Monographs: What is it? What is the cause? What are the symptoms? How is it treated? What can I expect? What to watch for. Qué es? Cuál es la causa?

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1 Angina Pectoris, Stable Monographs: What is it? Angina is chest pain or discomfort that occurs when not enough blood gets to the heart muscle. Blood carries oxygen and other nutrients needed by the heart muscle to work properly. We say angina is stable when it is not getting any worse and there is no immediate danger of a heart attack. What is the cause? The arteries in the heart may grow narrow or be blocked over time. This is because fat and calcium deposits build up inside the arteries. This is called coronary artery disease, or CAD. CAD can reduce the amount of blood that gets to the heart muscle. Angina occurs when your heart muscle requires more oxygen but does not get it. Oxygen is carried in the blood. Your heart muscle needs more blood when it beats faster or stronger. This can happen during eating, emotional stress, or physical activity. What are the symptoms? You may feel heaviness, squeezing, or pressure in the chest. It can spread to your arms or to your jaw. Some people have abdominal pain. You may also feel sick to your stomach or sweaty. You may feel like you are not able to get enough air. You may feel anxious. You may think you have indigestion. The discomfort usually lasts more than a few seconds but less than 30 minutes. It usually goes away quickly if you rest or take nitroglycerin. Angina can take many forms, depending on the person. Some people with CAD have shortness of breath or weakness. They may not have any chest pain. Some people may only have discomfort in their jaw or arm. How is it treated? Often angina can be prevented or controlled with daily medicine and lifestyle changes. If activity brings on your angina, often all you need to do is sit and rest. This can make it go away. If it does not subside quickly, a medicine called nitroglycerin may help. Lifestyle changes we may suggest include the following:. Stop smoking. Lose weight. Exercise. Eat a healthful diet that is low in fat. Take an aspirin every day We may treat you for high blood pressure. We may treat you for high cholesterol. We may do tests like a cardiac catheterization or a stress test to check your heart. What can I expect? The cause of your angina may never go away. However, it can usually be controlled with medications or cardiac procedures. It may take time. We may make adjustments to your medicines. Additional tests may be needed to find out how much your heart's arteries have narrowed. Usually each person's angina remains the same for them. For example, if you only get shortness of breath, we expect that to continue to be your only symptom. If you feel pain when you have angina, we expect that you will have the same amount of pain each time. The pain should not get worse. In stable angina, there is often a predictable cause. For example, overeating or walking uphill or up a set of stairs may cause it. If your angina cannot be controlled, we may do a procedure to increase the blood flow to your heart. Sometimes we do this by inserting a balloon into a blood vessel of the heart. The balloon is then inflated. This stretches the blood vessel and allows more blood to flow through. The balloon is then collapsed and removed. This is called a balloon angioplasty. We may insert a device to keep the vessel open. This is called a stent. A bypass surgery is needed when there are too many blockages to treat with stents. Aggressively treating your risk factors like hypertension, cholesterol, smoking and taking an aspirin are importaing for improving your symptoms and reducing the risk for a heart attack. What to watch for. If you have taken three nitroglycerin pills as prescribed and your angina is still there, call an ambulance right away. You need to go to the hospital. While waiting for the ambulance to come, take two adult aspirin. Only do this if you are not allergic to aspirin and have not already taken aspirin that day. Chew them instead of swallowing them with water. Do not try to drive yourself. Do not let a family member or friend drive you. You need the care that can be provided by the ambulance medics. Call us if you are having angina more often. Call us if you are having it when you wouldn't expect to have it. Call us if you have worse pain than you have had before, even if it goes away. Do not use Viagra if you are taking a nitrate medicine. Viagra is a medicine used to help men get erections. The generic name of Viagra is sildenafil. The two medicines together can be very dangerous. If you are not sure what you are taking, ask us. Qué es? La angina es un dolor o molestia en el pecho que ocurre cuando no llega suficiente sangre al músculo cardíaco. La sangre transporta oxígeno y otros nutrientes que el músculo cardíaco necesita para trabajar correctamente.decimos que la angina es estable cuando no empeora y no hay riesgo inminente de sufrir un ataque cardíaco. Cuál es la causa? Las arterias del corazón pueden estrecharse u obstruirse con el paso del tiempo. Esto sucede porque se forman depósitos de calcio y grasa dentro de las arterias. Esto se llama enfermedad de la arteria coronaria o EAC. La EAC puede reducir la cantidad de sangre que llega al músculo cardíaco. La angina ocurre cuando el músculo cardíaco necesita más oxígeno pero no lo obtiene. El oxígeno viaja en la sangre. El músculo cardíaco necesita más sangre cuando late más rápido o con más fuerza. Esto puede suceder mientras come, tiene estrés emocional o realiza actividad física. Cuáles son los síntomas? Puede sentir pesadez, apretamiento u opresión en el pecho. Puede extenderse a los brazos o a la mandíbula. Algunas personas presentan dolor abdominal. También puede tener náuseas o sentirse sudoroso. Puede sentir que le falta el 1

2 aire. Puede sentirse ansioso. Puede pensar que tiene una indigestión. La molestia por lo general dura más de unos pocos segundos pero menos de 30 minutos. Generalmente desaparece rápidamente si descansa o toma nitroglicerina.la angina puede manifestarse de diversas maneras, de acuerdo con la persona. Algunas personas que sufren de EAC tienen falta de aire o debilidad. Pueden no tener dolor de pecho. Algunas personas pueden sólo sentir molestias en la mandíbula o en el brazo. Cómo se trata? Generalmente la angina puede prevenirse o controlarse con medicamentos diarios y cambios en el estilo de vida. Si la actividad le produce angina, por lo general lo único que debe hacer es sentarse y descansar. Esto puede hacer que desaparezca. Si no se pasa rápidamente, un medicamento llamado nitroglicerina puede serle de ayuda.los cambios en el estilo de vida que podemos sugerirle incluyen:. Deje de fumar. Perder peso. Haga ejercicio. Tener una dieta saludable que sea baja en grasas. Tomar una aspirina todos los díastal vez tratemos su presión arterial alta. Tal vez tratemos su colesterol alto. Es posible que le hagamos exámenes para controlarle el corazón. Qué puedo esperar? Probablemente la causa de su angina nunca desaparezca. No obstante, generalmente se puede controlar. Puede llevar tiempo. Podemos adaptar sus medicamentos. Es posible que se necesiten exámenes adicionales para averiguar cuánto se han estrechado las arterias de su corazón.por lo general, la angina permanece estable en una misma persona. Por ejemplo, si usted sólo presenta falta de aire, ése continuará siendo su único síntoma. Si siente dolor cuando tiene angina, el dolor tendrá la misma intensidad todas las veces. El dolor no debe empeorar. En la angina estable, generalmente existe una causa predecible. Por ejemplo, pueden causarla comer en exceso, caminar cuesta arriba o subir escaleras.si su angina no puede controlarse, podemos realizar un procedimiento para aumentar el flujo de sangre al corazón. Algunas veces lo hacemos insertando un balón en un vaso sanguíneo del corazón. Allí se infla el balón. Esto dilata el vaso sanguíneo y permite que circule más sangre. Luego el balón se desinfla y se retira. Esto se llama angioplastia con balón. Tal vez insertemos un dispositivo para mantener el vaso abierto. Éste se llama stent. Algunas veces se necesita cirugía. El tratamiento para la EAC puede reducir el riesgo de sufrir un ataque cardíaco. Lo que deberá tener presente. Si ha tomado tres pastillas de nitroglicerina tal como se le recetó y todavía tiene angina, llame a una ambulancia de inmediato. Debe ir al hospital. Mientras espera a la ambulancia, tome dos aspirinas para adultos. Sólo haga esto si no es alérgico a la aspirina y si todavía no ha tomado ninguna ese día. Mastíquelas en vez de tragarlas con agua. No intente conducir. No permita que un miembro de la familia o un amigo lo lleven. Necesita el cuidado que pueden brindarle los médicos de la ambulancia. Llámenos si tiene angina con más frecuencia. Llámenos si tiene angina cuando no debería tenerla. Llámenos si el dolor es más fuerte que otras veces, aun si desaparece.no tome Viagra si está tomando un medicamento con nitrato. El Viagra es un medicamento que se utiliza para ayudar a los hombres a tener erecciones. El nombre genérico del Viagra es sildenafil. La combinación de estos dos medicamentos puede ser muy peligrosa. Si no está seguro de lo que está tomando, consúltenos. Page 6 of 252 Copyright Allscripts, LLC Angina Pectoris, Stable Medications: ACE Inhibitors: Enalapril Maleate 5 MG Oral Tablet TAKE 1 TABLET TWICE DAILY Twice daily Qty: 60 Lisinopril 5 MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Angiotension Receptor Blockers: Diovan 80 MG Oral Tablet TAKE 1 TABLET ONCE DAILY. Qty: 30 Cozaar 50 MG Oral Tablet TAKE 1 TABLET ONCE DAILY. Qty: 30 Beta-Blockers:: Coreg 12.5 MG Oral Tablet Take 1 twice daily. Qty: 60 Propranolol HCl CR 80 MG Oral Capsule Extended Release 24 Hour Take 1 every 12 hours. Qty: 60 Metoprolol Tartrate 50 MG Oral Tablet Take 1 twice daily. Qty: 60 Atenolol 50 MG Oral Tablet Take 1 daily. Qty: 30 Calcium Channel Blockers:: Diltiazem HCl CR 240 MG Oral Capsule Extended Release 24 Hour Take 1 daily. Qty: 30 Norvasc 5 MG Oral Tablet Take 1 daily. Qty: 30 Plendil 5 MG Oral Tablet Extended Release 24 Hour Take 1 daily. Qty: 30 Verapamil HCl CR 240 MG Oral Tablet Extended Release Take 1 daily. Qty: 30 NIFEdipine 30 MG Oral Tablet Extended Release 24 Hour Take 1 daily. Qty: 30 Cholesterol-Lowering Agents:: Crestor 10 MG Oral Tablet Take 1 daily. Qty: 30 Pravachol 10 MG Oral Tablet Take 1 daily at bedtime. Qty: 30 Zetia 10 MG Oral Tablet Take 1 daily. Qty: 30 Vytorin MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Lipitor 10 MG Oral Tablet Take 1 daily. Qty: 30 Zocor 10 MG Oral Tablet Take 1 daily in the evening. Qty: 30 Fish Oil 1000 MG Oral Capsule TAKE 3 CAPSULE DAILY Daily Qty: 90 Nitrates and other Anti-Anginal agents:: Isosorbide Dinitrate 20 MG Oral Tablet Take 1 three times daily. Qty: 90 Nitro-Dur 0.4 MG/HR Transdermal Patch 24 Hour Apply 1 patch daily in the morning, remove at bedtime. Qty: 1 EA 2

