable hematologic response, high organ response rate, and prolonged survival. The investigators stress the importance of careful, evidence based selection of patients according to strict eligibility requirements to optimize outcomes.
Picken, M. M. (2010). Amyloidosis-where are we now and where are we heading? Archives of Pathology and Laboratory Medicine 134(4), 545-551.
The author summarizes current recommendations for diagnosing amyloidosis. Congo red stain is currently the gold standard for amyloid detection and the goal is to detect amyloid early. Diagnosis of the type of amyloid is based on identification of amyloid protein within the deposits and not solely by reliance on clinical or DNA studies.
Clinical hours: 124
Clinical setting and preceptor: EP Device Clinic with Device Nurse Mario Castro
Date: March 7, 2012
Description of clinical experience: This was an incredibly helpful experience, clinically and technically, but it also illuminated the complexity of cardiac devices and their interrogation and troubleshooting. Mario was a wonderful teacher and skillfully explained the basics of pacemaker and ICD interrogation, indications for permanent pacing, as well as clinical trials and future directions for device therapy.
We spend the day in clinic, seeing patients for routine device checks. Some of the patients were only seen by the device nurse, while others had subsequent appointments in the Heart Failure clinic or in the EP clinic. I was surprised by the number of patients were only seen by the device nurse, as these appointments were billed as clinic visits without the patients actually seen by an NP or MD. The device nurses have a set of protocols that describe exactly what device settings may be adjusted without consultation with a physician.
In addition to seeing patients in the device clinic, we also travelled to various units in the hospital to interrogate devices and reprogram devices for procedures/surgery.
Of particular interest to me were the investigational uses for devices to assist with monitoring for heart failure exacerbation, particularly the Optivol, Multisense, RETHINQ, and Echo CRT trials
Major learning points:
1. Long tern right ventricular pacing can lead to worsening left ventricular function via cardiac dyssynchrony.
2. Important to limit RV pacing as much as possible. When patient is pacing the RV a majority of the time, it is important to evaluate for LV dysfunction and onset of HF, but current guidelines are still in development to guide the specific point at which BiV pacing should be implemented.
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, cardiac dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology. Objective 3. Objectives to acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting.
Related to Course Objectives for the ACNP student: 2, 3, 4, 5, 6, 7, 9, 10, 11, 16
Annotated bibliography:
Beshai, J. F., et al. (2007). Cardiac-resynchronization therapy in heart failure with narrow QRS complexes. New England Journal of Medicine, 357 (24), 2461-2471.
Inications for cardiac recynchronization therapy (CRT) in patients with heart failure include wide QRS, but some patients with narrow QRS complexes have echocardiographic evidence of ventricular dyssynchrony. This studyevaluated the benefit of CRT in patients with narrow QRS complexes and has become known as the RETHINQ study. The investigators found that at 6 months, CRT did not find significant evidence that patients with narrow QRS complexes benefit from CRT. The Echo-CRT study, currently underway, is a randomized multicenter international trial that builds on the RETHINQ study.
Hayes, D. L. (2012). Indications for permanent cardiac pacing. In B. Downey (Ed.), UptoDate. Retrieved from
The general factors guiding decisions regarding pacemaker insertion are symptoms and the potential for progression of rhythm disturbance, and both are largely dependent on the anatomical location of the conduction abnormality. The most common indications for pacemaker are sinus node dysfunction and AV block. Disease below the AV node is general considered least stable. Conditions for which pacemaker is not supported by evidence include: syncope of undermined cause; asymptomatic bradycardia, asymptomatic first or second degree Mobitz I, reversible AV block, long QT, or torsades de pointes due to reversible cause.
Stockburger, M., et al. (2011). Preventing ventricular dysfunction in pacemaker patients without advanced heart failure: results from a multicentre international randomized trial (PREVENT-HF). European Journal of Heart Failure,13 (6),633-641.
The PREVENT-HF study was an international randomized trial that explored differences in left ventricular remodeling during right ventricular v. biventricular pacing in patients with AV block. The study did not demonstrate significant LV volume differences at > 12 months between the groups. The investigators concluded that BiV pacing cannot be recommended as a routine treatment for AV block. They suggest larger trials to continue to investigate the growing concern over the significant undesired effects of RV pacing, including ventricular dyssynchrony, proarrhythmia, and promotion of HF.
