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February/March | Heart Health
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President's Perspective

Dear IAPA Members:

As the President of Illinois Academy of PA's (IAPA), I welcome you into what will most definitely prove to be a crucial year for every PA in Illinois. IAPA leadership finds ourselves immersed in a very challenging legislative agenda. The PA Practice Act of 1987 will sunset, or expire, December 31, 2017.  What does this mean for you? Without a Practice Act in place, PAs will be unable to practice medicine in the state of Illinois. As you can imagine, legislation written 20 years ago needs updating to accurately reflect modern PA practice.  IAPA is the only organization in Illinois that works to monitor, create, and expand the practice privileges for licensed PAs in Illinois. Your leadership within IAPA is composed of a truly dedicated, top notch assembly of PAs who volunteer to uphold the mission and vision of the organization. I am honored to lead such an inspiring group. In the past, this compact collection of PAs has been able to accomplish impressive legislative victories...victories that have enabled you the practicing PA to write for controlled substances, inject medications, order mammograms, etc. As a PA, your entire scope of practice has been shaped by the efforts of IAPA.

Illinois has approximately 3,200 licensed PAs. This year, I am making an urgent call for every PA in Illinois to pledge support to the only organization that is advocating for you. With the support of your membership, the IAPA leadership team will represent our profession in negotiations with legislators and interest groups to ensure that we can pass a Practice Act that will allow PAs to continue providing excellent patient care. Are you a current member? Do you have friends and colleagues who should become members? I urge you to sign up today online. Do you have questions about the organization? Feel free to contact our Associate Director, Kristin Wormley- Lee, MPA to learn more about our great organization and ways to get involved!

Finally, as you may know, each edition of the Insider is focused on a different major public health priority that we as PAs are committed to improving. As you may know, February is American Heart Month. We hope you enjoy this month's articles written by PAs for PAs around cardiology related themes! Are you interested in writing for the Insider? Contact us today!


Thank you for your support!

Sincerely,

Mindy

 

Mindy Sanders, PA-C, CPAAPA
IAPA President 2017-18

Mindy Sanders is the 2017-2018 President of Illinois Academy of Physician Assistants. She is passionate about legislative advocacy as well as promoting and protecting PA practice. Mindy is a graduate of the Southern Illinois University PA program. She practices full time in Family Practice at Springfield Clinic in Springfield, Illinois. 

Watch our video on heart health! 


Risk Factors in Pregnancy That Predispose Women for Cardiovascular Disease

by Vishali Chand Shah, PA-C


WOMEN AT RISK

Generally speaking, risk factors for cardiovascular disease (CVD) in the childbearing age group include cigarette smoking, family history of premature CVD, an atherogenic lipid profile, DM, HTN, oral contraceptive use and cocaine use.  CVD complicates 1% to 4% of pregnancies, with congenital heart disease being the most common preexisting condition and HTN the most common acquired condition.  Pregnancy contributes to these risk factors by increasing total cholesterol, low-density lipoprotein, and triglycerides; and decreasing high-density lipoproteins.
 
Emerging risk factors for future CVD in women include maternal obesity and gestational diabetes.  Maternal obesity is associated with increased risk of gestational HTN, preeclampsia, gestational diabetes, and high fetal birth weight (>4,000 grams). Gestational diabetes can progress to type 2 diabetes, with the cumulative incidence increasing markedly in the first 5 years after pregnancy. Women with gestational diabetes are 50% more likely to develop type 2 diabetes within 5 years – this puts these women at an even higher risk for heart disease later in life. 
 
