Understanding Cardiomyopathies: Definition, Diagnosis, Treatment, and Prognosis

 

Definition:

Cardiomyopathy refers to diseases of the heart muscle that affect its size, shape, or structure, leading to impaired function. These conditions can lead to heart failure, arrhythmias, and other serious cardiac issues.

Types:

1. Dilated Cardiomyopathy (DCM):

   • The heart's ventricles enlarge and weaken, reducing the heart's ability to pump blood efficiently.
   • Common causes include genetic factors, infections, and toxins such as alcohol.

2. Hypertrophic Cardiomyopathy (HCM):

   • The heart muscle thickens abnormally, often leading to obstructed blood flow.
   • It is usually inherited and can cause sudden cardiac death, especially in young athletes.

3. Restrictive Cardiomyopathy (RCM):

   • The heart muscle becomes rigid and less elastic, preventing proper filling of the heart chambers.
   • It is often associated with conditions like amyloidosis and can result from radiation therapy or connective tissue disorders.

4. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC):

   • Fat and fibrous tissue replace the muscle of the right ventricle, leading to arrhythmias.
   • This type is typically genetic.

Fig. 1 Cardiomyopathies according to pathophysiologic types a. normal, b. dilated, c. hypertrophic (obstructive), d. hypertrophic (non-obstructive), e. hypertrophic (obliterative), f. restrictive (obliterative), g. restrictive (non-obliterative) (From: Overview of Cardiomyopathies - Cardiovascular Disorders - Merck Manual Professional Edition (merckmanuals.com) )

Diagnosis:

• Medical History and Physical Examination: Key to identifying symptoms and risk factors.
• Electrocardiogram (ECG): Detects electrical activity abnormalities.
• Echocardiogram: Visualizes heart structure and function.
• Cardiac MRI: Provides detailed images of heart tissues.
• Blood Tests: Identify markers of heart damage or underlying conditions.
• Genetic Testing: Important for detecting inherited forms of cardiomyopathy.
• Biopsy: In some cases, a small sample of heart tissue is examined.

Prognosis

The prognosis for patients with cardiomyopathy varies widely depending on several factors, including the type and severity of the cardiomyopathy, the patient's overall health, the presence of other medical conditions, and how well the condition is managed. Here is an overview of the prognosis for different types of cardiomyopathy:

1. Dilated Cardiomyopathy (DCM):

   • Prognosis: The prognosis can vary significantly. Some patients may remain stable for many years with appropriate treatment, while others may experience progressive heart failure.
   • Factors Influencing Prognosis: Severity of symptoms, response to treatment, presence of complications such as arrhythmias, and whether the underlying cause (e.g., alcohol use, viral infection) is reversible.

2. Hypertrophic Cardiomyopathy (HCM):

   • Prognosis: Many people with HCM live normal lifespans with few symptoms. However, there is a risk of sudden cardiac death, particularly in younger individuals and athletes.
   • Factors Influencing Prognosis: Family history of sudden cardiac death, severity of left ventricular hypertrophy, presence of arrhythmias, and adherence to treatment and lifestyle recommendations.

3. Restrictive Cardiomyopathy (RCM):

   • Prognosis: This type generally has a poorer prognosis compared to other forms of cardiomyopathy due to its association with underlying conditions such as amyloidosis or other systemic diseases.
   • Factors Influencing Prognosis: The underlying cause of the restrictive cardiomyopathy, the extent of heart damage, and the patient's response to treatment for the underlying condition.

4. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC):

   • Prognosis: The prognosis can be quite variable. Some individuals may experience only mild symptoms, while others may develop severe heart failure or life-threatening arrhythmias.
   • Factors Influencing Prognosis: The presence of arrhythmias, the extent of right ventricular involvement, and adherence to treatment including the use of ICDs to prevent sudden cardiac death.

General Factors Influencing Prognosis:

• Early Diagnosis and Treatment: Early detection and management of cardiomyopathy can improve outcomes significantly.
• Adherence to Treatment: Following prescribed medications, lifestyle modifications, and regular follow-ups with a healthcare provider.
• Management of Comorbid Conditions: Controlling conditions such as hypertension, diabetes, and coronary artery disease.
• Access to Advanced Therapies: Availability of advanced treatments such as heart transplantation or gene therapy can impact prognosis.

Here is a table comparing the three main types of cardiomyopathies: Dilated Cardiomyopathy (DCM), Hypertrophic Cardiomyopathy (HCM), and Restrictive Cardiomyopathy (RCM).