Wilkoff, B. L., et al. (2002). Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA, 288 (24), 3115-3123.
This landmark trial compared dual chamber pacing with back-up ventricular pacing in patients with standard indications for implantable cardiac defibrillator (ICD) but without indications for antibradycardia pacing. The investigators found that for patients with standard indications for ICD therapy, no indication for cardiac pacing, and an LVEF of 40% or less, dual chamber pacing (DDDR) offers no clinical advantage over ventricular backup pacing (VVI) and may increase mortality and onset of congestive heart failure by worsening cardiac dyssynchrony.
Clinical hours: 132
Clinical setting and preceptor: CCU with Libby Smith, Greg and Carole Ballew
Date: March 8 and March 14, 2012
Description of clinical experience: This experience really helped me apply some of the concepts and techniques of critical care studied earlier in the semester. On the first day I focused on deepening my understanding of the pulmonary artery catheter and its clinical utility, as well as general nursing care and nursing skills necessary to maintain the integrity of the PA catheter. Libby taught me how to use the PA catheter to get cardiac output estimates by thermodilution and how to set up and calibrate the equipment for central venous pressure monitoring.
During the morning I also had some introduction to the fine balance of managing a patient’s blood pressure with IV fluids and continuous phenylephrine, which is virtually uncharted water for me. We used both manual BP readings and the PA catheter readings to determine the patient’s response to our interventions to manage her hypotension. Libby discussed the basics of using drips for VS management and showed me a Powerpoint presention that reviews the basic pharmacology of the most commonly used medication drips in critical care.
Later in the afternoon, Carole presented me with clinical scenario typical of a patient requiring admission to the CCU and gave me 1 hour to “work-up” the patient and present to her my H&P and clinical management plan. The clinical scenario was a 61 y.o. female with PMH of Afib, NICM, HF, COPD, ICD presents by EMS following an unwitnessed syncopal event with BP 65/40 and is admitted to me in CCU. My differential for my CCU patient was acute decompensated HF, cardiogenic shock, sepsis, PE, arrhythmia and subsequent ICD shock, MI. This practice CCU work-up and presentation helped me work through prioritization of problems and management of unstable VS using the clinical knowledge and skills that I had been building during the earlier part of the day with Libby.
Major learning points:
1. Pharmacology of vasopressors
2. Bergin loves Milrinone
3. PA catheter 101: skills to maintain, how to obtain useful information, what can go wrong, i.e. there is a balloon in the patient’s pulmonary artery so don’t rupture the pulmonary artery by doing something foolish.
4. Tracheostomy should be considered in patients requiring mechanical ventilation via ET tube longer than 10-14 days, due to increasing risk of injury to vocal cords, laryngeal ulceration, sinusitis, and other damage to surrounding tissues with prolonged use of artificial airway.
5. will be my best friend during my CCU rotation
Related to Cardiology Objective: Objective 1.1: Develop foundational skill and knowledge to care for the critically ill patient with complex cardiac condition.
Related to Course Objectives for the ACNP student:
Annotated bibliography:
Armstrong, E. J., McCabe, J. M., Cheitlin, M. D. (2011). Pulmonary artery rupture from invasive hemodynamic monitoring. Archives of Internal Medicine, 171 (12), 1109.
The authors present a case study about a patient in heart failure who was admitted to the intensive care unit, underwent placement of a pulmonary artery catheter and subsequent pulmonary artery rupture during routine ballooin inflation to measure wedge pressure. The patient remained intubated for 8 days and was treated for ventilator associated pneumonia. While spending time in CCU, the nurses discussed a similar case. Invasive hemodynamic monitoring is not without serious potential risks and the decision to utilize this system should be considered very thoughtfully.
Binanay, C., et al. (2005). ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA, 294 (13),1625-1633.
In a randomized controlled trial of 433 patients at 26 sites, the investigators wanted to determine whether pulmonary artery catheter use improved clinical outcomes in heart failure patients. They found that therapy to reduce volume overload during hospitalization for heart failure led to marked improvement in signs and symptoms of elevated filling pressures with or without the PAC. Addition of the PAC for careful clinical assessment increased anticipated adverse events, but did not affect overall mortality and hospitalization.
Clinical hours: 146
Clinical Conference with faculty
Date: February 2 & March 15
Description of clinical experience: AT the first clinical conference, we were given presentation on the most up to date evidence based management of diabetes. At the second clinical conference, we were given presentation on refeeding syndrome, a common and often overlooked medical problem across a wide array of clinical settings. We discussed the process of applying for and taking board exams and obtaining credentialing.