An update to the 2011 AHA guideline for the prevention of cardiovascular disease (CVD) in women recommends that risk assessment at any stage of life include a detailed history of pregnancy complications.  A complicated pregnancy history of gestational diabetes, preeclampsia, preterm birth, pregnancy-induced HTN and birth of an infant small for gestational age are ranked as major risk factors for CVD.  A group of disorders collectively known as maternal placental syndromes (MPS) have been associated with increased risk of maternal premature CVD. In CHAMPS (Controlled High-Risk Avonex Multiple Sclerosis Study), MPS were defined as the presence of preeclampsia, eclampsia, gestational HTN, placental abruption or placental infarction during pregnancy. Traditional CV risk factors were more prevalent in women with MPS as compared to women without MPS. The growing body of evidence linking cardiovascular risk factors, MPS, and future CVD might indicate underlying vascular pathology that predates pregnancy and can manifest as MPS during pregnancy or show up as chronic CVD later in life.
 
HTN IN PREGNANCY

HTN (>140/90mmHg) is the most common medical complication of pregnancy and the second most common cause of maternal morbidity and mortality in the US.  Patients can present with gestational HTN, preeclampsia, chronic HTN or preeclampsia superimposed on chronic HTN. Women with a history of preeclampsia have double the increase in risk of future CVD events and strokes later in life.  Anti-hypertensive therapy known to have adverse fetal outcomes should be immediately discontinued prior to conception.  Initial prenatal visits typically include a CMP with particular attention to lab results that may indicate end-organ damage.  Close BP monitoring throughout pregnancy and fetal assessment (ultrasound, NST) is recommended, along with monitoring BP at home as well.  Commonly used medications during pregnancy include labetalol, nifedipine slow release and methyldopa. Pregnancy-induced HTN typically resolves after delivery, however women with this condition are still at risk for developing HTN or CVD in the future.
 
Women with a history of preeclampsia have approximately double the risk for subsequent ischemic heart disease, stroke, and venous thromboembolic events over the 5 to 15 years after pregnancy.  Women with preeclampsia have four times the risk of developing high BP later in life.  Astoundingly, women who have premature births (before 37 weeks) AND preeclampsia have 8-10 times more of a risk of death from heart disease later in life. BNP can be a useful marker in women with preeclampsia. During normal pregnancy, BNP remains low despite volume overload. In mild preeclampsia, elevation of BNP can precede other laboratory abnormalities, such as platelet and abnormal LFTs. Both preeclampsia and eclampsia have been linked to future development of CVD.  Therefore, women with these conditions should receive a traditional annual physical exam for cardiovascular risk factors after pregnancy.
 
DSYLIPIDEMIA IN PREGNANCY

The AAP/ACOG Guidelines currently recommend screening with a fasting lipid panel prior to pregnancy and to monitor throughout pregnancy (every trimester) if values are elevated as well as close follow-up after pregnancy.  Women with pregnancy complications and those who gain excessive weight are more likely to have abnormal lipid profiles. Women with a family history of premature ASCVD have a greater rise in LDL during pregnancy.  Currently there is no association between maternal lipid levels and maternal or perinatal outcomes, preterm delivery, infant low birth weight, or congenital malformations compared to women without family history of CAD.   Treatment of dyslipidemia in pregnancy includes diet, weight management, exercise and lipid lowering medication prior to pregnancy.  Only bile acid sequestrants and mipomersen (for women with homozygous FH) are recommended during pregnancy (pregnancy category B).  After completion of breastfeeding, it is recommended to restart lipid lowering therapy.
 
HEART FAILURE IN PREGNANCY

Peripartum cardiomyopathy (last month of pregnancy to first 5 months postpartum) is associated with increased maternal and fetal risk. The course of peripartum cardiomyopathy differs from that of traditional cardiomyopathy with normalization of left ventricular (LV) dysfunction occurring in about 50% of patients within 6 months after delivery.  In these patients with normalization of LV function following delivery, subsequent pregnancies should be managed at maternal-fetal high risk centers.  An evaluation for CVD should be considered, especially with a family history of early CAD or other risk factors such as smoking, long-standing diabetes, dyslipidemia, or cocaine use.
 
