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10: CARDIOVASCULAR GUIDELINES
4. PAD.
5. Varicose veins with risk of hemorrhage.
B. Varicose veins:
1. Arthritis.
2. Peripheral neuritis.
3. Nerve root compression.
4. Telangiectasia.
5. DVT.
6. Inammatory liposclerosis.
PLAN
A. General interventions:
1. Prevention: general:
a. Avoid prolonged standing or sitting.
b. Exercise on a regular basis.
c. Encourage smoking cessation, weight loss, and
exercise, if applicable.
d. Encourage strategies to better manage other chronic
medical conditions that directly affect the progression
of PAD—for example, diabetes, dyslipidemia, obesity,
and HTN.
B. CVI:
1. Nonpharmaceutical therapy:
a. Extremity elevation.
b. Compression stockings.
c. Exercise.
d. Venous ulcerations treated with wound care and
compression therapy.
i. Compression therapy is the primary mode of
management and has demonstrated venous ulcer
healing rates as high as 97%.
2. Pharmaceutical therapy:
a. Diuretics: management of edema, short-term
administration.
i. Hydrochlorothiazide.
b. Antiplatelet: may increase the speed of healing to
ulcerations.
i. Aspirin: 325mg tablet.
c. Systemic antibiotics: management of infection in
persons demonstrating an increase in pain, erythema,
or size of ulceration.
3. Surgery:
a. Venous ablation is for clients who continue to be
symptomatic after 6 months of nonpharmacologic
therapies. The types of ablation are chemical, thermal,
and mechanical.
C. Varicose veins:
1. Client teaching: See Client Teaching Guides for this chap-
ter, “Chronic Venous Insufciency” and “Varicose Veins.”
a. If prolonged standing is required, shift weight from
one leg to the other.
b. Do not sit with legs dependent.
2. Nonpharmaceutical therapy:
a. Extremity elevation.
b. Compression stockings.
c. Exercise.
3. Surgery:
a. Supercial vein:
i. Vein stripping or ligation.
ii. Sclerotherapy.
iii. Endovascular thermal ablation.
iv. Radiofrequency ablation.
b. Deep vein:
i. Valvuloplasty.
ii. Valvular construction.
iii. Valve transplantation.
iv. Valve transposition.
c. Perforating vein:
i. Subfascial endoscopic perforator surgery
(SEPS).
ii. Linton operation.
iii. Percutaneous ablation of perforators (PAPs).
FOLLOW-UP
A. Follow-up is determined by the client’s needs, frequency
and intensity of symptoms, and the presence of other medical
conditions.
B. PVD manifesting persistent symptoms should always be
followed by a cardiologist.
CONSULTATION/REFERRAL
A. If you suspect acute limb ischemia (ALI), refer the client
for immediate hospitalization to obtain diagnostic testing to
determine the presence of a thrombus and restore circulation
to the affected extremity.
B. If chronic limb ischemia (CLI) has led to ulceration and/or
superimposed infection, hospitalization is indicated to initiate a wound care consultation and diagnostic testing to determine the degree of arterial occlusion.
C. Referral to a cardiologist is indicated in the presence of
persistent PVD symptoms.
D. Referral to a podiatrist becomes necessary to trim toenails
and assess the client for proper-tting shoes.
E. Referral to pain management is indicated if pain is resis-
tant to treatment.
INDIVIDUAL CONSIDERATIONS
A. Nonambulatory clients:
1. Using rocking chairs is a possible substitute for per-
sons unable to participate in a walking program.
B. Geriatrics:
1. Be alert to signs and symptoms of depression related to
immobility and pain.
BIBLIOGRAPHY
Alguire, P. C., & Mathes, B. M. (2021, April 13). Diagnostic evaluation of
chronic venous insufciency. UpToDate. https://www.uptodate.com/c
ontents/diagnostic-evaluation-of-chronic-venous-insufciency
Barstow, C., & Kassop, D. (2019, April). Cardiovascular disease: Chronic
venous insufciency and varicose veins. Family Practice Essentials, 479,
16–20. https://www.ncbi.nlm.nih.gov/pubmed/30995000
Kabnick, L. S., & Scovell, S. (2020, September 22). Overview of lower extrem-
ity chronic venous disease. UpToDate. https://www.uptodate.com/con
tents/overview-of-lower-extremity-chronic-venous-disease
Moneta, G. (2021, June 11). Classication of lower extremity chronic
venous disorders. UpToDate. https://www.uptodate.com/contents/
classication-of-lower-extremity-chronic-venous-disorders
Ortega, M.A., Fraile-Martinez, O., Garcia-Montero, C., Alvarez-Mon, M.
A., Chaowen, C., Ruiz-Grande, F., Pekarek, L., Monserrat, J., Asúnsolo,
A., García-Honduvilla, N., Álvarez-Mon, M., & Bujan, J. (2021, July
22). Understanding chronic venous disease: A critical overview of
its pathophysiology and medical management. Journal of Clinical
Medicine, 10(15), 3239. https://doi.org/10.3390/jcm10153239
DEEP VEIN THROMBOSIS
DEFINITION
A. Peripheral vascular disease (PVD) is a general term that
encompasses all occlusive or inammatory diseases that occur
within the peripheral arteries, veins, and lymphatics. Deep vein
thrombosis (DVT) is included with PVD and is a condition in
which a thrombus forms in one or more veins (Figure 10.4) and
greatly increases the risk of pulmonary embolism (PE).
