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2 EAZ - Cardiovascular Emergencies
2 EAZ - Cardiovascular Emergencies
Erwin Azmar
Cardiology Division Dept of Internal Medicine
Faculty of Medicine University of Sriwijaya
2016
Cardiovascular emergencies
Life-threatening
Immediately recognized
Avoid delayed treatment
Minimize morbidity and mortality
Cardiac anatomy
9. Right Atrium
1.Left Anterior Descending
10. Right Ventricle
2.Left Circumflex
11. Left Atrium
3.Superior Vena Cava
12. Left Ventricle
4.Inferior Vena Cava
13. Papillary Muscles
5.Aorta
14. Chordae Tendineae
6.Pulmonary Artery
15. Tricuspid Valve
7.Pulmonary Vein
16. Mitral Valve
8.Right Coronary
17. Pulmonary Valve
Aortic Valve (Not pictured)
Etiology and underlying diseases
Congenital heart diseases
Valvular heart diseases
Hypertensive heart disease
Coronary artery disease
Cardiac dysrhythmia
Trauma, myopathy, infection, tumor, toxin
Vascular diseases
Systemic diseases
Diagnostic
History : chest pain, shortness of breath,
palpitation, racing heart beat, syncope, dizziness,
epigastric pain, leg pain, vomitus, convulsion,
numbness.
Physical exam : BP HR RR PR consciousness,
Temperature, pallor, sweating, heart sounds,
pulmonary sounds, JVP, pulsation, struma, vessel
dilation.
Modalities : ECG, Echo, Imaging, Blood, cardiac
biomarkes, urinalysis.
Acute cardiac emergencies
Cardiac arrest : anaphylactic, electrocution, hypothermia, drug overdose,
pregnancy
Cardiogenic shock
Peri-arrest arrhythmia : bradycardia, broad-complex tachycardias, narrow
complex tachycardias
Cardiac tamponade : pericardial effusion
Valve and Septal Rupture : after AMI, trauma
Sinus of valsava rupture : congenital aneurysm, infective endocarditis
Acute aortic dissection
Acute prosthetic valve rupture
ACS
Acute cardiac failure
Hypertensive emergency
Vascular thrombosis
Emergency cardiological procedures
Frequent PVCs
Consecutive PVCs
Multiform PVCs
R-on-T phenomenon
Any PVC occurring during an acute
myocardial infarction (or in any patient with
underlying heart disease)
RBBB
Sinus rhythm
Broad QRS complexes with notch in the R wave in I, VL, V5, V6
Inverted T waves are associated with bundle branch block, and
have no other significance.
Acute coronary syndrome
Hypertensive crise
Clinical Vignette
65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain and
shortness of breath that developed after lunch the day of
admission; non-exertional; no alleviating factors.
Physical Exam:
Vitals: 37.3, 195/125, 92, 24, 93% on RA
HEENT: Decreased A:V on retinal exam (<25%)
Heart: S4 heard on exam, no m/r/g
Lungs: mild resp distress, otherwise clear to auscultation
Hypertensive Urgency:
Systolic
BP >180 or Diastolic BP >120 in the absence
of end-organ damage
Definitions Continued:
Hypertensive Emergencies:
SBP>180 OR DBP>120 in the presence of end-organ
damage
Malignant Hypertension: End-organ damage--eyes, kidneys,
brain (hemorrhage/infarct) affected
Hypertensive encephalopathy: Cerebral edema leading to
neurological symptoms
Signs and Symptoms:
Hypertensive Urgency:
Can be completely asymptomatic
Some symptoms include:
Severe headache
Shortness of breath
Nosebleeds
Severe anxiety
Signs:
Elevated BP on consecutive readings
S&S Continued
Hypertensive Emergencies
Symptoms:
nausea, vomiting (cerebral edema)
Chest Pain
SOB
Blurry vision
Confusion
Loss of consciousness
Signs:
Retinal hemorrhages, exudates, or papilledema
Renal involvement (malignant nephrosclerosis) with AKI,
proteinuria, hematuria
Cerebral edema seizures and coma
Pulmonary Edema
Myocardial Infarction
CIRCULATORY NEUROREGULATORY
CYTOKINE
INSUFFICIENCY
HEART FAILURE
PATHOPHYSIOLOGY
Heart Failure is a Dropsical Condition with
Generalized Edema from Fluide Retention.
Heart Failure is Due to a Central Cardiac Pump inadequacy.
Heart Failure is Precipitated by Decompansated Ventricular
Hypertrophy.
Heart Failure is due to Circulatory Dysfunction.
Heart Failure is an Endocrinopathy.
Heart Failure is a Fever
DIAGNOSIS
HISTORY.
PHYSICAL EXAMINATION.
APPROPRIAT INVESTIGATION.
1. SYMPTOMS OF HEART FAILURE(AT REST OR DURING EXERCISE).
2.Objective evidence of cardiac dysfunction.
3.Response to treatment directed towards heart failure.
CRITERIA FOR CONGESTIVE HEART FAILURE
Systolic vs Diastolic.
Systolic dysfunction:
Coronary artery disease.
Hypertension.
Dilated Cardiomyopathy.
Myocarditis.
Causes of Chronic Heart Failure cont.
Diastolic Dysfunction:
Coronary artery disease.
Systemic Hypertension.
Diabetis Mellitus.
Aortic stenosis.
Hypertrophic cardiomypathy.
Infiltrative cardiomypathy
Endocardial fibrosis.
Normal aging process.
Causes of worsening Heart Failure
Non- cardiac:
Atrial fibrillation.
Other supraventricular or ventricular arrhythmias.
Bradycardia.
Appearance or worsening mitral or ticusped
regurgitation.
Myocardial ischaemia.
Excessive preload reduction(diuretics,ACE inhibitors).
The Heart Failure Milieu :
Clinical Presentation Physical findings
Peripheral edema
Disease Ascites
process Vascular congestion
Jugular venous distension
Rales
Ventricular Tachycardia
dysfunction
Hypotension
Cachexia
Disease-specific findings
Hemodynamic
abnormalities
Physical findings
Azotemia Metabolic
Hyponatremia changes
Hypocalemia Compensatory
Hypomagnesemia mechanisms Symtoms and
Symptoms
Hyperuricemia physical findings Fatique and weakness
Acidosis/alkalosis Dyspnea and fluid
Hypoxia/O2 desaturatuion retention syndromes
Decreased MVO2 Nocturia
Gastrointestinal symptoms
Diminished mentation
The Heart Failure Milieu :
Disease
End-Organ Failure and Death
process
Systemic organ failure
Renal failure
Ventricular Hepatic failure
dysfunction
Respiratory failure
Multi-organ failure
Pulmonary embolism
Hemodynamic Peripheral (cerebral embolism)
abnormalities
Metabolic Death
changes
Compensatory
Sudden
mechanisms End-Organ Death
Failure
Mechanical transducers
Intracellular signals
Ventricular remodeling
Physical
Laboratory
Examination
tests
History
Diagnostic
studies
Assessment of heart failure
Diagnostic studies:
Laboratory tests,ECG,Chest X ray,Echo,Exercise testing,
Cardiac catheterization,Radionuclited studies
Investigation :Laboratory
Complete Blood Count.
Serum electrolytes, blood urea nitrogen,serum creatinine.
Liver function test.
Prothrombin time.
Lipid profile.
Thyroid function test.
Anaemia evaluation.
Arterial blood gases.
Serum drug levels(digoxin,phenytoin).
Atrial natriuretic peptides.
Urin analysis.
Chest X- ray
Other investigation
Transthoracic Echocardiography.
Stress Echo.
Exercise stress testing.
24- hour Holter monitoring.
Nuclear imaging,thallium perfusion scan,cardiac
MRI.
Coronary angiography
Chronic Congestive Heart Failure
EVOLUTION OF
CLINICAL STAGES
NORMAL
No symptoms
Normal exercise
Asymptomatic
Normal LV fxn LV Dysfunction
No symptoms
Normal exercise
Compensated
Abnormal LV fxn CHF
No symptoms Decompensated
Exercise
Abnormal LV fxn CHF
Symptoms
Exercise
Refractory
Abnormal LV fxn CHF
Symptoms not controlled
with treatment
TREATMENT OBJECTIVES
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
Treatment Options
Non-pharmacological.
General advice and measures.
Exercise and exercice training.
Pharmacological therapy.
Angiotensin-converting enzyme inhibitors(ACI).
Beta-adrenoreceptor antagonists.
Cardiac glycosides.
Diuretics.
Vasodilators(nitrats,hydralazine).
Antiarrhythmic agent.
Anticoagulantion.
Oxyggen.
Divices and surgery.
Revascularization.
Pacemaker.
Implantable cardioverter defibrillator(ICD).
Cadiac trnsplantation.
Ultrafiltration,haemodialysis.
TREATMENT
Correction of aggravating factors
Pregnancy Endocarditis
Arrhythmias (AF) Obesity
Infections Hypertension
Hyperthyroidism Physical activity
Thromboembolism Dietary excess
MEDICATIONS
TREATMENT
PHARMACOLOGIC THERAPY
DIURETICS
INOTROPES
VASODILATORS
NEUROHORMONAL ANTAGONISTS