NR 566 Week 3 Discussion and QUIZ {2020} | NR566 Week 3 Discussion and QUIZ {A Grade}

NR 566 Week 3 Discussion and QUIZ {2020} Week 3 Quiz Question 1 1 / 1 pts Diagnosis of heart failure cannot be made by symptoms alone because many disorders share the same symptoms. The most specific and sensitive diagnostic test for heart failure is: Complete blood count, blood urea nitrogen, and serum electrolytes that facilitate staging for end-organ damage. Chest x-rays that show cephalization and measure heart size. Correct! Two-dimensional echocardiograms that identify structural anomalies and cardiac dysfunction. Measurement of brain natriuretic peptide to distinguish between systolic and diastolic dysfunction. Question 2 1 / 1 pts Because primary hypertension has no identifiable cause, treatment is based on interfering with the physiological mechanisms that regulate blood pressure. Thiazide diuretics treat hypertension because they do which of the following? Correct! Deplete body sodium and reduce fluid volume. Decrease the production of aldosterone. Increase renin secretion. Decrease blood viscosity. Question 3 1 / 1 pts A patient presents to the clinic with complaint of a persistent, dry and nagging cough that begin shortly after starting lisinopril. What action should the clinician take? Correct! Discontinue the medication and start losartan (Cozaar). Discontinue the medication and start clonidine (Catapres). Continue the medication and refer the patient to a pulmonologist. Continue the medication and advise the patient that this side effect will resolve in a few weeks. Question 4 1 / 1 pts Compelling indications for an ACE inhibitor as treatment for hypertension based on clinical trials includes: Correct! Post myocardial infarction. Dyslipidemia. Pregnancy. Renal calculi. Question 5 1 / 1 pts One of the three types of heart failure involves systolic dysfunction. Potential causes of this most common form of heart failure include: Correct! Myocardial ischemia and injury secondary to myocardial infarction. Inadequate relaxation and loss of muscle fiber secondary to valvular dysfunction. Increased demands of the heart beyond its ability to adapt secondary to anemia. Slower filling rate and elevated systolic pressures secondary to uncontrolled hypertension. Question 6 1 / 1 pts Which of the following medications require monitoring of pulmonary and thyroid function tests every 6 months? Procainamide (Pronestyl). Correct! Amiodarone (Cordarone). Mexilitine (Mexitil). Flecainide (Tambocor). Question 7 1 / 1 pts A 59-year-old male has poorly controlled hypertension. He is currently taking furosemide (Lasix) 40mg daily for congestive heart failure. When choosing to add another antihypertensive, which of the following should the clinician avoid due to its strong negative inotropic effect? Losartan (Cozaar). Carvedilol (Coreg). Amlodipine (Norvasc). Correct! Verapamil (Calan). Question 8 1 / 1 pts The clinician has decided to prescribe an angiotensin-converting enzyme inhibitor (ACEI) for a patient with hypertension. The patient informs the clinician that she is "really bad at taking medication more than once per day". Which of the following medications requires more than once daily dosing and therefore should be avoided? Correct! Captopril (Captoten). Benazapril (Lotensin). Lisinopril (Zestril). Enalapril (Vasotec). Question 9 1 / 1 pts Omega 3 fatty acids are best used to help treat which of the following? High total cholesterol. Elevated HDL. Correct! High triglycerides. Reduced LDL. Question 10 1 / 1 pts The clinician is prescribing an angiotensin-converting enzyme inhibitor (ACEI) for hypertension. Which of the following should be checked at baseline and repeated after the first week of therapy? Liver function tests. Thyroid function tests. Platelets. Correct! Serum creatinine and potassium. The first-line medications for the treatment of HTN are CCB, thiazides, ACEIs, or ARBs. What would be the preferred choice for someone who has HF with reduced EF? Thanks! Among hypertensive patients with MI or heart failure (HF), it appears desirable to select the most appropriate drugs, ACEIs or ARBs, in each case by considering the function level, patient background, comorbidity presence, blood pressure target, drug price, and other such factors comprehensively in addition to considering tolerability (Toshio et al., 2019). ACE inhibitors continue to be a strong contender to help with heart failure and left ventricular remodeling protection (Woo & Robinson, 2016). ACE inhibitors, the cornerstone of therapy for HF in all the guidelines, are recommended for patients with a history of atherosclerotic vascular disease, diabetes mellitus, or HTN and associated cardiovascular