Hi, welcome back to Cardiovascular Nursing Essentials. In this module, we're gonna talk a little bit about pharmacology and device therapies. My name is Jenny Kennedy, VP of Care Transformation. These are my disclosures. So today, as I said, we're gonna go over some therapies and talk about the goals and just review some of the common medications and cardiology and some of the therapeutic devices. So here are your reading assignments. You will note that we will have an additional medication list if you wanna use that as a reference. I encourage you to keep that close by. You can print it off and be able to access it easily. So when we're talking about therapy goals, it's important that we know what's important to our patient and what their goals of care are. So while we are minimizing disease progression and managing their symptoms, we do wanna connect with that patient and identify what their specific individualized goals are. And overall, no matter what their goals are, it's our goal to improve their quality of life. And that also means, what does that mean to the patient? So we've gotta look at risk and benefits when we're setting up therapy plans for these patients. So when we're talking about pharmacology, I wanna remind us a little bit about our medication history because it's very important that we know accurate medications and doses. So again, I know we've talked a little bit about this, but we wanna make sure we encourage them to bring in their pill bottles. We need to confirm their dose and their frequency and not just rely on that bottle or list. Make sure they're taking it as they are supposed to. And if they're not, we need to correct that in the system. Also remember, we're not talking just about prescriptions, but we're including any over-the-counter medications like Tylenol, cold medicines. And any supplements, so vitamins, herbs, things that they may be taking in addition to those prescriptions. Also remember, there's generic and brand names for all medications, so that can get confusing. And we wanna make sure that the patients are not on duplicate classes of medication, so that's gonna be important. And don't be afraid to ask clarifying questions or escalate anything that seems incorrect because you guys are the ones really catching a lot of these mistakes or variations in the way the patients are taking their medications. And when in doubt, sometimes we do need to take a little bit of extra time and steps by calling a pharmacy or calling someone who may know how they're taking their medications just so we can get accurate information. So when we talk about brand versus generic, just a quick refresher, all of these, regardless of if they're brand or generic, go through FDA and have to get approval. So not all brands have generic brands with them. So the brand is really that pioneer or the innovator drug, it's the first to hit the market. And it's exclusively patented for a specific period of time, so they do not have any kind of competition from companies making generics immediately, that takes some time. Generics have to meet the same quality, strength, and purity standards of the brand. So it does look different, that's why you'll see different shapes, colors, pills, or it is less in cost. So when you see the nomenclature, your brand is usually first with a capitalized first letter and your generic is gonna be in all lower casing. So just a little refresher, and for example, you have Tylenol is the brand and acetaminophen is the generic. So these are the main classes we're gonna talk through today. And as I said, you're gonna have a lot of these reference sheets, so I just am gonna kind of hit the highlights. For lipid management, you're gonna see a lot of these medications and we are gonna go into a little bit more detail in another module, but our main goals are to increase HDL or that good cholesterol, decrease triglycerides, which includes our LDLs, and really here's your targets that you're looking to achieve for all of your triglycerides and lipids. One thing you're gonna note, even though we're talking about pharmacology, one of the first line of therapies for all of our disease states is gonna be lifestyle modification. That should be number one before we initiate any kind of therapy. So we wanna look at lifestyle modifications and then we also have statins. We may need to escalate more and add Zadia or PCKS9 inhibitors, and then there's also phenofibrates. So lifestyle modification, you guys are probably very familiar with this, but again, we wanna look at smoking cessation. We wanna increase their physical activity. We wanna promote weight loss. And a lot of these things are gonna be the lifestyle modifications we are looking at in general when we're treating any cardiovascular disease. We really wanna encourage that diet to be more consistent with Mediterranean, so high in fruits and vegetables, more whole grains, leaner proteins, healthier fats. Those really have been effective based on research and lowering our triglycerides and