was looking to see if anyone had a printable sheet for the CMC with key points/highlights etc or a study guide. Currently using AACN but anyone help or info would be appreciated, thanks!

Cardiac ICU = waiting for heart, long-term heart failure patients

CVICU = they got the heart, post-op heart-transplant patients

what kind of machines and skills should I be familiarize before I start in the unit?

impella? art line? CRRT? what type of vent? and any tips along the way will be very much appreciated! I am super nervous and I don't want to make a mistake! Please help this new grad ! ?

Graduating an ABSN program in December 2023 and very interested in CRNA as a specialty down the line. I know this requires a ton of work and at least 2 years of experience, but I noticed that these programs like to see experience in ICU or CCU of some sort. Most interestingly, I was wondering what the chances are of getting a position in CVICU, CTICU, CSICU or PACU would be for a new grad in 2023-2024.

Wondering if this is possible, or what the best path to get to one of these positions could be. Interested in timeline and career path here.

Thank You in Advance.

• Every 34 seconds, someone dies of heart disease in the US.
• 697,000 people die annually of heart disease in the US. That's 1 out of 5 deaths.
• In 2017-2018, the cost of healthcare services, medication, and lost productivity due to heart disease totaled about $229 million.

Heart Disease and LDL

For the last thirty years, the statin class of drugs (HMG-CoA reductase inhibitors) remains one of the most widely used drugs. Drugs like atorvastatin, pravastatin, and simvastatin are given to reduce LDL (low-density lipids) and stabilize plaque on vessel walls. Statins are the standard for reducing arterial inflammation, and the risk of myocardial infarctions and strokes.

However, millions of patients suffer from statin intolerance due to myalgia, myopathy, and in severe cases, rhabdomyolysis, leaving them with few treatment options.

Alternatives and Adjuncts to Statins

CoQ10 is believed to alleviate the myalgia some patients experience when taking statins. Studies on the efficacy of CoQ10 have been promising but inconclusive.

Niacin is another cholesterol-reducing agent which causes many patients to have severe hot skin flushing and dizziness.

Red rice yeast is an alternative supplement some patients swear by, while others report it didn't lower their LDL at all.

Questran (cholestyramine) is a bile acid sequestrant that has been in use since the 1970s. Bile acid sequestrants are highly positively charged molecules that bind to negatively charged bile acids in the intestine, inhibiting their lipid solubilizing activity, and thus blocking cholesterol absorption.

Zetia (Ezetimibe) is a cholesterol absorption inhibitor that performs well to lower cholesterol when combined with a statin (simvastatin) =Vytorin.  Although, trials showed that ezetimibe combined with statins didn't have much effect on heart-related death.

Praluent (alirocumab) & Repatha (evolocumab) PCSK9 Inhibitors are a new class of LDL-reducing drugs. The route is by injection, and many patients do not like to self-inject.

Bempedoic acid (ATP citrate lyase inhibitor). An alternate choice became available when bempedoic acid was approved by the FDA in February 2020. At the time, bempedoic acid was meant to be used as an adjunct with statins, it was unclear whether the drug was associated with a reduced risk of a major adverse cardiovascular event (MACE).

Major adverse cardiovascular events include death from cardiovascular causes, nonfatal myocardial infarction, nonfatal cerebrovascular accident, and coronary revascularization.

CLEAR OUTCOMES Trial

On March 4, the CLEAR OUTCOMES Trial, presented at the annual American College of Cardiology 23/WCC (World Congress of Cardiologists) in New Orleans, revealed that in patients with statin intolerance, bempedoic acid was associated with a lower risk of major adverse cardiovascular events.

According to Steven E. Nissen, MD, MACC, the chief academic officer of the Heart Vascular and Thoracic Institute at Cleveland Clinic and chair of the study, "Most people can take statins, but some cannot. This is the first study that directly addressed the problem of statin-intolerant patients. We achieved what we hoped we would get – a very positive result in a population of people who just could not tolerate statins."

Given that heart disease remains the number one killer of men and women, clinicians need more treatment options to offer patients. It's difficult to get patients to comply with these treatments if they have uncomfortable side effects. And that may have a negative impact on their outcomes.

