Clinical Log Spring Semester 2012Emily KochACNP Student

Clinical setting and preceptor: CCU, Carole BallewDate: 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 balance3. 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 http://www.uptodate.com/home/index.html

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 http://www.uptodate.com/home/index.html

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 http://www.uptodate.com/home/index.html

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 BeirneDate: 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 warfarin7. 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 PVCs11. 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 BeirneDate: 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.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.

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.

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 http://www.omicsonline.org/2155-9864/2155-9864-S1-002.pdf

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 CharleboisDate: 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

Abnormalities2. POTS3. Heart Rhythm Society website has great resources for clinical guidance4. Donna and Dr. Pamela Mason role-modeled respectful and effective collaborative

practice5. General pacemaker guidelines6. 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 http://circ.ahajournals.org/content/early/2012/01/03/CIRCULATIONAHA.111.085159

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 http://circ.ahajournals.org/content/early/2012/01/03/CIRCULATIONAHA.111.065722

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 cardiologyDate: 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 servicec. Documentation compliance with codingd. Physician satisfaction (informally)e. LOS (length of stay) for inpt servicef. Pt acuity (inpt service)g. Compliance with core measures for AMI and heart failureh. Looking at compliance with HRS compliance with device peri-procedural

guidelinesi. Donna Charlebois is working on a pt education study in EP clinicsj. 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.

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 FallinDate: February 15 & 22, 2012

Description of clinical experience: This was a unique clinical experience in that 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.

Major learning points:1. Recommended and organizational guidelines for heart transplant surveillance2. Side effect profiles of heart transplant medications3. Description, objectives, and benefits of Interagency Registry for Mechanically Assisted

Circulatory Support (INTERMACS)4. Clinical utility, indications, contraindications, and interpretation of AlloMap testing

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 http://www.uptodate.com/home/index.html

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.

International Society for Heart & Lung Transplantation. (2010). Guidelines. Retrieved from http:/www.ishlt.org/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 http://www.uptodate.com/home/index.html

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 HallDate: February 25, 2012

Description of clinical experience: We started the day …

Major learning points:4. ...5. …

Related to Cardiology Objective: Related to Course Objectives for the ACNP student:

Annotated bibliography: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.

Clinical hours: 108

Clinical setting and preceptor: Heart Failure Clinic, Nita ReigleDate: February 27 & 28, 2012

Description of clinical experience: We started the day …

Major learning points:6. ...7. …

Related to Cardiology Objective: Related to Course Objectives for the ACNP student:

Annotated bibliography:

Clinical hours: 124

Clinical setting and preceptor: EP Device Clinic with Device Nurse Mario CastroDate: March 7, 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: 132

Clinical setting and preceptor: Inpatient Acute Cardiology, Amanda BeirneDate: March 16, 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: 144

Clinical setting and preceptor: CCU, Jim BerginDate: 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: