10.1 Cardiovascular Diagnosis

The current FNP-BC Test Content Outline lists cardiovascular among the 13 body systems that cut across every nursing-process domain. This section is the Diagnosis home — pathogenesis, clinical manifestations, test selection, and interpretation. You name the problem before 10.2 writes the prescription, 10.3 writes the lifestyle order, and 10.4 applies the same diseases to children, pregnancy, and frail older adults. If the stem is a cuff average, a murmur grade, an ABI, a BNP, or an irregularly irregular ECG, you are here.

Hypertension is a pattern, not one high reading

The 2025 AHA/ACC High Blood Pressure Guideline replaced the 2017 document but kept the same numeric categories. Classification uses the average of ≥2 readings on ≥2 occasions, obtained with a validated device and a cuff that actually fits. Seat the patient with the back supported, feet on the floor, and the arm at heart level. Empty the bladder. No caffeine, exercise, or tobacco for 30 minutes. Talking during the measurement is a technique error, not a personality trait.

A single 162/94 in triage is not a diagnosis. Recheck after five quiet minutes. If the average remains high, confirm out of office with home blood-pressure monitoring (HBPM) or ambulatory blood-pressure monitoring (ABPM) whenever you can. ABPM is the reference standard when it is available; a validated upper-arm home cuff is the practical primary-care substitute. Treatment thresholds and the PREVENT™ risk conversation belong in Section 10.2. Diagnosis ends when you know whether the elevation is real, white-coat, or masked.

White-coat hypertension is high in the office and normal on HBPM or ABPM. Do not tattoo a lifelong hypertension label or a two-drug combination onto white-coat numbers alone. Teach lifestyle, arrange follow-up, and do not ignore the pattern forever — some people convert to sustained hypertension.

Masked hypertension is the opposite and more dangerous on the exam: the office looks fine and the home or ABPM average is hypertensive. Treat confirmed masked hypertension as real hypertension. Its cardiovascular risk sits closer to sustained HTN than to true normotension. If the stem hands you a calm clinic number and a week of 148/88 mornings, you are looking at masked disease, not a clean bill of health.

Hunt for secondary clues instead of assuming essential hypertension in every 28-year-old: abrupt onset, truly resistant BP, unprovoked hypokalemia, an abdominal bruit, delayed femoral pulses (coarctation — Section 10.4), paroxysms of headache plus palpitations plus sweating, or untreated obstructive sleep apnea. You do not order a pheochromocytoma panel on every new diagnosis. You do notice the stem that is not essential HTN.

Coronary disease: stable angina versus an ACS you must not send home

Stable angina is reproducible exertional pressure or tightness, often with a known threshold, relieved by rest or nitroglycerin within minutes, without rest pain and without a changing pattern. The FNP's diagnosis job is to recognize the ischemic story, obtain a resting ECG, and arrange outpatient risk stratification (exercise or pharmacologic stress, or a cardiology referral) when the patient is truly stable.

Acute coronary syndrome is a different diagnosis and a different building. Red flags: pain at rest, a crescendo or newly severe episode, diaphoresis, nausea, radiation to the jaw or either arm, sudden dyspnea, syncope, hypotension, a new mitral regurgitant murmur, or pulmonary edema. Do not order an outpatient treadmill from the clinic hallway. Activate emergency care. If there is no contraindication and EMS is in the loop, the patient can chew non-enteric aspirin 325 mg. Atypical presentations in women, older adults, and people with diabetes — fatigue, epigastric burning, isolated dyspnea — are still ACS until proven otherwise. Domain II is identification. Implementation is the aspirin and the ambulance, not a next-Thursday stress-lab slot.

Heart failure: HFrEF versus HFpEF, then prove it

Suspect heart failure when there is dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, or unexplained fatigue plus Framingham-type signs: elevated jugular venous pressure, an S3, pulmonary rales, hepatojugular reflux, or a laterally displaced PMI. Those signs raise pretest probability. They do not replace imaging.

HFrEF (reduced ejection fraction, generally LVEF ≤40%) behaves like a weak pump: ischemic or dilated cardiomyopathy, a displaced PMI, an S3, and a wet exam. HFpEF (LVEF ≥50%) is a stiff ventricle: older adult, long-standing hypertension, obesity, atrial fibrillation, diabetes — often an S4, with congestion out of proportion to a remembered "normal EF." Mid-range EF (about 41–49%) exists; do not invent a third disease if the stem only offers reduced versus preserved.