FIGURE 10.4 Deep vein thrombosis.
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Source: Image courtesy of Dr. Sellers/Emory University/Centers for Disease
Control and Prevention. Retrieved from https://phil.cdc.gov/Details.aspx?pid=
1345Predisposing Factors.
DEEP VEIN THROMBOSIS
289
POTENTIAL COMPLICATIONS
A. PE.
B. Arterial embolism with arteriovenous shunting.
C. Myocardial infarction (MI).
D. Chronic venous insufciency (CVI).
E. Postphlebitic syndrome.
F. Phlegmasia cerulea dolens.
SUBJECTIVE DATA
A. Ask the client when the symptom were rst noticed.
B. Have the client describe the duration of the symptoms.
C. Ask the client to describe the pain—for example, crushing,
stabbing, or burning.
D. Ask the client what makes the symptoms better and what
makes them worse.
E. Have the client rate the pain on a scale of 1 to 10, with 1
being the least painful.
F. Ask the client to list all medications currently being taken,
particularly substances not prescribed and illicit drugs such as
cocaine.
G. Review recent history of invasive procedures or surgery.
INCIDENCE
A. Estimates show as many as 900,000 Americans are affected
by DVT or PE for the rst time annually. Between 60,000 and
180,000 deaths annually are directly or indirectly attributed to
DVT or PE.
PATHOGENESIS
A. Changes within the venous system precipitate the for-
mation of a DVT. These changes, formally called Virchow
triad, include hypercoagulability, stasis, and endothelial
cell injury. At least two of the three must be present for a
DVT to form. Essentially, an injury to the vessel wall causes
inammation that attracts platelets, especially in a state of
altered coagulation. The thrombus that forms spreads in
the direction of blood ow, and additional layers of platelets are added to the thrombus as time progresses. As it
grows, the vessel becomes further occluded and symptoms
worsen.
1. Age: 60 years and older.
2. Hip or femur fracture.
3. Recent surgery, especially cardiac or extremity surgery.
4. Prolonged inactivity/immobility.
5. Pregnancy.
6. Medication:
a. Hormone replacement therapy (HRT).
b. Oral contraceptives.
c. Tamoxifen.
7. Current or recent hospitalization.
8. Smoking.
9. Obesity.
10. Cancer.
11. Inherited hypercoagulable conditions.
COMMON COMPLAINTS
A. Symptoms are usually unilateral and have a sudden
onset.
1. Extremity edema.
2. Extremity pain.
3. Increased temperature of extremity.
4. Change in color or extremity.
5. Asymptomatic, depending on the size and location of
the thrombus.
PHYSICAL EXAMINATION
A. Clients presenting with acute shortness of breath and/
or chest pain should be quickly assessed for the need to call
emergency services/911 for immediate transport to the hospital. Clients presenting with symptoms of DVT that include
cyanosis of the distal extremity should be quickly assessed for
the need to call emergency services/911 for immediate transport to the hospital.
B. Check vital signs: Check and document resting heart rate,
respirations, height, and weight.
C. Inspect:
1. Assess for signs of erythema, increased temperature,
and edema.
2. Assess for Homans sign:calf pain with forced plantar
exion.
3. Assess for Moses or Bancroft sign:pain when calf mus-
cle is compressed forward against the tibia.
4. Assess for Lisker sign:pain upon tibial percussion.
D. Palpate:
1. Pulses distal to affected area, noting symmetry.
2. Capillary rell.
3. Extremity for tenderness. Do not perform deep
palpation.
E. Auscultate:
1. Heart: Assess the rate, rhythm, heart sounds, murmur,
and gallops.
2. Lungs: Assess lung sounds in all elds.
DIAGNOSTIC TESTS
A. Serum laboratory testing:
1. D-dimer.
2. Complete blood count with differential.
3. Coagulation panel (prothrombin time, partial throm-
boplastin time [PTT], international normalized ratio).
4. Testing for idiopathic DVT: Add factor V Leiden,
homocysteine, G20210A prothrombin, factor VIII, lupus
anticoagulant antibody, protein C and protein S levels,
anticardiolipin antibodies, and antithrombin.
B. Compression ultrasound.
C. MRI, if thrombus is suspected in the pelvic veins or vena
cava.
D. Venography, not utilized often because of expense and risk
of phlebitis.
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10: CARDIOVASCULAR GUIDELINES
DIFFERENTIAL DIAGNOSES
A. DVT.
B. Cellulitis.
C. Fracture.
D. Lymphedema.
E. Congestive heart failure (CHF).
F. Vein compression (caused by enlarged lymph nodes or
mass).
G. Filariasis.
H. Allergic reaction, localized.
I. Compartment syndrome.
PLAN
A. General interventions:
1. Encourage strategies to better manage other chronic
medical conditions that directly affect the progression of
peripheral artery disease. Examples of these conditions
include diabetes, dyslipidemia, obesity, and hypertension.