Clinical hours: 154
Clinical setting and preceptor: Inpatient Acute Cardiology, Mahesh Murugesan
Date: March 21, 2012
Description of clinical experience: This was a very useful and focused clinical day, and I think it was quite representative of a typical day in the life of the Acute Cardiology NP service. Mahesh and I had three patients. Two were patients with Atrial fibrillation who were hospitalized for Tikosyn loading. One was a patient who was transferred to the NP service from the TCV surgery service after he was deemed a poor candidate for CABG. The patient underwent PCI instead of CABG and Mahesh and I encountered him the next day and discharged him home.
The discharge provided the opportunity to practice thorough medication reconciliation, review and practice in accordance with Acute Myocardial Infarction core measures and NSTEMI practice guidelines, perform patient teaching, offer smoking cessation, write a progress note, and write a discharge summary.
The Tikosyn load patients provided the opportunity to review pharmacological and clinical considerations associated with this antidysrythmic medication, calculate QTc intervals, write progress notes, order lab studies, and perform episodic physical exams.
Major learning points:
1. Pharmacologic and clinical considerations associated with Tikosyn loading:
a. Monitor potassium and magnesium closely because Torsades is a common complication; Tikosyn works via potassium channels
b. The following drugs should never be given to patient son Tikosyn:
i. Verapamil
ii. Cimetidine (Tagamet)
iii. Trimethroprim (found in Bactrim)
iv. Ketoconazole
v. Megestrol (Megace)
vi. Hydrochlorothiazide (alone or in combination with other medicines)
vii. Prochlorperazine (Compazine)
a. Patients are hospitalized for the first 6 doses
b. When patients have irregular rhythm, the average of all QTc measurements guides dosing decisions.
2. Sleep apnea worsens arrhythmia and heart failure
3. We do not do a very good job with smoking cessation education as a profession and as an organization.
4. What is the consensus about holding ACE-I and ARB in the setting of renal disease?
5. What are the considerations when giving metoprolol to a patient with COPD?
6. Review persistent v. paroxysmal atrial fibrillation
a. Paroxysmal AFib: Paroxysmal AF is defined as recurrent AF (≥2 episodes) that terminates spontaneously in less than seven days, usually less than 24 hours.
b. Persistent AFib: Persistent AF is defined as AF that fails to self-terminate within seven days. Episodes often require pharmacologic or electrical cardioversion to restore sinus rhythm. While a patient who has had persistent AF can have later episodes of paroxysmal AF, AF is generally considered a progressive disease. In individuals with paroxysmal AF, progression to persistent and permanent AF occur in >50 percent beyond 10 years despite antiarrhythmic therapy.
7. Tachycardia-mediated cardiomyopathy
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology.
Related to Course Objectives for the ACNP student: 1, 3, 5, 6, 7, 8, 9, 10, 13, 14, 16
Annotated bibliography:
Dandamudi, G., et al. (2008). Persistent left ventricular dilatation in tachycardia-induced cardiomyopathy patients after appropriate treatment and normalization of ejection fraction. Heart Rhythm, 5 (8), 1111-1114.
The initial treatments for a patient with heart failure and tachycardia-mediated cardiomyopathy are the same as those used in most other patients with heart failure. However, because of the potential reversible nature of tachycardia-mediated cardiomyopathy, aggressive efforts should be made to achieve excellent ventricular heart rate control or to restore sinus rhythm. Following the restoration of sinus rhythm, or ventricular rate control of the presenting tachycardia, most patients will have significant improvement and/or normalization of left ventricular ejection fraction (LVEF) over a period of months. However, whereas the initial cardiomyopathy may have taken months to develop, recurrent tachycardia can lead to an abrupt decline in LVEF. As such, close ongoing monitoring with clinic visits, ambulatory (Holter) monitoring, and echocardiography is essential. There is minimal data and no society guidelines regarding the frequency of monitoring in these patients. Thus the authors suggest that if tachycardia-mediated cardiomyopathy recurs, these patients are at substantial risk for sudden death and ICD implantation should be contemplated.
Devulapally, K., Pongonis, R., & Khayat, R. (2009). OSA: the new cardiovascular disease part II: Overview of cardiovascular diseases associated with obstructive sleep apnea. Heart Failure Review, 14 (3), 155-164.
