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Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

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AANPCB Adult-Gerontology Primary Care Nurse Practitioner A-GNP

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1 Exam Structure, APRN Foundations & Geriatric Assessment

A-GNP Exam Logistics, Blueprint & Scoring Structure APRN Scope of Practice, Consensus Model & Interprofessional Collaboration Comprehensive Health History & Subjective Assessment Across Adult Lifespan Comprehensive Physical Examination & Clinical Assessment Skills

2 Health Assessment, Diagnostic Reasoning & Clinical Procedures

Diagnostic Reasoning, Test Interpretation & Clinical Decision-Making Screening Guidelines & Evidence-Based Health Promotion (USPSTF) Comprehensive Geriatric Assessment (CGA), Frailty & Function In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

3 Cardiovascular & Peripheral Vascular Disorders

Essential Hypertension & Hypertensive Urgency/Emergency Management Coronary Artery Disease, Acute Coronary Syndromes & Post-MI Care Heart Failure (HFrEF & HFpEF) Diagnosis, Staging & 4-Pillar GDMT Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

4 Respiratory, HEENT & Dermatological Disorders

Asthma Management across the Adult Lifespan (GINA Guidelines) Chronic Obstructive Pulmonary Disease (COPD) Staging & Management (GOLD Guidelines) Community-Acquired Pneumonia & Lower Respiratory Tract Infections Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

5 Endocrine, Metabolic & Renal/Genitourinary Disorders

Type 2 Diabetes Mellitus Management Thyroid Disorders: Hypothyroidism, Hyperthyroidism & Subclinical Disease Chronic Kidney Disease (CKD) Staging & Diabetic/Hypertensive Nephropathy Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

6 Gastrointestinal, Hematologic & Immunologic Disorders

Upper Gastrointestinal Disorders: Dyspepsia, GERD, PUD & H. pylori Lower Gastrointestinal Disorders: IBS, IBD, Diverticulitis & Colorectal Screening Liver, Biliary & Pancreatic Disorders: NAFLD/MASLD, Cirrhosis & Cholecystitis Hematologic & Immunologic Disorders: Anemias, Anticoagulation & Immunizations

7 Neurological, Cognitive & Psychiatric Disorders

Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment Neurological Disorders: Stroke, TIA, Parkinson's Disease & Headache Syndromes Major Depressive Disorder & Anxiety Disorders in Adults & Older Adults Sleep Disorders, Insomnia & Restless Legs Syndrome

8 Geriatric Syndromes, Polypharmacy & Deprescribing

The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use Polypharmacy Management, Pharmacokinetics/Pharmacodynamics in Aging & Deprescribing Protocols Fall Risk Assessment (CDC STEADI), Gait/Balance & Mobility Impairments Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

9 APRN Professional Practice, Ethics, Quality & Healthcare Policy

Musculoskeletal Disorders: Osteoarthritis, Osteoporosis, Gout & Back Pain Dermatological Disorders: Lesions, Skin Cancers, Infections & Rash Evaluation Palliative Care, Advance Care Planning, Pain Management & End-of-Life APRN Professional Practice, Quality Improvement, Ethics & Healthcare Policy

Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

Key Takeaways Explain This Topic AI

In non-valvular atrial fibrillation, stroke risk is calculated using the CHA2DS2-VASc score; a score >=2 in men or >=3 in women warrants anticoagulation with a Direct Oral Anticoagulant (DOAC) preferred over Warfarin.

Warfarin (target INR 2.0-3.0 or 2.5-3.5) remains mandatory over DOACs for anticoagulation in patients with mechanical heart valves or moderate-to-severe mitral stenosis.

Aortic stenosis presents with the classic triad of exertional dyspnea, syncope, and angina, accompanied by a crescendo-decrescendo systolic ejection murmur at the right upper sternal border radiating to the carotid arteries.