LDL levels. So statins are usually our first line of defense for primary and secondary prevention of coronary artery disease in patients that have dyslipidemias. Of course, there are those patients who have side effects and do not tolerate them, but this is generally our first line. Zatia is usually considered when we're on a statin, but we're not meeting that LDL goal. So it's not quite bringing it down enough. So we can use it with that statin, or if they cannot tolerate the statin, they can use it independently. So PCSK9 inhibitors are fairly new. These can be monoclonal antibodies or siRNAs, and we'll talk a little bit about that, but they're generally an injectable. So again, can be used with a statin to effectively drive LDLs and triglycerides lower, or they can be used independently. And then phenofibrates are really targeted at just triglycerides. So these may be used independently if they're really trying to lower triglycerides. So when we look at these different antihyperlipidemics, again, I just want you to kind of make note that they all work a little bit differently. So your statins, most commonly, are gonna be Lipitor, Crestor, Pravacol. These are what you really see, and they really are gonna aim to decrease your LDL and increase your HDL. So contraindications, liver disease, renal disease, pregnancy and breastfeeding, or hypersensitivity. Like we said, a lot of patients may get myalgias, aches and pains, therefore they don't tolerate the statin and may need to try something else. It is important that we're watching not only their lipids as they're on these, but their LFTs, their liver function. We wanna make sure their liver is protected and safe. So there is some baseline labs we expect, and we want to monitor LFTs. So again, this is just kind of showing you what you can expect in terms of monitoring and surveillance once it is started, and some of those big contraindications or side effects. Zadia is one that works actually in the intestinal tract, and it inhibits dietary and biliary cholesterol. So it works to decrease triglycerides and increase that HDL or good cholesterol. And as you can see with all of these medications, we really wanna be cautious of any liver, kidney disease, and these medications are not safe with pregnancy or breastfeeding. So again, a lot of similar side effects in terms of liver enzymes can increase or myalgias. So we wanna be aware of those and take action if our patient is having issues with that. The PCSK9 inhibitors, as I said, these are kind of new and they're monoclonal antibodies. So Repatha is most common, and they interfere with those PCSK9s when they bind with LDL-R to increase our hepatic LDL-R. So that decreases actual serum LDL levels. And this again is an injection. It's usually a subcutaneous injection. They usually come in, it's one to two times a month. And so really managing and monitoring lipids at baseline, and then generally every six to eight weeks. Side effects are fairly minimal, usually what you would expect to see with any type of injection. So maybe some mild injections, like pain, redness, or bruising. But other than that, not too many big side effects. Lecphio is something that's fairly new. It's a siRNA. So it silences that mRNA and blocks the synthesis or the creation of the PCSK9. So again, that's lowering LDL. This is also a subcutaneous injection, and it's every three months for two. So you'll get the initial, come back to get the second one in three months, and then it's every six months. So it ends up being twice a year. Very similar side effects to Repatha. But these are good options for kind of lower maintenance therapies for really getting a lower LDL effect. This next one is an ACL inhibitor, and it's fairly new to the market. And it inhibits cholesterol synthesis in the liver. So it kind of decreases the production of cholesterol. So again, you're gonna get that overall low LDL. This one, we're monitoring those lipids every eight to 12 weeks after that therapy is initiated. And this one is interesting because it has this side effect of gout or tendon rupture. So this is something that's not very common, obviously. And so to make sure that we're in line with the treatment, we do check uric acid levels and monitor for any kind of signs and symptoms that may indicate that there's a potential for tendon rupture. So moving on to hypertension, we know there's lots of drugs and medications, and we are gonna talk a little bit more about hypertension again in another module, but really aiming to get blood pressure in an optimal range for our patients. So remember, stage one hypertension is anything 130 to 139 systolic over 80 to 90 diastolic. So when you think about the population, we know there's a lot in that range, and then stage two is 140 over 90. So again, our lifestyle modifications are always the top of mind. And when those don't work, we wanna start looking at our medications. Generally, our choice of initial therapies in most patients are ACE inhibitors or an ARB, a calcium channel