Sarah Michelle Live Review Study Guide
2026/2027 Comprehensive Board Certification
Review for Family and Adult-Gerontology
Nurse Practitioners.
Exam Context:
The Sarah Michelle NP Review course is a rigorous, board-focused intensive designed to
prepare Family and Adult-Gerontology Nurse Practitioners for the AANP and ANCC
certification exams. The study guide emphasizes the integration of advanced pharmacology
with clinical diagnosis, the specific interpretation of a "Gram Stain" culture to select the
correct antibiotic, and the high-yield "red flag" symptoms for an emergent referral. The
material is structured around the major body systems and the "must-know" clinical topics.
SECTION 1: CARDIOLOGY & HYPERTENSION — 10 Must-Know Pearls
Pearl 1: STEMI Management — The "90-Minute Rule"
The specific treatment of a STEMI requires:
• Immediate ASA load (325 mg chewable or 325 mg non-enteric coated)
• P2Y12 inhibitor (Clopidogrel 600 mg loading dose, Prasugrel, or Ticagrelor)
• Cath lab activation within 90 minutes (door-to-balloon time ≤90 minutes)
• Door-to-needle time for fibrinolysis ≤30 minutes if PCI unavailable
• MONA-B mnemonic: Morphine, Oxygen, Nitrates, ASA, Beta-blocker (avoid morphine if
possible due to adverse outcomes)
Clinical Red Flag: Chest pain with ST-elevation in contiguous leads = STEMI. Do NOT wait for
troponins. Activate cath lab immediately.
Pearl 2: STEMI vs. NSTEMI — Know the Difference
Table
, Feature STEMI NSTEMI
ECG ST-elevation ≥1mm in 2+ ST-depression, T-wave inversion, or
contiguous leads normal
Troponin Elevated Elevated
Treatment Primary PCI within 90 min Risk stratification + medical management
± PCI within 24-72 hrs
Anticoagulation Heparin during PCI Heparin + dual antiplatelet
Pearl 3: Calcium Channel Blockers — Dihydropyridine vs. Non-Dihydropyridine
The specific pharmacologic distinction:
Table
Feature Dihydropyridine (DHP) Non-Dihydropyridine (Non-DHP)
Examples Amlodipine, Nifedipine, Verapamil, Diltiazem
Felodipine
Mechanism Vasodilation (arterioles) Vasodilation + negative chronotrope &
inotrope
Heart Rate Reflex tachycardia ↓ Heart rate (AV nodal blockade)
Atrial NOT first-line for rate control FIRST-LINE for rate control in AF
Fibrillation
Heart Failure Safe in HFrEF AVOID in HFrEF (negative inotropy)
Sarah Michelle Memory Trick: "Non-DHP = Non-tachycardia = Good for AF rate control."
,Pearl 4: Verapamil vs. Diltiazem in AF with RVR
For a patient with concurrent atrial fibrillation:
• Verapamil = More potent negative inotrope; use caution in heart failure
• Diltiazem = Preferred in patients with borderline BP or mild HF
• Both block L-type calcium channels in the AV node → slow ventricular response
• Contraindicated in AF with WPW (use Procainamide or Amiodarone instead)
Pearl 5: Diabetic + Proteinuria — The ACE/ARB Rule
The specific BP target for a diabetic patient with proteinuria:
• Target BP: <130/80 mmHg (JNC 8 / ADA guidelines)
• First-line agent: ACE inhibitor OR ARB — NOT both together (increases
AKI/hyperkalemia risk)
• Why ACE/ARB? Reduces intraglomerular pressure → slows progression of diabetic
nephropathy
• Monitor: Serum creatinine and potassium within 1-2 weeks of initiation
• Acceptable creatinine rise: Up to 30% from baseline (expected hemodynamic effect)
Pearl 6: JNC 8 Hypertension Guidelines — Key Targets
Table
Population Target BP First-Line Agents
General population <60 years <140/90 Thiazide, ACE, ARB, CCB
General population ≥60 years <150/90 Thiazide, ACE, ARB, CCB
Diabetic patients <140/90 ACE or ARB preferred
, Population Target BP First-Line Agents
CKD with proteinuria <130/80 ACE or ARB
Black patients (without CKD/DM) <140/90 Thiazide or CCB
Pearl 7: ACE Inhibitor Cough vs. ARB
• ACE inhibitor cough (dry, tickly) occurs in 5-20% of patients due to bradykinin
accumulation
• Switch to ARB (Losartan, Valsartan) — no cough, same renal protection
• Both reduce proteinuria and slow diabetic nephropathy progression
• Avoid ACE + ARB combination (ONTARGET trial showed increased harm without added
benefit)
Pearl 8: S3 Heart Sound + JVD = Acute Systolic Heart Failure
The specific clinical sign triad:
• S3 heart sound ("Kentucky" — S1-S2-S3; ventricular gallop)
• JVD (Jugular Venous Distention) >8 cm H₂O at 45°
• Peripheral edema / pulmonary crackles
Diagnosis: Acute exacerbation of systolic (HFrEF) heart failure
• S3 = rapid ventricular filling into a dilated, non-compliant ventricle
• JVD = elevated right-sided pressures
• BNP >400 pg/mL strongly supports diagnosis
Pearl 9: Acute Decompensated Heart Failure — Treatment Algorithm
1. Oxygen (maintain SpO₂ >90%)
2. IV Loop diuretics (Furosemide — give 2.5x oral home dose IV)
2026/2027 Comprehensive Board Certification
Review for Family and Adult-Gerontology
Nurse Practitioners.
