NCD's

Care of Clients with Non-Communicable Diseases

Hypertension

is a chronic condition characterized by a persistent elevation in arterial blood pressure, resulting in increased workload of the heart and blood vessels. It is a major risk factor for cardiovascular, cerebrovascular, and renal diseases.

Renin-Angiotensin-Aldosterone System

What is the meaning of RAAS?

Renin

is a protein enzyme produced by the kidneys when blood pressure is low, blood volume is decreased, or sodium levels are too low to create homeostasis in the body.

ACE or Angiotensin converting enzyme

Angiotensinogen is converted into Angiotensin I via?

Heart

Brain

Kidneys

Eyes

Persistent elevation of blood pressure can damage these 4 target organs.

120/80

Normal Blood Pressure

120–129/<80

Elevated Blood Pressure

130–139/80–89

Stage I Hypertension

≥140/≥90

Stage II Hypertension

≥180/≥120

Hypertensive Crisis

Asymptomatic

Game Changer: Hypertension is commonly _________

Headache (especially occipital)

Dizziness

Blurred vision

Fatigue

Palpitations

Nosebleeds (epistaxis)

Clinical manifestations of Hypertension

Chest pain

Dyspnea

Neurologic deficits

Altered mental status

Clinical manifestations of Severe Hypertension

Captopril, Enalapril, Lisinopril

ACE inhibitors

Losartan, Valsartan

ARBs (Angiotensin Receptor Blockers)

Amlodipine, Nifedipine

CCB (Calcium Channel Blockers)

Hydrochlorothiazide, Chlorthalidone

Thiazide Diuretics

Two

Stage II Hypertension usually requires how many antihypertensive agents from different classes?

Hypertensive Urgency

Severe BP elevation without acute target-organ damage.

Captopril, Clonidine, Labetalol

Oral Antihypertensives for Severe BP elevation without acute target-organ damage.

Hypertensive Emergency

Severe BP elevation with acute organ damage. Examples: Stroke, Myocardial infarction, Acute heart failure, Aortic dissection, and Acute kidney injury

Nicardipine

Medication indicated for Stroke, hypertensive emergency

Labetalol or Hydralazine

Medication indicated for Stroke, pregnancy-induced HTN

Nitroprusside

Medication indicated for severe hypertensive emergencies

Nitroglycerin

Medication indicated for ACS, pulmonary edema

Dietary Approaches to Stop Hypertension

In DASH Diet, DASH means?

Cardiac Output × Systemic Vascular Resistance

Game Changer: Blood Pressure = ___________ x ___________

Most antihypertensive medications lower blood pressure by:

1. Decreasing cardiac output,

2. Reducing blood volume, or

3. Decreasing peripheral vascular resistance.

o Fruits

o Vegetables

o Whole grains

o Fish

o Low-fat dairy products

In DASH diet, there must be an increase in:

o Saturated fats

o Processed foods

o Sugary beverages

In DASH diet, there must be a decrease in:

Coronary Artery Disease (CAD)

_________________ is a condition in which the coronary arteries become narrowed or blocked due to atherosclerosis, resulting in decreased blood flow and oxygen supply to the myocardium.

LDL or Low Density Lipoprotein

Accumulates in Arterial Wall that causes CAD

Myocardial ischemia

Occurs when blood flow to your heart is reduced, preventing the heart muscle from receiving enough oxygen.

Angina (Angina pectoris)

Medical term for chest pain

Occlusion

Blockage or closure that prevents normal flow through a passage in the body

Chest pain (angina)

Chest pressure or heaviness

Dyspnea

Fatigue

Palpitations

Clinical manifestations for CAD

P – Provoked by: exertion, stress, cold exposure

Q – Quality: squeezing, pressure, tightness

R – Radiation: left arm, shoulder, neck, jaw, back

S – Severity: varies

T – Timing: relieved by rest or nitroglycerin

Angina Characteristics (PQRST)

Myocardial Infarction (Heart Attack)

___________ is the irreversible necrosis of myocardial tissue due to

prolonged interruption of coronary blood flow.