3 Nitroglycerin 0.4 MG Sublingual Tablet Sublingual Place 1 under the tongue as needed for chest pain. May repeat in 5 minutes for 3 doses. If no relief, call 911 Qty: 25 Imdur 60 MG Oral Tablet Extended Release 24 Hour Take 1 daily. Qty: 30 Nitro-Bid 2 % Transdermal Ointment Apply 1/2 to 1 inch 3-4 times daily as directed Qty: 1 GM Platelet Aggregation Inhibitors:: Aspirin 81 MG Oral Tablet Delayed Release Take 1 daily. Qty: 100 Aggrenox MG Oral Capsule Extended Release 12 Hour Take 1 twice daily. Qty: 60 Aspirin EC 325 MG Oral Tablet Delayed Release Take 1 daily. Qty: 30 Plavix 75 MG Oral Tablet Take 1 daily. Qty: 30 Orders: Reminders: Lipid Panel: every 6 MONTHS Hepatic Function Panel: every 6 MONTHS Imaging: Chest X-Ray Echo (2-D) Mode With Pharmacologic Stress Echocardiogram Cardiac Catheterization (Diagnostic) PET Scan Myocardial Imaging, Perfusion Lab tests: Serum Creatinine Blood Glucose Hepatic Function Panel Serum Triglycerides Lipid Panel Thyroid Function Tests Hemoglobin Stress Test ECG Performed Electrolyte Panel BUN level Instructions: Activity: Continue with our present treatment plan If you get chest pain with activity, stop what you are doing and sit down. Diet: Limit your use of alcohol to 2 drinks or cans of beer a day. Eat no more than 30 grams of fat per day. A diet that is low in fat, cholesterol and sodium is considered a cardiac diet. Home monitoring: Keep a record of your angina. Lifestyle modifications: Decreasing the stress in your life may help your condition improve. Your ideal weight is 160 pounds. There are many exercise options for seniors. You need to quit smoking. Begin a limited exercise program. Procedures: We recommend that you have an angioplasty. We recommend a cardiac catheterization. Precautions: Call: Your chest pain feels different to you. Your chest pain is happening more often. Emergent: Your chest pain (angina) does not go away after 15 minutes of your usual treatment. You have fainted or passed out. You have any symptoms of a stroke. Urgent: You faint or lose consciousness. Your chest pain (angina) happens at rest. You are feeling short of breath. Follow-ups and Referrals: Ungrouped: 3

4 Cardiac Rehabilitation Referral; Consult Only; Consult for adult Follow Up; Evaluation and Treatment; Change treatment adult Cardiology Referral; Evaluation and Treatment; Change treatment adult Dietician Referral; ; 4

5 Atrial Fibrillation, Chronic Template: Atrial Fibrillation, Chronic Erratic heartbeat (atrial fibrillation) Physiologic Category: Cardiovascular Print Name: Review Status: Status: Active Activation Date: Allscripts Release Date: 03/26/2008 Edit Date: Reviewed By: 0 Monographs: What is it? Atrial fibrillation is an irregular and weak heartbeat. The upper part of the heart is not beating in an organized way. This disorganized movement is called fibrillation. Fibrillation does not effectively pump blood. The upper part contains two chambers. These are called the atria. In addition to pumping blood, the atria also send an electric signal to the lower chambers telling them when to beat. The lower chambers of the heart are called the ventricles. The ventricles continue to beat normally but their speed of beating is irregular and may be too fast or too slow. The ventricles are the most important chambers for pumping blood to the body. They can do this job even when the atria are fibrillating. However, if all the chambers of the heart do not pump together, the heart is not as effective at pumping blood. Atrial fibrillation is a problem mostly because the heart chambers do not empty completely with each beat. Blood can pool in the chambers. If it does, it can clot. A blood clot may then travel to the lungs. This can cause a problem called pulmonary embolism. If a clot travels to your brain, it can cause a stroke. What is the cause? A tiny pulse of electricity tells each part of the heart muscle when to contract and cause a beat. Atrial fibrillation occurs when the atria are not getting a clear signal when to beat. This can happen for many reasons. It can be a sign of high blood pressure, heart disease, or lung disease. It may just be part of aging. It is more common in people over 60. Diabetes increases the risk of this problem. What are the symptoms? You could have had these irregular beats for a long period of time without knowing it. We often only know about the problem because we did tests to see how the heart is beating. Some people feel tired, weak, or dizzy. You may be aware that your heart is beating fast, irregularly, or unevenly. You may have chest pain when you are active. You may feel short of breath. You may tire more easily than you did before. How is it treated? The goal of treatment is to have your heart beat at a regular rate. We may give you medicine to slow down how often your heart beats. We may also give you medicine that helps your heart beat evenly. Another important goal is to prevent blood clots. We may want you to take a medicine to help thin your blood and prevent blood clots. We may just have you take aspirin every day. Aspirin is a mild blood thinner. What can I expect? We may do tests to check the condition of your heart. These include an echocardiogram. This is a picture of your heart taken with sound waves. It can show us how your heart muscle works, how the valves work, and if there are any blood clots in your heart. We may do periodic blood tests to check the dose of any medicines we have given you. Blood thinner doses may need to be changed occasionally. The longer you have been in atrial fibrillation, the harder it can be to get back into a normal heart rhythm. It may take time to find what works best for you. Some people get used to the irregular beat and live comfortably with it for many years. In some cases, we may need to insert a pacemaker and stop the electrical signals that are driving your heart too fast. A pacemaker can help control your heartbeat. We may try a procedure called ablation. It can help correct the electrical signals in your heart. What to watch for. Call 911 or seek emergency help if any of the following occur:. Sudden loss of strength, feeling, or the ability to move part of your body. Dizziness for no obvious reason. Severe headache. Difficulty with speech. Confusion Call 911 or go to the hospital right away if you have any of the following symptoms:. Chest pain that is severe or crushing, or lasts longer than 30 minutes. The pain may spread up to your neck or down one arm.. Severe trouble breathing. You can't get your breath even while resting.. Your heartbeat feels wrong and you are sweating or feel dizzy, faint, or sick to your stomach. If possible, take one or two aspirin right away. Chew them instead of swallowing them with water. Do not take any if you have already taken aspirin that day. Call us right away if you have any of the following:. Pain or pressure under your breastbone. Shortness of breath even when you are doing very little. Any new pain in your neck or arm, especially if you feel unwell Let us know if treatment does not seem to be helping your symptoms. Let us know if you are bruising easily or see any blood in your stool. Qué es? La fibrilación auricular es un latido cardíaco irregular y débil. La parte superior del corazón no late de manera organizada. Este movimiento desorganizado se llama fibrilación. La fibrilación hace que el corazón no bombee la 5