Exam Context:
The Sarah Michelle NP Review course is a rigorous, board-focused intensive designed to
prepare Family and Adult-Gerontology Nurse Practitioners for the AANP and ANCC
certification exams. The study guide emphasizes the integration of advanced pharmacology
with clinical diagnosis, the specific interpretation of a "Gram Stain" culture to select the
correct antibiotic, and the high-yield "red flag" symptoms for an emergent referral. The
material is structured around the major body systems and the "must-know" clinical topics.
SECTION 1: CARDIOLOGY & HYPERTENSION — 10 Must-Know Pearls
Pearl 1: STEMI Management — The "90-Minute Rule"
The specific treatment of a STEMI requires:
• Immediate ASA load (325 mg chewable or 325 mg non-enteric coated)
• P2Y12 inhibitor (Clopidogrel 600 mg loading dose, Prasugrel, or Ticagrelor)
• Cath lab activation within 90 minutes (door-to-balloon time ≤90 minutes)
• Door-to-needle time for fibrinolysis ≤30 minutes if PCI unavailable
• MONA-B mnemonic: Morphine, Oxygen, Nitrates, ASA, Beta-blocker (avoid morphine if
possible due to adverse outcomes)
Clinical Red Flag: Chest pain with ST-elevation in contiguous leads = STEMI. Do NOT wait for
troponins. Activate cath lab immediately.
Pearl 2: STEMI vs. NSTEMI — Know the Difference
Table
, Feature STEMI NSTEMI
ECG ST-elevation ≥1mm in 2+ ST-depression, T-wave inversion, or
contiguous leads normal
Troponin Elevated Elevated
Treatment Primary PCI within 90 min Risk stratification + medical management
± PCI within 24-72 hrs
Anticoagulation Heparin during PCI Heparin + dual antiplatelet
Pearl 3: Calcium Channel Blockers — Dihydropyridine vs. Non-Dihydropyridine
The specific pharmacologic distinction:
Table
Feature Dihydropyridine (DHP) Non-Dihydropyridine (Non-DHP)
Examples Amlodipine, Nifedipine, Verapamil, Diltiazem
Felodipine
Mechanism Vasodilation (arterioles) Vasodilation + negative chronotrope &
inotrope
Heart Rate Reflex tachycardia ↓ Heart rate (AV nodal blockade)
Atrial NOT first-line for rate control FIRST-LINE for rate control in AF
Fibrillation
Heart Failure Safe in HFrEF AVOID in HFrEF (negative inotropy)
Sarah Michelle Memory Trick: "Non-DHP = Non-tachycardia = Good for AF rate control."
,Pearl 4: Verapamil vs. Diltiazem in AF with RVR
For a patient with concurrent atrial fibrillation:
• Verapamil = More potent negative inotrope; use caution in heart failure
• Diltiazem = Preferred in patients with borderline BP or mild HF
• Both block L-type calcium channels in the AV node → slow ventricular response
• Contraindicated in AF with WPW (use Procainamide or Amiodarone instead)
Pearl 5: Diabetic + Proteinuria — The ACE/ARB Rule
The specific BP target for a diabetic patient with proteinuria:
• Target BP: <130/80 mmHg (JNC 8 / ADA guidelines)
• First-line agent: ACE inhibitor OR ARB — NOT both together (increases
AKI/hyperkalemia risk)
• Why ACE/ARB? Reduces intraglomerular pressure → slows progression of diabetic
nephropathy
• Monitor: Serum creatinine and potassium within 1-2 weeks of initiation
• Acceptable creatinine rise: Up to 30% from baseline (expected hemodynamic effect)
Pearl 6: JNC 8 Hypertension Guidelines — Key Targets
Table
Population Target BP First-Line Agents
General population <60 years <140/90 Thiazide, ACE, ARB, CCB
General population ≥60 years <150/90 Thiazide, ACE, ARB, CCB
Diabetic patients <140/90 ACE or ARB preferred
, Population Target BP First-Line Agents
CKD with proteinuria <130/80 ACE or ARB
Black patients (without CKD/DM) <140/90 Thiazide or CCB
Pearl 7: ACE Inhibitor Cough vs. ARB
• ACE inhibitor cough (dry, tickly) occurs in 5-20% of patients due to bradykinin
accumulation
• Switch to ARB (Losartan, Valsartan) — no cough, same renal protection
• Both reduce proteinuria and slow diabetic nephropathy progression
• Avoid ACE + ARB combination (ONTARGET trial showed increased harm without added
benefit)
Pearl 8: S3 Heart Sound + JVD = Acute Systolic Heart Failure
The specific clinical sign triad:
• S3 heart sound ("Kentucky" — S1-S2-S3; ventricular gallop)
• JVD (Jugular Venous Distention) >8 cm H₂O at 45°
• Peripheral edema / pulmonary crackles
Diagnosis: Acute exacerbation of systolic (HFrEF) heart failure
• S3 = rapid ventricular filling into a dilated, non-compliant ventricle
• JVD = elevated right-sided pressures
• BNP >400 pg/mL strongly supports diagnosis
Pearl 9: Acute Decompensated Heart Failure — Treatment Algorithm
1. Oxygen (maintain SpO₂ >90%)
2. IV Loop diuretics (Furosemide — give 2.5x oral home dose IV)