Feature	Dilated Cardiomyopathy (DCM)	Hypertrophic Cardiomyopathy (HCM)	Restrictive Cardiomyopathy (RCM)
Definition	Enlarged and weakened ventricles	Abnormally thickened heart muscle	Rigid and less elastic heart muscle
Primary Cause	Genetic, viral infections, toxins	Mostly genetic	Often related to systemic diseases
Symptoms	Fatigue, shortness of breath, edema	Chest pain, shortness of breath, palpitations	Shortness of breath, fatigue, edema
Heart Chamber Affected	Mainly left ventricle	Typically left ventricle	Both ventricles
Heart Function	Reduced ejection fraction	Often preserved ejection fraction but with outflow obstruction	Preserved ejection fraction but impaired filling
Risk of Arrhythmias	High	High	Moderate to high
Common Complications	Heart failure, arrhythmias, thromboembolism	Sudden cardiac death, heart failure	Heart failure, arrhythmias
Diagnostic Tools	Echocardiogram, MRI, ECG, blood tests, genetic testing	Echocardiogram, MRI, ECG, genetic testing	Echocardiogram, MRI, ECG, biopsy
Treatment Options	Medications, lifestyle changes, ICD, heart transplant	Medications, lifestyle changes, ICD, septal myectomy	Medications, lifestyle changes, treat underlying cause, heart transplant
Prognosis	Variable; can be stable or progressive	Generally good with treatment, but risk of sudden death	Poorer prognosis due to underlying conditions
Lifestyle Modifications	Avoid alcohol, low-sodium diet, regular exercise	Avoid intense exercise, maintain healthy diet	Low-sodium diet, regular but moderate exercise

Treatment:

• Medications:
  • Beta-blockers, ACE inhibitors, or ARBs to reduce heart strain.
  • Diuretics to manage fluid retention.
  • Anti-arrhythmic drugs to control irregular heartbeats.
• Lifestyle Changes:
  • Dietary modifications, exercise, and avoiding alcohol.
• Implantable Devices:
  • Pacemakers or Implantable Cardioverter Defibrillators (ICDs) to regulate heartbeat.
• Surgery:
  • Septal myectomy (removal of thickened heart muscle) in severe HCM.
  • Heart transplant in advanced cases.
• Gene Therapy: Emerging treatments aimed at addressing underlying genetic causes.

In summary, while cardiomyopathy can be a serious condition, many patients manage well with appropriate treatment and lifestyle changes. The prognosis is highly individualized and depends on a combination of factors specific to each patient. Early diagnosis and treatment are crucial to managing cardiomyopathy and improving the quality of life and prognosis for affected individuals. Regular follow-up with a cardiologist is crucial for monitoring the condition and adjusting treatment as necessary.

Just for fun: Emergency Department Roadsigns and Acronyms

Just for fun: Emergency Department Roadsigns 

from "The Back Passage" 

by Ian Miller, the impactednurse.com

Too much information! At least that’s what it seems like on any given second in the Emergency Department. What with all those flyers on the walls and all those medication sheets and special orders and acronyms and abbreviations. What we need is a roadmap to guide us through this sensory overload. Our own department has begun using some specialized signage to clarify information and highlight patient needs. Here are a few of the more important ones:

Smelly bedpan. 

Danger: nurse carrying extremely smelly bedpan at arms length. Whenever you see a nurse walking in this manner take immediate evasive action. 

Urinal hazard.

Do not carry urinal in this position. Walking around for the remainder of

the shift with squishy shoes is to say the least: sub-optimal.  

sleep deprived nurse.

Danger: nursing staff have worked too many consecutive night shifts. Divergent gaze is causing double vision. Brain gone bad. 

Fecal loading hazard.

This patient has not had their bowels open for a very long time.

But, they have just had an enormously potent enema.

Avoid contact at all costs. Transfer to ward ASAP. 

Failure to launch. 

This patient is in need of Viagra. If unable to obtain from pharmacy may substitute: madixafloppin or macoxafillin. 

Triage Nurse Hazard. 

Do not come to the Emergency Department with that splinter in your thumb. Go to your own doctor or get it out with a pair of tweezers you big pillow. 

Extreme Triage Nurse Hazard. 

If you have amputated your hands or feet, do not enter the emergency department dripping or squirting blood over the newly cleaned floors

Catheter insertion hazard. 

This patient needs a large bore catheter passed. He is intoxicated, angry and has the words LOVE and HATE tattooed on either side of his penis. The doctor asks you to pass the catheter.

