L4: Cardiac, Vascular, and Pulmonary emergencies Flashcards
Classic angina history
Pressure, heaviness, tightness, fullness, or squeezing in the center or left of the chest
Precipitated by exertion
Relieved by rest
+/- Radiates to shoulder, arms, neck, jaw
Indicates ischemic event in coronary arteries
Angina equivalents for atypical presentation in women, elderly, diabetics
SOB N/V diaphoresis fatigue dizzy/lightheaded weak palpitations syncope
Angina labs
CBC CMP D-Dimer Lipids BNP Troponin \+/- CK-MB
Stable angina
Substernal chest pain 2-5 minutes
Symptoms are stable, resolve with rest
Unstable angina
Increasing severity/frequency/duration OR occurs at rest
ST depression or T inversion with normal troponin
NSTEMI
Non-occlusive thrombus, ischemia
ST depression or T inversion with elevated troponin
STEMI
Occlusive thrombus,
transmural infarction
ST elevation or new left bundle branch block or true posterior MI
Acute coronary syndrome encompasses
Unstable angina + MI
MI=NSTEMI, STEMI
Heart score
0-2 points based on criteria: Suspicious history ECG changes Age Number of risk factors Initial troponin value
TIMI score
Age > 65 >3 CAD risk factors Known CAD ASA use in past 7 days Severe Angina ECD changes Positive cardiac marker
What is a positive high-sensitivity troponin?
(+)= Acutely increased hs-cTn >100 ng/L
(+)= <100 ng/L but 2 hour delta >10ng/L
high-sensitivity troponin aka
hs-cTn Assay
How to rule out MI using cardiac enzymes
Negative enzymes 4-6 hours after symptom onset
Negative enzymes <4-6 hours after onset
repeated at 2 hours and still negative
When to do stress testing
ONLY if unsure of ACS
Stress echocardiogram
Can be done exercise or pharmacologic (dobutamine)
Radionucleotide Myocardial Perfusion Imaging
AKA nuclear stress test
Perfusion defect/ hypoperfusion visualization
During stress testing, monitor _____ and stop the test if _______
Monitor: BP, ECG changes, echo
Stop test: CP, SOB, ST changes, decreased BP, ventricular arrhythmias
Initial management for all Acute Coronary Syndrome patients
Aspirin + Analgesia
Stable angina diagnostics
No ECG changes
No enzyme elevation
(-) stress test (most)
Stable angina management
+/- Angiography for PCI interventions
Nitrates→ SL nitroglycerin PRN
Q5 min, >3 doses→ ER
Beta blockers
+/- CCB
Antiplatelet: ASA (81-325 mg), Clopidogrel, or combo
Prinzmetal’s angina aka
Variant angina
Vasospastic angina
Prinzmetal’s angina presentation
5-12 minute angina episodes
Usually at rest between midnight and early morning
Prinzmetal’s angina diagnostics
EKG→ ST elevation during episodes
Rule out MI→ serial cardiac enzymes
Holter monitor
Coronary angiography→ diagnostic
Prinzmetal’s angina management
Nitrates
CCBs
Contraindications to use of Nitrates
hypotension
RV infarct/inferior MI recent PDE5 inhibitors (sildenafil)
STEMI symptoms
Chest pain/heaviness/pressure
SOB, radiates to arm, neck, back
Weakness, fatigue, diaphoresis
N/V. Palpitations, dizziness, syncope
Management of a STEMI
ABCs Telemetry, IV access SL nitro, ASA 325 chewed Call Cardiology→ cath lab Percutaneous coronary intervention Extensive disease→ CABG
Your patient is having a STEMI but PCI isn’t available quickly….
if not available within 120 minutes, consider fibrinolytics
NSTEMI or UA management
ABCs
Telemetry, IV access
SL nitro
PCI, no fibrinolytics
When is PCI contradicted? What is the management in these cases for UA/NSTEMI?
Renal failure, sepsis, unstable patient medically manage with continuous IV heparin and ASA
Which parts of MONA (Morphine, Oxygen, Nitro, Aspirin) are being phased out, and why?
Morphine→ inhibits absorption of platelet meds, associated with increased mortality
Oxygen→ use when not associated with hypoxia may increase early myocardial injury and increase infarct size
Gold standard for CAD
Coronary angiography Threaded through femoral vessels to heart→ dye→ patency assessed via fluoroscopy: Percutaneous Coronary Intervention Angioplasty Stenting
Indications for Coronary Artery Bypass Graft
Multi-vessel disease, large area of potentially ischemic myocardium
Anatomic complexity of lesions
Likelihood of successful revascularization with PCI
Comorbidities
Peri-infarction Pericarditis
Occurs 2-3 days after MI, transient
Auscultate: Pericardial rub
Echo→ pericardial inflammation +/- effusion
Peri-infarction Pericarditis treatment
Supportive, self limited
Tylenol
ASA+/- colchicine
Avoid NSAIDs
Acute Pericarditis which ISN’T post-cardiac injury syndrome
Infectious radiation drugs toxins uremia myxedema ovarian hyperstimulation syndrome breast/lung cancer hodgkin lymphoma mesothelioma collagen vascular disease, immune-related idiopathic
Acute pericarditis: post-cardiac injury syndrome
MI
pericardiotomy
trauma
Acute pericarditis EKG
diffuse ST elevation on most beats
Symptoms of cardiac tamponade
CP, tachypnea, dyspnea
Sinus tachycardia, pericardial rub, pulsus paradoxus
Beck’s triad
Beck’s triad (cardiac tamponade)
hypotension
JVD
muffled heart sounds
Cardiac tamponade diagnostics
EKG→ sinus tachycardia, low voltage, electrical alternanas
CXR→ enlarged cardiac silhouette
Echo→ effusion with tamponade
Cardiac tamponade tx
Drainage of pericardial effusion:
- Percutaneous/pericardiocentesis
- Surgical +/- pericardiectomy
Monitoring:
Telemetry
Vital signs x 24-48 hours
Repeat echo prior to discharge
Acute mitral regurgitation
Caused by ischemia to papillary muscle
LV dilation
true aneurysm
papillary muscle/choral rupture usually 2-7 days after infarct
Acute mitral regurgitation on physical exam
Hypotension
New murmur
Acute mitral regurgitation diagnostics
Transthoracic echo
If inconclusive: Transesophageal Echo
Acute mitral regurgitation treatment
emergency surgery
Dressler’s syndrome occurs
Weeks to months after MI, cardiac surgery, cardiac trauma, pulmonary embolism
Dressler’s syndrome AKA
Post-cardiac injury syndrome
Dressler’s syndrome presentation
Pleuritic chest pain, fever, malaise
Pericardial friction rub
Dressler’s syndrome diagnostics
Labs→ leukocytosis, elevated ESR
CXR→ pleural and or pericardial effusion or pulmonary infiltrates