Ankle-Brachial Index (ABI) values <=0.90 confirm Peripheral Artery Disease (PAD), while values >1.40 indicate non-compressible, calcified vessels requiring a Toe-Brachial Index (TBI) evaluation.

Cilostazol improves walking distance in patients with PAD claudication but is strictly contraindicated in patients with heart failure of any severity due to increased mortality.

Last updated: July 2026

  • Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD
  • Atrial Fibrillation: Pathophysiology, Classification, and ECG Diagnostics

Atrial Fibrillation (AFib) is the most common sustained cardiac arrhythmia. Disorganized atrial electrical activity originates predominantly from ectopic foci near the pulmonary veins in the left atrium. Rapid, uncoordinated atrial depolarizations (300-600 bpm) cause loss of the "atrial kick" (20-30% of end-diastolic filling), reducing cardiac output and causing blood stasis in the left atrial appendage, predisposing to thrombus formation and ischemic stroke.

AFib Classification:

Paroxysmal AFib: Terminates spontaneously or with intervention within 7 days.

Persistent AFib: Sustained >7 days, requiring cardioversion.

Long-Standing Persistent AFib: Continuous AFib lasting >12 months under active rhythm control.

Permanent AFib: Decision made to cease rhythm control attempts.

12-Lead ECG Triad:

Absolutely irregularly irregular ventricular rhythm (variable R-R intervals).

Complete absence of distinct P waves , replaced by chaotic baseline fibrillatory waves (f waves).

Variable ventricular response (heart rate 110-180 bpm in untreated cases).

Atrial Fibrillation Management: Rate vs. Rhythm Control

Rate Control Strategy: Initial approach for most older adults (AFFIRM trial demonstrated equal mortality between rate and rhythm control).

Target Heart Rate: Lenient rate control (resting HR <110 bpm ) is acceptable for asymptomatic patients. Strict rate control (resting HR <80 bpm ) is indicated for symptomatic patients or LV dysfunction.

First-Line Pharmacotherapy: Beta-blockers (metoprolol, atenolol, carvedilol) or Non-dihydropyridine CCBs (diltiazem, verapamil). CONTRAINDICATION: Avoid diltiazem and verapamil in HFrEF (LVEF <=40%) due to negative inotropic effects. Digoxin is a second-line option in sedentary older adults.

Rhythm Control Strategy: Indicated for symptomatic or young patients using antiarrhythmics (amiodarone, flecainide, sotalol) or catheter ablation. Cardioversion Protocol: If AFib duration is >=48 hours (or unknown), the patient must be effectively anticoagulated for at least 3 weeks prior and 4 weeks post-cardioversion , OR undergo Transesophageal Echocardiography (TEE) to exclude left atrial appendage thrombus prior to cardioversion.

Thromboembolic Risk Stratification: CHA2DS2-VASc and Anticoagulation Rules

Stroke risk in non-valvular AFib is evaluated using the CHA2DS2-VASc score :

  • CHA2DS2-VASc Risk Factor Point Value
  • C - Congestive Heart Failure (or LVEF <=40%) 1 point
  • H - Hypertension 1 point
  • A2 - Age >=75 years 2 points
  • D - Diabetes Mellitus 1 point
  • S2 - Stroke / TIA / Thromboembolism history 2 points
  • V - Vascular Disease (prior MI, PAD, aortic plaque) 1 point
  • A - Age 65 to 74 years 1 point
  • Sc - Sex Category: Female 1 point

Anticoagulation Recommendations:

Score 0 in Men / 1 in Women: Low risk; no anticoagulation needed.

Score 1 in Men / 2 in Women: Intermediate risk; oral anticoagulation considered.

Score >=2 in Men / >=3 in Women: High risk; oral anticoagulation recommended (Class I).