6 sangre de manera efectiva. La parte superior del corazón contiene dos cámaras. Éstas se llaman aurículas. Además de bombear sangre, las aurículas también envían una señal eléctrica a las cámaras inferiores que les indican cuándo deben latir. Las cámaras inferiores del corazón se llaman ventrículos. Los ventrículos continúan latiendo normalmente, pero la velocidad de los latidos será irregular y puede ser demasiado rápida o demasiado lenta. Los ventrículos son las cámaras más importantes que bombean sangre al cuerpo. Pueden hacerlo aun cuando las aurículas fibrilan. No obstante, si las cámaras del corazón no bombean todas juntas, el corazón no es tan eficiente al bombear sangre.la fibrilación auricular representa un problema principalmente porque las cámaras del corazón no se vacían completamente en cada latido. La sangre se puede acumular en las cámaras. Si lo hace, puede coagularse. Luego, un coágulo de sangre puede viajar hasta los pulmones. Esto puede causar un problema llamado embolia pulmonar. Si un coágulo viaja hasta el cerebro, puede ocasionar un accidente cerebrovascular. Cuál es la causa? Un pequeño pulso de electricidad le dice a cada parte del músculo cardíaco cuándo contraerse y causar un latido. La fibrilación auricular se produce cuando las aurículas no reciben una señal clara que determine cuándo deben latir. Esto puede suceder por varias razones. Puede ser un signo de presión arterial alta, enfermedades cardíacas o enfermedades pulmonares. Puede que sea sólo por causa de la edad. Es más común en personas mayores de 60 años. La diabetes aumenta el riesgo de esta enfermedad. Cuáles son los síntomas? Es posible que haya tenido estos latidos irregulares durante un largo tiempo y no lo haya notado. Generalmente, descubrimos el problema al realizar estudios para examinar los latidos del corazón. Algunas personas se sienten cansadas, débiles o mareadas. Tal vez sea consciente de que su corazón está latiendo rápida, irregular o desigualmente. Puede tener dolor de pecho cuando realiza una actividad. Puede sentir que le falta el aire. Puede cansarse con mayor facilidad que antes. Cómo se trata? El objetivo del tratamiento es lograr que el corazón lata a una frecuencia regular. Es posible que le administremos medicamentos para disminuir la frecuencia de los latidos de su corazón. Posiblemente también le recetemos medicamentos para ayudar a su corazón a latir de manera regular. Otro objetivo importante es prevenir la formación de coágulos. Tal vez le solicitemos que tome un medicamento que lo ayude a diluir la sangre y prevenir la formación de coágulos. Quizás sólo deba tomar aspirina diariamente. La aspirina es un anticoagulante suave. Qué puedo esperar? Tal vez realicemos estudios para controlar el estado de su corazón. Éstos incluyen un ecocardiograma. Éste es una imagen de su corazón tomada con ondas sonoras. Nos puede mostrar el funcionamiento del músculo cardíaco, el funcionamiento de las válvulas y la existencia de coágulos de sangre en el corazón. Posiblemente hagamos análisis de sangre periódicos para controlar la dosis de cualquier medicamento que le recetemos. Es posible que la dosis de anticoagulantes necesite ser cambiada ocasionalmente.cuanto más tiempo haya tenido la fibrilación auricular, más difícil puede ser recuperar la frecuencia cardíaca normal. Puede tomar tiempo descubrir cuál es el mejor tratamiento para usted. Algunas personas se acostumbran a los latidos irregulares y conviven con ellos cómodamente durante muchos años.en algunos casos, es posible que necesitemos colocar un marcapasos y detener las señales eléctricas que producen la aceleración de los latidos de su corazón. Un marcapasos puede ayudar a controlar los latidos. Es posible que intentemos solucionar el problema con un procedimiento llama ablación. Éste puede ayudar a corregir las señales eléctricas en su corazón. Lo que deberá tener presente. Llame al 911 o busque ayuda de emergencia en los siguientes casos:. Pérdida repentina de la fuerza, la sensibilidad o la capacidad para mover parte de su cuerpo. Mareos sin ninguna razón aparente. Fuerte dolor de cabeza. Dificultad para hablar. ConfusiónLlame al 911 o vaya al hospital de inmediato si tiene alguno de los siguientes síntomas:. Dolor de pecho agudo u opresivo, o que dura más de 30 minutos. El dolor puede extenderse hasta el cuello o por un brazo.. Problemas graves para respirar. No puede recuperar el aliento aun mientras descansa.. Los latidos no son normales y transpira o se siente mareado, débil o descompuesto.si es posible, tome una o dos aspirinas de inmediato. Mastíquelas en vez de tragarlas con agua. No tome ninguna si ya ha tomado una aspirina ese día.llámenos inmediatamente si presenta alguno de los siguientes síntomas:. Dolor o presión debajo del esternón. Falta de aire aun cuando hace poco esfuerzo. Cualquier dolor nuevo en el cuello o en el brazo, especialmente si siente malestarinfórmenos si cree que el tratamiento no lo está ayudando a aliviar los síntomas. Infórmenos si se le forman moretones fácilmente o descubre sangre en su materia fecal. Page 30 of 252 Copyright Allscripts, LLC Atrial Fibrillation, Chronic Medications: FLU (SPLT) Antiarrhythmics:: Tikosyn 125 MCG Oral Capsule TAKE AS DIRECTED. Qty: 30 Disopyramide Phosphate 150 MG Oral Capsule Extended Release 12 Hour Take 1 every 12 hours. Qty: 60 Amiodarone HCl 200 MG Oral Tablet Take 1 daily. Qty: 30 Flecainide Acetate 50 MG Oral Tablet TAKE 1 TABLET TWICE DAILY Twice daily Qty: 60 Propafenone HCl 150 MG Oral Tablet Take 1 three times daily. Qty: 90 Betapace 80 MG Oral Tablet TAKE 1 TABLET TWICE DAILY Twice daily Qty: 60 Procainamide HCl CR 1000 MG Oral Tablet Extended Release Take one tablet three times daily Qty: 90 Quinidine Gluconate CR 324 MG Oral Tablet Extended Release Take 1 every 8 hours. Qty: 90 Anticoagulation/antiplatelet:: Warfarin Sodium 5 MG Oral Tablet TAKE AS DIRECTED. Qty: 30 Aspirin 81 MG Oral Tablet Delayed Release Take 1 daily Qty: 100 Aspirin EC 325 MG Oral Tablet Delayed Release Take 1 daily Qty: 100 6

7 Beta-blockers:: Metoprolol Tartrate 50 MG Oral Tablet Take 1 twice daily. Qty: 60 Nadolol 40 MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Atenolol 50 MG Oral Tablet Take 1 daily. Qty: 30 Propranolol HCl CR 80 MG Oral Capsule Extended Release 24 Hour Take 1 every 12 hours. Qty: 60 Calcium channel blockers:: Diltiazem HCl 30 MG Oral Tablet TAKE 1 TABLET 4 TIMES DAILY 4 times daily Qty: 120 Verapamil HCl CR 180 MG Oral Tablet Extended Release TAKE 1 TABLET TWICE DAILY Twice daily Qty: 60 Diltiazem HCl 120 MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Verapamil HCl 40 MG Oral Tablet TAKE 1 TABLET 3 TIMES DAILY 3 times daily Qty: 90 Cardiac glycosides:: Digoxin MG Oral Tablet TAKE ONE TABLET EVERY MORNING Qty: 30 Orders: Reminders: Partial Thromboplastin Time (PTT): every 1 MONTHS Therapeutic Drug Assay - Digoxin: every 3 MONTHS Electrocardiogram: every 6 MONTHS Echocardiogram: every 1 YEAR Coagulation Studies: INR: every 3 MONTHS Fluarix Intramuscular Suspension: every 12 MONTHS Fecal Analysis - Occult Blood Imaging: Echo (2-D) During Stress Test Electrocardiogram Cardiac Isotope Image Acquisition Protocol Stress Only Echocardiogram Cardiovascular Stress Test Lab tests: Serum Thyroid Stimulating Hormone (TSH) Coagulation Studies: INR Partial Thromboplastin Time (PTT) Automated Blood Chem. - SMA-6 [see Basic Metabolic Panel] Therapeutic Drug Assay - Digoxin Blood Counts - CBC Instructions: Activity: Continue with our present treatment plan. Page 31 of 252 Copyright Allscripts, LLC Atrial Fibrillation, Chronic Diet: Eat no more than 30 grams of fat per day. Avoid foods and beverages that contain caffeine. Eat a low fat and low cholesterol diet. We recommend you eat foods that will give you 350 mg of magnesium each day. Limit your use of alcohol to 2 drinks or cans of beer a day. We want to put you on the DASH diet for 2000 calories. Lifestyle modifications: There are many exercise options for seniors. Begin a limited exercise program. You need to quit smoking. Monitoring: We want you to wear a Holter monitor. Precautions: Call: You are having chest pain with exercise. You see any blood in the stool. You are falling often. Emergent: You experience a new kind of chest pain (angina) or pressure. You feel your heart is beating too fast. Urgent: You have fainted or passed out. You are too short of breath to talk, you can speak only one or two words between breaths, or your lips or November

8 nails look blue. You have a severe headache that will not go away. Follow-ups and Referrals: Ungrouped: Follow Up; Evaluation and Treatment; Change treatment adult Cardiology Referral; Consult Only; Consult for adult 8