Bempedoic Acid Overview

The CLEAR OUTCOMES Trial showed that bempedoic acid lowered study participants' LDL cholesterol by 20%-25% on average throughout the study. Participants taking a placebo saw an average of 10% reduction in LDL, which demonstrates closer monitoring and the addition of other cholesterol-reducing agents as part of their background therapy, according to researchers.

Bempedoic acid is not without side effects. Participants experienced renal impairment, gout, gallstones, and elevated hepatic enzymes. Nevertheless, side effects didn't indicate discontinuation of the drug.

As a rule, statins reduce LDL by about 40-50%, suggesting that bempedoic acid is not as effective at reducing cholesterol as statins or other drugs such as PCSK9 inhibitors (Praluent, Repatha). Moreover, the study determines that this measure of change can still make a difference in the risk of cardiac events for patients who cannot take statins.

Bempedoic acid may be prescribed under the brand name Nexletol and is manufactured by Esperion Therapeutics. A one-month supply costs about $400. Insurance companies need to consider that the cost of not taking this medication could greatly outweigh the expense of taking it when factoring in the cost of a hospital course for an MI or stroke.

When patients are:

• Non-compliant with their disease management.
• Do not take their medications.
• Blow off follow-up appointments.
• Continue to smoke with freshly deployed drug-eluting stents in their major coronary arteries, 

The risk of MACE increases.

Many patients report that they cannot or will not take their prescribed statin because it gives them terrible life-altering discomfort. These are patients who:

• have had multiple MIs
• have multiple stents
• have CABG
• are already at risk for additional major adverse cardiovascular events. 

Recall the fact I shared above; the cost of health care services, medications, and lost productivity secondary to heart disease totals about $229 million annually. As advances in technology and new therapies are discovered, clinicians can offer patients alternative options. Offering alternatives keeps patients compliant and reduces their overall risk of a major cardiac event. Bempedoic acid bears a two-fold benefit in that it can contribute to cost reduction and reduce the risk of MACE. 

References/Resources

Bempedoic Acid Improves Outcomes in Statin-Intolerant Patients: American College of Cardiology Foundation

Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients: The New England Journal of Medicine

Heart Disease Facts: Centers for Disease Control and Prevention

Ezetimibe for the prevention of cardiovascular disease and all‐cause mortality events: National Center for Biotechnology Information: National Library of Medicine

What is Atherosclerosis? - Atherosclerosis and cholesterol: American Heart Association, Inc.

Ezetimibe: National Center for Biotechnology Information: National Library of Medicine

I have been approached by my fellow coworkers to see how other organizations handle double nurse medication verification. In my current hospital medication is scanned once and the a 2nd nurse signs with login name and passcode. How are other organizations handle this? Is a 2nd scan required or such and how are the medications labeled (any specialized stickers such as Fentanyl, heparin, insulin or such) how are the IV lines distinguished by others. Right now we just hand write labels. Any suggestions? Apparently a new nurse and a veteran nurse made an error. The new nurse was devastated and my heart broke for her so I want to know how either organizations handle this topic. 
thank you as always!

I recently interviewed for 2 units Interventional cardiac and CVICU. To my surprise I was offered both positions. I have previous experience in Cardiac Stepdown, interventional cardiac and Psych. My current job I am in psych.

I really liked both units and managers. I went back and forth weighing pros and cons. I like interventional cardiac because for most part patients are usually stable, I have previous knowledge and experience working on this unit at another hospital. The CVICU scares me I have read about so many nurses not liking it, the steep learning curve, and even being sent to a medsurg ,stepdown, or terminated altogether if they did not appear to be catching on.

I need advice is it crazy for me to even step foot on a CVICU unit knowing that I haven’t worked in a true medical floor in almost 2 years? Should I slow down and get back acclimated and take the interventional cardiac position. Does that matter if I get 12 weeks of precept if and classes??