PREVENTION

A critical component of health promotion and ASCVD risk reduction is prevention before or during pregnancy.  This includes a heart-healthy diet, regular exercise, avoidance of tobacco products and maintenance of a healthy weight.  Goal numbers to use as screening include: BP < 120/80mmHg, BMI < 25 kg/m2 and fasting blood glucose < 100mg/dl and total cholesterol < 200 mg/dl.  Post delivery, it is recommended not only for the baby but also for the mother’s heart health to breastfeed as long as possible; mothers who nursed for 6-12 months were 10% less likely to develop heart disease later in life.
 
Increasing the awareness about these conditions during pregnancy may help to identify a woman’s heart disease risk sooner and prevent CVD in women. Obtaining a thorough pregnancy history from all our female patients is vital. Together, we can change the future!

References 

Weiss BM, von Segesser LK, Alon E, Seifert B, Turina MI. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Am J Obstet Gynecol 1998; 179:1643–1653.

Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116:1302–1309.

Siu SC, Sermer M, Harrison DA, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96:2789–2794.

Vrijkotte TG et al., J Clin Endocrinol Metab 2012;97:3917-3925; Toleikyte I et al., Circulation 2011

Ahmed R et al. Pre-eclampsia and future cardiovascular risk among women.J Am Coll Cardiol. 2014;63:1815-1822. doi.org/10.1016/j.jacc.2014.02.529.

Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet 2005; 366:1797–18

 

Mosca L et al., Circulation 2011;123:1243-1262.

Bellamy L et al., BMJ 2007;335:974.

Eckel RH et al., Circulation 2014, doi: 10.1161/01.cir.0000437740.48606.d1. 

Epub 2013 Nov 12.

Wiznitzer A et al., Am J Obstet Gynecol 2009;201:482.e1-e8

Potter JM, Nestel PJ, Am J Obstet Gynecol 1979;133:165

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Washington DC, 2012.

Jacobson TA et al., J Clin Lipidol 2015;9:S1-S122; 

Goldberg AS, Hegele RA, J Clin Endocrinol Metab 2012;97:2589-2596.

Moussa, Arian, Sibai, Women’s Health 2014;10:385-404

Author | Vishali Chand Shah, PA-C
Rush University, University Cardiologists
Vishali Chand Shah, PA-C is currently practicing in outpatient & inpatient cardiology at Rush University.  She has spent the last 8 years of her profession in cardiology and truly enjoys what she does.  She was at Northwestern Memorial Hospital from 2011-2015 working on Galter 10, an inpatient cardiology floor covering telemetry, heart failure and heart transplant patients. Her love of cardiology started while a student in the Emory PA program and came to fruition while landing her first cardiology job in Philadelphia, PA.  She was lucky to cultivate her passion for cardiology with a wonderful father-daughter cardiology practice.  She continues to provide learning experiences to PA students and truly loves her role in cardiology.


Stroke Prevention in Atrial Fibrillation

by Carmen Kaufman, PA-C

 

Atrial fibrillation (afib) is the most common heart arrhythmia. Currently, 4% of people at age 60 have afib and 10% of people over age 80. At least 33 million people worldwide are living with atrial fibrillation. Atrial fibrillation is morbid and there is an overall increased risk of death soon after diagnosis.  Atrial fibrillation has associations with congestive heart failure, coronary artery disease, valvular heart disease and hypertension. The main characteristic of atrial fibrillation is irregular, and often rapid, heartbeats. There can be a multitude of precipitating factors in atrial fibrillation including stress, caffeine, alcohol intake and exertion. Once patients are diagnosed with atrial fibrillation they have a lifelong chance of the atrial fibrillation recurring. Workup for atrial fibrillation includes: checking electrolytes and thyroid function, obtaining ECG, evaluating for ischemia and obtaining an echocardiogram.

In addition to heart rate control, it is important to protect patients in atrial fibrillation from having a stroke. Strokes in atrial fibrillation occur because patients lose their atrial function resulting in impaired emptying from the atria. This leads to stasis of the blood in the atria and can result in clot formation. Approximately 15% of the strokes in the US are related to atrial fibrillation and strokes from atrial fibrillation are associated with increased disability and mortality compared to strokes not related to atrial fibrillation. 