Caution with catheter insertion. 

This person has not passed urine for 48 hours. Their bladder is the size of the Hindenburg and she is ready to blow. 

High wind speeds. 

Caution. High velocity flatus in this area. Patient has habit of *busting a grumpy* every time they roll over cough or think nobody is watching.

Rectal foreign body. 

This patient has inserted a beetroot far up into their descending colon. Listen to their explanation with a straight face. Pass patient off to student nurse. 

Found objects. 

Do not give little yellow tablets that you find lying on the floor to your patients. 

Nurse taking a shower. 

Nothing will pour iced water on those flames of passion like a subtle musky aroma of Melena wafting between you. Or the fragment top notes of a semi-digested Quarter Pounder with Cheese hanging in the air. Make a bee line from the front door to the shower and scrub-a dub dub.

Emergency Room Accepted Acronyms 

Documentation is a most important aspect of your craft as an Emergency Department nurse. The ability to communicate fluently and accurately is not only an essential competency, it is a legal fingerprint of the care you deliver. So… you should make your charts, history’s and notes a justifiable reflection of the quality care you deliver. 

With this foremost in our minds, we present the following list of useful acronyms to add to your literary kitbag. Use them to squeeze some vital juices into your notes. Use them to add an objective and accurate sub-context to your reporting. Use them to tell it like it is. Use them at your peril. 

AOX3 

Alert, Oriented times 3 (person, place, time). 

AFOL 

All fine on leaving. 

AGA 

Acute Gravity Attack. (Patient fell over) 

ART 

Assuming Room Temperature. (dead) 

AWOL 

All Well On Leaving.

AWTF 

Away With The Fairies. 

BBSS 

Big Boobs, See Soon. 

BUNDY 

But Unfortunately Not Dead Yet. 

BVA 

Breathing Valuable Air. 

BWS 

Beached Whale Syndrome.

CTD

Circling the Drain/Close To Death.

DTS

Danger To Shipping.

DRT

Dead Right There.

DRTTTT

Dead Right There, There, There, and There.

FITH

F****d In The Head.

FLK

Funny Looking Kid.

FND

Friggin’ Nearly Died.

FRACS

Fornicates Regularly And Chain Smokes.

GAK

God Alone Knows.

GOMER

Get Out of My Emergency Room.

HIVI

Husband Is Village Idiot.

NFN

Normal For Nurses.

NOONG

Not One Of Nature’s Gentlemen.

NQR

Not Quite Right.

NYDN

Not Yet Diagnosed - Nervous.

OSINTOT

Oh Shit I Never Thought Of That.

PAFO

Pissed And Fell Over.

PANIC

Pressured And Not In Control. Descriptive

and useful acronym for all sorts of situations.

A reminder also that pressure alone does

not produce panic - it’s whether you can

control it.

PRATFO

Patient Reassured And Told to F**k Off.

SIG

Stroppy Ignorant Git.

SOB

Shortness Of Breath.

STIO/SIO SupraTentorial in Origin.

(psychosomatic)

TATT

Tired All The Time.

TEETH

Tried Everything Else?..Try Homeopathy.

TOBASH

Take Out Back And SHoot.

TTFO

Told To F**k Off.

TUBE

Totally Unnecessary Breast Examination.

TWOFT

Total Waste Of Frigging Time.

UBI

Unexplained Beer Injury.

UNIVAC

Unusually Nasty Infection; Vultures Are Circling. 

 

Cardiovascular System Assessment

In this article we will learn how to gather the patient's health history concerning the heart and peripheral vascular systems, conduct a physical examination of the heart and peripheral vascular system using appropriate techniques, and record the results of the cardiac and peripheral vascular assessment.

I. Overview of the Cardiovascular System 

The cardiovascular system assessment involves examining the peripheral vascular system by evaluating color, temperature, swelling, capillary refill, and peripheral pulses. It also includes examining the heart through inspection, palpation, and auscultation of specific heart landmarks.

II. Step-by-Step Assessment

• Wash hands thoroughly.
• Assess room for necessary contact precautions.
• Introduce yourself to the patient.
• Verify patient identity using two identifiers (e.g., name and date of birth).
• Explain the assessment procedure to the patient.
• Prepare all required equipment before beginning the examination.
• Conduct the assessment in an orderly and methodical manner.
• Employ effective listening and questioning techniques.
• Attend closely to any cues provided by the patient.
• Respect patient privacy and maintain dignity throughout.
• Adhere to principles of cleanliness (asepsis) and safety.
• Record vital signs.

