Cardiac/Vascular Nurse Exam Secrets Study Guide (16 page)

Supplemental oxygen may prevent further worsening of cor pulmonale and underlying disease progression. Oxygen supplementation also improves survival, decreases symptom burden, and improves patient quality of life.

Treatment approaches for type I and type II diabetes

Treatment of both type I and type II diabetes involves management of short-term and long-term complications. Proper lifestyle modifications as well as pharmaceutical management need to be maintained in an effort to prevent long-term complications such as coronary artery disease, peripheral vascular disease, and vision problems. Patients also need to monitor their blood sugar levels on a daily basis and comply with treatment recommendations.

Patients need to make lifestyle modifications including diet, exercise and smoking cession. Pharmacologic management, including proper insulin or oral diabetic agent usage, is also necessary.

Lifestyle modifications and pharmaceutical treatment of type II diabetes

For type II diabetes, patients need to maintain a healthy diet, exercise, and comply with oral pharmacologic agents and insulin regimens. In some cases, type II diabetes can be cured with gastric bypass surgery in obese patients.

Pharmaceutical agents used for treatment of type II diabetes include sulfonylurea agents such as glipizide, glyburide, and glimepiride; meglitinides such as repaglinide; biguanides such as metformin; thiazolidinediones such as pioglitazone and rosiglitazone; dipeptidyl inhibitors such as sitagliptin; incretin mimetics such as exenatide; amylin analogs such as pramlintide acetate; and alpha glucosidase inhibitors such as acarbose and miglitol.

Lifestyle modifications and pharmaceutical treatment

Type I diabetes

For type I diabetes, patients need to maintain a consistent healthy weight and exercise routine as well as maintain compliance with insulin use. Blood sugar monitoring is of extreme importance to avoid the extreme highs and lows, both of which can be life threatening. They also need to avoid smoking and/or tobacco use to decrease risk of cardiovascular complications.

Type I diabetes pharmacologic approaches include antidiabetic agents such as insulin lispro, insulin NPH, protamine zinc, insulin aspart, insulin glargine and insulin glulisine. There is no cure for type I diabetes and management of the disease requires chronic care. However, pancreatic transplantation, islet cell transplantation and stem cell transplantation are possible cures for type I diabetes, but are currently investigational and not always successful.

Type II diabetes

Onset of type I and type II diabetes can be attributed to both genetic as well as environmental factors. Therefore, certain steps can be taken to control environmental triggers, but nothing can be done to prevent the genetic contribution. However, type I diabetes is typically not preventable, as the disease is associated with a larger genetic contribution.

Prevention of type II diabetes involves maintaining a healthy diet rich in proteins, fruits, and vegetables and low in saturated fats, increasing physical activity with 2 1/2 hours of exercise per week, management of other comorbid conditions, and maintaining proper body fat and weight for an individual’s height.

Other preventative measures for type I and type II diabetes are under investigation and not recommended by the American Diabetes Association, such as copper supplementation and niacin.

Treatment and prevention of metabolic syndrome

Currently, there are no set guidelines for the management of metabolic syndrome. However, the overall goal is to reduce an individual’s risk of developing cardiovascular disease and development of type II diabetes. It is recommended to encourage patients to maintain proper diet and exercise, avoid smoking and tobacco use, lose excess weight, maintain proper lipid levels, maintain proper blood pressure levels, maintain proper glucose levels, and maintain proper albumin excretion and creatinine levels.

Pharmacologic agents used to treat metabolic syndrome include lipid-lowering agents, antihypertensives, anticoagulants and diabetic agents such as oral agents and insulin.

Certain risk factors such as having a genetic predisposition for metabolic syndrome and natural aging are unpreventable. To prevent the onset, individuals need to maintain proper diet and exercise, avoid smoking and tobacco use, lose excess weight, maintain proper lipid levels, maintain proper blood pressure levels, maintain proper sugar levels, and maintain proper albumin excretion and creatinine levels.