I want to be successful in which ever path I choose. Sorry it’s a long read but looking for opinions, advice, feedback anything you can share would helpful

CardiacRN

I was assisting in removal of arterial sheath with my co-worker, I was not able to monitor the patient constantly on our medsurg floor but was there during pt arrival. 5 or 6 hrs after the procedure, my co-worker was removing the arterial sheath on the left femoral artery. She held it for about 12 or 15 mins then she asked me to check on the pt abdomen because he was complaining of belly pain. I checked his lower belly and he said it is tender to the touch on a certain spot and I feel a hard lump. His BP started to drop to 80s systolic as well as the HR to low 50s. I called the cardiologist while my co worker was holding pressure. I thought she did great because I did not see any significant bleeding or hematoma below pt's thigh or around the groin area.  So we thought he had a vasovagal episode. we did a ct of abdomen and it confirms a moderate RH. Pt was was stable but his bp drops especially when pressure is applied to groin. H and H drops from 11 to 9.1 and the next day to 8.6 with ongoing abdominal pain. he eventually got a unit of blood in ICU and air lifted for a vascular surgeon.  

I thought about the scenario, I am not sure what had happened? Was it a slow bleed during and after the procedure and coincidentally we just noticed it when we were removing the sheath 5 hrs after?

what do you think are your thoughts on this? I am now anxious if pressure was not held correctly on the femoral artery or it was a high stick puncture by a cardiologist? But why did it happened so fast during removal of sheath?

Please fill me in on your EP lab experiences.  Why do you love it and why do you hate it? I’ve always been interested in this area and like to be challenged. My background is mostly recovery (5 yrs cardiac specific). There are some openings in one of our hospitals and I am entertaining the change.

Also what was your previous experience and did you feel prepared?? 

Thanks! 

So I'm considering taking the plunge and transitioning to the ICU CCU from almost 4 years in the ED. I'm coming from a 34 bed community hospital (patients are sick sick) and thinking about going to a level 2 trauma hospital ICU CCU setting. Only trauma experience I have was a travel contract at a 40 bed level 1 trauma center. But I always request the sick patients in my current ED (septic/shock, codes/post codes, DKA/HHNS, STEMIs/unstable NSTEMIs, ODs, patients needing transcutaneous pacing, CVAs etc) and enjoy taking care of these patients. However, I'm getting emotionally/mentally exhausted and found myself snapping at stable patients who are demanding more from me than the sick ones. At times it's more work caring for the stable belly pain versus the intubated and unstable patient. It's to the point where it's somehow my fault they're sick.

So I'm coming to AN asking how's the transition from ED to ICU CCU or ED to MICU. What is/was the learning curve like for someone with 4 years of experience. My sole purpose of the transition is to expand my knowledge and skillset and get back to being that "nice" person I was. 

I’ve only visited the Cath lab at my hospital  once, but the set up appears identical to our endovascular surgical suite and we even used the Cath lab to do endovascular procedures while that OR was being remodeled.

I'd appreciate any experiences and advice you have to offer.

(I'm a cath lab nurse who scrubs, monitors and circulates. Have 1.5 yrs experience in the lab)

I've never heard of a wide complex tachycardia being anything but vtach, but I was told it is aberrant conduction, not ventricular. Should it not be treated as a vtach, if s/he is symptomatic? We were needing 100%o2 to keep sats above 90%. I'll enclose the IM comment on the rhythm. The patient converted to an afib at about 2200.

"ECG at 1945 queries limb lead reversal. The rhythm suggests atrial
fibrillation with a rate of 150 beats per minute.  There is aberrant
conduction with QRS increased at 146 milliseconds with a large voltage in the
precordial leads.  Repeat tracing at 2215 showed atrial fibrillation at 139
beats per minute with a QRS narrowed to 106 milliseconds.  There is evidence
of a prior anterolateral infarct.  Corrected QT interval is now within normal
limits."

I'm looking to educate myself on this, so if anyone can point me to reading material, that would be great.

What are the guidelines/policies within your facility? I'm asking in hopes to work with our surgeon and administration to develop new standards for the care of our CABG pts. Also, do you have any articles or references for CABG ratios?

Thank you for your input in advance.