9 Chest Pain, Etiology Unknown Monographs: What is it? You have pain in your chest. At this point, we do not know why. What is the cause? The most common worry about chest pain is that there is something wrong with the heart. While chest pain can be a sign of heart disease, there are many other causes.a common cause of chest pain is acid reflux. This means that acid from the stomach backs up into the tube that leads from the mouth. This is also called heartburn. The pain is usually a burning feeling and occurs in the same area as the heart. A stomach ulcer or a problem with the gallbladder can also cause pain in the chest.you may have strained a muscle in the chest wall. You may have an inflamed cartilage in the rib cage. Your pain may be from a problem in the lungs. Your chest pain may be a sign that you are feeling anxious.at this point we think your pain is not a life-threatening problem. What are the symptoms? The pain may be sharp or dull. The pain may become worse with deep breathing. It may stay in one place or spread to your shoulders, arms, or back. It may get worse when you cough or when you lie down. It may get better if you sit up and lean forward. It may be a burning pain. There may be a place that is tender or sore to the touch. You may notice the pain more when you move or exercise hard. You may have worries about your pain. How is it treated? How we will treat your chest pain depends on the cause. We may do tests to check for possible causes. We may give you medicine to see if that helps. We may refer you for special tests. We may just watch and see if your symptoms change. What can I expect? It may take a while for us to figure out what is causing your pain. For now, continue your regular activities. Be alert to any further incidents of pain. Also be alert to new symptoms or a change in the severity or type of chest pain. It may help to write down when you have pain and what you were doing at the time. What to watch for. Call 911 or go to the hospital right away if you have any of the following symptoms. If possible, take an aspirin on the way.. Chest pain that is severe or crushing, or lasts longer than you have had in the past or longer than 30 minutes. The pain may spread up to your neck or down one arm.. Severe trouble breathing (you can't get your breath even while resting).. Your heartbeat feels wrong and you are sweating or feel dizzy, faint, or sick to your stomach.call us right away if you have any of the following:. Pain or pressure under your breastbone. Shortness of breath even when you are doing very little. Any new pain in your neck or arm, especially if you feel unwellcall us if you have new symptoms or a change in your pain. This information may help us figure out what is causing your pain. Qué es? Tiene dolor en el pecho. A esta altura, no sabemos por qué. Cuál es la causa? Es muy común que la gente piense que el dolor en el pecho representa un problema en el corazón. Aunque el dolor en el pecho puede ser una señal de enfermedad cardíaca, hay muchas otras causas.una causa común del dolor en el pecho es el reflujo ácido. Esto significa que el ácido del estómago sube por el tubo que conecta con la boca. Esto también se llama acidez. Por lo general, el dolor es una sensación de ardor y se produce en la misma área del corazón. Una úlcera gástrica o un problema en la vesícula biliar también pueden causar dolor en el pecho.puede haberse distendido un músculo de la pared torácica. Puede tener un cartílago inflamado en la caja torácica. El dolor puede originarse por un problema en los pulmones. El dolor de pecho puede ser una señal de ansiedad.a esta altura, creemos que este dolor no es un problema que ponga en riesgo su vida. Cuáles son los síntomas? El dolor puede ser fuerte o leve. El dolor puede ser más fuerte al respirar profundo. Puede quedarse en un solo lugar o extenderse hacia los hombros, brazos o espalda. Puede empeorar al toser o al recostarse. Puede mejorar si se sienta o se inclina hacia adelante. Puede ser un dolor con sensación de ardor. Puede haber un lugar sensible o doloroso al tacto. Es posible que note más el dolor al moverse o hacer ejercicio físico intenso. Es posible que esté preocupado por el dolor. Cómo se trata? Cómo trataremos el dolor de pecho depende de la causa. Es posible que hagamos exámenes para buscar las posibles causas. Es posible que le demos un medicamento para ver si ayuda. Es posible que lo refiramos para que se haga pruebas especiales. Es posible que simplemente observemos para ver si los síntomas cambian. Qué puedo esperar? Deducir la causa de su dolor puede tomarnos un tiempo. Por ahora, continúe con sus actividades normales. Esté atento ante cualquier episodio de dolor. También esté atento a nuevos síntomas o ante un cambio en la intensidad o el tipo de dolor de pecho. Escribir en qué momento empezó el dolor y qué estaba haciendo entonces puede ser de ayuda. Lo que deberá tener presente. Llame al 911 o vaya al hospital de inmediato si tiene alguno de los siguientes síntomas. Si es posible, tome una aspirina en el camino.. Dolor de pecho agudo u opresivo o que dura más tiempo que los dolores que ya tuvo o más de 30 minutos. El dolor puede extenderse hasta el cuello o por un brazo.. Serios problemas para respirar (no puede recuperar el aliento aun mientras descansa).. Los latidos no son normales y transpira o se siente mareado, débil o descompuesto.llámenos inmediatamente si presenta alguno de los siguientes síntomas:. Dolor o presión debajo del esternón. Falta de aire aun cuando hace poco esfuerzo. Cualquier dolor nuevo en el cuello o en el brazo, especialmente si siente malestarllámenos si tiene nuevos síntomas o si su dolor cambia. Esta información puede ayudarnos a deducir la causa del dolor. Page 61 of 252 Copyright Allscripts, LLC Chest Pain, Etiology Unknown 9

10 Medications: Antacids:: Aluminum-Magnesium-Simethicone MG/5ML Oral Suspension Take 1 tablespoonful every 2-3 hours as needed. Qty: 360 ML Ri-Mag 540 MG/5ML Oral Suspension Take 1 tablespoonful every 2-3 hours as needed. Qty: 1 ML Alamag MG/5ML Oral Suspension Take 1 tablespoonful every 2-3 hours as needed. Qty: 1 ML Ri Mag Plus MG/5ML Oral Suspension Take 1 tablespoonful every 2-3 hours as needed. Qty: 1 ML Gastric acid inhibitors:: Aciphex 20 MG Oral Tablet Delayed Release Take 1 daily. Qty: 30 Protonix 40 MG Oral Tablet Delayed Release Take 1 daily. Qty: 30 Ranitidine HCl 150 MG Oral Tablet Take 1 every 12 hours. Qty: 60 Nexium 20 MG Oral Capsule Delayed Release Take 1 daily. Qty: 30 Famotidine 20 MG Oral Tablet Take 1 twice daily. Qty: 60 Prevacid 30 MG Oral Capsule Delayed Release Take 1 daily. Qty: 30 Omeprazole 20 MG Oral Capsule Delayed Release Take 1 daily in the morning. Qty: 30 Cimetidine 300 MG Oral Tablet Take 1 four times daily. Qty: 120 GI stimulants:: Metoclopramide HCl 10 MG Oral Tablet Take 1 four times daily. Qty: 120 Muscle relaxants:: Carisoprodol 350 MG Oral Tablet Take 1 four times daily. Qty: 28 Methocarbamol 750 MG Oral Tablet Take 1 four times daily. Qty: 40 Cyclobenzaprine HCl 10 MG Oral Tablet Take 1 three times daily. Qty: 30 NSAIDs:: Celebrex 100 MG Oral Capsule Take 1 twice daily. Qty: 20 Naproxen 375 MG Oral Tablet Take 1 twice daily. Qty: 20 Ibuprofen 600 MG Oral Tablet Take 1 three times daily. Qty: 30 Diclofenac Potassium 50 MG Oral Tablet Take 1 twice daily. Qty: 20 Nabumetone 500 MG Oral Tablet Take 1 twice daily. Qty: 20 Orders: Imaging: Isotopic Scans Lung V/Q Chest X-Ray CT Scan Of The Thorax Echocardiogram CT Thorax With Angiography Coronary Arteries Abdominal Ultrasound Lab tests: Hematology - Erythrocyte Sedimentation Rate Electrocardiogram Stress Test ECG Performed Automated Blood Chem. - SMA-6 [see Basic Metabolic Panel] Blood D-Dimer Test Blood Counts - CBC Troponin Serum Enzyme Levels - Myoglobin Serum Enzyme Levels - CK Isoenzymes MB Fraction Instructions: Activity: You may slowly resume your normal level of activity once you feel better. Do not take aspirin or anti-inflammatory medicines. Regular aerobic exercise can help reduce stress. Begin a limited exercise program. Page 62 of 252 Copyright Allscripts, LLC Chest Pain, Etiology Unknown Several things can be done to help treat and prevent your gastric reflux. Diet: A diet that is low in fat, cholesterol and sodium is considered a cardiac diet. Lifestyle modifications: You need to quit smoking. Procedures: We recommend an EGD. We recommend a cardiac catheterization. Precautions: 10

11 Call: Your chest pain is happening more often. You develop a cough. Your temperature is higher than 101F. Your chest pain feels different to you. You feel nauseated. New symptoms occur. The pain in your chest is not better in 3 days. Emergent: You experience a new kind of chest pain (angina) or pressure. Urgent: You have pain in the stomach area. You become dizzy or lightheaded, especially when you stand up after sitting for awhile. You are feeling short of breath. You feel short of breath even while resting. Follow-ups and Referrals: Ungrouped: Radiology Referral; Evaluation and Treatment; Testing Follow Up; Evaluation and Treatment; Change treatment adult Cardiology Referral; Consult Only; Second opinion 11