Steps	Additional Information
1.Conduct a targeted interview regarding cardiovascular and peripheral vascular conditions.	Inquire about symptoms such as chest discomfort, irregular heartbeat (palpitations), difficulty breathing (dyspnea), cough, swelling, fatigue, known cardiac risk factors, leg discomfort, changes in skin condition, limb swelling, past medical history, and diabetes history.
2. Inspect: Face, lips, and ears for cyanosis, pallor Chest for scars, deformities, and visible pulsations Both arms/hands, noting color, temperature, moisture, movement, sensation (CTMMS), edema, nail beds, nail shape, and capillary refill Both legs, noting CTMMS, hair distribution, edema, nail beds, and capillary refill, numbness/tingling Calf size/pain for signs of deep venous thrombosis (DVT)	Cyanosis indicates reduced blood flow and oxygen levels. To assess capillary refill, press on the fingernails or finger pads until they blanch; release and note how quickly the original color returns. Normal capillary refill is within 2 seconds. Evaluate capillary refill on both lower legs. Assess capillary refill bilateral lower legs Changes and discrepancies in color, warmth, movement, and sensation (CWMS) may suggest underlying conditions or injury. When assessing capillary refill, also examine the angle of the nail base. Normally, the angle of the nail base is about 160 degrees. Clubbing of the fingers occurs when this angle increases beyond 160 degrees, often associated with chronic oxygen deprivation (hypoxemia). Clubbing fingers The sudden onset of severe, sharp muscle pain worsened by dorsiflexion of the foot suggests deep vein thrombosis (DVT), along with increased warmth, redness, tenderness, and swelling in the calf. Assess calf for CWMS Note: Immediate referral is necessary for deep vein thrombosis (DVT) due to the potential risk of developing a pulmonary embolism.
3. Auscultate: Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral Auscultate apical pulse for one minute. Note the rate and rhythm.   Source: Heart sounds - wikidoc	Instruct the patient to breathe normally. Use the diaphragm side of the stethoscope to auscultate the five landmark areas: Aortic – 2nd ICS on the right sternal border. Pulmonic – 2nd left ICS ERB’s Point – 3rd left ICS Tricuspid– 4th left ICS (for children 4th or 5th left ICS) Mitral Area – 5th left ICS medial to the MCL Auscultate for rate, rhythm, and pitch (the quality of the sound). Auscultate apical pulse at the fifth intercostal space and midclavicular line. Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.
4. Palpate: Inspect and palpate of the heart Bilateral radial, brachial, dorsalis pedis, and posterior tibialis pulses. Skin turgor edema (Tip from CNC on palpating pulses- Pulses are felt best when the artery is pressed against a bone, example radial pulse felt best when pressed against the radial bone, dorsalis pedis artery felt best when you palpate at the roundest curve of the dorsum of the foot, carotid pulse felt best at the angle of the jaw but palpate for only 5 to 10 seconds)	The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. Inspect and palpate for: Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow. The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded).  Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place. To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema. Source: Pitting Edema Assessment: Physical Exam (ebmconsult.com)    No clinical edema = 0 2-4 mm indentation = 2+ edema 4-6 mm indentation = 3+ edema 6-8 mm indentation = 4+ edema
5. Report and record assessment findings and associated health issues following organizational protocols.	Accurate and timely documentation and reporting promote patient safety.

Health Assessment in Clinical Practice

 In this article we will:

1. Explain the significance of health assessment in making clinical judgments and ensuring high-quality patient care

2. Describe the various types of health assessments

3. Distinguish between objective and subjective data

4. Apply physical assessment techniques

Health assessments are conducted by nurses and other healthcare providers using their knowledge of anatomy, physiology, therapeutic communication, and pathophysiology.

Precise patient assessment is crucial for implementing suitable interventions. This assessment entails identifying relevant cues not only from direct patient evaluation but also from environmental factors, health history, and laboratory results. 

This step is vital for clinical judgment, enabling the nurse to analyze these cues, develop hypotheses about their relationships, and prioritize issues to address. See Prompts for clinical judgement tasks in the table below:

 Types of health assessments include:

• Comprehensive Head-to-Toe Assessments: Performed upon patient admission (nursing admission assessment) and at the start of each shift or as needed based on the patient's condition.
• Brief Physical Assessments: Conducted to identify changes in a patient's status and compare with previous assessments.
• Focused Assessments: Targeted evaluations in response to a specific problem identified by the nurse.
• Emergency Assessments: Modified assessments in urgent situations to gather essential information for immediate care.
• Routine Physical Assessments: Regular evaluations to update a patient’s database, documented per agency policy, with unusual findings reported to the healthcare team.

