IN THIS ISSUE
APP SPOTLIGHT
SPECIALTY SPOTLIGHT: EP/Cardiology
Winter Blues information from Jenna Rhodaberger
UPCOMING EVENTS/CME
INDEPENDENCE
HEALTH SYSTEM
Greetings amazing, intelligent, compassionate APPs!
We have almost made it through arguably the worst part of the year in terms of mood-dwindling weather and relentless seasonal illnesses. I hope the winter has treated you all as well as possible and that you find yourselves feeling energized and hopeful as we head into the spring!
When looking at motivational quotes for this issue, I came across the following by Frederick Douglass, “If there is no struggle, there is no progress.” I found this to be very relevant to my practice and maybe at least a few of you can relate. Some days, it seems each patient case that walks through the door is straight forward, helping me to feel confident about how I am going to treat the patient. Conversely, there are other days when nothing seems textbook or simple leading me to “phone a friend” or reference UpToDate constantly.
The truth is, we are all learning every day: Especially on those days that humble us and shake our confidence. While those days don’t feel the best, those are the days that are shaping us into great providers and pushing us to be better.
Never be afraid to ask a peer for help, take a minute to steady yourself, or just simply acknowledge that the day is really tough. Keep pushing forward and give yourselves grace, especially on the hard days.
As always, thank you for your hard work and excellent patient care.
News for Independence Health System Advanced Practice
Specialty Spotlight: Cardiology/Electrophysiology
We are thrilled to highlight Cardiology and Electrophysiology for our specialty spotlight this issue. We would like to give a huge thank you to Maggie Spingola, CRNP and Melissa Shute CRNP for providing the great information below.
What are the most common consults you see (inpatient and outpatient)?
AFib patients are definitely the biggest subgroup of our patient population both inpatient and out! Device patients are also a large portion of our patients as well.
Are there any specific consults that you feel could often be managed by the primary service? Or is there anything you wish other services knew about your specialty?
We are always happy to see any patient and work with the primary and consulting teams to help out. One of consults we often get is for new reduced ejection fraction. As we know, patients with reduced EF can be candidates for ICD placement. There is, however, a global period of typically 90 days after first identifying low EF before a patient can be considered for an ICD implant (with some exceptions!). During this time, it's important to maximize guideline directed medical therapy to reduce morbidity, mortality, and rehospitalization as well as to determine if the EF will improve meaning the patient may not need an ICD.
What are some of your favorite things about your specialty?
EP offers a great opportunity for patient education which is a passion for me. Being able to spend time with patients and their families to ensure that the treatment plan is the best option for them and their lifestyle is incredibly rewarding.
What are the biggest challenges of your specialty?
One of the hardest things for me in starting in EP was learning about cardiac devices. This has been a very steep learning curve and I'm still learning new things every day!
Atrial fibrillation is a progressive condition. Episodes will increase in frequency and duration without treatment. This can lead to a higher burden of symptoms as well as increased risk for development of heart failure and cardiomyopathy. Antiarrhythmic drugs (including dofetilide, sotalol, amiodarone, flecainide, and propafenone) require close oversight with every 6-month monitoring of renal function and electrolytes as well as review of current EKG. Depending on the medication, yearly chest X ray, q 6 month thyroid and liver function testing, as well as routine ocular exams may also be indicated.
Amiodarone is a Class 3 antiarrhythmic that can be highly effective in arrhythmia management however it also has an extensive side effect profile. If at all possible, patients should not be maintained on amiodarone long term.
Test your Electrophysiology knowledge!
(Answers with rationales on last page of Newsletter)
1: What is the purpose of an EP study?
a: To evaluate the heart's native conduction system
b: To locate and identify arrhythmias
c: To assist in guiding treatment options for arrhythmia management
d: all of the above
2: A 62 yo patient with Atrial fibrillation presents to the office for a routine follow up. In discussion, you learn that she has not been taking Xarelto consistently with a large meal as she typically just snacks throughout the day. In addition to the AFib, her past medical history includes prior TIA and kidney disease with last creatinine 1.7. CrCl 43 mL/min. Vital signs in the office were BP 128/72, HR 65, O2 Sat 96% on RA, Weight is 70 kg. Current home medications include Xarelto 15 mg daily, diltiazem 180 mg daily, lisinopril 20 mg daily.
How would you manage anticoagulation?
a: Maintain Xarelto at the current dose without any lifestyle modifications
b: Change to Eliquis 5 mg BID
c: Change to Eliquis 2.5 mg BID
d: Increase Xarelto to 20 mg and encourage taking the medication with a larger meal daily
In this issue, we will be spotlighting Melissa Shute, CRNP. Melissa is a nurse practitioner with Electrophysiology. She completed her CRNP training at Georgetown University in 2015. She has been with our health system since 2017, starting with EP right away. Prior to this, she worked as an RN in the cardiac ICU, neonatal ICU, and pediatric ICU.