risk factors with these high-risk patients (Woo & Robinson, 2016). Patients taking ACE inhibitors show moderate increases in ejection fraction, decreased left-ventricular end-diastolic filling pressures, and improved myocardial energy metabolism (Woo & Robinson, 2016). Because they are the only drugs that address all of the pathological mechanisms that produce HF, ACE inhibitors are appropriate for all subsets of patients unless these patients are pregnant, have bilateral renal artery stenosis, serum potassium levels above 5.5 mEq, or a history of angioedema (Woo & Robinson, 2016). As monotherapy or in combination with beta-blockers, ACE inhibitors are superior to all other drugs and drug combinations used to treat heart failure. In patients with low ejection fractions (less than 40%), ACE inhibitors' vasodilating effects provide adequate perfusion, even with systolic blood pressure (SBP) at or below 90 mm Hg (Woo & Robinson, 2016). Current practice for HF with reduced EF (HFrEF) consists of initiating an ACE inhibitor or angiotensin receptor blocker (ARB) and beta-blocker therapy titrated to a target dose (Bowers, 2019). The 2017 AHA update of managing hypertension guidelines identified a new target of 130/80 mm Hg (Whelton et al., 2018). Aggressively titrating antihypertensive medications to achieve this target is beneficial in both HFrEF and HFpEF (Bowers, 2019). Barriers to achieving goal BP include polypharmacy, finances, and multiple medications' adverse effects (Bowers, 2019). These issues are often more prevalent in older adults and may be worsened by cognitive and social impairment, social isolation, and functional limitations (Bowers, 2019). Managing chronic HF requires a multifaceted approach and vigilance as the course of the disease waxes and wanes (Bowers, 2019). There are opportunities to adjust medical therapy to improve symptoms, reduce mortality, and reduce hospitalizations as advanced care providers (Bowers, 2019). All patients with HF require diligence in managing cardiac medications and maximizing dosing strategies to address this chronic illness (Bowers, 2019). Advanced practice providers practicing in primary care settings are well situated to address HF prevention issues and manage comorbidities (Bowers, 2019). By engaging patients through shared decision-making strategies, there are opportunities to gradually reduce the effect of chronic HF and improve quality of life (Bowers, 2019). References: Bowers, M. T. (2019). Chronic Heart Failure: Impact of the current Guidelines. The Journal for Nurse Practitioners, 15(1), 125-131.e2. Toshio, O., Rei, S., Hisashi, K., Ryuji, O., Eita K., Hiroaki, K., Fujiwara, A., Kitazono, T., Murohara, T., & Arima, H.. (2019). Angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers in hypertensive patients with myocardial infarction or heart failure: A systematic review and meta-analysis. Hypertension Research, 42(5):641-649. doi: 10.1038/s Whelton, P. K., Carey, R.M., Aronow, W. S., Casey, D.E., Collins, K.J., Himmelfarb, C., D., DePalma, SM, Gidding, S., Jamerson, K.A., Jones, D.W., MacLaughlin, E.J., Muntner, P., Ovbiagele, B., Smith, S.C., Spencer, C.C., Stafford, R.S., Taler, S.J., Thomas, R.J., Williams, K.A., Williamson, J.D., & Wright, J.T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. Woo, T.M. & Robinson, M.V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (4th ed.). F.A. Davis Company.  Define different hypertension classes (normal, elevated, stage 1 & stage 2) according to each guideline. In the ambulatory setting, the American College of Cardiology and the American Heart Association recommendations (ACC/AHA) hypertension guideline BP categories are classified as follows: 1) normal (<120 systolic and <80 mm Hg diastolic), 2) elevated (120–129 systolic and <80 mm Hg diastolic), 3) stage 1 hypertension (130–139 systolic or 80–89 mm Hg diastolic) and stage 2 hypertension (≥140 systolic or ≥90 mm Hg diastolic), these categories should not be based on BP readings at a single point in time but rather should be confirmed by two or more readings (averaged) made on at least two separate occasions (Flack & Adekola, 2020). Individuals are classified according to their highest systolic or diastolic BP category with out of office BP readings (home or ambulatory BP monitoring) obtained for comparison with office BP readings. The BP category of pre-hypertension is no longer used (Flack & Adekola, 2020). As per the Eighth Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure JNC8 guidelines and criteria for hypertension, elevated hypertension is defined as having a blood pressure of ≥140/90 mmHg to be considered as elevated (Gaidhane et al., 2020). The testing recommendations