Anticoagulation can prevent strokes in patients with atrial fibrillation. The pneumonic CHA2DS2-VASc is used to determine a patient’s stroke risk. The CHA2DS2-VASc scoring system is:


Using the CHA2DS2-VASc scoring system, scores can range from 0-9. The higher CHA2DS2-VASc score a patient has, the higher his/her risk of stroke related to afib. For example, a patient with a CHA2DS2-VASc score of 2 has a 2.2% risk of having a stroke each year related to atrial fibrillation.  A patient with a score of 9 has a 15.2% risk of having a stroke each year related to atrial fibrillation. It is important to understand the guidelines and have a conversion with patients regarding anticoagulation. The American Heart Association (AHA), American College of Cardiology (ACC) and Heart Rhythm Society (HRS) guidelines indicate that “it is reasonable to omit antithrombotic therapy” patients with a score of 0. Per guidelines, patients with a CHA2DS2-VASc score of 1 can omit antithrombotic therapy, use daily aspirin or use an oral anticoagulant. Patients with a score of 2 or more need a vitamin K antagonist (Warfarin) or a novel oral anticoagulant (NOAC). The NOACs include: Dabigatran (Pradaxa), Rivaroxaban (Xarelto), Apixaban (Eliquis) and Edoxaban (Savaysa). NOACs are not approved for patients with “valvular afib”. Valvular afib is patients with mitral stenosis or artificial heart valves. Valvular afib needs to be treated with a vitamin K antagonist (Warfarin), not a NOAC. 

We have used Warfarin for years.  Warfarin has the longest track record and does requiring routine PT/INR monitoring and dose adjustments to keep the INR in therapeutic range. There are numerous drug and dietary interactions with Warfarin. The time in therapeutic range (INR 2.0-3.0) determines the benefit of Warfarin for patients and when the INR goes above 3 there is an increased risk for intracranial hemorrhage. When each of the NOACs were studied against Warfarin, research proved that all of the NOACs are noninferior to Warfarin for prevention of strooke and systolic embolism in patients with afib. All of the NOACs reduced the risk of intracerebral hemorrhage compared to Warfarin. Additionally, outcomes of major bleeding were generally better with the NOACs than with Warfarin. Dabigatran is a thrombin inhibitor and is associated with a higher rate of dyspepsia compared the other NOACs. Rivaroxaban, Apixaban and Edoxaban are factor Xa inhibitors and often have less GI side effects than Dabigatran. When comparing fall risk on an anticoagulant compared to stroke risk in afib, stratify first based on stroke risk and then think about bleeding.  ACC/AHA guidelines don’t endorse the formal use of bleeding scores as bleeding scores haven’t been well validated with NOACs. The bleeding scores available are designed to predict “major bleeding”, not necessarily intracranial or fatal bleeding. 

In conclusion, the incidence and prevalence of atrial fibrillation continues to rise. Fortunately there are highly effective therapies on the market to prevent or reduce the risk of a stroke in patients with atrial fibrillation. 

Author | Carmen Kaufman, PA-C
Rush-Copley Medical Center

Carmen Kaufman obtained her Bachelor of Science degree in Health Administration from University of Illinois in Urbana-Champaign and attended PA school at Southern Illinois University in Carbondale. She has been practicing for the last 10 years in inpatient cardiology at Rush-Copley Medical Center (RCMC). She is also the chest pain coordinator and co-chairperson of the Advanced Practice Provider Committee at RCMC. Carmen remains a member of IAPA and previously served as President in 2011 and Northern IL Regional Director from 2008-2012. She lives in Naperville with her husband and their 2 sons. 

Capitol Connection

Modernization of PA Practice Act Underway
by Dan Shomon

IAPA's new legislative chairman Dave Purves and IAPA President Mindy Sanders met in January with key legislators in the State Capitol to discuss key issues in the passage of a rewrite of the PA Practice Act.