12 Coronary Artery Disease, Female Monographs: What is it? Coronary artery disease, or CAD, occurs when fat and cholesterol builds up in the vessels that bring blood to the heart muscle. These deposits limit how much blood and oxygen gets to the heart. The heart is not able to work as well. These deposits can also cause breaks in the lining of the vessels. These breaks may lead to clots and complete blockage. If an artery is entirely blocked, the person may have a heart attack. Even if it is only partly blocked, the heart muscle may not get enough oxygen. People often think of heart disease as a men's problem. This is not true. CAD is the leading cause of death in women as well as men. Only 1 out of every 28 women dies from breast cancer, while half of all deaths in women are caused by heart disease. What is the cause? The main cause of CAD is deposits of cholesterol and calcium on the inside of the arteries leading to the heart. This is called atherosclerosis. It makes the inside of the arteries narrower. Not as much blood can get through. Blood carries oxygen, which is needed by the heart muscles. The deposits tend to crack, and the cracks can tear the vessel walls and cause blood clots to form. Sudden clots are the most common cause of heart attacks. High levels of cholesterol, a kind of fat, in the blood can cause CAD. The tendency to have high cholesterol often runs in families. It can also be caused by eating a diet that has lots of saturated fat and cholesterol. High blood pressure can also raise your risk of CAD. Diabetes is another risk factor. Women who have diabetes are at greater risk of having heart disease than men who have diabetes. Smoking, being overweight, stress, and not exercising can also increase your risk of CAD. Women tend to have lower cholesterol levels and lower blood pressure before menopause. They also are less likely to have CAD before menopause. It appears that estrogen, one of the female hormones, protects against CAD. After menopause, when a woman's body stops making estrogen, her risk of CAD quickly becomes equal to that of a man's. What are the symptoms? You may not have any symptoms at all. We may have found the problem when we did a test called an electrocardiogram. This test can show evidence of a past heart attack or other problems. We may have done an exercise treadmill or other test that shows your heart may not be getting enough oxygen due to coronary heart disease. You may feel pain or pressure under your breastbone when you exercise or exert yourself. If you are older, your only symptom may be that you get out of breath or dizzy when you exert yourself. Climbing stairs, holding your arms up over your head, or having sex may bring on the symptoms. You may also notice symptoms when you are under stress or right after you eat. How is it treated? CAD can often be helped by lifestyle changes, including:. Changes in your diet. One important change is to eat less fat and eat healthier fats. Avoid saturated fats. They are found in animal products, such as meat, butter, and cheese. You also want to avoid trans fats or hydrogenated fats. Basically, you want to avoid any form of fat that is solid at room temperature. It's better to eat monounsaturated fats such as olive and canola oil. Polyunsaturated fats that are found in fish and nuts are also good for you. Women who eat fish regularly or take fish oil supplements have a lower risk of heart attacks. These supplements are sometimes called omega-3 oil. Another healthy change is to eat more vegetables and fruit each day. Avoid simple starches such as sugar and foods made with white flour. Eat whole grains instead.. Exercising more. Even walking 10 to 20 minutes a day will help.. Losing weight if you are overweight. Losing even a few pounds can help lower your risk.. Quitting smoking. We can help you to do this. Smoking greatly raises your risk of heart attack and stroke. If you stop smoking, your risk will drop quickly. This is true even if you have been smoking for many years.. Taking an aspirin every day. This has been shown to lower the risk of heart attack and stroke. The risk of heart disease appears to be less in those who drink alcoholic beverages moderately. This means no more than one drink a day for women. A drink is one 12-ounce beer, one 5-ounce glass of wine, one wine cooler, or one shot of hard liquor. Having CAD is not a reason to begin drinking if you did not drink before, however. You can get the same benefits from drinking grape juice and eating lots of fruits and vegetables. Heavy drinking can lead to high blood pressure, obesity, alcoholism, and stroke. It can cause problems for you at work and at home. If drinking is a problem, we can help you deal with it. Page 68 of 252 Copyright Allscripts, LLC Coronary Artery Disease, Female It used to be thought that hormone replacement therapy, or HRT, helped reduce the risk of heart disease in postmenopausal women. HRT is often given to women after menopause to replace the hormones your body stops making at this time. However, recent studies have not confirmed that HRT prevents heart disease. It does not seem to help if you already have heart disease. We can talk with you about the benefits and drawbacks of HRT. We may prescribe medicine. We may suggest a procedure to open the clogged arteries or surgery to bypass them. What can I expect? If you have symptoms, they should improve when we treat you. You may need to make permanent changes in your lifestyle. This is especially true of the way you eat and exercise. If not treated, CAD increases your chance of having a heart attack. It can raise your risk of stroke. What to watch for. Call 911 right away if you have any of the following symptoms. If possible, take an aspirin.. Chest pain that is severe or crushing, or any pain that lasts longer than 30 minutes. The pain may spread up your neck, to your shoulder, or down one arm. Some women only have pain in the neck or arm.. Severe trouble breathing (you can't get your breath even while resting).. Your heartbeat feels wrong and you are sweating or feel dizzy, faint, or sick to your stomach. You may even vomit. 12

13 Call us right away or seek immediate care if you have any of the following:. Pain, pressure, sense of heaviness, or discomfort under your breastbone. Shortness of breath even when you are doing very little. Any unusual pain in your neck or arm, especially if you feel unwell Qué es? La enfermedad de la arteria coronaria, o EAC, se produce cuando se acumula grasa en los vasos que proveen sangre al músculo cardíaco. Estos depósitos de grasa limitan la cantidad de sangre y oxígeno que ingresa en el corazón. El corazón no puede funcionar correctamente. Estos depósitos de grasa también pueden provocar rupturas en el revestimiento de los vasos. Estas rupturas pueden ocasionar coágulos y obstrucciones completas. Si una arteria está completamente bloqueada, la persona puede sufrir un ataque cardíaco. Incluso si está sólo parcialmente bloqueada, es posible que el músculo cardíaco no reciba suficiente oxígeno.generalmente se piensa que las enfermedades cardíacas son un problema de los hombres. Esto no es verdad. La EAC es la principal causa de muerte tanto en mujeres como en hombres. Sólo 1 de cada 28 mujeres muere de cáncer de mama, mientras que la mitad de las muertes de mujeres son causadas por una enfermedad cardíaca. Cuál es la causa? La principal causa de la EAC son los depósitos de grasa y calcio en el interior de las arterias que conducen al corazón. Esto se llama aterosclerosis. Provoca el estrechamiento del interior de las arterias. Ya no puede pasar la misma cantidad de sangre. La sangre transporta oxígeno, el cual es necesario para los músculos cardíacos. Los depósitos tienden a romperse, y las rupturas pueden desgarrar las paredes de los vasos y ocasionar la formación de coágulos de sangre. La formación repentina de coágulos es la causa más común de los ataques cardíacos.el alto nivel de colesterol (un tipo de grasa) en la sangre puede ocasionar la EAC. La tendencia a tener colesterol alto a menudo es hereditaria. También puede estar ocasionado por una dieta abundante en grasas saturadas y colesterol. La presión arterial alta puede incrementar el riesgo de sufrir de la EAC. La diabetes es otro factor de riesgo. Las mujeres diabéticas tienen un mayor riesgo de contraer enfermedades cardíacas que los hombres diabéticos. El cigarrillo, el sobrepeso, el estrés y la falta de ejercicio físico también pueden incrementar su riesgo de contraer la EAC. Las mujeres en general tienen niveles más bajos de colesterol y una presión arterial más baja antes de la menopausia. También tienen menos probabilidades de contraer la EAC antes de la menopausia. Al parecer, el estrógeno, una de las hormonas femeninas, protege contra la EAC. Después de la menopausia, cuando el cuerpo de la mujer deja de producir estrógeno, su riesgo de contraer la EAC se iguala rápidamente al de los hombres. Cuáles son los síntomas? Usted puede no tener ningún síntoma. Posiblemente hayamos descubierto el problema al realizar un estudio llamado electrocardiograma. Este estudio puede mostrar pruebas de un ataque cardíaco previo u otros problemas.es posible que lo hayamos evaluado en una cinta para correr o con otro estudio que demuestre que su corazón tal vez no esté recibiendo suficiente oxígeno debido a la enfermedad de la arteria coronaria.puede sentir dolor o presión debajo del esternón cuando hace ejercicio o cuando se esfuerza. Si usted es mayor, el único síntoma puede ser que le falta el aire o se marea cuando se esfuerza. Subir escaleras, levantar los brazos por sobre la cabeza o tener sexo pueden provocar los síntomas. También puede notar síntomas cuando está estresado o después de comer. Cómo se trata? A menudo las EAC se pueden aliviar mediante cambios en el estilo de vida, los cuales incluyen:. Cambios en la dieta. Un cambio importante es consumir una menor cantidad de grasas y consumir grasas más saludables. Evite las grasas saturadas. Éstas se encuentran en productos animales, como la carne, la manteca y el queso. También debe evitar las grasas trans o grasas hidrogenadas. Básicamente, debe evitar cualquier forma de grasa que sea sólida a temperatura ambiente. Es mejor consumir grasas monoinsaturadas, como el aceite de oliva y el aceite de canola. También son buenas las grasas poliinsaturadas que se encuentran en el pescado y las nueces. Las mujeres que comen pescado regularmente o toman suplementos de aceite de pescado tienen un menor riesgo de sufrir ataques cardíacos. Estos suplementos a veces se llaman aceites de omega 3. Otro cambio saludable es consumir más verduras y frutas diariamente. Evite los almidones simples, como el azúcar y las comidas preparadas con harina blanca. Por el contrario, consuma granos enteros.. Haga más ejercicio físico. Incluso lo ayudará caminar de 10 a 20 minutos diarios.. Baje de peso si tiene sobrepeso. Bajar incluso unas pocas libras puede ayudar a disminuir el riesgo.. Deje de fumar. Podemos ayudarlo a hacerlo. El cigarrillo aumenta enormemente el riesgo de sufrir un ataque cardíaco y un accidente cerebrovascular. Si deja de fumar, el riesgo disminuirá rápidamente. Esto sucede aunque haya fumado durante muchos años.. Tome una aspirina por día. Se ha demostrado que esto reduce el riesgo de sufrir ataques cardíacos y accidentes cerebrovasculares.el riesgo de sufrir una enfermedad cardíaca es menor en las personas que beben alcohol moderadamente. Esto significa no más de una bebida por día para las mujeres. Una bebida equivale a una cerveza de 12 onzas (354 ml), un vaso de vino de 5 onzas (147 ml), un refresco de vino o un trago de bebida alcohólica fuerte. Sin embargo, tener la EAC no es una razón para comenzar a beber si antes no lo hacía. Usted puede obtener los mismos beneficios si toma jugo de uva y come muchas frutas y verduras. El beber en exceso puede provocar presión arterial alta, obesidad, alcoholismo y accidente cerebrovascular. Le puede causar problemas en el trabajo y el hogar. Si la bebida es un problema, podemos ayudarle a tratarlo.se solía creer que la terapia de reemplazo hormonal, o TRH, ayudaba a reducir el riesgo de enfermedad cardíaca en las mujeres posmenopáusicas. La TRH a menudo es practicada en mujeres posmenopáusicas con el fin de reemplazar las hormonas que el cuerpo deja de producir en ese momento. De todos modos, los estudios recientes no han confirmado que la TRH previene las enfermedades cardíacas. Al parecer, no ayuda si usted ya sufre de una enfermedad cardíaca. Podemos conversar con usted acerca de las ventajas y desventajas de la TRH.Podemos recetarle medicamentos. Podemos recomendar un procedimiento para abrir las arterias obstruidas o una cirugía para revascularizarlas. Qué puedo esperar? Si presenta síntomas, éstos deben mejorar con el tratamiento. Posiblemente necesite realizar cambios permanentes en su estilo de vida. Esto debe aplicarse especialmente a la forma en que se alimenta y se ejercita.si no se la trata, la EAC aumenta el riesgo de sufrir un ataque cardíaco. Puede incrementar su riesgo de sufrir un accidente cerebrovascular. Lo que deberá tener presente. 13