for the initial diagnosis of HTN of the JNC-7, listed below, were not altered and a reliable reference (James et al., 2014). The guidelines built on systematic methods to evaluate and classify evidence offer a cornerstone for quality cardiovascular care (Whelton et al., 2018). The categorization differed from that previous recommendation in the JNC 7 report, with stage 1 hypertension now specified as an SBP of 130–139 or a DBP of 80–89 mm Hg, and with the stage 2 hypertension in the present document corresponding to stages 1 and 2 in the JNC 7 report (Whelton et al., 2018). Stage JNC-8 ACC/AHA Normal <120/<80 <120/<80 Elevated SBP 120-139 DBP 80-89 SBP 120-129 DBP <80 Stage 1 SBP 140-159 DBP 90-99 SBP 130-139 DBP 80-89 Stage 2 >160/>100 >140/>90 The table shows the BP readings that fall into each of these categories per ACC/AHA and the JNC-7 standards, which were not altered by the JNC-8, and this classification is based on the average of two or more properly measured seated BP readings on each of two or more office visits (Woo & Robinson, 2016). What are the thresholds for initiating treatment? With 8th JNC, the thresholds set for starting the treatment regimen includes any individual above the age of 60 with systolic blood pressure over 150 and 90 diastolic and patients with other existing comorbidities such as diabetes or chronic kidney disease with blood pressure over 140 systolic and 90 diastolic (Hernandez-Vila, 2015). Based on the American College of Cardiology/American Heart Association (ACC/AHA), guidelines for beginning treatment are intended for patients with systolic blood pressure over 130 or diastolic pressure over 90 if they have a known existing risk of cardiovascular disease or if there exists a 10 percent greater risk of atherosclerotic CVD (Muntner et al., 2018). What are the treatment goals? (Hint: there may be multiple treatment goals based on certain populations such as diabetics) 8th JNC The treatment goal is to keep blood pressure controlled less than 140/90 if the patient is under 60 years of age or has other comorbid existing illnesses identified like diabetes or chronic kidney disease (Hernandez-Vila, 2015). If the patient is elderly above the age of 60, the treatment goal is to retain the blood pressure under 150/90 (Hernandez-Vila, 2015). ACC/AHA The treatment goal is to maintain blood pressure under 130/80 (Whelton et al., 2018). The treatment regimen begins when the patient has an elevated blood pressure with the recommendation of lifestyle and diet therapy and reassessment of the patient's blood pressure should be done in three to six months (Whelton et al., 2018). Suppose the patient has cardiovascular risk factors identified greater than ten percent or has other existing comorbidities. In that case, they should be put on a blood pressure-lowering medication and should be reassessed in one month to determine effectiveness (Whelton et al., 2018). The ACC/AHA guidelines separated the BP threshold for hypertension diagnosis from the BP threshold for pharmacological therapy initiation. In most patients, the latter is different from the on-target blood pressure. High-risk patients, those with diabetes, CKD (eGFR<60 ml/min/1.73 m2 and urine albumin: creatinine ratio ≥300 mg/g), post-renal transplantation, heart failure with reduced or preserved ejection fraction, known CVD, peripheral arterial disease, and ≥10% ten-year ASCVD risk qualify for antihypertensive drug therapy when BP is persistently ≥130 systolic and ≥80 mm Hg; the on-treatment target BP is <130/80 mm Hg (Flack & Adekola, 2020). Lower-risk patients (under 65 years of age), defined as those without the aforementioned high-risk comorbidities and 10-year ASCVD risk <10%, are recommended for antihypertensive drug therapy when BP is ≥140/90 mm Hg. Like most high-risk hypertensives, their target BP is <130/80 mm Hg (Flack & Adekola, 2020). What medications are recommended to treat hypertension in the African American population? The 8th Joint National Committee (JNC 8) and the American Heart Association guidelines recommend that African Americans with high blood pressure be prescribed with a calcium channel blocker or a thiazide diuretic as initial drug therapy (Hernandez-Vila, 2015). The ACC/AHA guideline-recommended thiazide diuretics as one of four acceptable first-line drug therapies with no preference between thiazide and thiazide-like diuretics in patients without selected comorbidities that would alter this recommendation (Flack & Adekola, 2020). The only race-specific recommendation in the ACC/AHA guideline was for African Americans. Accordingly, those without heart failure or CKD who do not meet two-drug therapy criteria should be initially treated with