Ongoing, thorough, and objective assessments ensure continuity in patient care.

Types of Data:

Subjective Data:

• Information reported by the patient or a knowledgeable historian, organized into a health history.
• Health history is taken and updated as needed with each patient encounter, informing patient care.

Objective Data:

• Observable and measurable data obtained through systematic physical assessment, vital signs measurement, and correlation with lab and diagnostic findings.
• Observation: Uses senses to assess (e.g., heart sounds, moisture, wound odor).
• Measurement: Compares assessment values to normal standards (e.g., pain scale, weight, tenderness).

Techniques of Physical Assessment:

The standard physical examination includes:

• Inspection: Observing visual clues, such as appearance, demeanor, and expressions.
• Palpation: Gathering information through touch, noting what the patient feels during palpation.
• Percussion: Listening to and interpreting different percussion sounds related to the patient's condition.
• Auscultation: Using a stethoscope to listen to internal body sounds.

These techniques rely on understanding normal conditions to identify abnormalities and require knowledge of common patterns associated with various conditions. Information from these techniques helps nurses formulate nursing diagnoses and identify functional health problems. 

How to Perform the Techniques of Physical Examination:

The typical sequence for physical assessment techniques is: inspection, palpation, percussion, and auscultation. For abdominal assessments, the sequence changes to: inspection, auscultation, percussion, and palpation to avoid altering bowel sounds.

1. Inspection: Use vision, smell, and hearing to assess each body system, noting color, size, location, movement, texture, symmetry, odors, and sounds.

2. Palpation:

   • Touch the patient with different parts of your hands, applying varying degrees of pressure.
   • Keep fingernails short, hands warm, and wear gloves when palpating mucous membranes or areas in contact with body fluids.
   • Palpate tender areas last.  
   

   
   
   

   Types of Palpation:

• Light Palpation:
• Used to feel surface abnormalities.
• Depress the skin ½ to ¾ inch (about 1 to 2 cm) with finger pads.
• Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

• Deep Palpation:

• Used to assess internal organs and masses for size, shape, tenderness, symmetry, and mobility.
• Depress the skin 1½ to 2 inches (4 to 5 cm) with firm pressure.
• Use one hand on top of the other for firmer pressure if needed.

3. Percussion

   • Involves tapping fingers or hands against the patient's body to locate organ borders, identify shape and position, and determine if an organ is solid or filled with fluid or gas.   

   Types of Percussion

• Direct Percussion:
• Reveals tenderness, commonly used for assessing adult sinuses.
• Tap directly on the body part with one or two fingers.
• Ask the patient to indicate painful areas and observe their facial expressions

• Indirect Percussion:

• Elicits sounds that provide clues about the underlying tissue composition.
• Here’s how to do it:   Press the distal part of the middle finger of your nondominant hand firmly on the body part. Keep the rest of your hands off the body surface. Flex the wrist of your nondominant hand. Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient’s skin. Listen to the sounds produced.

        4. Auscultation- involves using a stethoscope to listen to lung, heart, and bowel sounds.

                Preparation:

                    Ensure a quiet environment.

                    Expose the area to be auscultated (avoid interference from gowns or bed linens).

                    Warm the stethoscope head in your hand.

                    Close your eyes to focus better.

                 How to Auscultate:

                        Diaphragm: Used for high-pitched sounds (e.g., S1 and S2 heart sounds). Hold it firmly against the skin, applying enough pressure to leave a slight ring.

                        Bell: Used for low-pitched sounds (e.g., S3 and S4 heart sounds). Hold it lightly against the skin to form a seal without pressing too hard, as excessive pressure can eliminate low-pitched sounds.

                Focus on identifying the characteristics of one sound at a time.

References:

 Introduction to Patient Assessment:   https://opentextbc.ca/clinicalskills/chapter/introduction-2/

Shinnick, M.A. and Cabrera-Mino, C. ( 2021). Predictors of nursing clinical judgment in simulation. Nursing Education Perspectives. Vol 42, No 2; pp 107-109.

Learning Clinical ( Free) 2006. Assessing patients effectively: Here’s how to do the basic four techniques

Nursing2006: November-December 2006 – Volume 8 – Issue 2 – p 6

Cholesterol Lowering Drugs

These medications are used for patients with hyperlipidemia, dyslipidemia, and hypercholesterolemia. The first line of treatment for increased cholesterol level is still dietary therapy, lifestyle changes, weight loss, and exercise.