Metabolic syndrome is a chronic condition that needs to be managed by lifestyle modifications and pharmacologic management of comorbid conditions. Patients should carefully watch their waistline measurement and calculate their body mass index in order to prevent abdominal obesity.

Treatment of endothelial dysfunction

Comorbid conditions that can lead to the development of endothelial dysfunction include septic shock, hypertension, hypercholesterolemia, congestive heart failure, peripheral artery disease, chronic renal failure, diabetes, and insulin resistance. Another factor that can increase the risk of developing endothelial dysfunction is smoking and/or tobacco use.

Treatment of endothelial dysfunction involves dietary changes and increased physical activity. Pharmacologic agents such as anticoagulants, antihypertensive agents and lipid-lowering agents may be used to treat comorbid conditions and reduce an individual’s risk for developing cardiovascular disease.

Treatment and prevention of hypertension

The treatment of hypertension involves lifestyle modification and pharmacologic management. Lifestyle modifications include weight loss, diet low in saturated fats and sodium, physical activity, smoking cessation, limiting tobacco use and stress reduction.

The goals of pharmacologic management include reduction of blood pressure in order to prevent onset of comorbid conditions and/or complications. Pharmacologic agents include diuretics such as hydrochlorothiazide, spironolactone, amiloride and furosemide; alpha-1-adrenergic blockers including prazosin; beta-adrenergic blockers such as atenolol; alpha/beta-adrenergic blockers such as labetalol; peripheral vasodilators such as hydralazine; calcium channel blockers such as diltiazem; angiotensin-converting enzyme inhibitors such as captopril; angiotensin II receptor antagonists such as losartan; aldosterone antagonists such as eplerenone; alpha-adrenergic agonists such as methyldopa; and renin inhibitors such as aliskiren.

Patients with diabetes and/or renal disease should be treated with pharmacologic approaches at a blood pressure of 130/80 mmHg or below due to increased risk of cardiovascular events.

Certain risk factors such as having a genetic predisposition for hypertension and natural aging are not preventable. However, certain aspects of hypertension can help reduce the onset of the condition by having individuals maintain a diet low in sodium and saturated fats, increase potassium intake, increase exercise and physical activity, avoid smoking and tobacco use, lose excess weight, maintain proper lipid levels, maintain proper sugar levels and maintain proper albumin excretion and creatinine levels.

Treatment of comorbid conditions is necessary to prevent the onset of secondary hypertension. Also, individuals being prescribed oral contraceptives, NSAIDs or other pharmacologic agents that can elevate blood pressure should monitor their blood pressure on a daily basis if at risk for hypertension or cardiovascular complications.

Pharmacologic agents

Elevated triglyceride (TG) levels and decreased high-density lipoprotein (HDL) cholesterol levels in dyslipidemia management

Pharmacologic agents used for the treatment of elevated triglyceride levels include fibrates such as gemfibrozil, ciprofibrate, clofibrate, fenofibrate and bezafibrate; nicotinic acid such as niacin; and statins such as fluvastatin, lovastatin, simvastatin, pravastatin, atorvastatin and rosuvastatin. Another approach that has been demonstrated to be effective in lowering triglyceride levels includes high doses of omega-3 fatty acids.

Elevated low-density lipoprotein (LDL) levels

Pharmacologic agents used for treatment depend on the type of lipid abnormality, even though multiple lipid abnormalities may present together. The goal of low-density lipoprotein levels is 100 mg/dL or below, but recent evidence suggests lower target of 70 mg/dL. Lipid-lowering approaches available include statins such as fluvastatin, lovastatin, simvastatin, pravastatin, atorvastatin, and rosuvastatin; nicotinic acid such as niacin; bile acid sequestrants such as cholestyramine, colestipol, and colesevelam; fibrates such as gemfibrozil, ciprofibrate, clofibrate, fenofibrate, and bezafibrate; cholesterol absorption agents such as ezetimibe; and combination agents such as extended release niacin/lovastatin.