Obstructive sleep apnea (OSA), present in 5-15% of adults, is strongly associated with the incidence and poor outcome of hypertension, coronary artery disease, arrhythmia, heart failure, and stroke. Treatment of OSA completely reverses its cardiovascular consequences. In this review, the authors discuss the clinical evidence for the strong association between OSA and cardiovascular disease and present an argument for approaching OSA as a cardiovascular disease. They particularly focus on the causative relationship between OSA and hypertension, and on the increasingly recognized relationship between OSA and heart failure.
Salpeter, S. S., Ormiston, T., Salpeter, E., Poole, P., & Cates, C. (2005). Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Databse Systematic Reviews, (4), CD003566.
Nonselective beta1/beta2 blockers (eg, propranolol) can cause bronchoconstriction in susceptible individuals, but this effect is substantially less likely to occur with selective beta1 blockers (eg, atenolol, metoprolol). We believe that carefully selected patients with coronary heart disease or heart failure are candidates for treatment with selective beta1 blockers (eg, metoprolol, atenolol) or combined alpha/beta blockers (eg, carvedilol).
Weir, M. R. (2002). Progressive renal and cardiovascular disease: Optimal treatment strategies. Kidney International, 62 (4), 1482-1492.
The author argues that optimal strategies to provide more effective prevention or protection against renal disease progression should focus on earlier and more intensive blood pressure reduction, proteinuria re- duction (preferably eliminated), and renin-angiotensin- aldosterone system pharmacologic blockade. These are modifiable risk factors for development of progressive renal insufficiency. I believe that the weight of medical evidence supports the need for earlier and more intensive efforts to control blood pressure below traditionally ac- ceptable levels (less than 130/80 mm Hg), particularly if evidence of microalbuminuria or proteinuria is present.
Clinical hours: 164
Clinical setting and preceptor: TCV Clinic, David Strider & Ann Rossi
Date: March 19 & March 29, 2012
Description of clinical experience: I spent the first day in this clinic trying to adjust my paradigm for thinking about patient care and management. Patients seen in surgery clinics are usually unknown to the NP and physician on the first visit and are presenting with a problem that has been referred to the clinic for evaluation of whether or not the problem and/or patient is a good candidate for a surgical solution. On the subsequent visits, the patients are usually being seen for post-operative evaluation and sometimes for presentation of symptoms similar to those that were previously ameliorated by surgical intervention. The clinic visits are surprisingly lengthy and comprehensive during the work-up phase and very short in the follow-up phase.
Dr. Kern was the only surgeon in clinic on Monday, but there were three NPs, 2 PAs, and several medical students, all of whom functioned as “mid-level providers” (MLP). The job of the MLP was to screen patients, reconcile medications, perform focused ROS and PE, and review existing imaging diagnostics. Then the MLP presented the patient to Dr. Kern and gave a reasonable opinion about whether surgery was or was not advisable in the particular clinical scenario. On a few occasions, the MLP essentially made the clinical decision to perform a surgical intervention, and the surgeon just concurred based on the MLP’s presentation, demonstrating very trusting relationships between the surgeon and his MLPs.
New to me was the almost compulsive reliance on diagnostic results and imaging studies to make decisions with less attention to physical exam findings or symptomatology. I think a significant explanation for this has to do with inclusion/exclusion criteria for various surgical procedures. For example, the heart valve trials have criteria that rely on measurements taken during echocardiogram, cardiac catheterization, and CT scan. In some ways, this eliminates surgeon bias when making decisions about which patients are candidates for surgery and which are not.
On the second day of this clinical experience I did the full work-up, presentation, and H&P on a 89 year old female with PMH of Afib, pacemaker, HTN, CKD, and severe aortic stenosis who presented to clinic for a second opinion of her candidacy for aortic valve replacement. Her primary cardiologist told her that she was not a candidate for open heart surgery, but when she was evaluated at another center participating in the PARTNER trials, she was determined to be appropriate for randomization to transcatheter v. open valve repair. Her primary cardiologists opinion was based on her age and his professional experience and biases. The PARTNER trial criteria are fairly straightforward and draw on a wide array of clinical data to determine a patient’s candidacy for surgery. Using the inclusion/exclusion criteria for PARTNER trial, I also determined that the patient was appropriate for randomization. This paradigm is very difficult for patients and families to understand, but it alleviates some pressure from the provider to have such specific guidelines to rely on when making clinical decisions, particularly regarding invasive procedures.
Major learning points:
1. Valves
2. Surgery v. medicine
3. Clinical trials
4. Guidelines: calculating surgical risk scores
Related to Cardiology Objective: Objective 2.1 Develop foundational skill and knowledge to care for and manage the acutely ill patient with a spectrum of acute coronary syndromes, cardiac dysrhythmias, valve disease, hypertensive crisis, and myocardial infarction. Objective 2.2 Develop foundational skill and knowledge to care for and manage acutely ill patient requiring interventional cardiology. Objective 3. Objectives to acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting.
Related to Course Objectives for the ACNP student: 1, 2, 3, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 16
Annotated bibliography:
Makary, M. A., et al. (2010). Frailty as a predictor of surgical outcomes in older patients. Journal of the American College of Surgeons, 210 (6), 901-908.
The authors designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models. Frailty was classified using a validated scale (0-5) that included weakness, weight loss, exhaustion, low physical activity, and slow walking speed. Main outcomes measured were 30 day surgical complications, length of stay, and discharge disposition. The authors concluded that frailty does predict postoperative outcomes and enhances conventional risk models. They argue that assessing frailty using a standardized definition can help patients and physicians make more informed decisions.
Clinical hours: 178
Clinical setting and preceptor: TCV Clinic Administrator, Kathie Ward, APRN
Date: March 28, 2012
Description of clinical experience: I met with the APRN who manages the TCV surgery clinics are UVA to discuss the role of the ACNP on the TCV surgery team, which is composed of physicians, physician assistants, nurses, patient care techs, and administrative assistants. She described a team based model of care, within which each member’s role is both autonomous and collaborative. She discussed a team task force developed to provide efficient patient care in clinic whose charge it was to fully utilize each team member to their full scope of practice and an interdisciplinary collaboration project with the renal service to evaluate and optimize patient renal function and overall outcomes after surgery. What was most refreshing was to hear about how much the surgeons and physician assistants value the ACNPs and are eager to give up medical management responsibilities in order to focus on surgical procedures and surgical responsibilities. This is a little different than in medical clinics where physicians and ACNPs seem to struggle to decide how to divide management responsibilities and where ACNPs are not always utilized to their full scope of practice.
Major learning points:
1. Clinical research
2. Task force to respond to staff discontent
3. APRN value added
4. Interdisciplinary collaboration
Related to Cardiology Objective: Objective 3. Objectives to acquire skill and knowledge to care for and manage complex cardiac conditions in the outpatient setting.
Related to Course Objectives for the ACNP student: 11, 13, 15, 16
Annotated bibliography:
Meyer, S. C. & Miers, L. J. (2005). Cardiovascular surgeon and acute care nurse practitioner: Collaboration on postoperative outcomes. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 16 (2), 149-158.
The authors argue that changes in healthcare environments and delivery are increasing pressure to provide high quality care services with increased efficiency and cost-effectiveness. These changes also provide incentive for healthcare systems to use less expensive care providers for medical management responsibilities while maintaining or increasing the quality of patient care. Meanwhile healthcare systems are also seeing increased patient acuity. The authors compared outcomes for cardiovascular surgery patients who were managed by surgeons alone or in collaboration with ACNPs. In patients managed collaboratively, length of hospitalization decreased almost 2 days and total cost decreased $5000 per patient.
Sargen, M., Hooker, R. S., & Cooper, R. A. (2011). Gaps in the supply of physicians, advance practice nurses, and physician assistants. Journal of the American College of Surgeons, 212 (6), 991-999.
The authors advocate for a team based model of care and predict a national shortage of advanced clinicians of about 20% less than the demand in the year 2025. The authors recognize the increasingly important value and role of physician collaboration with advanced practice nurses and endorse increasing efforts to strengthen the infrastructure of clinical practice by facilitating and delegating tasks to a broad spectrum of caregivers who are supported to practice to the full extent of their training and education.
Clinical hours: 181
Clinical setting and preceptor: CCU, Jim Bergin
Date: April 9-22, 2012
Description of clinical experience: We started the day …
Major learning points:
1. ...
2. …
Related to Cardiology Objective:
Related to Course Objectives for the ACNP student:
Annotated bibliography:
Clinical hours:
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