AANP Member Spotlight: Sharing the Nurse Practitioner (NP) Perspective at Heart House Roundtables

Hear from Leslie Davis, PhD, RN, ANP-BC, FAANP, FPCNA, FAHA, on why NPs need a seat at the table to discuss our country’s most important cardiovascular issues.

The American College of Cardiology (ACC) invites nationally recognized experts from a variety of government agencies, health systems and professional organizations to its Heart House Roundtables for facilitated, in-depth discussions on a variety of cardiovascular topics. These roundtable meetings are designed to explore the day-to-day challenges that both health care providers and patients face across the country and to encourage solutions through the development of expert consensus papers, patient education, guidelines and other documents.

Since 2013, more than a dozen Heart House Roundtables have addressed pressing topics, including risk assessment and management in cardio-oncology, cardiovascular disease risk for patients with diabetes, emerging strategies for heart failure, low-density lipoprotein (LDL) and much more. Dr. Davis, who has represented the American Association of Nurse Practitioners® (AANP) on several Heart House Roundtables, explains that these meetings have rollout implications for all health care providers.

“I love bringing my expertise to Heart House, respectfully making key points and learning from the participants, whether they are cardiologists, internists, advanced practice registered nurses, nurses, patients or other experts,” she says. “It really matters who is at the Heart House, because they can directly impact the future of health care. When someone has particular expertise on a topic, they may be invited to contribute in a way that actively changes how we practice.”

Myocardial Infarction: Differences in Type 1 and Type 2

In 2016, Dr. Davis attended a Heart House Roundtable on heart failure: “Mortality rates are still very high for patients with heart failure. We have heard that patients have a lot of unmet needs and clinical questions that need to be answered. We were very hands-on and action-item driven in figuring out how to best meet the needs of these patients.”

Products from the roundtable, for which Dr. Davis was a contributing author, included two expert consensus documents and several tools and resources for clinicians and patients newly diagnosed with heart failure with reduced ejection fraction.

In November 2019, Dr. Davis represented AANP on a roundtable addressing dilemmas related to type 2 myocardial infarction (MI), which is just one of several types of MI. According to the ACC, the term MI should be used when there is acute myocardial injury with clinical evidence of acute myocardial ischemia and with detection of a rise and/or fall of cardiac troponin values (cTn) with at least one value above the 99th percentile upper reference limit (URL) and at least one of the following:

• Symptoms of myocardial ischemia.
• New ischemic ECG changes.
• Development of pathological Q waves.
• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology.
• Identification of a coronary thrombus by angiography or autopsy (not for type 2 or 3 MI).

In addition, post-mortem demonstration of acute athero-thrombosis in the artery supplying the infarcted myocardium meets the criteria for type 1. Evidence of an imbalance between myocardial oxygen supply and demand unrelated to acute athero-thrombosis meets the criteria for type 2.

“What we are trying to figure out is: Does the average clinician know the difference between type 1 and type 2 MI? The average clinical team member may see that blood work showed MI and will treat the patient to prevent a second incident along type 1 MI guidelines. However, with type 2 MI, patients are sicker because there is another cause of their MI even though they may look identical to type 1 patients. This means they may be admitted more frequently, and clinicians may need to bill differently according to Centers for Medicare and Medicaid Services [CMS] guidelines,” she explains.

“In addition, sometimes it may be myocardial injury instead of MI. Our discussion among the room full of scientists and clinicians was on how we can best educate health care providers, help them interpret these different components, and explain the differences and care plans to patients. As blood tests become more sensitive and new lab tests are rolled out nationwide, ongoing education will be necessary for all clinicians and their patients.”

The NP Point of View

In December 2019, Dr. Davis participated in the roundtable on navigating treatment decisions for patients with atherosclerotic cardiovascular disease (ASCVD) and multiple comorbidities. About four in 10 adults in the U.S. have two or more chronic conditions, and the two most common comorbidities are cardiovascular conditions.

“These are some of our sickest patients, and while there are clinical guidelines for each individual condition, they need to be merged together to allow clinicians to offer more patient-centered treatment, with personalized care that takes into consideration all comorbidities. This is especially important for NPs, as we treat all of these conditions,” says Dr. Davis.

“The roundtable allowed presenters to share case studies and explain how to juggle multiple guidelines, set priorities and best communicate with patients. While expert cardiologists were at the table, it was very important to be able to explain that other members of a patients’ care team need this information as well. One participant, a patient herself, expressed the need for patients to be able to share which condition bothers them the most to prioritize care. This discussion on shared goal setting allowed me to bring up an article I read that showed how nurses and NPs can conduct pre-visit calls with patients to help with this prioritization.”

Inviting a diverse selection of participants, including NPs, to join these roundtable meetings is imperative to creating inclusive clinical documents and guidance. Whereas, in the past, a document might have only referred to “doctors” or “cardiologists,” newer products may use “cardiovascular team members,” instead.

“It’s about using the right language, including moving away from terms like ‘mid-level providers’ and speaking from both a specialist and primary care perspective,” says Dr. Davis. “I’m able to remind others that NPs have Full Practice Authority in several states across the U.S. and that we take a whole-person approach to care.”