Care of a Complex Cardiac Patient

Care of a Complex Cardiac Patient:

​Unfolding Group Case Study

by Ginny Bayes

​Let's Review

​Most common criteria for CRT (biventricular pacemaker): SR, LVEF <35%, heart failure with reversible causes already identified and/or treated, treatment with optimal evidence-based medical therapy for at least 3 months, QRS >150 ms with LBBB, NYHA class II to ambulatory class IV. Most patients with an LVEF ≤35% with an indication for CRT also have an indication for an implantable cardioverter-defibrillator (ICD), they are likely to receive CRT-ICD therapy.

​TAVR:

​Transcatheter Aortic Valve Replacement

​Complex Cardiac Patient: Colby

​Colby, a 60 year old male, is admitted to the medical telemetry unit for chest pain. He has an extensive medical history and a long list of comorbidities.

​Obesity with a BMI of 38

​Dyslipidemia

​HTN

​Dilated & ischemic cardiomyopathy

​Systolic HF (last LVEF approx. 45%)

​Biventricular pacemaker with ICD (CRT-ICD)

​TAVR 5 years ago

​CAD with DES x2 in LAD placed 8 years ago

​Osteoarthritis

​GERD

​CKD stage 3a

​You will work in groups for the

rest of activity:

​Review Colby's list of medical problems, what comorbidities can you potentially connect, either directly or indirectly?

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​For example: the CRT-ICD was placed due to his systolic heart failure (which was caused by his dilated cardiomyopathy but what caused the DCM?) with low ejection fraction and functional NYHA classification of at least a class II.

​Admission & Med Reconciliation

​Bree, a nurse with one year of experience who started working on the medical telemetry unit as a new graduate nurse is completing Colby's admission questionnaire and med rec. A list of updated medications are listed below:

​Spironolactone 50 mg po daily

​Isosorbide mononitrate 20 mg po BID

​Aspirin 81 mg po daily

​Lisinopril 20 mg po daily

​Metoprolol succinate 100 mg po daily

Furosemide 40 po BID (0600 & 1400)

​Sacubitril-valsartan 97mg/103mg po BID

​Famotidine 20 mg po BID

​Rosuvastatin 20 mg po daily

​Naproxen 550 mg po BID prn

​

Clinical Reasoning: ​

Medication Reconciliation Review

​As a group review each of Colby's medications and decide what type of medication it is (medication class and/or therapeutic class) and why he is taking it.

​

​Then decide if there are any potential medication interactions or contraindications that you can identify.

​Admission Orders

​Bree checks the EHR for admission orders placed by the admitting hospitalist.

​All home medications are continued and admission orders include:

​Admit as observation status

​Serial cardiac enzymes q6h x3

​12 lead ecg qam

​BMP daily in am

​NT-proBNP level today and day of discharge

​Cardiac diet, 2 gram sodium limit

​Chest pain protocol, cardiology consult

​Continuous cardiac telemetry monitoring

​SCDs while in bed

​Oxygen per protocol

​Nurse initiated mobility protocol

​Admission Labs

​BMP results:

​Glucose, serum - 112 mg/dL

​BUN - 27 mg/dL

​Creatinine - 1.5 mg/dL

​eGFR - 52 mL/min/1.73

​Sodium, serum - 132 mEq/L

​Potassium, serum - 4.8 mEq/L

​Chloride, serum - 93 mEq/L

​Carbon dioxide, total - 24 mmol/L

​NT-proBNP - 3400 pg/mL

​Troponin I - 0.04 ng/mL

​CBC: slightly anemic but other parameters WNL

Clinical Reasoning: ​

Lab Results Review

​Review each of Colby's lab results and discuss all abnormal values.

​

​Are they high or low, why are they abnormal and what is their clinical significance?

​

​Use Nursing Central or another reputable resource to determine if they are normal or abnormal if you don't remember the reference ranges.

Multiple Select

If you were the admitting nurse, what concerns do you have regarding the medication reconciliation?

Select all that apply.

• Colby should not be on lisinopril and Entresto (sacubitril-valsartan) at the same time

• Colby should be on full dose aspirin because of his history of CAD

• Colby should be on an anticoagulant due to his history of undergoing a TAVR

• Colby should not be taking an NSAID and should take acetaminophen instead

• Colby should be on a potassium supplement because he takes furosemide BID

Critical Thinking Questions​

​At this point, with the data that you have about Colby, do you think his chest pain is related to his CAD or something else? Make sure to include laboratory values in your explanation.

​

​What concerns do you have after looking at all of the labs?

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​Why do you think Colby's potassium level is on the high end of normal despite the furosemide he takes BID?

​Physical Assessment

​Bree performs a thorough head to toe assessment on her new patient and finds the following abnormalities:

​An extra heart sound

​Crackles in bilateral lung bases

​Weak peripheral pulses in upper and lower extremities

​2+ pitting edema BLE mid calf down

​

​Subjective data:

​Mild SOB at rest, moderate SOB with minimal exertion, severe with mod exertion

​PND, improved with moving to the recliner at night, frequent angina and palpitations with exertion

​Recent weight gain and reports "my legs feel heavy"

Multiple Choice

What is most likely the extra heart sound Bree heard on cardiac auscultation?

• Split S2

• Systolic ejection click

• S3

• S4

Multiple Choice

Using the attached chart, which NYHA heart failure functional classification best describes Colby?

• Class I

• Class II

• Class III

• Class IV

Multiple Choice

Which of the following is true about dilated cardiomyopathy?

• It is the most common type of cardiomyopathy and most commonly affecting adults ages 20-60

• It is most often caused by abnormal genes in the heart muscle that cause the left ventricle to become thick and stiff

• Frequently caused by an accompanying disease process such as hemochromatosis or sarcoidosis

• Is known to cause sudden cardiac arrest in young athletes

​Conclusion

​Colby is treated for his heart failure exacerbation with IV loop diuretics and a continuous milrinone drip. A right heart catheterization is also performed in order to get further diagnostic information about his cardiac function.

​After 7 days in the hospital he is discharged back home with his wife - who is also his caregiver. She is luckily in very good health and is able to provide him with the intense care he needs at home. Colby admits he had not been to see his cardiologist since the pandemic started so that is probably the reason for the issues with his medication reconciliation. He vows to be more involved in his plan of care and attend his follow up appointments regularly.