Treatment of dyslipidemia

Individuals are typically diagnosed with dyslipidemia during routine physical examinations or when seeking medical attention for other complaints. Xanthelasma, or yellow streaks on the eyelids, and xanthomas, yellow nodules on tendons, can be suggestive. Diagnostic testing involves measurement of fasting serum lipid levels including low-density lipoprotein levels, high-density lipoprotein levels and triglyceride levels. Diagnostic tests for secondary causes of dyslipidemia should be performed including fasting serum glucose level, liver enzymes, creatinine levels, thyroid-stimulating hormone, and urinalysis.

Dyslipidemia does not typically present with any specific symptoms unless associated with comorbid cardiovascular disease including coronary artery disease or peripheral artery disease. Increased low-density lipoprotein levels may cause symptoms including vision problems and joint problems. Individuals with elevated triglyceride levels may also present with vision and joint problems as well.

Complications, prognosis, and prevention of dyslipidemia

The main complication associated with dyslipidemia is cardiovascular disease complications such as heart attack, stroke, and sudden death. However, aggressive treatment with lipid-lowering agents such as statins has been shown to reduce plaque formation and onset of cardiovascular disease.

Certain risk factors, such as having a genetic predisposition for dyslipidemia and natural aging, are not preventable. However, certain complications of dyslipidemia can be prevented by having individuals maintain a diet low in sodium and saturated fats, increase potassium intake, increase exercise and physical activity, avoid smoking and tobacco use, lose excess weight, maintain proper lipid levels, and maintain proper glucose levels.

Treatment and prevention of myocardial infarction

In individuals who experience an acute myocardial infarction, practicing clinicians should initiate oxygen, aspirin and sub lingual glyceryl trinitrate therapies to prevent further myocardium damage and/or complications. Invasive approaches for the treatment of myocardial infarction and underlying comorbid conditions include thrombolysis, percutaneous coronary intervention, angioplasty and stent insertion. In more severe cases, with invasive plaque formation or multiple blockages, cardiopulmonary bypass surgery may be performed.

Upon myocardial infarction diagnosis, pharmacologic agents prescribed include antithrombotic agents such as aspirin; blood thinners such as heparin and enoxaparin; vasodilators such as nitroglycerin; beta-adrenergic blockers such as metoprolol and esmolol; thrombolytic agents such as alteplase, anistreplase and tenecteplase; platelet aggregation inhibitors such as clopidogrel, eptifibatide and tirofiban; analgesics such as morphine sulfate; and angiotensin-converting enzyme inhibitors such as captopril.

Post myocardial infarction, patients are recommended to make lifestyle modifications including a diet with low fat and low sodium foods, increased physical activity, smoking and alcohol cessation as well as stress reduction. It is also recommended to comply with pharmacologic treatment regimens despite their complexity.

Lifestyle modifications and pharmacologic management can prevent the onset of myocardial infarction as well as recurrent myocardial infarction in patients with a previous occurrence. Patients should maintain a diet low in sodium and saturated fats, increase potassium intake, increase exercise and physical activity, avoid smoking and tobacco use, lose excess weight, maintain proper lipid levels, and control diabetes if present.

Patients with previous myocardial infarction who comply with lifestyle modification and pharmacologic management are at a much lower risk for recurrent disease. Pharmacologic agents used to prevent recurrent myocardial infarction include antiplatelet agents such as aspirin or clopidogrel, beta-blockers such as metoprolol or carvedilol, ACE inhibitor agents and statin therapy. Other approaches include aldosterone antagonists such as eplerenone and omega-3 fatty acids.

Treatment and prevention of stroke

An acute stroke is a medical emergency and requires immediate medical attention. Individuals experiencing an ischemic stroke should seek medical attention within 3 hours of onset to receive anticoagulant and/or thrombolytic approaches to restore blood flow. Other surgical approaches include carotid endarterectomy, angioplasty, and catheter embolectomy. Pharmacologic approaches used post stroke include antiplatelet agents and anticoagulants.

Surgical approaches are typically used to treat hemorrhagic stroke including aneurysm coiling, coiling, and arteriovenous malformation (AVM) removal.