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stethoscope - cardiology

NP Roles: Spotlight on Cardiology

When I was a bedside CVICU nurse (and recovering hearts), cardiology was consulted for the occasional postoperative atrial fibrillation or sinus node dysfunction, and they certainly managed all our patients with MIs. The same cardiology group had just hired one of my previous co-workers, and although she had been an ICU nurse for 3+ years, her words to me were, “There’s a lot to learn.” I remember being surprised that she sounded a little overwhelmed. After all, she was an incredible ICU RN, and I had no doubt she’d be a fantastic “cards” APRN- we ICU nurses could handle anything, right?! But every specialty has its own learning curve, as I would certainly find out first-hand.

I joined a cardiology practice after 5 years of being a nurse practitioner (3 in orthopedic surgery straight out of NP school, and 2 in family practice: each a learning curve story for a different day). It had been a long time since I watched telemetry and managed vasopressors/airways/fluid status/etc. and recovered all those hearts (CABGs, valve replacements, MIs, and other surgical patients- vascular bypasses, thoracotomies, CEAs, etc.) for 12 hours at a time.

Cardiology is Guidelines-Driven

The “easy part” (if you can call it that) about cardiology is that it is very guidelines-driven. Very “the right way to treat a certain diagnosis” kind of practice. If you read the (American College of Cardiology’s) guidelines, then you’ll understand. Sure, there’s some variability in how even different cardiologists manage medications, diagnose conditions, read EKGs, and practice in general, but the guidelines are the place to start. Check out the ACC’s “Guideline Clinical App” for a great on-the-go, at-your-fingertips reference.

Our practice was about half and half inpatient and outpatient cardiology. Cardiology was consulted for chest pain admissions, sometimes following positive stress testing and sometimes before the troponins had resulted. A new cardiology NP would quickly learn that a “rule-in” for any myocardial infarction (STEMI or NSTEMI) or stent placement typically necessitates dual antiplatelet therapy (DAPT) for a minimum of 1 year according to current guidelines. When it becomes appropriate to consider cessation (of DAPT) can be confusing, and there’s an app for that, too: the “DAPT Risk Calculator,” also put out by the ACC.

There were also countless arrhythmia consultations- atrial fibrillation and flutter and other supraventricular tachycardias necessitating diltiazem drips and beta blockade adjustments. We saw a good amount of ventricular tachycardia as well. I learned the difference in approach between rhythm and rate control, and that despite whatever you saw as a bedside nurse, amiodarone is NOT to be used for long-term rate control (risks do not outweigh benefits in that scenario). Calcium channel and beta blockers were widely used, and with variable efficacy for rate control. Their efficacy, along with symptomology, is where consideration of rhythm control is particularly useful. Rhythm control was achieved by cardioversion- either electrical or by the use of medications, or sometimes by ablation (Afib/flutter, SVT, and VT). The world of electrophysiology is its own area to master- one of action potentials and electrical pathways.

With atrial arrhythmias comes understanding the initiation of anticoagulation, and the ACC has a very useful smartphone app called “Anticoag Evaluator.” It can be easily used in real-time (until you know the scoring and recommendations by heart). We were very lucky to not have to manage Coumadin dosing (thanks, pharmacy-run clinic), but knowing when to start/stop/hold Coumadin as well as managing all the DOACs is certainly within the cardiology scope.

A Helpful Hint of Pacing Management

On the other end of the spectrum was heart block. Sometimes we’d be holding the very same beta blockers in hopes that they’d wear off and the SA node would recover. But, in the event that a pacemaker was placed, device checks were necessary every few months (optimally every 3). You also learn there are multiple kinds of CRT (chronic resynchronization therapy) devices that pace and/or defibrillate- single lead, dual-chamber, bi-ventricular, subQ, leadless. A helpful hint of pacing management is that we adjust pacemaker parameters for a narrower QRS. By doing so, the device activates the ventricles in the least amount of time. Carrying this forward, you’d learn that you have to watch the percentage of paced beats and the width of the QRS over time.  Chronically pacing the right ventricle (in the setting of a single lead, or depending on settings), can contribute to the development of (and certainly exacerbate) heart failure and left ventricular dysfunction.

I often used to say during the orientation process that cardiology was a “if this, then ___” specialty. You need <20/10mmHg blood pressure reduction? Monotherapy (think low-dose thiazide diuretic, ACE, ARB, or dihydropyridine calcium channel blocker). Require combination therapy? Think ACE/ARB plus dihydropyridine Ca2+ channel blocker. If they’re not responding? JNC-8 suggests pushing the initial drug to the maximum recommended dose or adding a second drug rather than determining the potential efficacy of sequential (or a different) monotherapy (however, UpToDate will suggest the opposite if you think the patient can be managed with monotherapy). In cardiology, we love beta blockers in general. But for control of hypertension withOUT a history of angina/CAD, MI, LV dysfunction, heart failure, atrial fibrillation/flutter/SVT, or ventricular arrhythmia/PVCs, beta blockers are not recommended for first-line therapy, especially in elderly patients. Compared with other drugs, they may have inferior stroke risk protection, perhaps (with atenolol) a small increase in mortality, and impaired glucose tolerance/risk of new-onset diabetes (with exception of carvedilol and nebivolol). Of note, we rarely used alpha blockers (increased risk of heart failure compared to chlorthalidone, higher rate of CV events) except, possibly, with older men with BPH who didn’t have a high CV risk.

Don’t Stop Learning

As with any specialty, there’s a lot to learn. We could write an entire essay on beta-blockade management, indications for pacemakers, give a hours-long presentation of the management of heart failure, or spend a day just reviewing interpretation of EKGs. How in the world can you master cardiology? As a wise physician told me, “Read one of the guidelines every day.” In addition, I’d add: look it up as you come to it. Use the ACC guidelines apps mentioned above (so easy in real-time!). Put them into action, with specific patients (and their comorbidities). This will help mentally create for you those algorhythms (ie: HTN, HTN + DM, HTN + DM+ HLD + MI+ CAD + CHF + AAA+ AF + CKD, etc.), and you will much more easily navigate the “if this, then that” world of cardiology and all its management recommendations.

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