Anaerobic Metabolism

Defined as the biochemical process that generates adenosine triphosphate (ATP) without the requirement of oxygen in oxygen limited conditions such as myocardial ischemia.

Lactic Acid or Lactate

Substance that body produces by breaking down glucose in anaerobic metabolism.

STEMI and NSTEMI

Two types of Myocardial Infarction

ST-Elevation Myocardial Infarction

STEMI means?

Non ST-Elevation Myocardial Infarction

NSTEMI means?

STEMI

• Complete coronary artery occlusion

• ST-segment elevation on ECG

• Medical emergency requiring immediate reperfusion

NSTEMI

• Partial coronary artery occlusion

• No ST elevation

• Positive cardiac biomarkers

Chest Pain

• Severe crushing pain

• Lasts >20 minutes

• Not relieved by rest or nitroglycerin

Pain Radiation

• Left arm

• Shoulder

• Jaw

• Neck

• Back

Associated Symptoms

• Shortness of breath

• Diaphoresis (cold clammy skin)

• Nausea and vomiting

• Weakness

• Anxiety

• Palpitations

Classic symptoms of Myocardial Infarction

Troponin

Game Changer: ________ = Gold Standard biomarker for diagnosing MI.

Electrocardiogram (ECG)

Cardiac Biomarkers (Troponin, CK-MB, Myoglobin)

Echocardiography

Coronary Angiography

Diagnostic evaluations needed for Myocardial Infarction.

Coronary Angiography

Gold Standard for identifying coronary artery occlusion/obstruction.

Cardiac Biomarkers (Review Image)

Common Complications of Myocardial Infraction (Review Image)

Stable

Game Changer for CAD

______ Angina

• Triggered by exertion

• Relieved by rest and nitroglycerin

Unstable

Game Changer for CAD

_______ Angina

• Occurs at rest

• Not consistently relieved by nitroglycerin

• Medical emergency

20

Chest pain lasting more than __ minutes and unrelieved by rest or nitroglycerin strongly

suggests MI.

PCI or thrombolytic therapy

Time is Muscle: Rapid reperfusion with ___________ can save myocardium and improve survival.

Percutaneous Coronary Intervention

PCI meaning

Time is Muscle

A quote commonly used which means the longer it takes to get treatment during a heart attack, the more damage the heart muscle sustains.

Heart Failure (HF)

A clinical syndrome in which the heart is unable to pump sufficient blood to meet the body's metabolic demands or can do so only at elevated filling pressures. It results in inadequate tissue perfusion and/or fluid congestion.

Pulmonary Manifestations

o Dyspnea

o Orthopnea

o Paroxysmal nocturnal dyspnea (PND)

o Tachypnea

o Crackles/rales

o Pulmonary edema

Left Sided Heart Failure Signs and Symptoms

Venous Congestion Manifestations

o Peripheral edema

o Jugular vein distention (JVD)

o Hepatomegaly

o Splenomegaly

o Ascites

o Weight gain

o Anorexia

o Nausea

Right Sided Heart Failure Signs and Symptoms

"Left = Lungs"

"Right = Rest of the Body"

Game Changer for Heart Failure

Echocardiography

Gold standard diagnostic test for evaluating heart failure.

Brain Natriuretic Peptide

BNP meaning

BNP interpretation for CHF (Review Image)

ARBs

Used when ACE inhibitors are not tolerated for CHF

Beta Blockers

Examples:

• Metoprolol

• Bisoprolol

• Carvedilol

Action

• Reduce heart rate

• Reduce myocardial oxygen demand

Diuretics

Examples:

• Furosemide

• Bumetanide

• Hydrochlorothiazide

Action

• Remove excess fluid

• Relieve pulmonary congestion and edema

Aldosterone Antagonists

Examples:

• Spironolactone

• Eplerenone

Action

• Reduce sodium and water retention

SGLT2 Inhibitors (Sodium- Glucose Cotransporter 2 Inhibitors)

Examples:

• Dapagliflozin

• Empagliflozin

Benefits

• Reduce HF hospitalization

• Improve cardiovascular outcomes

Cardiac Glycoside

Example:

• Digoxin

Action

• Increases cardiac contractility

• Slows heart rate

Daily weight

Game Changer: _____ is the most reliable indicator of fluid retention.