B. Client teaching: See Client Teaching Guide for this chapter,
“Deep Vein Thrombosis.”
1. Clients taking Coumadin should be educated regard-
ing foods that are high in vitamin K. Some foods will
interfere with clotting factors. See Appendix B, “Diet
Recommendations” for common foods that interfere with
clotting factors.
2. Teach the client to perform activities that can help pre-
vent DVT.
a. Avoid prolonged standing or sitting.
b. Avoid crossing the legs.
c. Gradually resume normal activity after a period of
inactivity.
d. Avoid immobility.
e. Exercise on a regular basis.
f. Stop smoking.
g. Wear compression stockings frequently.
C. Pharmaceutical therapy:
1. Thrombolytics:
a. Administered in the inpatient setting.
2. Anticoagulants:
a. Heparin, intravenous (IV), administered in the inpa-
tient setting.
b. Coumadin (warfarin sodium; Jantoven).
i. Doses: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6
mg, 7.5 mg, and 10mg tablets.
ii. See the “Atrial Fibrillation” section in this chap-
ter for specics on Coumadin therapy.
3. Low-molecular-weight heparin (LMWH):
a. Enoxaparin sodium (Lovenox):
i. Doses (multidose vial): 300mg/3 mL.
ii. Doses (prelled syringes): 30 mg/0.3 mL,
40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL,
100mg/mL, 120mg/0.8 mL, and 150mg/mL.
b. Dalteparin sodium (Fragmin):
i. Doses (multidose vial): 95,000 IU/9.5 mL.
ii. Doses (by injection): 2,500 IU/0.2 mL, 5,000
IU/0.2 mL, 7,500 IU/0.3 mL, 10,000 IU/0.4 mL,
10,000 IU/mL, 12,500 IU/0.5 mL, 15,000 IU/0.6 mL,
and 18,000 IU/0.72mL.
4. Non-vitamin K oral anticoagulants:
a. Rivaroxaban (Xarelto):
i. 2.5 mg, 10mg, 15mg, and 20mg tablets.
ii. Dosage indications based on creatinine clear-
ance (CrCl).
1) CrCl >50 mL/min: 20 mg with evening
meal.
2) CrCl of 15 to 50mL/min: 15mg with eve-
ning meal.
b. Apixaban (Eliquis):
i. 2.5 mg and 5 mg tablets.
ii. Dosage indications:
1) Recommended dose is 2.5 mg, taken BID in
clients who t any of the following criteria:
a) 80 years of age or older.
b) Weight ≥60kg (132 lbs).
c) Serum creatinine ≥1.5 mg/dL.
c. Edoxaban (Savaysa):
i. 15mg, 30mg, and 60mg tablets.
ii. Dosage indications:
1) CrCl between 15 and 50 mL/min: 30 mg,
once daily.
2) CrCl >95mL/min: Do not prescribe.
d. Betrixaban (Bevyxxa):
i. 40mg and 80mg.
ii. Initial dose of 160mg, then maintenance dose of
80mg daily, with duration of therapy being 35 to 42
days.
5. Thrombin inhibitors:
a. Bivalirudin (Angiomax):
i. 250mg per vial, add 5 mL of sterile water for
injection. Recommended IV bolus of 0.75 mg/kg
followed by an infusion of 1.75mg/kg/hr.
b. Argatroban (Acova):
i. 2 mcg/kg/min in constant infusion until PTT is
1.5 to 3 times the initial baseline PTT value.
c. Dabigatran etexilate mesylate(Pradaxa):
i. 75mg, 110mg, and 150mg tablets.
ii. Dosage indications based on CrCl:
1) CrCl >30mL/min: 150mg, taken BID.
2) CrCl of 15 to 30mL/min: 75mg, taken BID.
d. Thrombate III (antithrombin III).
6. Specic factor Xa inhibitor:
a. Fondaparinux sodium (Arixtra):
i. Doses: 2.5 mg/0.5 mL, 5 mg/0.4 mL, 7.5 mg/0.6
mL, and 10mg/0.8 mL by injection.
D. Surgery:
1. Insertion of vena cava lter to prevent PE.
2. Venous thrombectomy.
FOLLOW-UP
A. Follow-up is determined by the client’s needs, frequency
and intensity of symptoms, and the presence of other medical
conditions.
B. Persistent symptoms of a DVT should be managed by a
cardiologist.
C. Clients taking anticoagulants are best followed by an anti-
coagulant clinic and/or cardiologist.
CONSULTATION/REFERRAL
A. If you suspect acute limb ischemia, refer the client for
immediate hospitalization to obtain diagnostic testing to
determine the presence of a thrombus and restore circulation
to the affected extremity.
B. If chronic limb ischemia has led to ulceration and/or
superimposed infection, hospitalization is indicated to initiate a wound care consultation and diagnostic testing to determine the degree of arterial occlusion.
HEART FAILURE
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291
C. Referral to a cardiologist is indicated in the presence of
persistent PVD symptoms.
D. Refer to pain management if pain is resistant to treatment.
E. Refer to a registered dietitian as indicated by the cli-
ent’s understanding of the dietary modication necessary to
improve their status in terms of risk factors.