14 Llame al 911 inmediatamente si presenta alguno de los siguientes síntomas: Si es posible, tome una aspirina.. Dolor de pecho agudo u opresivo, o cualquier dolor que dure más de 30 minutos. Este dolor puede extenderse hasta el cuello, un hombro o un brazo. Algunas mujeres sólo sufren de dolor en el cuello o en el brazo.. Serios problemas para respirar (no puede recuperar el aliento aun mientras descansa).. Los latidos no son normales y transpira o se siente mareado, débil o descompuesto. Incluso puede vomitar.llámenos inmediatamente o busque atención médica si presenta algunos de los siguientes síntomas:. Dolor, presión, sensación de pesadez o molestia debajo del esternón. Falta de aire aun cuando hace poco esfuerzo. Cualquier dolor inusual en el cuello o en el brazo, especialmente si no se siente bien Page 70 of 252 Copyright Allscripts, LLC Coronary Artery Disease, Female Medications: ACE Inhibitors:: Altace 10 MG Oral Capsule Take 1 a day Qty: 30 Fosinopril Sodium 10 MG Oral Tablet Take 1 daily Qty: 30 Enalapril Maleate 5 MG Oral Tablet Take 1 twice daily Qty: 60 Captopril 12.5 MG Oral Tablet Take 1 three times daily Qty: 90 Lisinopril 10 MG Oral Tablet Take 1 daily. Qty: 30 Quinapril HCl 10 MG Oral Tablet Take 1 daily Qty: 30 Aceon 4 MG Oral Tablet Take 1 daily Qty: 30 Benazepril HCl 10 MG Oral Tablet Take 1 daily. Qty: 30 Beta-Blockers:: Metoprolol Tartrate 50 MG Oral Tablet Take 1 twice daily. Qty: 60 Coreg MG Oral Tablet TAKE 2 TABLETS TWICE DAILY Qty: 60 Atenolol 50 MG Oral Tablet Take 1 daily in the morning. Qty: 30 Propranolol HCl 40 MG Oral Tablet Take 1 tablet three times daily Qty: 90 Cholesterol-Lowering Agents:: Colestipol HCl 5 GM Oral Packet Take one daily. Qty: 30 Fenofibrate 67 MG Oral Capsule Take 3 daily. Qty: 90 Crestor 10 MG Oral Tablet Take 1 daily. Qty: 30 Gemfibrozil 600 MG Oral Tablet Take 1 twice daily. Qty: 60 Lescol 20 MG Oral Capsule Take 1 daily at bedtime. Qty: 30 Zetia 10 MG Oral Tablet Take 1 daily. Qty: 30 WelChol 625 MG Oral Tablet Take 6 tablets daily with meal. Qty: 90 Zocor 40 MG Oral Tablet Take 1 daily in the evening. Qty: 30 Fish Oil 1000 MG Oral Capsule TAKE 1 CAPSULE 3 TIMES DAILY 3 times daily Qty: 100 Lipitor 20 MG Oral Tablet Take 1 daily. Qty: 30 Vytorin MG Oral Tablet Take 1 daily. Qty: 30 Lovastatin 20 MG Oral Tablet Take 1 with evening meal. Qty: 30 Cholestyramine 4 GM Oral Packet Take 4 grams twice daily. Mix thoroughly in water, milk, or juice. Qty: 1 EA Niacin 500 MG Oral Tablet Take 1 tablet three times daily. Qty: 90 Pravastatin Sodium 40 MG Oral Tablet Take 1 daily at bedtime. Qty: 30 Platelet Aggregation Inhibitors:: Aspirin 81 MG Oral Tablet Delayed Release Take 1 daily in the morning. Qty: 60 Plavix 75 MG Oral Tablet Take once daily Qty: 30 Aspirin EC 325 MG Oral Tablet Delayed Release Take 1 daily in the morning. Qty: 60 Orders: Reminders: Lipid Panel: every 1 YEAR Blood Glucose: every 1 YEAR Hepatic Function Panel: every 6 MONTHS Serum Uric Acid: every 6 MONTHS Serum Triglycerides: every 1 YEAR Electrocardiogram: every 1 YEAR Stress Test ECG Performed: every 1 YEAR Imaging: CT Angiography Coronary Arteries With Quantitative Calcium PET Scan Myocardial Imaging, Perfusion Stress Test ECG Performed Cath Angiography Cardiac Coronary Echocardiogram CT Thorax With Angiography Coronary Arteries Electrocardiogram Lab tests: Page 71 of 252 Copyright Allscripts, LLC November

15 Coronary Artery Disease, Female Hepatic Function Panel Serum Triglycerides Plasma Amino Acids - Homocysteine Blood Glucose Serum Uric Acid Lipid Panel Coagulation Studies - Plasma Fibrinogen Serum C-Reactive Protein Instructions: Activity: Continue with our present treatment plan. Diet: We want you to follow the Therapeutic Lifestyle Changes (TLC) diet. We want to put you on the DASH diet for 2000 calories. Limit your use of alcohol to 2 drinks or cans of beer a day. Lifestyle modifications: Begin a limited exercise program. Regular aerobic exercise can help reduce stress. There are many exercise options for seniors. Decreasing the stress in your life may help your condition improve. You need to quit smoking. Procedures: We recommend that you have a cardiac catheterization. Precautions: Call: Your chest pain is happening more often. Your dizziness is not getting better in 2 days. Your chest pain with exercise is not better in 3 days. Your palpitations are not getting better after treatment at home. You are having more frequent or more severe chest pain with exercise. You have difficulty breathing while lying down and you are comfortable only when sitting up. You are still having difficulty breathing while lying down in 2 days. You start getting short of breath with your normal exercise or physical labor. You feel your heart is beating very fast or skipping beats. You become dizzy or lightheaded, especially when you stand up after sitting for awhile. Your dizziness is getting worse. You are having chest pain with exercise. Emergent: You experience a new kind of chest pain (angina) or pressure. You have fainted or passed out. You have any symptoms of a stroke. You are too short of breath to talk, you can speak only one or two words between breaths, or your lips or nails look blue. Urgent: Your chest pain (angina) happens at rest. Your chest pain feels different to you. Your chest pain (angina) does not go away after 10 minutes of your usual treatment. You have difficulty breathing, or you are short of breath more often. Follow-ups and Referrals: Ungrouped: Follow Up; Evaluation and Treatment; Change treatment adult Cardiology Referral; Consult Only; Second opinion November