either a thiazide-type diuretic or calcium antagonist (Flack & Adekola, 2020). Implicit in the monotherapy recommendations is that RAS blocker drugs should be initially prescribed to African Americans with hypertension with these comorbidities (CKD and HF) despite the lesser average BP response monotherapy with this drug class relative to thiazide diuretics and calcium antagonists (Flack & Adekola, 2020). Another recommendation was to encourage two-drug combination therapy in most African Americans (Flack & Adekola, 2020). Discuss why one set of guidelines might be used over the other (i.e., is one superior to the other ?) The American Heart Association/the American College of Cardiology and nine other professional organizations have issued a new hypertension clinical practice guideline (CPG) in November 2017, which has lowered the hypertension threshold to 130/80 mmHg (Miyazaki, 2018). The American Academy of Family Medicine has opted not to endorse this new CPG for various reasons, including flaws in the CPG development process and a limited additional benefit for lower treatment targets (Miyazaki, 2018). The major concern was an intellectual conflict of interest (COI) on why one set of guidelines might be used over the other (Miyazaki, 2018). Based on the Journal of General and Family Medicine, the new threshold for blood pressure guidelines from the AHA would produce an overdiagnosis of patients with hypertension (Miyazaki, 2018). The new AHA guidelines came out after the SPRINT trial, which was the basis for the guideline change. The SPRINT trial showed that blood pressure control with systolic blood pressure under 120mmHG resulted in a significant cardiovascular benefit, especially to high-risk patients (Miyazaki, 2018). The trial was conducted after the JNC 8 guidelines were produced (Miyazaki, 2018). The trial only tested those who were 50 years of age or older, had a systolic blood pressure 130 or over, and had one cardiovascular risk factor. The review was not based on a systematic review of the evidence, and the Journal of General and Family Medicine felt there was a conflict of interest in the trial (Miyazaki, 2018). As providers, the guidelines set by the Centers for Medicare and Medicaid Services (CMS) should also be taken into consideration. The CMS has measure specifications focusing on patients age 18 and older with a diagnosis of hypertension whose blood pressure is adequately controlled at a level of 140/90 or less (CMS, 2019). The United States Preventive Services Task Force recommends screening for high blood pressure in adults age 18 years and older (CMS, 2019). The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure also recommends treating systolic blood pressure and diastolic blood pressure to targets that are <140/90 mmHg as associated with a decrease in cardiovascular disease complications (CMS, 2019). References: Centers for Medicare and Medicaid Services [CMS] (2019). HTN-2 (NQF 0018): Controlling high blood pressure measure steward: NCQA. Flack, J. M., & Adekola, B. (2020). Blood pressure and the new ACC/AHA hypertension guidelines. Trends in Cardiovascular Medicine, 30(3), 160–164. Gaidhane, S., Khatib, N., Zahiruddin, Q., Bang, A., Choudhari, S., & Gaidhane, A. (2020). Cardiovascular disease risk assessment and treatment among persons with type 2 diabetes mellitus at the primary care level in rural central India. Journal of Family Medicine & Primary Care, 9(4), 2033–2039. Hernandez-Vila, E. (2015). A review of the JNC 8 blood pressure guideline. Texas Heart Institute Journal, 42(3), 226–228. James, P. A., Oparil, S., Carter, B. I., Cushman, W. C., Dennison‐Himmelfarb, C., Handler, J., et al. (2014). Evidence‐based guideline for managing higher blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association, 311 (5), 507–520. Miyazaki, K. (2018). Overdiagnosis or not? 2017 ACC/AHA high blood pressure clinical practice guideline: Consequences of intellectual conflict of interest. Journal of General and Family Medicine, 19(4), 123–126. Muntner, P., Carey, R.M., Gidding, S., Jones, D.W., Talker, S.J., Wright, J.T., & Whelton, P.K. (2018). Potential US population impact on the 2017 ACC/AHA high blood pressure guideline. Circulation 137(s). 109-118. Whelton, P. K., Carey, R.M., Aronow, W. S., Casey, D.E., Collins, K.J., Himmelfarb, C, D., DePalma, SM, Gidding, S., Jamerson, K.A., Jones, D.W., MacLaughlin, E.J., Muntner, P., Ovbiagele, B., Smith, S.C., Spencer, C.C., Stafford, R.S., Taler, S.J., Thomas, R.J., Williams, K.A., Williamson, J.D., & Wright, J.T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. Woo, T.M. & Robinson, M.V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (4th ed.). F.A. Davis Company.