INDIVIDUAL CONSIDERATIONS
A. Nonambulatory clients:
1. Using rocking chairs is a possible substitute for per-
sons unable to participate in a walking program.
B. Geriatrics:
1. Be alert to signs and symptoms of depression related to
immobility and pain.
BIBLIOGRAPHY
Chang, S., Huang, Y., Lee, M., Hu, S., Hsiao, Y., Chang, S., Chang, C. J., &
Chen, P. (2018, February 27). Association of varicose veins with incident venous thromboembolism and peripheral artery disease. Journal
of the American Medical Association, 319(8), 807–817. https://doi.
org/10.1001/jama.2018.0246
Fawzy, A. M., Yang, W., & Lip, G.Y. (2019, March). Safety of direct oral
anticoagulants in real-world clinical practice: Translating the trials to
everyday clinical management. Expert Opinion of Drug Safety, 18(3),
187–209. https://doi.org/10.1080/14740338.2019.1578344
Lip, G. Y. H., & Hull, R. D. (2021, May 20). Overview of the treatment of lower
extremity deep vein thrombosis (DVT). UpToDate. https://www.uptoda
te.com/contents/overview-of-the-treatment-of-lower-extremity-deep
-vein-thrombosis-dvt
Ortel, T. L., Neumann, I., Ageno, W., Beyth, R., Clark, N. P., Cuker,
A., Hutten, B. A., Jaff, M. R., Manja, V., Schulman, S., Thurston, C.,
Vedantham, S., Verhamme, P., Witt, D. M., Florez, I. D., Izcovich, A.,
Nieuwlaat, R., Ross, S., Schünemann, H. J., & Zhang, Y. (2020, October
2). American Society of Hematology 2020 Guidelines for management
of venous thromboembolism: treatment of deep vein thrombosis and
pulmonary embolism. Blood Advances, 4(19), 4693–4738. https://doi.
org/10.1182/bloodadvances.2020001830
Scovell, S. (2021, Feb 18). Supercial thrombosis and phlebitis of the
lower extremity veins. UpToDate. https://www.uptodate.com/co
ntents/superficial-vein-thrombosis-and-phlebitis-of-the-lowerextremity-veins
HEART FAILURE
DEFINITION
A. Heart failure (HF) is failure of the heart to pump sufcient
blood to meet the metabolic demands of the tissues. However,
the 2017 guidelines from the American College of Cardiology/
American Heart Association (ACC/AHA) address management of HF with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).
1. HFrEF:
a. Ejection fraction (EF) less than 40% due to weak,
inefcient systolic contractions. The left ventricular
ejection fraction (LVEF) is a measurement of systolic
failure.
b. An S3 ventricular gallop rhythm commonly occurs.
c. Systolic failure is often the result of coronary heart
disease and/or myocardial infarction (MI).
d. It can result from right- or left-sided failure, or both.
2. HFpEF:
a. EF is greater than 50%, but with poor compliance of
the ventricle, which impedes ventricular diastolic lling (the ventricle is unable to relax).
b. There are two subgroups:
i. HFpEF borderline (or intermediate): clients
with an EF of 41% to 49%.
ii. HFpEF with an EF greater than 40% who pre-
viously had HFrEF (EF <40%) but improvement or
recovery was noted in EF.
c. The client may be asymptomatic for years. HFpEF
presents with the same symptoms of systolic failure,
pulmonary congestion, and peripheral edema.
d. An S4 atrial gallop rhythm commonly occurs.
INCIDENCE
A. HFrEF incidence is higher in older females, chronic his-
tory of hypertension (HTN), obesity, left ventricular hypertrophy, cardiomyopathy, excessive alcohol use, end-stage chronic
obstructive pulmonary disease (COPD), valvular disorders,
anemia, renal failure, atrial brillation (AF), coronary artery
disease, or diabetes.
B. Approximately 6.5 million people in the United States
have HF. By the year 2030, the AHA estimates that more than
8 million people will be affected by HF.
C. The costs of direct client care (e.g., healthcare services, hos-
pitalization, medications) for these clients with chronic disease are projected to increase to approximately $69.7 billion by
the year 2030.
PATHOGENESIS
A. Injuries to the myocardium may cause loss of function-
ing muscle. Compensatory mechanisms, including cardiac
hypertrophy and neurohumoral processes, lead to adverse
long-term effects. An inotropic insult results in incomplete
emptying (systolic failure), and a compliance abnormality
results in incomplete lling (diastolic failure). Most clients
with HF have some degree of both abnormalities.
PREDISPOSING FACTORS
A. Atherosclerotic heart disease.
B. MI.
C. Rheumatic heart disease involving mitral and aortic valves.
D. Cardiomyopathies.
E. Hypertensive heart disease.
F. Aortic stenosis or regurgitation.
G. Thyrotoxicosis.
H. Pregnancy-related disorders such as multiple births with
preexisting heart disease.
