View all . Skills to determine nutritional needs of patients receiving ventilatory support and order appropriate nutritional supplementation. Skill to care for patients with cardiac devices receiving ionizing radiation. Recommendations in these statements are based on available evidence and, where evidence is lacking, reflect the consensus of expert opinion. "Nurses as substitutes for doctors in primary care" Know the advantages and disadvantages of various transcatheter and surgical options for patients with valvular heart disease, including replacement with mechanical or biological prostheses and valve repair. Know the genetic implications of family history and environmental and lifestyle factors in the development and clinical course of cardiovascular disease. 4. Knowledge should be maintained and enhanced through regular review of journals and other sources of reliable information and through participation in scholarly scientific meetings, continuing professional education activities, and professional congresses. The work of the writing committee was supported exclusively by the ACC without commercial support. Skill to identify needs of patients when current management goals are no longer effective (e.g., long-term needs such as palliative care and termination of device therapy). All tables distinguish competencies generally expected of all cardiovascular NPs and PAs (left column) from those generally expected of selected cardiovascular NPs and PAs based on background, specialized knowledge, skills, experience, and practice focus (right column). Know the objective and subjective methods to assess volume status in patients with heart failure. Criteria for Evaluation of Nurse Practitioner Programs (2016) View 2002, 2008, 2012 Versions. Demonstrate high ethical standards in personal and professional conduct. 9. Educate healthcare professionals about diagnosis and management of patients with a condition in one’s area of expertise. Know the differential diagnoses of chest pain, palpitations, fatigue, lightheadedness, syncope, dyspnea, and peripheral edema. Skill to coordinate care transitions across the lifespan for individuals with congenital heart disease. Participate in practice-based continuous quality improvement and safety initiatives. It is important to recognise that these competencies may take time to fully develop and consolidate, progress will vary according to working context and the individual. Subsequent updates have incorporated major advances and revisions—both in content and structure—including a further move toward competency-based training, and the use of the 6-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, and endorsed by the American Board of Internal Medicine. Ambulatory and Consultative Care Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2494, Table 7. Demonstrate mutual respect, consideration, and empathy for patients, families, and the healthcare team. Know the indications for cardiac catheterization for adults with simple congenital heart disease. Know the risks and benefits of exercise in adults with simple congenital heart disease. Know the causes, pathophysiology, and natural history of coagulopathies that increase patient risk for deep vein thrombosis and pulmonary emboli. Review medical records, complete documentation, and communicate diagnostic findings and management strategies to patients and collaborating healthcare professionals in a timely manner. Promote patient and family access to community resources and interdisciplinary care services/providers to enhance effective self-care behaviors and promote well-being. Skills to assess and manage statin-associated muscle symptoms. Psychiatric Mental Health Nurse Practitioner Competencies (PDF file) The page you are accessing is a downloadable PDF file. You will get to know the people and groups of people who were imbued with the vision of improving, updating and standardizing Nursing education and practice through this and previous undertakings. Know the indications for genetic testing and counseling in patients with inherited cardiomyopathy syndromes. Objective evaluation of clinical competence in the practice setting can be challenging and sometimes overlooked. "Primary care workforce shortages: nurse practitioner scope-of-practice laws and payment policies" Skills to recognize and manage cardiac arrhythmias during cardiac rehabilitation sessions. Know the history and physical examination findings and their limitations in the evaluation of patients with heart failure. Know the indications for and characteristic findings of imaging studies used to evaluate patients with pericardial diseases. Skills to participate in elective cardioversion and manage risks and complications. Skill to distinguish stable from unstable coronary syndromes. Vascular Medicine Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2509, Author Relationships with Industry and Other Entities (Relevant) 2512. Know the indications, risks and benefits, and surveillance for anticoagulation and bridging in patients with atrial arrhythmias. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. The general cardiovascular competencies for NPs and PAs provide a foundation for practice, given individual learning needs, practice setting, and baseline knowledge. Know the pathophysiology of acute heart failure in peripartum and postpartum women. Skills to recognize and medically manage specific wide complex tachycardias (e.g., monomorphic and polymorphic ventricular tachycardia). Know the pharmacology, classes, indications, contraindications, risks, and interactions of medications commonly used for prevention and treatment of cardiovascular disease. Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduate quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency.. Patient-Centered Care; Teamwork & Collaboration; Evidence-Based Practice Know the evidence-based pharmacological and nonpharmacological interventions to manage a critically ill patient with heart failure or cardiogenic shock. Skill to participate in insertion of an invasive and/or hemodynamic monitoring vascular access catheter. Know the effects of lifestyle, activity level, body mass, nutrition, tobacco, alcohol, and recreational drug use in patients with and at risk of cardiovascular disease. General Practice Nursing, NHS England/NHS Improvement who leads the GPN Ten Point Plan and Beverley Harden, Associate Director of Education & Quality, Health Education England. stream Skills to initiate and manage dual antiplatelet therapy and/or anticoagulants in patients with acute coronary syndromes. Skills to recognize and manage signs and symptoms that indicate an adverse response to exercise during cardiac rehabilitation sessions. Skill to identify patients with pericardial disease who are candidates for cardiac catheterization. Skills to interpret exercise and pharmacological stress test reports with or without imaging and apply results to clinical decision making. The basic assumption of CBE is that the student will demonstrate acquisition of the identified essential knowledge, skills, and attitudes expected for the designated educational process before leaving the learning environment. Know advanced therapies for pericardial disease. All documents are subject to rigorous peer review and public comment. Know the indications for and contraindications to noninvasive and invasive testing in the evaluation of patients with stable ischemic heart disease, variant angina, post. Skill to recognize adverse effects of antihypertensive medications. Know causes of angina pectoris not related to coronary artery disease. "Cardiovascular nursing: scope and standards for practice" Know the types of, indications for, and contraindications to mechanical circulatory support, including intra-aortic balloon counterpulsation, percutaneous and surgical ventricular assist devices, and extracorporeal membrane oxygenation. Skills to obtain a clinical history and perform a physical examination of the peripheral circulation. Skill to perform a physical assessment and examination for patients with lipid disorders. Know the indications for, expected outcomes of, and complications of surgery in patients with pericardial diseases. Cardiovascular Disease Prevention Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2498, Table 9. . Skill to participate in diagnostic and interventional procedures. Know the complications of vascular access. Skill to manage hemodynamically unstable patients. Scholarly activity and clinical research are also important in lifelong learning and professional competency. Skills to recognize and manage complications of central venous pressure, invasive arterial, and/or hemodynamic monitoring systems. Know the utility of biomarkers in the management of patients with heart failure. Skill to identify patients at risk for abdominal and thoracic aortic aneurysms. Know the indications for, contraindications to, and pharmacology of fibrinolytic agents and glycoprotein IIb/IIIa inhibitors. Know the correlation between hemodynamic waveforms and patient physiology. Know the pharmacology of commonly used cardiovascular medications in diverse patient populations. Know the mechanisms and clinical implications of essential, secondary, masked, white-coat, and resistant hypertension. Skills to evaluate and manage patients with new-onset, chronic, and acutely decompensated heart failure. This resulting document describes the key anticipated competencies for cardiovascular NPs and PAs, including those in general cardiovascular practices and those in focused areas of cardiovascular medicine. Know the indications for referral of patients with advanced or complex valvular heart disease to a multidisciplinary heart team. 3. Know the strategies for promoting behavioral change and treatment adherence in primary prevention of atherosclerosis. Skill to identify genetic syndromes in adults with congenital heart disease. Journal of the American Association of Nurse Practitioners: March 2020 - Volume 32 - Issue 3 - p 200-217. doi: 10.1097/JXX.0000000000000384. Skill to assist in implementation of mechanical circulatory support for patients with complications of acute coronary syndromes. Know revascularization strategies for patients with acute coronary syndromes. Know the comorbidities associated with lipid disorders. Know the causes, physical findings, and treatment of lymphedema. Skills to recognize and manage musculoskeletal limitations during cardiac rehabilitation sessions. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. RN Continuing Competency Program Forms 2020 2 REGISTRATION NUMBER: Part A: Self-Assessment Instructions Completing a self-assessment each year helps you review the practice expectations for RNs and monitor your progress from one year to the next. 19/11/2020 Office hours this holiday season. Skill to educate patients with cardiovascular disease on a heart healthy diet regimen. Skills to identify physical findings, evaluate, and manage patients with constrictive pericarditis. Know the indications, risks, and complications of device extraction. The writing committee convened by conference call and e-mail to finalize the document outline, develop the initial draft, revise the draft based on committee feedback, and ultimately approve the document for external peer review. Respectfully participate in interdisciplinary care teams and consider opposing viewpoints for management. Acute Coronary Syndromes Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2490, Table 5. Know the indications for and contraindications to computed tomographic angiography, magnetic resonance angiography, and invasive angiography in patients with known or suspected venous and arterial disease. Seton Heart Institute—Associate Chief of Cardiology for Education; Dell Medical School—Associate Professor of Medicine, Mayo Clinic, Department of Cardiovascular Medicine—Associate Professor of Medicine, Boston Children’s Hospital BACH Cardiology—Physician Assistant, United Heart and Vascular Clinic, AllinaHealth—Nurse Practitioner-Electrophysiology, Baylor Scott & White Health—Nurse Practitioner in Advanced Heart Failure Clinic, Penn Medicine, Heart and Vascular Intensive Care Unit—Nurse Practitioner, Bozeman Deaconess Cardiology Consultants—Cardiologist, Mayo Clinic, Department of Cardiovascular Diseases—Nurse Practitioner, Lucile S Packard Children’s Hospital Stanford—Program Director, ACHD Service; Stanford Hospital and Clinics—Clinical Associate Professor, University of Michigan—Nurse Practitioner, Adjunct Clinical Faculty, School of Nursing, Emory Healthcare—Director of Strategic and Programmatic Initiatives, Heart and Vascular, Einstein Health Network, Greater Philadelphia Region; Bryn Mawr Medical Specialists—Physician Assistant, Stanford University—Associate Program Director, Clinical Assistant Professor, Cardiology, Intermountain Heart Institute, Intermountain Healthcare and Rocky Mountain University of Health Professions Physician Assistant Program—Cardiology Research Physician Assistant, Vanderbilt Heart and Vascular Institute—Professor of Medicine, Director, CV Medicine Fellowship Program. Given the document design, the competencies that define an individual’s practice may overlap with multiple topic areas even for highly specialized practitioners. Skills to evaluate and manage patients with inherited and acquired forms of thrombophilia. Review and referral of patients for consideration and participation in clinical trials should be considered for both academic and nonacademic clinicians, including cardiologists, NPs, and PAs. . High-performing cardiovascular care teams aspire for each member to practice at the top of his or her education, training, licensure, and experience with clearly defined roles. Know the pathophysiology and clinical findings of pulmonary arterial hypertension. ONE Award Submissions ; Outstanding Orthopaedic Nurse Practice Award; Online Store; Online Store. NLN. Skill to recognize normal/abnormal 12-lead ECGs and rhythm strips. Skill to assist with or remove central venous or arterial catheters and hemodynamic monitoring systems. Former Competency Management Committee member; member during this writing effort. "Practice information by state: what you need to know about NP practice in your state" The writing committee consisted of a broad range of members selected by the ACC, including an equal number of cardiovascular NPs and PAs with expertise in the following clinical areas: acute coronary syndromes, adult congenital heart disease, ambulatory and consultative care cardiology, cardiac arrhythmias and electrophysiology, cardiovascular disease prevention, critical care cardiology, heart failure, pericardial disease, stable ischemic heart disease, valvular heart disease, and vascular medicine. Skill to refine the therapeutic plan of care of patients with pericardial disease based on laboratory and diagnostic test results. Know the common complications of cardiac surgery and procedures. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. "ACC 2015 core cardiovascular training statement (COCATS 4) (revision of COCATS 3) " . Participate in activities to promote a safe environment for patients, families, and healthcare professionals. 7. Use information technology to support patient care decisions and patient education. The writing committees reflect the diversity of cardiovascular medicine, including content experts, general cardiology and sub-subspecialty practitioners in both academic and private practice settings, and early, mid-, and later-career representatives. Background: Competency-based education (CBE) has been recommended for nurse practitioner (NP) education. Skill to classify angina pectoris using a functional classification system. Skill to refine the therapeutic plan of care of patients with valvular heart disease based on laboratory and diagnostic test results. "Expanding the role of advanced nurse practitioners—risks and rewards" This table represents relationships of committee members with industry and other entities that were determined to be relevant to this document. Skill to recommend lifestyle interventions for patients with stable coronary artery disease. The steering committee convened to plan the writing effort, determine the document framework, and initiate preliminary competency table development and project plans. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication. Nursing Education Perspectives (National League for Nursing), 29 (4), 217–219. Know the management of arrhythmias in pregnancy and women of childbearing age. This table represent the individuals, organizations, and groups that peer reviewed this document. Clinical competencies for NPs and PAs are designed to promote a framework for educational initiatives and practice performance. Skill to recognize cardiac biomarker abnormalities to aid in the diagnosis of acute coronary syndromes. Skill to provide preoperative risk assessment for patients with cardiovascular disease undergoing noncardiac surgery. Skill to participate in pericardiocentesis. Laurant M., van der Biezen M., Wijers N., "Nurses as substitutes for doctors in primary care", "Expanding the role of advanced nurse practitioners—risks and rewards", "Practice information by state: what you need to know about NP practice in your state", "Cardiovascular nursing: scope and standards for practice". Nurse practitioner core competencies are an essential element of nurse practitioner competence assessment. Skill to recognize ECG and rhythm strip abnormalities. Know the interventions and surgeries performed for complex congenital heart disease. ACGME = Accreditation Council for Graduate Medical Education. Know the effects of heart failure on perfusion, organ function, nutrition, and energy metabolism. Know the pathophysiology, differential diagnosis, and management of atrioventricular nodal re-entrant tachycardias and accessory pathways. Know the indications, contraindications, and management strategies for mechanical circulatory support in patients with heart failure. Nurse Practitioner Core Competencies with Suggested Curriculum Content 2017 In the development of the nurse practitioner (NP) population-focused competencies, a task force had extensive discussions of competencies vs. content. Know the normal physiological function of the autonomic nervous system. J Am Coll Cardiol 2020;75:2483–2517. American Nursing Association. Know the anatomy and physiology of the cardiac conduction system. Skill to manage patients on mechanical ventilator support. Core Practice Doctorate Clinical Nurse Specialist (CNS) Competencies (RETIRED) (PDF). Skill to manage patients with acute myocardial infarction and associated complications. Orthopaedic Nurses Week; Congress 2020 Virtual Bundles; Past and Future Congresses; Evaluations and Certificates; Outreach & Volunteer Opportunities; NAON Awards . Know the management of valvular heart disease in pregnancy and women of childbearing age. Refer patients who are facing advanced and end-stage cardiovascular disease to appropriate specialists. Prerequisite education, training, experience, and demonstrated competency provide a foundation to function in a collaborative team environment with significant autonomy, extending the capabilities of the general or subspecialty cardiologist and the entire cardiovascular team. Identify potential for impaired professional performance in oneself and colleagues and take action to mitigate in order to ensure a culture of safety. Know the pathophysiology and management of bicuspid aortic valve and associated aortopathy. NSTE-ACS = non–ST-elevation acute coronary syndrome, STEMI = ST-elevation myocardial infarction, Endorsed by the American Academy of Physician Assistants, American Association of Heart Failure Nurses, American Association of Nurse Practitioners, American Heart Association, American Nurses Credentialing Center, Association of Physician Assistants in Cardiology, Heart Rhythm Society, Physician Assistant Education Association, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and The National Organization of Nurse Practitioner Faculties. Core Competencies. Skills to develop, implement, manage, and evaluate a plan of care for patients with elevated blood pressure and hypertension. Cardiac Arrhythmias and Electrophysiology Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2496, Table 8. Skill to utilize diagnostic testing for initial diagnosis and follow-up care of patients with cardiovascular disease. Communicate with patients, families, and healthcare professionals in an effective, timely, and culturally-competent manner. 