The Illinois PA Practice Act expires on January 1, 2018 so it must be renewed and IAPA is working with the Illinois State Medical Society, the Illinois Department of Financial and Professional Regulation and other groups to try to craft a practice act that modernizes the practice of PAs. 

Legislation will be introduced by February 10 to extend the practice act until 2028 and the bill will significant improvements in the PA Practice Act to help PAs practice effectively and in a financially competitive manner. 

Dave Purves and Mindy Sanders and a group of Springfield-area PAs also held a reception in Springfield in November with key educators from the health care and licensing committees, the panels that decide on medical practice legislative issues. 

The second IAPA Lobby Day will be held at the State Capitol in Springfield and PAs from throughout the state will help educate legislators about PA practice. 

Author | Dan Shomon
IAPA Lobbyist
Dan Shomon Inc.

Dan Shomon is the CEO of Dan Shomon Incorporated, a full service lobbying and government relations firm. Principal Dan Shomon has 29 years of experience, including 27 working in and around the State Capitol in Springfield. Dan Shomon Inc. is in its second year of representing the Illinois Academy of Physician Assistants and also represents health care clients such as Pfizer, one of the world's largest pharmaceutical companies. Kristin Rubbelke is Director of Government Relations at Dan Shomon Inc. and also works full-time in Springfield on legislative session days. 

IAPA News and Updates

IAPA Legislative Update
by Dave Purves, PA-C

We continue to diligently work on the PA modernization act as our current act will be sunsetting on December 31, 2017. We must have a Practice Act in place in order to practice medicine legally in the state of Illinois. We have had discussions and  continue to work with AAPA and the Illinois State Medical Society on our updates and exclusions from the current bill. Changes such as removing the term supervising physician and replacing it with collaborating physician have been agreed upon.

We are working to remove language related to the current 5:1 ratio as this has become a major issue for PAs trying to work at a walk-in type clinic and also clinics with a limited number of physicians. There is currently no limit to the number of APNs that a physician can collaborate with. Many employers are starting to favor APNs because of this in Illinois. Current rules also contain language stating the PA must be within a reasonable distance to their collaborating physician. We now live in a connected world, where at almost any time of any day your collaborating physician is available by email, text, or phone if there is a problem that needs immediate attention. This is directly affecting PAs by not allowing us to work in minute-clinics that are popping up across the state at major retail locations including CVS, Walgreens, and Target as many of the collaborating physicians are not located within the state. In addition, this is limiting access to care in rural areas where PAs and collaborating physicians are not within the same office. 

Currently, clinics and hospitals across the state are submitting bills for Medicaid patients under collaborating physicians and not the PA that has obtained a history, performed a physical exam, ordered and reviewed labs, imaging, or other tests, made a diagnosis, and formulated a treatment plan. Although, your employer may have a way of tracking this, PAs across the state are not getting the recognized as the billing provider, only the rendering provider. As discussed previously we continue to work on full billing authorization from Medicaid -- The Illinois Academy of Physician Assistants has received clear guidance on Medicaid billing from the Illinois Department of Healthcare and Family Services. Some providers, especially hospitals, had been having problems submitting Medicaid claims because of conflicting information from the state. IAPA's letter clearly points out that Illinois medical providers must submit Medicaid bills with PAs as the rendering provider and their supervising doctor as the signing physician. Our new practice act directly addresses this issue and we will continue to work on this with all parties involved so that PAs can be recognized as billing providers.

The most recent issue in regards to legislation, is that the National Commission on Certification of Physician Assistants (NCCPA) has hired an Illinois lobbyist to try to put a 10-year recertification of PAs in Illinois into our practice act. NCCPA is pushing this because the group apparently lost its national battle with AAPA on maintaining certification. IAPA strongly opposes the proposed language from the NCCPA as this is not a requirement for MDs or APNs.