DOACs vs. Warfarin Rules: Direct Oral Anticoagulants (Apixaban 5 mg BID, Rivaroxaban 20 mg daily, Dabigatran 150 mg BID) are preferred over Warfarin for non-valvular AFib due to lower intracranial bleeding risk and no INR monitoring. MANDATORY WARFARIN EXCEPTION: DOACs are STRICTLY CONTRAINDICATED in AFib with moderate-to-severe Mitral Stenosis OR mechanical heart valves . These patients MUST receive Warfarin (target INR 2.0-3.0 for mechanical aortic valve/mitral stenosis; target INR 2.5-3.5 for mechanical mitral valve).

Valvular Heart Disease: Aortic Stenosis, Regurgitation, Mitral Lesions

Valvular Lesion Classic Etiology & Symptoms Physical Exam Murmur Characteristics Management Rules

Aortic Stenosis (AS) Senile calcification or bicuspid valve. Classic Triad: Angina, Syncope, Exertional Dyspnea (SAD) . Harsh crescendo-decrescendo systolic ejection murmur at RUSB radiating to carotid arteries . Delayed/weak carotid pulse ( pulsus parvus et tardus ), soft S2. TTE gold standard (valve area <1.0 cm² = severe). TAVR or SAVR. Avoid aggressive vasodilators and diuretics.

Aortic Regurgitation (AR) Aortic root dilation, endocarditis. High-pitched blowing diastolic decrescendo murmur at LSB. Wide pulse pressure , Water-hammer pulse. Afterload reduction (ACEi, nifedipine). Surgical replacement if symptomatic or EF <50%.

Mitral Regurgitation (MR) Mitral valve prolapse, post-MI papillary muscle ischemia. Holosystolic murmur at Apex radiating to left axilla . Associated S3 gallop. Afterload reduction (ACEi/ARB). MitraClip or surgical repair.

Mitral Stenosis (MS) Rheumatic heart disease history. Opening snap followed by low-pitched diastolic rumbling murmur at Apex. Anticoagulate with Warfarin (DOACs contraindicated). High AFib risk.

Peripheral Artery Disease (PAD): Pathophysiology and Diagnostics

PAD is caused by lower extremity arterial atherosclerosis (superficial femoral, popliteal, iliac arteries). Risk factors include smoking (strongest), diabetes, hypertension, hyperlipidemia, and age.

Intermittent Claudication: Exertional cramping calf/thigh pain relieved by 5-10 minutes of rest.

Critical Limb Ischemia: Advanced disease with ischemic rest pain (distal foot pain worse at night in bed, relieved by dangling leg), non-healing punched-out arterial ulcers, or gangrene.

Physical Exam: Diminished/absent DP and PT pulses, cool skin, hair loss, delayed capillary refill (>3 sec), elevation pallor , and dependent rubor (Buerger test).

Ankle-Brachial Index (ABI): Initial diagnostic test of choice (ankle SBP / brachial SBP):

ABI >1.40: Non-compressible calcified vessels (common in diabetes/CKD). Requires Toe-Brachial Index (TBI <=0.70 confirms PAD) .

ABI 1.00-1.40: Normal.

ABI 0.41-0.90: Mild-to-moderate PAD (claudication).

ABI <=0.40: Severe PAD (critical limb ischemia).

Evidence-Based Management of PAD

Risk Modification: Smoking cessation (single most effective intervention), High-intensity statin (Atorvastatin 80 mg), BP <130/80 mmHg, HbA1c <7%.

Antiplatelet Therapy: Aspirin 81 mg daily OR Clopidogrel 75 mg daily.

Exercise Therapy: Supervised Exercise Therapy (SET) 30-45 min 3x/week for 12+ weeks increases pain-free walking distance.

Claudication Pharmacotherapy: Cilostazol 100 mg BID (PDE-3 inhibitor) improves walking distance. BLACK BOX WARNING CONTRAINDICATION: Cilostazol is STRICTLY CONTRAINDICATED in patients with HEART FAILURE of any severity due to increased mortality.

Revascularization: Angioplasty/stenting or bypass graft indicated for critical limb ischemia or severe refractory claudication.