cardiac emergencies. hypertensive emergencies severe hypertension ◦systolic bp > 200 mm hg...
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CARDIAC EMERGENCIESCARDIAC EMERGENCIES
Hypertensive EmergenciesHypertensive Emergencies
Severe hypertension◦Systolic BP > 200 mm Hg◦Diastolic BP > 120
If life-threatening organ damage is present, then BP must be reduced quickly to normal
levelsRapid BP reductions can cause strokes, renal
failure, and myocardial ischemiaIf life-threatening organ damage is not
present, reduce the BP gradually to avoid the side effects
PathophysiologyPathophysiology
Most organ damage is from arteriolar necrotizing vasculitis (platelet and fibrin
deposition) and loss of autoregulation of the blood vessels
The most common cause is discontinuation of BP medication
Young patients (<30) or black patients may have secondary causes for HTN, such as
renal disease, endocrine syndromes, drug-induced catecholamine release, or
pregnancy-induced
Clinical Features of HTN-Clinical Features of HTN-induced organ damageinduced organ damage
Encephalopathy◦HA, nausea, vomiting, blurred vision, confusion, seizures,
coma◦stroke
Pulmonary edema◦Due to increased afterload, not fluid overload
Renal impairment◦Decreased glomerular filtration rate, blood/protein in the
urineRetinopathyAortic dissectionAngina/MI
◦Due to increased afterload and decreased perfusionPregnancy related
◦Pre-eclampsia/eclampsia
TreatmentTreatment
With life-threatening organ damage◦Close monitoring◦Sodium nitroprusside (Nipride)
Arteriovenous dilator◦Gylceryl trinitrate
Arteriovenous dilatorEspecially effective when MI/pulm edema co-exist◦Labetalol
An alpha and beta blockerCan exacerbate asthma, heart failure, heart block◦Hydralazine and diazoxide
TreatmentTreatment
Without life-threatening organ damage◦Oral antihypertensives
Sublingual NifedipineBeta blockersACE inhibitorsCalcium channel blockers◦Goal is to reduce the diastolic BP to ~100 mm
Hg by 24-48 hours
Infective EndocarditisInfective Endocarditis
Infection of the heart valves or endocardium
Usually causes a chronic illness but can be acute when due to a virulent organism
Causitive organisms◦Streptococcus viridans: ~50%...poor dentition◦Staphylococcus aureus: 20-25%...IV drug use◦Staphylococcus epidermidis: valve
replacement surgery◦Staphylococcus faecalis:
5%...abortion/genitourinary surgery◦Gram negative organisms: drug addicts/heart
valve replacement◦Fungi: immunosuppressed patient
Infective EndocarditisInfective Endocarditis
Etiology◦Most common in elderly people with
degenerative aortic/mitral valve disease◦Patients with prosthetic valves, rheumatic heart
dx, congenital heart dx◦Abnormal valves are particularly susceptible
following dental or surgical procedures
Infective EndocarditisInfective Endocarditis
Clinical Features◦CNS: embolic infarction, abscesses, meningitis◦General infection: low grade fever, lethargy, malaise,
anemia, wt loss◦Cardiac: murmurs, heart failure, aneurysms◦Late signs: clubbing of digits, splenomegaly◦Joints: arthralgia, septic arthritis◦Skin: vasculitic rash◦Soles of feet: Janeway lesion◦Eyes: retinal hemorrhages◦Mucosal: subconjunctival hemorrhage◦Nail bed: splinter hemorrhages, nailfold infarcts◦Hands: small, red macular lesions, painful swelling of
fingers/toes◦Kidneys: microscopic hematuria, glomerulonephritis◦Embolic infarcts and abscesses: lungs, kidneys, CNS…
loss of peripheral pulses
Infective EndocarditisInfective Endocarditis
Diagnosis◦Mainly clinical◦Confirmed by anemia, raised ESR or CRP,
microscopic hematuria, positive blood cultures, and echocardiography
Management◦ID and treat infection (ATB for ~6 wks)◦Surgery to replace infected prosthetic valves
and native valves if infection/heart failure occurs
Prognosis◦Mortality is ~15%◦Prophylactic ATB used before procedures in
patients with valvular heart disease
Pericardial EmergenciesPericardial Emergencies
Acute pericarditis◦Due to infection (usually viral), MI, uremia,
connective tissue dx, trauma, TB, or neoplasms◦Clinical features: severe positional (sitting
forward relieves) retrosternal chest pain with pericardial rub
◦Diagnosis: concave ST segment elevation…cardiac enzymes may be elevated
◦Management: bed rest, anti-inflammatories, steroids
Pericardial EmergenciesPericardial Emergencies
Pericardial Effusion◦Due to infection, uremia, MI, aortic dissection,
myxedema, neoplasms, radiotherapy◦Clinical features: cardiac tamponade reducing CO, SOB,
pericarditis, venous congestion that increases with inspiration, hypotension with a paradoxical pulse (BP falls
>15 mm Hg during inspiration), distant heart sounds◦Diagnosis: low voltage EKG, CXR shows cardiomegaly,
echocardiography◦Management: pericardial drainage
Constrictive pericarditis◦A progressive fibrotic constriction of the pericardium◦Surgical removal of the pericardium is the only tx