Order BNP or NT-proBNP when the diagnosis is uncertain — dyspnea that could be COPD, deconditioning, or HF. A clearly low value in an untreated patient makes HF unlikely. A high value supports HF but is not specific: age, AF, and CKD raise it; obesity lowers it. Echocardiography is the confirmatory test for new suspected HF: EF, valves, wall-motion, pulmonary pressures. Do not lock a lifelong HFrEF regimen to a clinic hunch without an imaging plan.

Atrial fibrillation: the pulse, the stroke score, the referral

AF is an irregularly irregular rhythm without consistent P waves. Confirm it with a 12-lead ECG (or a rhythm strip you can defend). New AF with instability, chest pain, or pulmonary edema is emergency care, not a next-week Holter.

CHA2DS2-VASc is the conceptual stroke-risk inventory: heart failure, hypertension, age ≥75 (2 points), diabetes, prior stroke/TIA/thromboembolism (2 points), vascular disease, age 65–74, and sex category (female). You do not need to be an electrophysiologist to know the point of the score: stroke risk drives the anticoagulation conversation, not whether today's pulse "looks okay." Rate versus rhythm is a referral decision. Many stable patients live on rate control (a beta blocker; a non-dihydropyridine calcium-channel blocker only if the ventricle is not reduced). Rhythm control, cardioversion, antiarrhythmic drugs, and ablation belong with cardiology. Refer new AF, failed rate control, suspected valvular AF, or anyone you cannot safely anticoagulate in primary care.

PAD and the ABI

Claudication is reproducible exertional calf, thigh, or buttock pain that stops with rest and is not positional the way lumbar stenosis is. Rest pain, a nonhealing ulcer, or gangrene is chronic limb-threatening ischemia — a same-day vascular pathway, not a routine ABI and a three-month follow-up.

Ankle-brachial index (ABI) ≤0.90 supports PAD. 0.91–0.99 is borderline. 1.00–1.40 is generally normal. >1.40 means noncompressible vessels (diabetes, CKD, older age) — use a toe-brachial index or refer; do not call the arteries healthy because the number is large. If classic claudication meets a normal resting ABI, an exercise ABI is the next diagnostic step.

Murmurs you do not watch at home

Refer any diastolic murmur, any continuous murmur that is not a clear venous hum, a systolic murmur ≥3/6, a holosystolic murmur, a murmur with a thrill, syncope, progressive dyspnea or chest pain, a click-plus-radiation story, or a family history of sudden death or cardiomyopathy. Innocent Still murmurs are a pediatric diagnosis (Section 10.4). They are not a license to ignore a new grade 3/6 adult murmur.

Lipid disorders as diagnoses, not platitudes

Familial hypercholesterolemia (FH) is a diagnosis: untreated LDL-C often ≥190 mg/dL, premature ASCVD in the patient or first-degree relatives, tendon xanthomas, or a known pathogenic variant. Cascade-screen the family. Secondary dyslipidemia includes hypothyroidism, nephrotic syndrome, cholestasis, uncontrolled diabetes, heavy alcohol, thiazides, and some antipsychotics. Check TSH, A1c, creatinine, and a liver panel before you freeze the chart as "primary hyperlipidemia." Severe hypertriglyceridemia (typically ≥500 mg/dL, and especially near 1000) is a pancreatitis diagnosis as much as an ASCVD one.

Vignette. A 54-year-old's first office BP is 148/86. A repeat today averages 144/84. A week of validated home logs averages 126/74. That is white-coat physiology — lifestyle and follow-up, not automatic dual therapy. The sibling with office 118/76 and home averages 142/88 has masked hypertension. A 61-year-old with calf pain at two blocks and ABI 0.72 has PAD. The same story plus a cold pulseless foot does not need you to finish the ABI worksheet in the hallway.

Exam trap. Diagnosis items punish the candidate who treats one number as a disease or who sends ACS to an outpatient stress lab. Average the readings. Confirm out of office. Separate white-coat from masked. Send rest pain and diaphoresis to the ED. Echo new HF. Think about anticoagulating AF by stroke risk, not by how regular you wish the pulse were.