1. Bile acid sequestrants lower LDL cholesterol by binding to bile acids, preventing cholesterol absorption in the small intestine. 

They benefit patients with Type 2 diabetes by reducing blood sugar levels and can quickly lower plasma thyroid hormones, making them useful for refractory thyrotoxicosis. Additionally, they can raise HDL-C levels and are used to manage pruritus in patients with cholestatic disease and incomplete biliary obstruction. 

However, these medications can cause gastrointestinal side effects like nausea, bloating, cramping, and increased liver enzymes. Dyspepsia and bloating can be mitigated if cholestyramine is fully suspended in liquid hours before ingestion. Bile acid sequestrants can also inhibit the absorption of fat-soluble vitamins such as vitamin K, leading to potential clotting issues.

Examples: 

cholestyramine (Questran)

colesevelam (Welchol)

colestipol (Colestid)

2. Fibric Acids- prevent cardiovascular disease in patients with elevated triglycerides and low HDL when diet and lifestyle changes are unsuccessful. Fibrate commonly causes dyspepsia and has also been shown to produce fatigue, vertigo, pancytopenia, and elevation of serum transaminases.

Examples: 

fenofibrate (Tricor)

fenofibric acid (Trilipix)

Gemfibrozil (Lopid)

3. HMG CoA Reductase Inhibitors- inhibit the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. 

Examples: 

atorvastatin (Lipitor)

pitavastatin (Livalo)

pravastatin (Pravachol)

osuvastatin (Crestor)

simvastatin (Zocor)

lovastatin (Mevacor)

4. Other

Ezetimibe (Zetia) is a synthetic 2-azetidinone agent that lowers cholesterol by inhibiting its absorption in the intestines, unlike other cholesterol-lowering agents that increase bile acid excretion or inhibit cholesterol synthesis in the liver. It can be taken with meals and safely used with statins or fibrates. When taken with bile acid sequestrants, it should be dosed at least 2 hours before or 4 hours after. Side effects of ezetimibe include fatigue, diarrhea, headache, runny nose, body aches, back pain, chest pain, joint pain, sore throat, and elevated serum transaminases.

ezetimibe & simvastatin (Vytorin)

MORE ON STATINS

Statins, also known as HMG-CoA Reductase Inhibitors, reduce low-density lipoproteins (LDL) or "bad" cholesterol but typically do not affect high-density lipoprotein (HDL) or "good" cholesterol. They work by inhibiting the liver enzyme HMG-CoA reductase, which is responsible for cholesterol production. Statins also stabilize and shrink fatty plaques, prevent their rupture, inhibit clot formation, and reduce inflammation. Statins usually have the suffix "-statin."

When taken correctly, statins can lower the risk of coronary artery disease and the risk and recurrence of stroke. However, they can cause side effects such as nausea, headache, blurred vision, muscle pain, rashes, flushing, and gastrointestinal disturbances. Additionally, some patients may experience elevated liver enzymes, hyperglycemia, and hyperuricemia.

Lab Values to Watch Out for When on Statins

Normal Liver Function Test

ALT 7-55 units per liter (U/L)

AST 8-48 U/L

ALP 45- 115 U/L

Albumin 3.5-5 grams per deciliter (g/dL)

Total protein 6.3-7.9 g/dL

Bilirubin 0.1 to 1 mg/dL

GGT 9-48 U/L

LD 122-222 U/L

PT 9.5-13.8 seconds

Normal random blood glucose: 70-140 mg/dl

BUN 7-20 mg/dL

Nursing Precautions and Recommendations for Statins

1. Advise your client to take this during evening meal. Most cholesterol synthesis occurs at night, reflecting the fasting state. Thus, prompting the statins to be administered at evening or bedtime.

2. Assess and monitor the increase in muscle pain and liver enzyme

3. Annual eye exam should be facilitated so as to monitor for the formation of cataracts

4. Never give to clients with preexisting gallbladder disease

5. Patients should avoid taking grapefruit juice since it may increase drug toxicity and adverse effects

References: 

Bansal AB, Cassagnol M. HMG-CoA Reductase Inhibitors. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542212/

Chhetry M, Jialal I. Lipid-Lowering Drug Therapy. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541128/

Duong H, Bajaj T. Lovastatin. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540994/

Sizar O, Nassereddin A, Talati R. Ezetimibe. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532879/