Mindy Sanders, Dan Shomon, and myself met with Representative Mike Zalewski on January 25th to review the new act, provide rationale for what we are asking for, and discuss many of the issues we currently have as PAs and how this act will help resolve those. Ultimately our new act is about providing better patient access and care from PAs and removing language that is more than 20 years old. Our profession has and will continue to evolve, as will our practice act. The bill will be filed next week with excellent co-sponsorship from the House of Representative and Senate. The bill will be introduced by Representative Zalewski, with Representatives Cynthia Soto, Randy Frese, Brandon Phelps, Sara Wojcicki-Jimenez, Jaime Andrade Jr., Gregory Harris, and Marcus Evans Jr. co-sponsoring from the House. Senators Iris Martinez, Pamela Althoff, Michael Connelly, and Wm. Sam McCann are the co-sponsors from the Senate. We have excellent bi-partisan support of the bill.

Please consider taking the time to contact your Senator and Representative to ask for their support of our new practice act bill. We will also have our annual “IAPA Lobby Day” in March to ask for further support of the new practice act, review the bill and answer any questions Senators and Representative may have. Thank you for your support of IAPA. We have to continue to push for increased membership and involvement in IAPA to support these efforts.

Current Senate Members
Current House of Representatives 

Author | Dave Purves, PA-C
President-Elect, IAPA
Legislative Chair, IAPA
Dave Purves PA-C, is a Physician Assistant in The Orthopedic Group at Springfield Clinic. He has been at Springfield Clinic since he graduated from Marywood University, in Scranton, PA in 2007. He is originally from Springfield, IL. In addition to practicing Orthopedics full-time for the past 10 years, he has also worked in Emergency Medicine and also at Springfield Clinic Prompt Care setting. He has held leadership roles within Orthopedics and served on board level committees at Springfield Clinic. Prior to becoming President-Elect in 2017 he was on the IAPA Legislative Committee and will continue to serve as the Legislative Chair in 2017. Dave loves spending time with his family, including 2 kids and living a active lifestyle, participating in triathlons throughout the year. 

IAPA CME Needs Your Help!

IAPA is in the process of planning their Fall CME which will be held, Friday, September 15-16 at the Big Ten Conference Center.  If you are interested in being part of the planning process, a speaker, or know someone who would like to be a speaker please contact your Associate Director,
Kristin Wormley-Lee at kristin@affinity-strategies.com

The Student Section

 

Beyond the Basics Women’s Drive

by Brianne Cassidy, PAS

While the holiday season is a time for baking cookies and family gatherings (and no exams for PA students!), it is also a time for giving. Rosalind Franklin University’s PA program kicked off December with a philanthropic event titled Beyond the Basics Women’s Drive. Spearheaded by the Class of 2018 Co-chairs of Diversity, Inclusion and Philanthropy, Tara Miller and Rashawn Sims, this campaign sought to collect items for a local battered women’s shelter. The goal was to donate not only essentials but also those non-essentials that truly help a woman look and feel her best, such as makeup and hair products.

A scary statistic is that one in three women are victims of domestic abuse. Women who escape the cycle are forced to start over with no income, little support and few resources.  A Safe Place in Lake County, IL provides safe housing and other supportive services for survivors of domestic violence at no cost. Partnering with three other diversity and inclusion clubs from RFU (WHIG, WISDOM, and American Medical Woman’s Association), our PA program set a goal of 100 items. Whether it was adding a couple things to holiday shopping lists or looking around for unused and unwanted toiletries, everyone got in the altruistic holiday spirit and the boxes began to fill with bedding, winter hats, body wash and more. Within two weeks we had exceeded our goal. A Safe Place was grateful for all our donations and we were happy to help out a very worthy cause.


Photo: Rashawn Sims drops off donated goods at A Safe Place.
 

Events

 

Illinois Region 1 Trauma Symposium 

Saturday, March 4, 2017 
Radisson Hotel & Conference Center 
Rockford, IL 
Download Registration Form
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