blocker or a thiazide diuretic. So we are gonna look at this, and generally we wanna start with just one therapy and not jump to combination therapy for compliance reasons. And you don't wanna expose a patient to more medication than they actually need. So when we're looking at some of our initial therapies, our ACE inhibitors, these are pretty cheap. So usually low financial risk to the patient, easily accessible. These are, your ACE inhibitors are your prills. So anything that ends in prill. So you've got lisinopril, captopril, enalapril, those are all your ACE inhibitors. And what these do is they inhibit the conversion of angiotensin I to angiotensin II. So it creates more of a vasodilation because what we know is angiotensin II causes vasoconstriction. So this acts to help those vessels dilate. Again, I don't wanna read through everything more, but just hit the highlights. And some of our considerations with ACE inhibitors are what we call the ACE cough. So some patients get a really kind of annoying cough that's hard for them to tolerate. Or more seriously is angioedema, which is a allergic reaction and that it can be very harmful or deadly to a patient. So we do wanna make sure that we're educating them and they're monitoring for any of those issues. If a patient can't be on an ACE, which could be from those two side effects or perhaps their kidney function, we do look at ARBs or these are our ARTNs. So our Losartan, Valsartan, Candesartan. These are similar to ACEs. They have a similar effect. They just work a little bit differently in a different area in the RAS system. So they block angiotensin II at the receptor. So both are targeting angiotensin II. It's just kind of in a different place on the pathway. So again, blocking angiotensin II results in a vasodilation and opening those blood vessels and helping decrease blood pressure. Okay, you can get angioedema with ARBs. However, it's not as common. So generally you just wanna be aware if someone's had a reaction with an ACE, but generally it is safer. So our beta blockers are our WOLs. So we have our Carvedilol, Metoprolol, Atenolol. We see these commonly. Most likely you're probably gonna see your Coreg and your low pressers. The difference between low presser and Toprol XL is really about the frequency. So our low presser is Metoprolol Tartrate or twice a day. So Tartrate T twice a day. And then our Toprol XL is the once a day extended release. So Metoprolol Succinate single for once a day or XL for that extended release. And I like to mention that cause this does come important in some of our guidelines, especially with heart failure. And commonly we may just see low presser or Toprol and not fully appreciate the difference between the two. And these block our beta receptors. So you've got beta one and beta two receptors. And when we block those, we decrease the workload of oxygen and demand in the heart. So that results in a lower heart rate and a lower blood pressure. So we do wanna be cautious and look for symptomatic bradycardia in these patients and make sure that they're keeping track of their blood pressure and their heart rate at home. I would really encourage that. And if they're feeling any dizziness, lightheadedness, extreme fatigue, really correlating that to their blood pressure log. With beta blockers, patients will tend to complain of fatigue. This is very common. And sometimes it leads to other issues, hypotension, bradycardia, sexual dysfunction, but that decreasing that workload and oxygen on the heart does come with extra fatigue. Our calcium channel blockers are our EANS. So amlodipine, nacardipine, and these work by blocking some of those calcium channels, which slows down the cell's use of calcium, which also makes the body respond by vasodilation, decreasing the blood pressure. So again, just really looking to monitor for signs of symptomatic bradycardia and hypotension can also be some fatigue in this population. So diuretics, we usually use thiazide and thiazide-like diuretics, not loop diuretics like we use in heart failure. So these diuretics inhibit sodium reabsorption. So it makes our bodies get rid of more sodium, more water, and potassium. So by decreasing the volume, we're decreasing that blood pressure. Again, we just wanna be cautious. With kidney disease, we're gonna monitor that kidney function and electrolytes generally upfront, and then we can space it out a little bit more. So main thing with diuretics is, yes, you can get hypotension. They may have orthostatic hypotension, but also those electrolyte imbalances, because we can lower their potassium and their sodium. So we wanna make sure we're assessing them for complaints of anything associated with that. All right, so with ASCVD, atherosclerotic cardiovascular disease, often our patients should be on antiplatelets, and sometimes it does require dual antiplatelet therapy. So with ASCVD, we're really looking to decrease any kind of risk of blood clot formation, especially with a new stent or revascularization. So generally after a stent is placed, they should be on an antiplatelet for 90 days post-acute coronary syndrome, or 30 days post-coronary stenting. Sometimes they do need dual antiplatelet therapy, which is the combination of aspirin plus a P2Y12, and that really limits the early platelet adhesion and aggregation, so it prevents thrombus formation. And when we're talking about ASCVD, it's not just MIs, yes, that's part of it. So we are talking about coronary artery disease, so MIs, angina, heart failure, things like that. But beyond that, we could be, these patients may be stroke, or TIA patients may have PAD, or maybe have any sort of aortic aneurysm, atherosclerosis, anything like that. So it's beyond just those post-MI patients. So I want you to remember that when you're thinking of this population. So we know aspirin is really intended to, it decreases that reactivity of platelets, so they're not quite so sticky. But some patients can't tolerate aspirin, they might get a rash, they might get some sort of asthma. If they can't tolerate that, then we just have to put them on the P2Y12 receptor blockers. These are your Plavix, your Effia, your Berlinta. And these reduce platelet aggregation because they block the ADP receptors on the platelet service. So all of these are really trying to keep those platelets from being so sticky, so they don't stick together, they kind of bounce off each other a little bit more, so they're not making clots. Of course, with these medications, you wanna monitor for any signs or symptoms of major bleeding, so GI risk. Fall precautions are gonna be important because if they hit their head, there's risk for hematomas and things like that. Of course, they're gonna be at risk for more bruising and bleeding easier if they're injured, so even a minor scrape could bleed for some time. So we're gonna be making sure we're monitoring for signs of active bleeding and checking H and Hs when those are indicated. So anti-ischemic and analgesic therapy for patients that may be having that chronic chest pain or if it's a PAD and they've just got really heavy legs and pain in their legs, we want to make sure we're dilating those arteries because that increases the oxygen flow to the heart. Obviously, if there's something going on where there's chest pain or restriction, they're not getting the oxygen. So we want to make sure that we are getting oxygen to the heart. If it's chronic, we want to make sure we're managing their angina. And so I want you to remember oxygen is a therapy. So if patients are having chest pain or experiencing any kind of angina, oxygen can help and should be put on if they're in the office so that you're making sure they're getting oxygen to their heart. Most common, of course, is nitrolycerin. We usually give that sublingual. On the inpatient side, it can be a patch. It could be a little tablet that dissolves under their tongue or it could be a spray. And really what that does is produce a vasodilation throughout the peripheral veins and arteries. So with that, you're going to get vasodilation everywhere. So one of the most common side effects may be headache, hypotension, dizziness, things associated with that. We do give these sublingual every five minutes for three PRN chest pain. That's different than somebody who's a chronic angina. But if you feel like they're at risk for acute MI, you want to make sure that they're getting that every five minutes times three for chest pain. Again, we want to make sure we're watching their blood pressure. This is a systematic vasodilator so they can have hypotension. And you'll notice if you haven't seen them already, they are stored in very dark containers. So like a brown container, so the sunlight does not get to it. We've got to protect it because that can break down the medication. Other nitrates, these are isergyl or indore. These could be for long-term chronic angina. And again, they're vasodilators. So they're working to expand those arteries and capillaries to improve blood and oxygen flow to the heart. Once to twice a day, they can be used to prevent or lessen angina. Similar side effects as nitroglycerin. So the headache, low blood pressure, dizziness, things of that nature. For both of these, we do want to be cautious of PDE5 inhibitors because that can, when used with Viagra or any other PDE5 inhibitors, cause profound hypotension. So with your gentleman, your male patients, you want to make sure that you're covering that with them so they don't get into a critical situation. Further anticoagulation medications. Again, these are a little bit different than our ASCVD. These are really saying that they're trying to decrease the risk of blood clot formation and stroke prevention for different reasons. So this would be more for Afib, Aflutter, not ASCVD, post-stent kind of conditions. And these medications can require very close monitoring and dosing. So they can be very patient specific. The number one medication we're talking about with monitoring would be Coumadin or