High Fowler's position or Semi-Fowler's position

Positioning recommended for Heart Failure

Diabetes Mellitus

A chronic metabolic disorder characterized by persistent hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

Type 1 DM

An autoimmune disorder in which the body's immune system destroys the insulin-producing beta cells of the pancreas.

Type 2 DM

Characterized by insulin resistanceand progressive impairment of insulin secretion.

Comparison of Type 1 and Type 2 Diabetes (Review Image)

• Weight loss

• Fatigue

• Blurred vision

• Irritability

• DKA

S/Sx of Type I DM

• Recurrent infections

• Delayed wound healing

• Fatigue

• Numbness and tingling

• Blurred Vision

S/Sx of Type II DM

• Polyuria - Excessive urination

• Polydipsia - Excessive thirst

• Polyphagia - Excessive hunger

Game Changer: Classic Symptoms (3 Ps) of DM

Diabetic Ketoacidosis (DKA)

Common in Type I DM

Manifestations:

• Hyperglycemia

• Ketonuria

• Fruity breath odor

• Kussmaul respirations

• Dehydration

• Abdominal pain

• Altered consciousness

Hyperosmolar Hyperglycemic State (HHS)

Common in Type II DM

Manifestations:

• Severe hyperglycemia

• Extreme dehydration

• Neurologic changes

• Minimal or absent ketosis

Fasting Plasma Glucose

FPG meaning

Diabetes

FPG of ≥126 mg/dL

Random Plasma Glucose

This is a diagnostic test where ≥200 mg/dL with classic symptoms indicates diabetes.

Oral Glucose Tolerance Test

OGTT meaning

≥200 mg/dL

OGTT value which indicates diabetes.

Hemoglobin A1c (HbA1c)

Reflects average blood glucose over the previous 2–3 months.

Insulin

Game Changer: Type 1 DM always requires _____ therapy.

*Neuropathy increases risk for foot ulcers and amputation

Rapid-Acting Insulin

Short-Acting Insulin

Intermediate-Acting Insulin

Long-Acting Insulin

Types of Insulin therapy (Mainstay Streatment)

Rapid-Acting Insulin

Lispro, Aspart, and Glulisine are examples of which type of insulin?

Short-Acting Insulin

Regular insulin is an example of which type of insulin?

Intermediate-Acting Insulin

NPH (Neutral Protamine Hagedorn) or Isophane is an example of which type of insulin?

Long-Acting Insulin

Glargine, Detemir, and Degludec are examples of which type of insulin?

Biguanide and Metformin

First-Line Medication for Type II DM which decreases hepatic glucose production and improves insulin sensitivity.

Other oral antidiabetic drugs for Type II DM (Review Image)

Acute complications for Hyper and hypo glycemia (Review Image)

Conscious Patient

15-15 Rule

• Give 15 g fast-acting carbohydrates

• Recheck glucose after 15 minutes

Examples:

• 4 oz fruit juice

• Glucose tablets

Unconscious Patient

• IV dextrose (D50W)

• Glucagon IM/Subcutaneous

Managements done for Hypoglycemia

Retinopathy

Nephropathy

Neuropathy

Chronic Complications from DM (Microvascular)

Coronary Artery Disease

Stroke

Peripheral Arterial Disease

Chronic Complications from DM (Macrovascular)

Type 1

Game Changer:

Which type of diabetes is this?

Problem: No Insulin

• Autoimmune

• Young onset

• Lean body

• DKA-prone

Type 2

Game Changer

Which type of diabetes is this?

Problem: Insulin Resistance

• Obesity-related

• Adult onset

• HHS-prone

• Metformin first-line treatment.