I. Volume overload.
J. Beta-blockers or other cardiac depressants.
K. Pulmonary embolism (PE).
L. Systemic infection.
M. Arrhythmias.
N. Renal disease.
COMMON COMPLAINTS
A. Clients are assigned the New York Heart Association clas-
sications based on their tolerance of physical activity and
shortness of breath (SOB). This classication may change
according to the progression or regression of their cardiovascular disease (Table 10.4).
1. Dyspnea on exertion.
2. Hemoptysis.
3. Fatigue.
4. Cough.
5. Orthopnea.
6. Edema/weight gain.
7. Paroxysmal nocturnal dyspnea.
8. Nausea.
9. Right upper abdominal pain or fullness.
10. Chest pain.
11. Palpitations.
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10: CARDIOVASCULAR GUIDELINES
OTHER SIGNS AND SYMPTOMS
A. Hemoptysis.
B. Bibasilar crackles.
C. S3 gallop.
D. Murmurs.
E. Exercise intolerance.
F. Weakness.
G. Cough.
H. Orthopnea.
I. Nocturnal dyspnea.
J. Tachycardia.
K. Pallor.
L. Cyanosis.
M. Anorexia.
N. Constipation.
O. Jugular venous distention.
P. Hepatomegaly.
Q. Hepatojugular reux (HJR).
R. Murmurs.
S. Exercise intolerance.
SUBJECTIVE DATA
A. Ask the client if they have difculty breathing.
B. Ask how many pillows they sleep on. Does the client need
to sit up in a recliner to sleep?
C. Inquire about how often the client wakes up at night with
SOB.
D. Inquire about how far the client can walk without getting
SOB. Have the client describe their routine activities of daily
living (ADLs) and how well the client tolerates each activity.
E. Discuss the client’s history of heart disease, heart attack,
HTN, or hyperlipidemia.
F. Ask the client about all current medications—prescription,
over-the-counter (OTC), and herbal products.
G. Question the client regarding all symptoms found in the
“Common Complaints” section.
H. Discuss drug and alcohol history.
I. Has the client ever been treated for cancer/chemotherapy,
and how long ago?
J. What is the client’s usual weight? Have they experienced
more symptoms if they have pedal edema?
K. Does the client have a cough (consider
angiotensin-converting enzyme inhibitors [ACEI] as the
cause)?
PHYSICAL EXAMINATION
A. Check pulse, respirations, blood pressure (BP), height, and
weight:
1. Check BP while client is sitting, standing, and lying
down.
2. Be alert for abnormal vital signs: hypotension, nar-
row or wide pulse pressure, tachycardia, bradycardia, and
tachypnea.
3. Calculate body mass index.
4. On all subsequent visits, note weight gain of more than
1 lb per day over 3 consecutive days or 3 lb in 1 day.
B. Inspect:
1. Overall physical appearance. Is the client in distress?
2. Skin: Note pallor, cyanosis, and temperature.
3. Neck: Check jugular veins for distention.
4. Extremities: Note edema, cyanosis, pallor, and ulcers.
C. Auscultate:
1. Heart for murmurs; tachycardia; S3 or S4 gallops; and
other abnormalities.
2. Lungs: Note moderate to severe crackles/rales and
other abnormal sounds.
3. Neck and carotid arteries.
D. Palpate:
1. Abdomen for hepatomegaly and HJR.
2. Extremities for peripheral pulses.
3. Chest wall for displaced point of maximal impulse
(PMI), lifts, heaves, and thrills.
E. Mental status:
1. Check mental status because confusion may occur,
especially in the elderly.
DIAGNOSTIC TESTS
A. Two-dimensional echocardiography with Doppler to eval-
uate LVEF.
B. Radionuclide ventriculography may be used to measure
LVEF and left ventricular (LV) volumes.
C. Coronary angiography.
D. Anterior/posterior chest x-ray.
E. EKG for clients with suspected arrhythmia, ischemia,
or cardiac disease. Identify acute and old EKG changes to
rule out pathologic Q wave, ST-segment elevation, and LV
hypertrophy.
F. Natriuretic peptides (brain natriuretic peptide or
N-terminal pro b-type natriuretic peptide).
TABLE 10.4 NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION FOR HEART FAILURE
Functional Class Activities Objective Assessment
AHA class I
ACCF stage A
AHA class II
ACCF stage B
AHA class III Marked limitations. No discomfort at rest. Fatigue,
ACCF stage C
AHA class IV Inability to do physical activity without discomfort.
ACCF stage D
ACCF, American College of Cardiology Foundation; AHA, American Heart Association; CVD, cardiovascular disease; SOB, shortness of breath.
Source: Data from the American Heart Association and includes staging by the American College of Cardiology Foundation.
No limitation. Ordinary activity does not cause undue
fatigue, palpitation, dyspnea, or angina.
Slight limitations. Fatigue, palpitation, SOB, and angina
with ordinary physical activity.
palpitation, SOB, and angina with less than usual
activities.
Symptoms of heart failure are present at rest and
become worse with activity.
No objective evidence of CVD
Objective evidence—minimal CVD
Objective evidence—moderately severe CVD
Objective evidence—severe CVD
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DIFFERENTIAL DIAGNOSES
A. HF:
1. HFrEF less than or equal to 40%.
2. HFpEF:
a. HFpEF borderline clients with an EF of 41% to 49%.
b. HFpEF clients with an EF greater than 40% who pre-
viously had HFrEF (EF, 40%) with improvement noted
in EF.