1 0 obj Know the indications for genetic screening of premature atherosclerotic disease. Cardiovascular NP and PA Competencies 2487, Table 1. J Am Coll Cardiol2015; 65:2118-2136. For the purpose of transparency, disclosure information for the Lifelong Learning Oversight Committee is available at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval. The NACNS CNS Statement for Clinical Nurse Specialist Practice and Education (3 rd ed.) Skills to recognize and document distinguishing characteristics of heart murmurs and sounds, vascular bruits, and peripheral pulses. 270 Washington, DC 20036 (202) 289-8044 nonpf@nonpf.org Know the risks associated with noncardiac surgery in adults with congenital heart disease. "A comparison of conventional and expanded physician assistant hospitalist staffing models at a community hospital", "PAs can bring cost-effective care to complex patients", "Primary care workforce shortages: nurse practitioner scope-of-practice laws and payment policies", ACC disclosure policy for document development, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043418/, https://www.aanp.org/practice/practice-information-by-state, https://www.aapa.org/news-central/2018/04/pas-can-bring-cost-effective-care-complex-patients/, https://www.nihcr.org/analysis/improving-care-delivery/prevention-improving-health/pcp-workforce-nps/, http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy, http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval, https://www.elsevier.com/about/our-business/policies/copyright/permissions. Identify personal knowledge gaps and seek educational training opportunities to improve knowledge, skills, and performance. <> Skill to counsel patients about levels of physical activity appropriate to their cardiovascular health status. Laurant M., van der Biezen M., Wijers N., et al. Participate in clinical conferences and team-based meetings to enhance communication and care of patients with cardiovascular disease. Skill to recognize patients with common inflammatory disorders or systemic diseases that may adversely impact cardiovascular disease risk. Know the pathophysiology, differential diagnosis, and management of atrial fibrillation, atrial flutter, and atrial tachycardias. Pericardial Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2505, Table 12. 2. Know the risk of arrhythmias and sudden death in patients with congenital or acquired structural heart disease. Know the postoperative complications of patients admitted to the critical care unit following cardiac surgery or catheter-based interventions. Know the basic anatomy, pathophysiology, presenting symptoms, and differential diagnosis of simple congenital heart disease in adults. Know the pharmacology, indications, contraindications, and side effects of antiarrhythmic medications. 2nd edition. Copies: This document is available on the World Wide Web sites of the American College of Cardiology ( www.acc.org), American Academy of Physician Assistants ( www.aapa.org), American Association of Heart Failure Nurses ( www.aahfn.org), American Association of Nurse Practitioners ( www.aanp.org), American Heart Association ( www.heart.org), Association of Physician Assistants in Cardiology ( www.cardiologypa.org), Heart Rhythm Society ( www.hrsonline.org), Physician Assistant Education Association ( www.paeaonline.org), Preventive Cardiovascular Nurses Association ( www.pcna.net), Society for Cardiovascular Angiography and Interventions ( www.scai.org), and The National Organization of Nurse Practitioner Faculties ( www.nonpf.org). Rather, it is intended to delineate those competencies relevant to services that cardiovascular NPs and PAs provide to patients within the care delivery system of a cardiovascular practice. Skill to perform pre-pregnancy risk assessment and peripartum coordination with obstetric colleagues for women with congenital heart disease. Also noted was the lack of formal postgraduate training programs for NPs and PAs such that most cardiovascular knowledge and skills are learned through practice experience from more experienced and tenured clinicians on the team. Know the primary prevention application of various cardiovascular risk assessment tools (e.g., atherosclerotic cardiovascular disease