16 Coronary Artery Disease, Male Monographs: What is it? Coronary artery disease, or CAD, occurs when fat and cholesterol builds up in the blood vessels that feed the heart muscle. These arteries lie on the surface of the heart and are called the coronary arteries. The fat deposits are called plaque. They limit how much blood and oxygen gets to the heart. The heart is not able to work as well. These fat deposits can also make the artery walls stiffer. A plaque can tear partly away from the wall, causing a break in the lining of the vessel. These breaks cause an inflammatory response in the body, which causes clots to form. If an artery is entirely blocked by plaque or a clot, the person may have a heart attack. CAD is the leading cause of death in men. What is the cause? High levels of cholesterol, a kind of fat, in the blood can cause coronary artery disease. The tendency to have high cholesterol often runs in families. It can also be caused by eating a diet that has lots of fat and cholesterol. Smoking, high blood pressure, being overweight, having diabetes, not exercising, stress and using illicit drugs, such as cocaine, also increase your risk of CAD. The risk goes up with age. What are the symptoms? You may not have any symptoms at all. We may have found the problem when we did a test called an exercise electrocardiogram. This is often called an exercise stress test or treadmill test. It measures how well your heart is working. You may feel pain or pressure under your breastbone when you exercise or exert yourself. If you are older, your only symptom may be that you get out of breath when you exert yourself. You may wake from sleep feeling short of breath. Climbing stairs, holding your arms up over your head, or having sex may bring on the symptoms. You may also notice symptoms when you are under stress or right after you eat. How is it treated? Two factors will determine how we treat your CAD. They are your age and how severe the problem is. We may need to do some more tests. Lifestyle changes are usually needed. We may suggest changes in your diet. A low-fat, high-fiber diet is best. Fiber is found in fruits, vegetables, and whole grains. We may recommend an exercise program. If you smoke, you must stop. If you are overweight, you may be helped by losing weight. We can help you make these lifestyle changes. We may prescribe medicine. We may suggest taking aspirin every day. This can help prevent clots from forming. Sometimes surgery is needed to open the clogged arteries. This can sometimes be done through a tube threaded into your heart from a blood vessel in the groin. Sometimes, open heart surgery is required. What can I expect? Your symptoms should improve with treatment. You will need to make permanent changes in your lifestyle. This will be especially true of your diet and exercise. The risk of heart disease appears to be less in those who drink alcoholic beverages moderately. Moderate drinking means no more than one to two drinks a day. A drink is one 12-ounce beer, one 5-ounce glass of wine, one wine cooler, or one shot of hard liquor. Having coronary artery disease is not a reason to begin drinking, however. You can get the same benefits from drinking grape juice and eating lots of fruits and vegetables. Drinking more than 1-2 alcoholic drinks a day leads to high blood pressure, obesity, alcoholism, and stroke. It can cause problems for you at work and at home. If drinking is a problem, we can help you deal with it. CAD, if not treated, increases your chance of having a heart attack. It may mean you also have a higher risk of stroke. What to watch for. Call 911 or go to the hospital right away if you have any of the following symptoms. If possible, chew an aspirin on the way.. Chest pain that is severe or crushing, or lasts longer than 30 minutes. The pain may spread up to your neck or down one arm.. Severe trouble breathing (you can't get your breath even while resting).. Your heartbeat feels wrong and you are sweating or feel dizzy, faint, or sick to your stomach. Call us right away or seek immediate care if you have any of the following:. Pain or pressure under your breastbone. Shortness of breath even when you are doing very little. Any new pain in your neck or arm, especially if you feel unwell Qué es? La enfermedad de la arteria coronaria o EAC sucede cuando la grasa y el colesterol se acumulan en los vasos sanguíneos que alimentan al músculo cardíaco. Estas arterias se encuentran en la superficie del corazón y se llaman arterias coronarias. Los depósitos de grasa se llaman placas. Limitan la cantidad de sangre y de oxígeno que llega al corazón. El corazón no puede funcionar correctamente. Estos depósitos de grasa también pueden hacer que las paredes de la arteria se vuelvan más rígidas. Una placa puede despegarse en parte de la pared y causar una ruptura en las paredes del vaso. Estas rupturas sangran y provocan la formación de coágulos. Si una placa o un coágulo obstruyen una arteria completamente, la persona puede sufrir un ataque cardíaco.la EAC es la principal causa de muerte en hombres. Cuál es la causa? Altos niveles de colesterol, un tipo de grasa, en la sangre pueden causar la enfermedad de la arteria coronaria. La tendencia a tener colesterol alto a menudo es hereditaria. También puede ser causada por una dieta con demasiada grasa y colesterol. El cigarrillo, la presión arterial alta, el sobrepeso, la diabetes, la falta de ejercicio y el estrés también aumentan el riesgo de sufrir una EAC. El riesgo aumenta con la edad. Cuáles son los síntomas? Usted puede no tener ningún síntoma. Quizás hayamos descubierto el problema cuando realizamos un estudio llamado electrocardiograma de esfuerzo. A este estudio se lo conoce también como prueba de esfuerzo o ergometría Mide el funcionamiento de su corazón.puede sentir dolor o presión debajo del esternón cuando hace ejercicio o cuando 16

17 se esfuerza. Si es mayor, su único síntoma puede ser la falta de aire cuando se esfuerza. Puede despertarse y sentir que le falta el aire. Subir escaleras, levantar los brazos por sobre la cabeza o tener sexo pueden provocar los síntomas. También puede notar síntomas cuando está estresado o después de comer. Cómo se trata? Dos factores determinarán cómo tratamos su EAC. Estos son: la edad y la gravedad del problema. Quizás sea necesario realizarle más estudios. Generalmente se necesitan cambios en el estilo de vida. Podemos sugerirle cambios en la dieta. Lo óptimo es seguir una dieta baja en grasas y alta en fibras. La fibra se encuentra en frutas, verduras y granos enteros. Podemos recomendarle un programa de ejercicios. Si fuma, deje de hacerlo. Si tiene sobrepeso, bajar de peso puede ayudarle. Podemos ayudarle a hacer estos cambios en su estilo de vida.podemos recetarle medicamentos. Podemos sugerirle que tome una aspirina todos los días. Esto ayuda a prevenir la formación de coágulos.algunas veces se necesita cirugía para abrir las arterias obstruidas. A veces, esto se puede hacer deslizando un tubo hacia el corazón a través de un vaso sanguíneo de la ingle. Rara vez se necesita cirugía a corazón abierto. Qué puedo esperar? Sus síntomas deberían mejorar con el tratamiento. Es probable que necesite hacer cambios permanentes en su estilo de vida. Especialmente en su dieta y ejercicios.el riesgo de sufrir una enfermedad cardíaca es menor en las personas que beben alcohol moderadamente. Beber con moderación significa no más de una a dos bebidas por día. Una bebida equivale a una cerveza de 12 onzas (354 ml), un vaso de vino de 5 onzas (147 ml), un refresco de vino o un trago de bebida alcohólica fuerte. Sin embargo, la enfermedad de la arteria coronaria no es una razón para comenzar a beber. Usted puede obtener los mismos beneficios si toma jugo de uva y come muchas frutas y verduras. El beber en exceso puede provocar presión arterial alta, obesidad, alcoholismo y accidente cerebrovascular. Le puede causar problemas en el trabajo y el hogar. Si la bebida es un problema, podemos ayudarle a tratarlo. Si la EAC no es tratada, aumenta el riesgo de sufrir un ataque cardíaco. Puede significar también un riesgo mayor de sufrir un accidente cerebrovascular. Lo que deberá tener presente. Llame al 911 o vaya al hospital de inmediato si tiene alguno de los siguientes síntomas. Si es posible, mastique una aspirina en el camino.. Dolor de pecho agudo u opresivo, o que dura más de 30 minutos. El dolor puede extenderse hasta el cuello o por un brazo.. Serios problemas para respirar (no puede recuperar el aliento aun mientras descansa).. Los latidos no son normales y transpira o se siente mareado, débil o descompuesto.llámenos inmediatamente o busque atención médica si presenta algunos de los siguientes síntomas:. Dolor o presión debajo del esternón. Falta de aire aun cuando hace poco esfuerzo. Cualquier dolor nuevo en el cuello o en el brazo, especialmente si siente malestar Coronary Artery Disease, Male Medications: Coreg MG Oral Tablet TAKE 1 TABLET TWICE DAILY FLU (SPLT) ACE Inhibitors: Altace 10 MG Oral Capsule Take 1 daily. Qty: 30 Ace Inhibitors:: Aceon 8 MG Oral Tablet Take 1/2 daily Qty: 30 Beta-Blockers:: Atenolol 25 MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Propranolol HCl 40 MG Oral Tablet Take 1 tablet three times daily Qty: 90 Coreg MG Oral Tablet take one tablet twice daily Qty: 60 Metoprolol Tartrate 25 MG Oral Tablet TAKE 1 TABLET TWICE DAILY Twice daily Qty: 60 Cholesterol Lowering Agents: Cholestyramine Light 4 GM Oral Packet Take 4 grams twice daily. Qty: 1 EA Fenofibrate 67 MG Oral Capsule Take one tablet daily Qty: 30 Zetia 10 MG Oral Tablet Take 1 daily. Qty: 30 Niacin 500 MG Oral Tablet Take 1 three times daily. Qty: 90 Lescol 20 MG Oral Capsule Take 1 daily at bedtime. Qty: 30 Crestor 10 MG Oral Tablet Take 1 daily. Qty: 30 Pravastatin Sodium 40 MG Oral Tablet Take 1 daily at bedtime. Qty: 30 Lipitor 20 MG Oral Tablet Take 1 daily. Qty: 30 Vytorin MG Oral Tablet TAKE 1 TABLET DAILY Daily Qty: 30 Gemfibrozil 600 MG Oral Tablet Take 1 twice daily. Qty: 60 Niaspan 500 MG Oral Tablet Extended Release TAKE 1 TABLET DAILY Daily Qty: 30 Zocor 40 MG Oral Tablet Take 1 daily in the evening. Qty: 30 Lovastatin 40 MG Oral Tablet Take one tablet with evening meal Qty: 30 Colestid 1 GM Oral Tablet TAKE 2 TABLET TWICE DAILY Twice daily Qty: 120 Platelet Aggregation Inhibitors:: Aspirin EC 325 MG Oral Tablet Delayed Release Take 1 daily. Qty: 60 Plavix 75 MG Oral Tablet Take 1 a day. Qty: 30 Aspirin 81 MG Oral Tablet Delayed Release Take 1 daily. Qty: 60 Orders: Reminders: Lipid Panel: every 1 YEAR November