B. Renal disease or nephrotic syndrome.
C. Liver disease.
D. Asthma.
E. COPD.
To distinguish between progressing HF and a COPD exacerbation when
both conditions are present, note that the presence of weight gain and
an S3 gallop indicates HF, not COPD.
PLAN
A. General interventions:
1. Determine the etiology of the failure state and treat
appropriately.
2. Treat HF stages:
a. Stage A: Treat/manage the client’s underlying condi-
tions (HTN, AF, hyperlipidemia, diabetes, tobacco cessation, obesity, substance abuse [e.g., alcohol, cocaine]).
b. Stage B: Begin ACEI with beta-blockers for clients
with HFrEF. Add statin therapy if the client has a history of MI.
c. Stage C: HFrEF: Implantable cardioverter debrilla-
tors and consider cardiac resynchronization therapy.
i. Digoxin may be used to manage symptoms.
Hydralazine and isosorbide dinitrate are indicated
for African American clients with HFrEF, clients
with kidney dysfunction, or clients who cannot take
ACEI or angiotensin receptor blocker (ARB) therapy. A diuretic agent is also recommended.
d. Stage D: Provide advanced treatment such as cardiac
transplant, mechanical support, and/or palliative care.
3. The goals of therapy are to improve the client’s qual-
ity of life by reducing symptoms, reducing morbidity, and
prolonging survival.
B. Client teaching:
1. Teach the client to weigh self daily at the same time, on
the same scale, and in the same clothing. Instruct the client
to call if there is a weight gain of more than 3 lb in 1 day or
more than 1 lb a day over a 3-day period.
a. Develop a plan of care for the increase of diuretic
dosing in case of edema/weight gain to reduce dyspnea and prevent hospitalization.
2. Encourage weight loss.
3. Recommend regular, moderate exercise as long as dys-
pnea is not induced. Encourage exercise to increase endurance and strengthen muscles even though the client may
tolerate only a few minutes of walking.
4. Encourage smoking cessation.
5. Encourage medication adherence. Instruct the cli-
ent about all medications and possible side effects. Do
not use OTC medicines without consulting the provider.
Nonsteroidal anti-inammatory drugs (NSAIDs) are con-
traindicated in HF.
6. Use continuous positive airway pressure (CPAP) or
bilevel positive airway pressure (BiPAP) for nighttime
sleep and naps for treatment of obstructive sleep apnea.
7. Educate the client and family about biventricular pac-
ing or an implantable debrillator that may be necessary
for advanced HF.
8. Discuss the need for palliative/hospice care when HF
does not respond despite maximal therapy.
9. Discuss the client’s desire for advanced therapies,
which might include an evaluation for heart transplant or
ventricular assist device.
C. Dietary management:
1. Read food labels for sodium content.
2. Teach dietary modications, especially salt restriction
of 2,000 to 3,000 mg/d for HFrEF and HFpEF. Less than
2,000 mg sodium per day is recommended in clients with
moderate to severe HF symptoms.
3. Fluid restriction is not recommended unless the cli-
ent is classied as stage D or is diagnosed with hyponatremia with sodium levels less than 130 mEq/L. Restrict
uid intake to 2,000 mL/d or less for clients with chronic
uid retention despite use of diuretics and sodium
restrictions.
4. Alcohol consumption should be limited to one glass of
beer or wine per day. This amount should be counted in
the daily uid restriction.
5. See Appendix B for the diet (Tables B.3 and B.4).
6. Other diet changes include low-fat/low-cholesterol
foods and the use of the following:
a. Monounsaturated fats, which decrease cholesterol:
i. Canola oil.
ii. Olive oil.
b. Polyunsaturated fats, which decrease cholesterol
but not as well as monounsaturated fats:
i. Vegetable and sh oils.
ii. Corn, safower, peanut, and soybean oils.
c. Avoid saturated fats.
i. Animal fats and some plant fats.
ii. Butter and lard.
iii. Coconut oil and palm oil.
D. Pharmaceutical therapy:
1. Therapy is based on the extent of cardiac impairment
and severity of symptoms. Medication regimens include a
combination of the following classes: diuretics, ACEI (ARB
if unable to tolerate ACEI), cardioselective beta-blockers,
inotropic agents such as digoxin, vasodilators, nitrates,
and anticoagulants if there is an increased risk of thrombus
formation. In general, calcium channel blockers (CCBs) are
not used in HF management.
2. Drug classications for antihypertensive and cardiac
medication are noted in Table 10.5.
3. Drugs that should be avoided and/or used with cau-
tion in HF because they cause exacerbations or are at high
risk of adverse reactions include:
a. NSAIDs: increased renal dysfunction, edema, and
impaired response to ACEI.
b. Cyclooxygenase (COX-2) inhibitors: increased rate
of HF and increased mortality.
c. Aspirin: interaction between acetylsalicylic acid and
ACEI; interference with benets of beta-blockers on
LVEF.
d. Metformin: increased risk of lethal lactic acidosis.
e. Thiazolidinediones: cause uid retention that may
precipitate HF.
f. CCBs: some data exist on possible effects on systolic
dysfunction.
