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Content Update
May 20, 2019
Update on Aspirin Use in Primary Prevention of Cardiovascular Disease: The American College of Cardiology and American Heart Association (ACC/AHA) published a guideline for the primary prevention of cardiovascular disease. The 2019 Guideline reinforces the importance of adopting lifelong, healthy dietary and exercise habits for everyone. In addition, tobacco cessation, weight loss, and pharmacologic treatment to address risk factors for atherosclerotic cardiovascular disease (ASCVD), such as hypertension and dyslipidemia, are given strong (Class I) recommendations. Aspirin should be used infrequently for primary prevention of ASCVD because its potential benefits are often offset by increased bleeding risk. A team-based approach to addressing factors that increase ASCVD risk is strongly endorsed (Class 1A recommendation).
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Patient Care Process for Stable Ischemic Heart Disease (SIHD)
Collect
Patient characteristics (e.g., age, sex, pregnant)
Description of chest discomfort and/or related symptoms (e.g., quality, location, severity, radiation, precipitating factors, palliative measures)
Patient medical (personal and family) & social histories (e.g. tobacco/ethanol use), dietary habits (e.g., intake of foods high in sodium, cholesterol, and/or saturated fat), physical activity (e.g., frequency & duration of moderate-intensity aerobic activity)
Current medications including over-the-counter (OTC) medications (e.g., aspirin-containing medications), herbals/dietary supplements
History of allergy or intolerance to previous medications
Objective data
Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation
Labs: serum creatinine (SCr), potassium (K+), hemoglobin (Hgb), platelets, liver function tests (LFTs), lipid profile, blood glucose, A1C
Diagnositc testing results (see Fig 16-3 and 16-4)
Assess
Description of chest discomfort to determine differential diagnosis & classification of angina symptoms
Presence of provoking factors (e.g. exertion, mental/emotional stress, tachyarrhythmia, high adrenergic state including the use of stimulant medications, exposure to cold)
Presence/control of risk factors for SIHD (e.g., hypertension, dyslipidemia, diabetes, smoking, obesity)
Presence/control of SIHD-related complications (e.g., myocardial infarction (MI), heart failure (HF), stroke)
Adverse effects from current/previous medications used to treat/prevent angina symptoms or major adverse cardiac events (MACE)
Previous/recent revascularization procedures (e.g., percutaneous coronary intervention [PCI] with/without stenting, coronary artery bypass graft surgery [CABG])
Contraindications to medications to treat/prevent angina symptoms and/or prevent MACE
Barriers that may impair adherence to the care plan
Plan*
Initiate/modify drug therapy to treat & prevent angina symptoms, prevent MACE, & address risk factors for SIHD including specific drug(s), dose, route, frequency, and duration; (see Fig 16-5, Tables 16-6, 16-7)
Monitoring parameters: efficacy (e.g. signs & symptoms of angina & SIHD-related complications) & adverse effects; frequency and timing of follow-up
Patient education: purpose of treatment, lifestyle modifications, planned procedures, drug-specific information (e.g., indication, dose, route, frequency, adverse effects; see Table 16-8)
Self-monitoring for worsening angina symptoms, signs & symptoms of SIHD-related complications, adverse effects, when to seek emergency medical attention
Address barriers to adherence to medications and lifestyle modification
Referals to other providers (e.g. primary care provider, endocrinologist, dietician, smoking cessation)
Implement*