Warfarin, which decreases clotting through blocking a part of that clotting cascade. So they're generally coming in anywhere from weekly to twice a week. They can do home INR checks and we're checking that INR. Many locations have a anticoagulation clinic. You may have that in your practice where it's a finger stick and protocol base to adjust what their dose of Coumadin is. It's important that the patients are well educated and it's reinforced ongoing that their diet can really impact their INR level or how thin their blood is. So we've got to educate them on their diets and also other medications can impact them. So antibiotics can really alter their effect. So these can be dangerous situations. So just make sure that education is always a part of your plan with Coumadin patients. Other medications like Eliquis, Pradaxa, Xarelto, these are effective anticoagulants because they decrease clotting through blocking, again, a portion of the clotting cascade just in a different area. But the great thing about these is you do not have to have that ongoing surveillance. It's kind of a, they prescribe a dose and they just go with it. And then generally they're only on it for a short period of time after a stent placement. So it's beneficial to these patients if they can be on one of those, as opposed to being on Coumadin, which requires so much more monitoring. Then we also have some injectables. So your heparin and Lovenox. These are generally IV or sub-Q. They're weight based. So the dose is dependent on the weight of the patient. These are typically given inpatient, but you may have to do a Lovenox bridge from Coumadin in some instances. So there is potential to see Lovenox on the outpatient setting. And then briefly, we're going to talk a little bit about heart failure diuretics. We have a whole section on heart failure, so it won't hit it too hard, but obviously with heart failure, we really want to make sure we're managing their fluid and improving their quality of life. Obviously we want to make sure their breathing is improved, that they're not experiencing significant shortness of breath or extra swelling. And really in terms of their quality of life, again, that's going to depend on what they feel like is their quality of life. However, if they're not able to get up and do their day-to-day activities, that we're not really helping them. So we want to improve their heart efficiency. We want to decrease that workload on their heart and try to improve their physical endurance so they can do their activities of daily living. So our most common medications, again, are diuretics. And we'll go through some of our guideline-directed medical therapy in another module. But the difference between the diuretics really is where they work within the renal system. So our loop diuretics, again, usually we start with Lasix or furosemide. It's the most common, but other loop diuretics are Bumex or Demodex, and they reduce sodium chloride reabsorption in the ascending loop of Henle. So that means it increases free water clearance by the kidney. So your body is able to excrete through urine extra fluid. Contraindication, so renal disease, depending on how severe it is, if they're in stage on dialysis, a diuretic is not going to help them. It can pull the fluid out of their system, but they don't have a way to excrete it. Hypotension, some patients can get severely hypotensive on these diuretics. So we do have to be cautious of that. As we discussed earlier with the other diuretics, we really want to monitor kidney function and electrolytes and just look for signs of hypokalemia, hyponatremia, things like that, because we want to make sure that we're replacing those electrolytes if need be. And alternately, if they get too much potassium, that can be dangerous as well. If a loop diuretic is not working, sometimes we go to another loop diuretic. So for example, Lasix, the absorption rate of Lasix is only about 50%. So if you have a patient that is already overloaded and they're not absorbing like they normally would, they're going to get less than 50%. So that's generally why they may have to come in and get some IV Lasix to get better absorption rates and be more effective. Bumex, on the other hand, and Torsamide have higher absorption rates, closer to 90%. So they're going to be more effective. So sometimes patients get used to that or they're not absorbing and they need to be bumped up to a different loop diuretic. Sometimes that's not enough and we need to add a thiazide or thiazide-like diuretic. This is your diuryl, hydrochlorothiazide, metolazone. And these are given in conjunction with the loop diuretic. And it's really kind of a booster, if you will. It's a diuretic booster. So we typically give it 30 to 60 minutes before the loop so that the body can really benefit from the most fluid excretion. So again, it works just in a different place. So it inhibits sodium transport in the distal convoluted tubule. It does not always have to be given with loops, but generally we do