To understand what Cardiac Sarcoidosis (CS) is, let's first explain Sarcoidosis. Sarcoidosis is an autoimmune disease that causes a collection of immune cells (granulomas) to form in one or many organs which can possibly change the structure or function of the affected organ. Although Sarcoidosis most commonly affects the lungs and lymph glands, this article will focus interest on the heart.

As with Sarcoidosis, Cardiac Sarcoidosis (CS) does not have a definitive cause. It is thought that exposure to pesticides or other environmental chemicals, certain bacteria or viruses, and perhaps mold can be risk factors for acquiring CS.  Of note, "Only 40-50% of patients with cardiac sarcoidosis diagnosed at autopsy have the diagnosis made during their lifetime.” ^(PubMed)  CS is often underdiagnosed partly because of the manifestations it presents. Heart conditions including complete heart block and ventricular tachycardia, cardiomyopathy, and heart failure are treated regardless of not knowing the specific underlying cause. Clinician awareness and newer technology are making CS easier to diagnose, yet still hard to differentiate from other heart diseases like heart failure because they share many of the same symptoms.

Who is Most at Risk for CS?

CS can affect all ethnicities and is not age-specific. As noted in an article featuring Dr. Nisha Gilotra, a Cardiac Sarcoidosis Expert at John Hopkins, CS is more common in those of African American and Northern European descent between ages 20-60 years of age.

What are the Signs & Symptoms of CS?

A patient with Cardiac Sarcoidosis may not have any symptoms but have an abnormal imaging scan. Others might report palpitations, chest pain, dizziness, fainting, shortness of breath, and/or leg swelling. Palpitations are often described as fluttering, racing, or skipping heartbeats and are caused by an arrhythmia in CS. Decreased blood flow through the heart vessels may cause chest pain. The lack of blood flow to the brain can induce dizziness or fainting (syncope). The heart's compromised ability to pump because of the presence of granulomas can increase fluid retention in the body causing shortness of breath and leg swelling in addition to arrhythmias.

How is CS Diagnosed?

Several diagnostic tests may be ordered by the Provider if CS is suspected. The endomyocardial biopsy is more specific in confirming the diagnosis; however, other imaging has been accepted as surrogate testing. The following is a list of testing that may be performed:

• ECG to confirm arrhythmias like ventricular tachycardia or heart block
• Event monitor to quantify the arrhythmic burden
• Echocardiogram to assess the heart structure and function
• MRI to provide a more accurate assessment of the heart structure and function
• PET scan to confirm presence of abnormal tissues (granulomas/tumors)
• Right Heart Cath is used as the pathway to obtain heart tissue (biopsy)
• Biopsy sample is taken from the endo myocardium to confirm Sarcoidosis

Treatment Options

According to the Mayo Clinic, there is no cure for Sarcoidosis and most people are treated modestly or not at all. Sarcoidosis has been known to go away on its own; however, long-term effects of Sarcoidosis involving damage to the heart will need lifelong treatment. Early detection and treatment are imperative in yielding more favorable outcomes. The following treatments are most used:

• Immunosuppressive medications (I.e., corticosteroids) which may reduce the production of granulomas
• Pacemaker or ICD may be implanted to help manage the arrhythmia
• Ablation can be performed by an Electrophysiologist to cauterize and create scar tissue areas of the heart in attempts to correct the arrhythmia
• Heart Transplant may be performed in some cases

Conclusion

Sarcoidosis is a potentially life-threatening inflammatory disease of unknown etiology and affects multiple organs including the heart. Cardiac Sarcoidosis is organ-specific and often under-diagnosed as it is hard to differentiate from other heart diseases due to similar symptoms. Through early detection, advanced technology, and Provider awareness, patients have better outcomes.

References/Resources

Cardiac sarcoidosis: a comprehensive review - PubMed (nih.gov)

Cardiac Sarcoidosis | Johns Hopkins Medicine

Sarcoidosis - Symptoms and causes - Mayo Clinic

Infographic: Cardiac sarcoidosis: A heart under attack (mayoclinic.org)

The reason I write you is to ask for your help my hospital is developing a Heart Failure Unit and I would like to contact a nurse who already have the experience, I need to create the instruments for assessment and monitoring (we will have mainly a remote communication with the patients) and other ideas are welcome too!!

Thank you!