risk). Accessed July 18, 2019. Know the prognostic factors used to assess patients with acute coronary syndromes and advanced heart failure. Skill to manage patients following catheter ablation of atrial fibrillation and atrial flutter, supraventricular tachycardias, and ventricular arrhythmias. A modified Delphi method was used to engage NPs in achieving consensus for advance care planning competencies. Know the clinical manifestations of acute aortic syndromes, including dissection, intramural hematoma, and penetrating ulcer. The American Academy of Physician Assistants, American Association of Nurse Practitioners, American Heart Association, Physician Assistant Education Association, and The National Organization of Nurse Practitioner Faculties endorsed the document in March 2020. Competency Framework for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine 2487, Table 3. To fill this educational gap, the Cardiovascular Team Section Leadership Council requested that the Competency Management Committee commission a competency statement. Know the pathophysiology and risks of thrombosis and thromboembolism in adults with congenital heart disease. Nurse practitioner practice is grounded in the five World Health Organization (WHO) principles of primary health care: accessibility, public participation, health promotion, appropriate technology and intersectoral collaboration. Know the major cardiovascular risk stratification tools and principles of primary and secondary prevention of cardiovascular disease. Know the pharmacology, classes, indications, contraindications, risks, and interactions of medications commonly used for lipid management. Know the risks and benefits of exercise in adults with complex congenital heart disease, including those with associated pulmonary hypertension. Skill to assess the cardiovascular risks associated with recreational and/or competitive sports, physically demanding occupations, and other vigorous physical activities. Know the determinants of coronary blood flow and myocardial oxygen consumption. Competencies in the Context of Entry-level Registered Nurse Practice in British Columbia | 35 pages | 250 KB | Entry-Level Competencies for Registered Nurses (in effect Dec. 31, 2020) | … Know discharge criteria for the critical care unit. Contribute to the design and implementation of information systems to enhance safety, quality, and cost effectiveness. Contact Us. Valvular Heart Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2508, Table 14. Skill to facilitate timely referral to cardiac rehabilitation following acute coronary syndromes. Know the indications for insertion of implantable loop recorders. Collaborate with all team members to reduce preventable hospitalizations for patients with cardiovascular disease. Skill to participate in the insertion of temporary transvenous pacemakers, measure pacing and sensing device thresholds, and monitor pacemaker function. Acknowledgments The College of Nurses of Ontario (CNO) would like to thank CNO members who participated in the review and revision of this document. Know the indications for ambulatory blood pressure monitoring. Know the indications and recommendations for initial testing for known or suspected simple congenital heart disease in adults. Know the natural history of simple congenital heart disease. Know the New York Heart Association functional classes (I, II, III, and IV) and stages (A, B, C, and D) of heart failure. Curriculum Survey on Master’s Level Nurse Practitioner Programs (2001) Interprofessional Oral Health Faculty Tool Kit for Primary Care Nurse Practitioner and Midwifery Programs. Know the physical examination findings of repaired and unrepaired forms of congenital heart disease in adults. Know the indications, contraindications, complications, and components of invasive and hemodynamic monitoring. Many hospital systems also now use the 6-domain structure as part of medical staff privileging and peer-review professional competence assessments. Skills to evaluate and manage patients with arterial access complications, including arteriovenous fistula and arterial pseudoaneurysm. Skill to participate in invasive electrophysiology procedures, including catheter ablation. Know general concepts and modes of mechanical ventilation (e.g., tidal volume, fraction of inspired oxygen, positive end-expiratory pressure). Skill to care for patients with direct arterial catheters, central venous catheters, and/or hemodynamic monitoring systems. 0=!�#�A�IO�Z!=�IHHڄ��C����x �� }BBc��' ����#h ĄUE;7 b²��b�`º��G�� ~ Ą��,� 1ai!2`@LX[Hz� ^\,�J��q�J�7[OOԤ.��Nf�穙���l�zR�,~zY�y�*�^�S�|w. Of heart failure safety initiatives to provide age appropriate, and interactions of medications for. Cardiac conduction disturbances in patients with acute coronary syndromes M Street, NW Ste... 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Third Edition Competencies and give specific examples age, gender, or ethnic background can be and...