see them given when patients are having trouble getting fluid off and they need a little extra boost. So we've also talked about over-the-counter medications and it's really important that you know what they're taking because there's several that we need them to avoid. So decongestants are common pseudofeds, pseudofedrin, phenylephrine. Those are dangerous to heart failure or cardiovascular patients because they do increase vasoconstriction and increase blood pressure. So you can see a increase in heart rate, increased blood pressure. So instead of these, we recommend things like Mucinex, things to help clear additional mucus. Things like Claritin, Flonase, those do not have those vasoconstricting effects. So fever and pain, we really want to avoid NSAIDs. So those can lead to swelling, increased blood pressure, or decreased kidney function. So these are things like your Advil and Aleve. So we really recommend Tylenol for fever and pain. We do want to be cautious with any vitamins, herbs, and supplements that could be in the form of pills, liquids, patches, injections. There's all sorts of routes. You can go pretty much anywhere and find some B12 patches for example, or go get an injection. It's very important that we check and cross-reference medications to make sure that there's no interaction with their prescription medication. So I always like to call out that we just never want to forsake their over-the-counter meds or what they may be taking. So our key takeaways today, we know medications are complicated. It's a lot to think about. It's a lot to consider. So that's why it's more important that we make sure that medication history is up to date and correct every visit and every time we're making any adjustments. And when in doubt, just ask. Use your resources. Talk to pharmacists. Talk to your providers. Ask the questions because there's the potential for many interactions and errors and clarifications. So you may be able to catch something that may not seem like a big deal, but it is. All right. So next we're going to talk a little bit about device therapy. And this is one of my favorite topics, but before a patient determines they want a device, I want to talk to us about shared decision-making, which is an approach between the physician provider, the healthcare provider, and the patient where they sit down, work together to figure out what's best for the patient. So it's an engagement, brings both parties to the table, and it's really bringing the best decision to that patient based on evidence-based information, the provider's knowledge and experience, and what that patient values and prefers. So not every patient wants to get an ICD. Well, they need to know the risks, the benefits, and then they can make an informed decision in conjunction with their provider. One example is the Colorado Shared Decision-Making Tool for ICDs. So you may be familiar with that, but this is something we're seeing in a lot of guidelines because we really need the emphasis of the patient and the provider making those choices together. So let's talk about permanent pacemakers. There's a couple different types, and our indications can be anywhere from one to three. There's tons of indications. Most commonly, we see AV blocks, bradycardias, sinus node dysfunctions as our top indications. Battery life varies. It can go anywhere from 5 to 15 years, really depending on how often it is used. I think in the future, we probably will get to a place where we can do external charging, but we're not there quite yet. And there's a variety of them. So they can be single chamber, meaning they're only triggering the RV, the right ventricle. They could be in the RV and the RA, so those are dual chambers. They can be biventricular, being in both ventricles, the right and the left. You may also hear these referred to as CRT for heart failure or cardiac resynchronization therapy, and we'll talk more about that later. But both of the ventricles are stimulated together in a by the pacemaker. And you can see, these are all just different types of pacemakers. There are a lot of them, but they all have the same components. So you have your pulse generator, which is the big part here, which houses the battery and all the electrical circuits that are needed. And then the leads come out here, and you can have anywhere from one to three leads, depending on the type of pacemaker. So your electrical impulse is stimulated from the generator and delivered through those leads to either the atria or the ventricles. Some newer exciting technology is the leadless pacemaker, which as you can see is much smaller. It's about 90% smaller than a transvenous pacemaker. There's no separate battery, there's no separate leads. And so as you can see, it comes right into the right ventricle. All the way down here, it's implanted there, so there's lower risk of complications such as pocket infections, hematoma, lead dislodgement, and lead fractions that you may see with a transvenous pacemaker. So obviously there's a big