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10: CARDIOVASCULAR GUIDELINES
TABLE 10.5 ANTIHYPERTENSIVE AND CARDIAC MEDICATIONS (SORTED ALPHABETICALLY)
Brand Name Generic Name Drug Class
Accupril Quinapril ACEI
Accuretic Quinapril ACEI/diuretic
Aceon Perindopril erbumine ACEI
Adalat CC DHP/nifedipine CCB
Aldactazide Spironolactone + HCTZ Combination: K+ sparing + thiazide
Aldactone Spironolactone Diuretic—K+ sparing
Altace Ramipril ACEI
Amiloride/HCTZ Amiloride/HCTZ Combination + diuretic
Amturnide Aliskiren/amlodipine/HCTZ CCB/renin inhibitor/HCTZ
Atacand Candesartan cilexetil Angiotensin II receptor blocker
Atacand HCT Candesartan + HCTZ Combination: ARB + diuretic
Avalide Irbesartan + HCTZ Combination: ARB + diuretic
Avalide Avapro Irbesartan + HCTZ irbesartan Combination: ARB + diuretic angiotensin II receptor blocker
Azor Amlodipine + olmesartan CCB + ARB
Benicar Olmesartan medoxomil Angiotensin II receptor blocker
Benicar HCT Olmesartan + HCTZ Combination: ARB + diuretic
Betapace Sotalol Beta-blocker/class II and III antiarrhythmic
Betapace AF Sotalol Class II and III antiarrhythmics
Betaxolol Bidil
Bumex Bumetanide Loop diuretic
Bystolic Nebivolol Beta-blocker (cardioselective)
Byvalson Nebivolol and valsartan Beta-blocker + ARB
Caduet Amlodipine + atorvastatin CCB/amlodipine/atorvastatin
Calan Verapamil CCB/antianginal
Calan SR Verapamil CCB
Capoten Captopril ACEI/CHF
Capozide Captopril + HCTZ Combination: ACE + diuretic
Cardizem LA Diltiazem CCB
Betaxolol HCl isosorbide dinitrate +
hydralazine
Beta-blocker (cardioselective) nitrate + diuretic
Cardura Doxazosin Alpha-2 blocker AAB
Catapres Clonidine Central alpha agonist
Chlorothiazide Various Thiazide diuretic
Chlorthalidone Various Monosulfamyl diuretic
Cleviprex Clevidipine CCB
Clorpres Clonidine/chlorthalidone Central alpha agonist + thiazide diuretic
Cordarone Amiodarone Class II and III antiarrhythmics
(continued)
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TABLE 10.5 ANTIHYPERTENSIVE AND CARDIAC MEDICATIONS (SORTED ALPHABETICALLY) (CONTINUED)
Brand Name Generic Name Drug Class
Coreg CR Carvedilol Beta-blocker (noncardioselective)/CHF
Corgard Nadolol Beta-blocker (noncardioselective)/antianginal
Corlanor Ivabradine Hyperpolarization-activated cyclic nucleotide-gated channel blocker
Corzide Nadolol + HCTZ Combination: beta-blocker (noncardioselective) + diuretic
Covera-HS Verapamil CCB/antianginal
Cozaar Losartan Angiotensin II receptor blocker (ARB)
Demadex Torsemide Loop diuretic
Dilacor XR Diltiazem CCB/antianginal
Dilatrate SR Isosorbide dinitrate Nitrate
Diovan Valsartan Angiotensin II receptor blocker/CHF class II–IV
Diovan HCT Valsartan + HCTZ Combination: ARB + diuretic
Diuril Chlorothiazide Thiazide diuretic
Dutoprol Dyazide
Dynacirc CR Isradipine controlled-release CCB
Edarbi Azilsartan Angiotensin II receptor blocker
Edarbyclor Azilsartan + chlorthalidone Angiotensin II receptor blocker + diuretic
Edecrin Ethacrynic acid Loop diuretic
Entresto Sacubitril/valsartan ARNi
Epaned Enalapril ACEI
Exforge Amlodipine + valsartan CCB + ARB
Exforge HCT Valsartan/amlodipine/HCTZ CCB + ARB + diuretic
Fosinopril HCTZ Various HCTZ ACEI thiazide diuretic
Hytrin Terazosin Alpha-1 blocker
Hyzaar Losartan potassium + HCTZ Combination ARB + diuretic
Imdur Isosorbide dinitrate Nitrate
Inderal Propranolol Beta-blocker (noncardioselective)/antianginal/antiarrhythmic
Inderide Propranolol + HCTZ Combination: beta-blocker (noncardioselective) + diuretic
InnoPran XL Propranolol HCL extended-release Beta-blocker (noncardioselective)
Metoprolol ext. release + HCTZ triamterene
+ HCTZ
Beta-blocker (cardioselective) + thiazide combination—K+ sparing +
thiazide
Inspra Eplerenone Aldosterone receptor blocker—mineralocorticoid selective/CHF
ISMO Isosorbide mononitrate Nitrate
Isoptin SR Verapamil CCB
Isordil Various Nitrate
Kerlone Betaxolol Beta-blocker (cardioselective)