What is your favorite thing about your career?
Melissa Shute, CRNP
Independence Health System, Butler: Electrophysiology
I love when I am able to help patients understand their specific cardiac arrhythmia and/or cardiac device. It is empowering for patients to understand what is happening with their heart, what the options are for management of the specific condition, and what their role is in their health. I feel that I am providing a valuable service to patients when they tell me that they truly understand their diagnosis when they leave their appointment with me.
What is your current role like?
I currently cover both the hospital and the office. Hospital coverage consists of rounding on patients who are admitted to our service as well as meeting with patients who require an Electrophysiology consult. Our consult patients range from both established patients of our practice to brand new patients and allow us to provide both ongoing EP Care during hospitalization or to establish care with patients who are newly diagnosed with an Electrophysiology concern. During office shifts, I see patients with a variety of needs, ranging from routine oversight for anti-arrhythmic medication, routine oversight of cardiac devices, patients who are experiencing malfunction of cardiac devices, patients who are post catheter ablation and patients who are experiencing difficulty managing their cardiac arrhythmia. One of the things that I value most is that as APP's, we meet with patients independently but work with very supportive physicians who are available to collaborate in the event of a particularly challenging case. It allows us to develop well-established patient-provider relationships and provide continuity in the care that we provide.
What inspired you about your career?
One of the things that I value most about my role as a nurse practitioner is knowing that I can provide reassurance to patients during their hospital admission. As a result of building relationships with patients through our office visits, it can be very reassuring for them to see a familiar face during an unexpected hospitalization. Being able to make a positive difference for patients is what inspires me the most.
What was your first job?
Dairy Queen.
What is the one thing you cannot live without?
Coffee ��
Upcoming Events and CME
UnwrAPPed: Thank you to those of you tuned into the “Rhythm and News” CME! Please stay tuned for information on the next UnwrAPPed segment
CME: Clinical Review of Measles with Dr. William Jenkins, MD, FACEP
3/19/2025 12pm-1pm virtually via teams
Please refer to Loop for link to join
Lifestyle Coaching: Total Joint Replacement Informational session with Dr. Thomas Muzzonigro and Zach Weber, PA-C 3/25/2025 5-6 pm Findley Auditorium
APP Committee Meeting: 5/14/25 12:30-1:00pm
Spring Symposium 2025
A Breath of Fresh Air: Updates in Pulmonary Medicine
2025 APP Spring Symposium will be held on April 11, 2025 from 1-5pm at Butler Memorial Hospital in the Findley Auditorium
Please refer to the Loop for the link to register!
As always, if you have any ideas of anything you would like to see in the newsletter or would like to see a certain peer or specialty in the spotlight, please do not hesitate to reach out: katelyn.soldner@independence.health
Welcome to the team newAPPs!
Melanie Bertges, PA-C: Primary Care
Daniel Hazelbaker, CRNA
Matthew Coy, CRNA
Robert Cooper, CRNA
Patrick Chirdon, CRNA
Jayme Lipnichan, CRNP: Psychiatry
Allison Hough, CRNP: urgent care
Stephanie Pasquarette, CRNP: Family Medicine
Shelby Fillman, CRNP: Women’s Care
Erin Lechner, PA-C: Family Medicine
Rhett Wahler, PA-C: Ortho, TriRivers
Alexander Altmire, PA-C: Bariatric Surgery
Tara Coulter, PA-C: Psychiatry
Corbin Miller, PA-C: Emergency Medicine
Answers to cardiology/EP questions-
1: D: EP studies are invasive, catheter-based procedures that allow the Electrophysiologist to both test the heart's native conduction system and also allow for mapping to locate arrhythmias. At times, IV medications can be used to actually induce arrhythmias to help identify the underlying rhythm as well as to determine the origin of an abnormal rhythm in the heart. Many times, an EP study is coupled with an ablation to treat the site of the arrhythmia. Other times, findings can help identify the need for a cardiac device such as a pacemaker or defibrillator.
2: B: Of the options listed, B is the best answer. Xarelto is dosed by Creatinine clearance. 20 mg daily is the correct dose for Afib patients with CrCl greater than or equal to 50 mL/min. With this patient's creatinine clearance at 43 mL/min, 15 mg would be the correct dose for her. Also, Xarelto needs to be taken with a large meal consistently each day to allow for optimized bioavailability. It would be reasonable to also consider keeping her on the current dose of 15 mg Xarelto and encouraging a lifestyle change to take this with a large meal consistently each day. Eliquis is dosed on renal function, but also based on weight and age. 2 of the following 3 criteria must be met:
• Age 80 or greater
• Body weight 60 kg or less
• Creatinine 1.5 or greater
While she does have renal disease with creatinine 1.7, she is only 62 and body weight is 70 kg. 5 mg BID is the correct dose of Eliquis for this patient.