cosmetic appeal because you don't have the pocket on the chest. Battery life is similar to a transvenous pacemaker 5 to 15 years. But what do you do at the end of that battery life? You actually, it just gets deactivated and left there, and then they can place another one in the area. It can be retrieved, but the risk of that is generally higher than just leaving it, so most of the time it's just left there and the new device is placed next to it. So ICDs, these are again very similar to our pacemakers. The difference is the indication and the use. So these are for people at risk for sudden death prevention, so they have a high risk arrhythmias, VT, VFib that are prolonged. Some of them may be pacemakers as well, so you can have a pacemaker with an ICD or just the ICD alone. It really is patient-specific, but basically what it does is it senses any prolonged lethal arrhythmias like VFib or VTAC, and it will shock if it detects a prolonged lethal arrhythmia. Generally patients will hear a beep before it deploys the shock, and that's really a note to say to anybody around them to not touch them so they don't also get shocked by touching them. Some actually have a kind of overdrive function, which if it detects a fast rhythm will help to slow it down. So again, lots of variations based on what the patient needs. Battery life is a little bit lower because than a permanent pacemaker at five to seven years, just again depending on how frequently it's used. And then you can see there's two different, so there's transvenous like a pacemaker which goes under the skin and goes through the veins, and then there's also the subcutaneous which is more kind of in the axillary under the skin. And so the pulse generator is the same, but it's got this shocking coil that goes on the parasternal margin on the left side of the heart. So again, these are really ideal for younger patients, so maybe less than 45 years. They're really just need the ICD and not the pacing component, and there may be higher risk for infections like bacteremia. So this is another option for patients. You may see some with external defibrillators, most commonly the zolifest, and these are indicated, you know, that period when a patient may need an ICD but they haven't gotten approval yet from their insurance. So obviously we don't want to just let them go without being protected. So these are something that is fitted to the patient. It's the same as an internal device, so they do have electrodes in this vest. Sometimes the vests do get uncomfortable, maybe they feel hot or itchy, so I always acknowledge that with patients and let them know if they need a break it's okay, but they need to do that with somebody present and make sure they know that they're not wearing the vest. If an event happens and they don't have the vest on, there's no way it can detect that there's an arrhythmia, so unfortunately it can, if they're not wearing it, it will not work. So just some points to consider, and then with our pacemakers, just some final considerations. It is best for them to take it easy for the first two to three weeks after the implant, so that means no heavy lifting, so less than 10 pounds, no pushing, no pulling, no twisting, no lifting the arm above the shoulder on the side the device was placed. You know, some patients get sent home with kind of a sling and it's not necessarily to support their arm, but it's to keep them from lifting it and risking any lead displacement. We want to make sure they're educated on devices that can interfere with ICDs and pacemakers, so those are metal detectors, our cell phones, so we want to make sure they're not keeping them, especially men in those front pockets. They need to keep it away from their device, so at least six inches from their device. Magnets, this includes those MRIs. There are some compatible MRIs, but we want to make sure that is compatible before exposing a patient to that, and then CT scans are fairly low probability of interference, but just something they want to make sure if they do need a CT scan, they're confirming they're in a safe one. Want to make sure that they are attending all their follow-up appointments. It's important that they are continuing that. They will get usually remote checks and in person, so we are watching them, but they do need to keep those appointments, and then also consider carrying any kind of ID, so maybe that's a card or a bracelet or a necklace so people know they do have a pacemaker or an ICD, and this is just a kind of nice example of one the American Heart Association has available for patients. They can keep in their wallet or anything like that so that people know if there is any kind of issue they do have a pacemaker or an ICD on them, and that concludes this week's module. If you have any questions, please feel free to email academy at medaxiom.com. Thanks for joining.

pharmacology

device therapies

cardiovascular nursing

medication history

anticoagulants

implantable cardioverter-defibrillators

comprehensive overview