18 Blood Glucose: every 1 YEAR Hepatic Function Panel: every 6 MONTHS Serum Triglycerides: every 1 YEAR Electrocardiogram: every 1 YEAR FLU (SPLT): every 1 YEAR Imaging: Echocardiogram Electrocardiogram PET Scan Myocardial Imaging, Perfusion Cath Angiography Cardiac Coronary Stress Test ECG Performed CT Thorax With Angiography Coronary Arteries Lab tests: Lipid Panel Plasma Amino Acids - Homocysteine Hepatic Function Panel Serum Triglycerides Serum C-Reactive Protein Blood Glucose Coagulation Studies - Plasma Fibrinogen Instructions: Activity: Regular aerobic exercise can help reduce stress. Decreasing the stress in your life may help your condition improve. Begin a limited exercise program. Continue with our present treatment plan. There are many exercise options for seniors. Diet: Eat a low fat and low cholesterol diet. We want to put you on the DASH diet for 2000 calories. We want you to follow the Therapeutic Lifestyle Changes (TLC) diet. Eat no more than 30 grams of fat per day. Limit your use of alcohol to 2 drinks or cans of beer a day. We recommend that you follow the "Mediterranean diet." Health Maintenance: You need to quit smoking. Brush your teeth 3 times a day and floss at least once a day. Lifestyle modifications: We recommend a goal of 160 pounds for your weight. This equals a body mass index (BMI) of 25. Your present BMI is 27. We recommend that you bring your body mass index down to 26. Monitoring: Keep a diary of when and what you eat. Procedure: We recommend a cardiac catheterization. Precautions: Call: You have difficulty breathing while lying down and you are comfortable only when sitting up. Your palpitations are not getting better after treatment at home. You are having more frequent or more severe chest pain with exercise. Your chest pain with exercise is not better in 3 days. You feel your heart is beating very fast or skipping beats. You are having chest pain with exercise. Your dizziness is getting worse. Your chest pain is happening more often. You become dizzy or lightheaded, especially when you stand up after sitting for awhile. You are still having difficulty breathing while lying down in 2 days. You start getting short of breath with your normal exercise or physical labor. Your dizziness is not getting better in 2 days. Emergent: You have any symptoms of a stroke. You are too short of breath to talk, you can speak only one or two words between breaths, or your lips or nails look blue. November

19 You experience a new kind of chest pain (angina) or pressure. You have fainted or passed out. Urgent: Your chest pain feels different to you. Your chest pain (angina) does not go away after 10 minutes of your usual treatment. Your chest pain (angina) happens at rest. You have difficulty breathing, or you are short of breath more often. Follow-ups and Referrals: Coronary Artery Disease, Male Ungrouped: Follow Up; Evaluation and Treatment; Change treatment adult Cardiac Rehabilitation Referral; ; Cardiology Referral; Consult Only; Second opinion 19

20 Heart Failure Monographs: What is it? Heart failure occurs when the heart muscle is weakened. The heart no longer pumps with enough force to send blood to all parts of the body. As this happens, fluid can build up in the lungs and other parts of the body. Either of these causes symptoms. Failure does not mean the heart has stopped working. It is just not working well. This problem is sometimes called congestive heart failure. What is the cause? Any disease that weakens the heart muscle and affects its ability to pump can cause heart failure. This can include past heart attacks, high blood pressure, narrowing of the arteries that supply the heart, and problems with the heart valves. These diseases can be present for years before you notice symptoms. Another common cause is a problem called cardiomyopathy. This means there is a problem with part of the heart muscle. This may be caused by infection, drinking too much alcohol, or certain medicines. The muscle may have become thickened, stretched, or stiff. This keeps the heart from working well. When the heart is not working well, your body will do some things differently to try to improve this condition. Your heart may beat faster. Part of the heart muscle may grow larger or thicken. Chemicals are released that cause other changes in how your body works. Although this helps you for a bit, after a while these changes cause new problems. For example, the chemicals can cause you to retain fluids. Many of the symptoms of heart failure are from your body's attempts to compensate for heart failure. What are the symptoms? This problem may begin slowly. The most common early symptom is shortness of breath. You may notice this only when you are working or exercising. You may have limited your activities as a result. You may only notice it when you are lying flat. You may have a cough or may notice swelling in your legs or feet. You may experience trouble sleeping. Some people need more pillows to prop them up when lying down in order to breathe comfortably. Some wake up breathless during the night. Feelings of weakness or fatigue after the slightest effort may be a symptom of heart failure. Mild or early heart failure may not cause any obvious symptoms. We may have found it when we did a test to see how well your heart is functioning. How is it treated? Heart failure is treated with medicines. We may give you medicines to help your heart pump better or lower your blood pressure. We may give you medicines to control the problems caused by your body's attempt to compensate. For example, we often give medicines called diuretics. These help you get rid of excess fluid. We may also restrict the salt in your diet. We may suggest that you lose weight or stop smoking. We may suggest exercise. If your heart failure is severe, you may need to be in the hospital for treatment for a few days. We may suggest a pacemaker to help your heart maintain a normal heartbeat. This device is implanted under the skin near your heart. What can I expect? This problem will never go away completely. Your symptoms can be kept under control by following the treatments we prescribe and by making certain lifestyle changes. We will need to monitor your medicines and how you are feeling. Tests may be needed to determine how well your heart is working. In some cases we may suggest surgery to treat heart disease that is causing your heart failure. What to watch for. Seek immediate medical help if your breathing problems get worse or you become overly tired. Get immediate medical help if you feel chest pains (or chest pressure) or if your breathing is getting worse. Qué es? Las insuficiencias cardíacas suceden cuando el músculo cardíaco se debilita. El corazón ya no bombea con la suficiente fuerza como para enviar sangre a todas las partes del cuerpo. Cuando esto sucede, se puede acumular líquido en los pulmones y en otras partes del cuerpo, lo cual produce síntomas. La "insuficiencia" no significa que el corazón haya dejado de funcionar. Simplemente no está funcionando correctamente. A veces, este problema se llama insuficiencia cardíaca congestiva. Cuál es la causa? Cualquier enfermedad que debilite el músculo del corazón y afecte su capacidad para bombear sangre puede producir una insuficiencia cardíaca. Esto puede incluir ataques cardíacos previos, presión arterial alta, estrechamiento de las arterias que alimentan el corazón y problemas con las válvulas del corazón. Estas enfermedades pueden estar en el cuerpo durante años antes notar los síntomas. Otra causa frecuente es un problema llamado miocardiopatía. Esto significa que hay un problema con parte del músculo del corazón. Se puede producir por una infección, el consumo excesivo de alcohol o por el uso de ciertos medicamentos. Es posible que el músculo haya crecido, se haya estirado o endurecido. Esto hace que el corazón no funcione bien.cuando el corazón no funciona bien, su cuerpo hará algunas cosas de forma diferente para intentar mejorar la deficiencia. Su corazón puede latir más rápido. Es posible que parte del corazón se agrande o se ensanche. Se liberan sustancias químicas que producen otros cambios en el funcionamiento del cuerpo. Esto le ayuda por un corto tiempo pero después estos cambios provocan nuevos problemas. Por ejemplo, las sustancias químicas pueden provocar retención de líquidos. Muchos de los síntomas de la insuficiencia cardíaca se originan en los intentos del cuerpo por compensarla. Cuáles son los síntomas? Este problema puede comenzar lentamente. El primer síntoma más común es la falta de aire. Es posible que sólo lo advierta cuando trabaja o realiza ejercicio. Como resultado, es posible que haya limitado sus actividades. Es posible que sólo lo note cuando esté acostado. Es posible que tenga tos o hinchadas las piernas o los pies. Puede tener problemas para dormir. Algunas personas necesitan más almohadas para dormir incorporadas y mejorar su capacidad pulmonar. Algunas se despiertan durante la noche por la falta de aire. Una sensación de debilidad o fatiga después de un esfuerzo menor puede ser un síntoma de insuficiencia cardíaca.la insuficiencia cardíaca leve o temprana puede no provocar síntomas obvios. Tal vez lo hayamos descubierto al controlar el funcionamiento de su 20

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