Lanoxin Digoxin Cardiac glycoside/antiarrhythmic
Lasix Furosemide Loop diuretic
(continued)
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10: CARDIOVASCULAR GUIDELINES
TABLE 10.5 ANTIHYPERTENSIVE AND CARDIAC MEDICATIONS (SORTED ALPHABETICALLY) (CONTINUED)
Brand Name Generic Name Drug Class
Levatol Penbutolol sulfate Beta-blocker (noncardioselective)
Lopressor Metoprolol tartrate Beta-blocker (cardioselective)/antianginal
Lopressor HCT Metoprolol + HCTZ Combination: beta-blocker (cardioselective) + diuretic
Lotensin Benazepril ACEI
Lotensin HCT Benazepril + HCTZ Combination: ACE + diuretic
Lotrel Amlodipine + benazepril Combination: CCB + ACEI
Mavik Trandolapril ACE inhibitor/CHF
Maxide Triamterene + HCTZ Combination—K+ sparing + thiazide
Micardis Telmisartan Angiotensin II receptor blocker
Micardis HCT Telmisartan + HCTZ Combination: ARB + diuretic
Microzide HCTZ Diuretic
Minitran Nitroglycerin Nitrate
Monoket Isosorbide dinitrate Nitrate
Monopril Fosinopril ACEI/CHF
Multaq Dronedarone Antiarrhythmic
Nicardipine Various CCB
Nitro-Bid Nitroglycerin Nitrate
Nitro-Dur Nitroglycerin Nitrate
Nitrolingual Nitroglycerin Nitrate
Nitrostat Nitroglycerin Nitrate
Normodyne Labetalol Beta-blocker
Norpace Disopyramide Antiarrhythmics—class 1 ventricular
Norvasc Amlodipine CCB/antianginal
Pindolol Pindolol Beta-blocker (noncardioselective)
Plendil Felodipine CCB
Prestalia Perindopril arginine/amlodipine ACEI/CCB
Prinivil Lisinopril ACEI/CHF
Prinzide Lisinopril + HCTZ Combination: ACE inhibitor + thiazide diuretic
Procanbid Procainamide Antiarrhythmics—class 1a ventricular
Procardia XL Nifedipine CCB/antianginal
Quinidine gluconate Various Antiarrhythmics—class 1 atrial and ventricular ACEI
Quinidine sulfate Various Antiarrhythmics—class 1 atrial and ventricular
Ranexa Ranolazine Antianginal
Rythmol Propafenone Antiarrhythmics—class 1c ventricular
Sectral Acebutolol Beta-blocker (cardioselective)
(continued)
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TABLE 10.5 ANTIHYPERTENSIVE AND CARDIAC MEDICATIONS (SORTED ALPHABETICALLY) (CONTINUED)
Brand Name Generic Name Drug Class
Sular Nisoldipine CCB
Tambocor Flecainide Antiarrhythmics—class 1c-ventricular
Tarka Trandolapril + verapamil Combination: ACE + CCB
Tekamlo Aliskiren + amlodipine Direct renin inhibitor + DHP CCB
Tekturna Aliskiren Direct renin inhibitor
Tekturna HCT Aliskiren + HCTZ Direct renin inhibitor + thiazide diuretic
Tenex Guanfacine Central alpha agonist
Tenoretic Atenolol + chlorthalidone Combination: beta-blocker (cardioselective) + diuretic
Tenormin Atenolol Beta-blocker (cardioselective)/antianginal
Teveten Eprosartan Angiotensin II receptor blocker
Teveten HCT Eprosartan + HCTZ Combination: ARB + diuretic
Thalitone Chlorthalidone Antihypertensive/diuretic
Tiazac Diltiazem CCB/antianginal
Timolide Timolol maleate + HCTZ Combination: beta-blocker (noncardioselective) + diuretic
Toprol-XL Metoprolol Beta-blocker (cardioselective)/antianginal/CHF class II or III
Trandate Labetalol Beta-blocker (noncardioselective)
Tribenzor Olmesartan + amlodipine + HCTZ ARB + CCB + thiazide diuretic
Twynsta Telmisartan + amlodipine ARB + CCB
Uniretic Moexipril + HCTZ Combination: ACE + diuretic
Univasc Moexipril ACEI
Valturna Aliskiren + valsartan Direct renin inhibitor + ARB
Vaseretic Enalapril + HCTZ Combination: ACE + diuretic
Vasotec Enalapril ACEI/CHF with digitalis and diuretics
Verelan PM Verapamil CCB
Zaroxolyn Metolazone Diuretic: quinazoline
Zebeta Bisoprolol Beta-blocker (cardioselective)
Zestoretic Lisinopril + HCTZ Combination: ACE + diuretic
Zestril Lisinopril ACEI/CHF with digitalis and diuretics
Ziac Bisoprolol + HCTZ Combination: beta-blocker (cardioselective) + diuretic
AAB, alpha-adrenergic blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor;CCB,
calcium channel blocker; CHF, congestive heart failure; DHP, dihydropyridine; HCTZ, hydrochlorothiazide.
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