FNP cardiology: hypertension, heart failure, and cardiovascular risk management

The 2017 ACC/AHA guidelines redefine hypertension at ≥130/80 mmHg (previously 140/90). Staging: Normal (<120/<80), Elevated (120–129/<80), Stage 1 HTN (130–139/80–89), Stage 2 HTN (≥140/≥90), Hypertensive Crisis (≥180/≥120).

Treatment targets: Most patients: <130/80 mmHg. Clinical atherosclerotic cardiovascular disease (ASCVD) or high 10-year ASCVD risk: same target. Older adults ≥65 years: <130/80 mmHg is appropriate when tolerated. Diabetes: <130/80 mmHg (ADA 2024).

First-line pharmacotherapy by patient type:

• General population (non-Black): Thiazide diuretics, CCBs, ACE inhibitors, or ARBs (any acceptable)
• Black patients without CKD: Thiazide or CCB preferred (ACE/ARB less effective for initial BP lowering)
• CKD with proteinuria: ACE inhibitor or ARB (renoprotective)
• Post-MI/CAD: Beta-blocker + ACE inhibitor or ARB
• Heart failure with reduced EF (HFrEF): ACE inhibitor/ARB, beta-blocker, MRA, SGLT2 inhibitor (four pillars of GDMT)
• Pregnancy: Labetalol, nifedipine, methyldopa — avoid ACE inhibitors/ARBs (teratogenic)

Resistant hypertension: Defined as BP above target despite maximum tolerated doses of ≥3 antihypertensives including a diuretic. Evaluate for secondary causes: primary aldosteronism (most common — serum aldosterone:renin ratio), renal artery stenosis, obstructive sleep apnoea, thyroid disease, pheochromocytoma. Add spironolactone as fourth agent for resistant HTN with normal K+.

The ACC/AHA 2022 Heart Failure guidelines provide the framework for FNP certification questions on HF management. Heart failure is classified by ejection fraction: HFrEF (EF <40%), HFmrEF (40–49%), HFpEF (≥50%).

Guideline-directed medical therapy (GDMT) for HFrEF — four pillars:

1. ACE inhibitor or ARB (or ARNI — sacubitril/valsartan): Sacubitril/valsartan (Entresto) is preferred over ACE inhibitor/ARB where tolerated — superior mortality benefit in PARADIGM-HF trial. Cannot be used with ACE inhibitor (washout period required).
2. Evidence-based beta-blocker: Carvedilol, metoprolol succinate, or bisoprolol only — not all beta-blockers are indicated in HF. Uptitrate to maximally tolerated dose.
3. Mineralocorticoid receptor antagonist (MRA): Spironolactone or eplerenone. Monitor K+ and renal function. Avoid if K+ >5.0 mEq/L or eGFR <30 mL/min.
4. SGLT2 inhibitor: Dapagliflozin or empagliflozin — cardiovascular mortality and HF hospitalisation benefit shown in patients with and without diabetes.

Diuretics: Loop diuretics (furosemide) for symptom management and decongestion — not proven mortality benefit but essential for symptom control. Target: dry weight achievement, resolution of oedema and orthopnoea.

HFpEF: No therapy has shown definitive mortality benefit. Current evidence-based approaches: diuretics for volume management, SGLT2 inhibitors (dapagliflozin shows benefit in DELIVER trial), blood pressure control, management of comorbidities (AF, HTN, obesity, diabetes).

FNP exams test the 2019 ACC/AHA guideline framework for atherosclerotic cardiovascular disease (ASCVD) prevention through lipid management. Key shift: treatment decisions are based on ASCVD risk category, not LDL target alone.

Patient categories and treatment intensity:

• Clinical ASCVD (secondary prevention): High-intensity statin; if LDL still ≥70 mg/dL, add ezetimibe; if still elevated, add PCSK9 inhibitor
• LDL ≥190 mg/dL (familial hypercholesterolaemia): Maximum-intensity statin regardless of risk score
• Diabetes age 40–75: Moderate-intensity statin; high-intensity if multiple risk factors or 10-year risk ≥20%
• Primary prevention age 40–75 with 10-year ASCVD risk ≥7.5%: Moderate-to-high intensity statin after risk discussion

10-year ASCVD risk calculation: Use pooled cohort equations. Risk enhancers that may tip decision toward treatment in intermediate-risk patients: family history of premature ASCVD, persistently elevated LDL ≥160 mg/dL, metabolic syndrome, CKD, inflammatory conditions (RA, psoriasis, HIV), high-risk race/ethnicity, elevated hsCRP, CAC score ≥100.

Atrial fibrillation: Most common sustained cardiac arrhythmia. FNP management: rate control (target HR <110 bpm at rest — metoprolol, diltiazem, or digoxin for HFrEF), rhythm control (class IC or III antiarrhythmics + electrical cardioversion), and stroke prevention (CHA₂DS₂-VASc score to guide anticoagulation — score ≥2 in males or ≥3 in females warrants anticoagulation). DOACs preferred over warfarin for non-valvular AF except in moderate-to-severe mitral stenosis or mechanical prosthetic valve.

ECG interpretation for NP practice: Core competencies: SR vs. AF, QTc prolongation (risk for torsades with fluoroquinolones, macrolides, antipsychotics), LVH pattern, LBBB (changes ischaemia interpretation), STEMI (ST elevation in ≥2 contiguous leads = emergency), and early repolarisation vs. pericarditis (diffuse ST elevation with PR depression = pericarditis).