Cardiovascular Cardiovascular EmergenciesEmergencies

ByBy

Dr. Z. SamarraeDr. Z. SamarraeFRCS, FICS ,CABS, DS, MB CHBFRCS, FICS ,CABS, DS, MB CHB

ACUTE CORONARY ACUTE CORONARY SYNDROMESSYNDROMES

• ACS encompass the following

• Stable angina

• USA

• Myocardial infarction

• What is the basic pathology?

coronary occlusioncoronary occlusion

• Atherosclerosis- a plaque causing gradual narrowing

• rupture of the plaque- rough surfaces exposed-platelets adhere-clot formation-resulting in partial or complete occlusion

• So what is the sequence?

• Plaque narrowing-plaque rupture-clot

• Can u relate each one to ACS spectrum?

Coronary occlusionCoronary occlusion

• Plaque narrowing---stable angina

• Plaque rupture(sudden)—either USA or MI (sudden rupture leads to sudden change in pattern of symptoms.

• Symptoms, ECG,&enzymes changes can be correlated to above 2 pathlogies,can u?

Approach to the patientApproach to the patient

• Listen,lissten,lisssten, lissssssssssssssten• Active listening---- donot interrupt• Listen to a story ,not scattered bits..• err on the worst side: donot be fooled by:• Patient is young• She is female• She is obese ---reflux oesophagitis• He is labourer-----it is musculoskeletal• Listen to the patient 1st ,then to relatives

Ischemia– visceral painIschemia– visceral pain

• What does it mean?• Diffuse(not submammary)-note how he used his

hands.• Nausea, vomiting, and dizziness---if present will

add more to the suspicion• Ask how severe pain is , but indirectly, donot

be fooled by: mild pain in ….?• Elderly, and diabetics.• Continuos pain---unlikely to be ischemic, but

good listening to story ,not direct,how u ask?

Physical examPhysical exam

• Usually normal..but look for complications

• LVF

• Arrythmia

• New murmurs---papillary muscle rupture

• ---VSD

ECG-what it can show?ECG-what it can show?

• 50% diagnostic.in MI may see ST elevation• In angina-may see ST كابة during pain• It may show arrythmias (fast or slow)• May see old ischemia, or LVH• what type of MI ? Is it important ?• ..yes. How ?• احتاط من العاقل ولكن وقع اذا لالمر احتاط من العاقل ليس

يقع ال حتى لالمر• MAY SEE NOTHING• ABSOLUTELY NOTHING-normal ECG does not exclude

ischemia• بعد؟ وماذا

Cardiac enzymesCardiac enzymes

• CK-MB,and the more specific Troponin• They are normal in stable angina.• May be elevated in USA & MI.• If ECG showed MI, do I need Troponin?• Those with +ve troponin do worse • Again a normal enzymes does not exclude

ischemia ؟ بعد وماذا• Serial reading- mind time since pain onset• Now ECG &enzymes are normal, والحين؟• Admit .

Other investigationsOther investigations

• LDH-not specific

• Hb

• Creatinine, sugar, lipids…PT, PTT..

• Any need for CXR?

• To screen for alternative Dx.e.g dissection of aorta –wide mediastinum,how history can help?

• Onset &response

Treatment Treatment

• MONA

• Reperfusion (PCI & Thrombolytics)

• B- blockers—reduce infarct size

• ACE—stabilize the plaque.

• Be ready for complication من العاقل ليساحتاط من العاقل ولكن وقع اذا لالمر احتاط

اليقع حتى لالمر• What is MONA?

MONAMONA

• A:150 Aspirin

•N :SL GTN 3 times-consider then IV

•O2 NASAL CANNULA 4 L

• If still pain –Morphin 2-4 q 5min titrate to response and side effects.

• Heparin

Reperfusion therapyReperfusion therapy

• PCI SUPERIOR TO THROMBOLYSIS• But PCI need a cath lab, trained staff>75/y , and

a high volume centre>200 /year.• esp. useful in cardiogenic shock• When thrombolytics are contraind or failed• Door to balloon should be 90 min. • Thrombolytics : door to needle 30 min, but best

given within 3hrs, but can be given up to 12 hrs.

Thrombolytics Thrombolytics

• Consider contraindication before • Watch for any bleeding esp in elderly• ECG indications for thrombolysis:• ST elevationin 2 contiguos leads• New BBB esp LBBB• How much elevation? 1mm in standard

leads, 2mm in chest leads.• Long term secondary prevention

ARRYTHMIASARRYTHMIAS

• Fast rhythm---tachycardias(AF/Aflutter,VT)• Slow rhythm---bradycar(sinus&AV blocks)• Treat patient NOT the ECG, many arrythmias

donot need treatment.• Tachycardias <150 generally no Rx.• How tachycar & bradycar give symptoms?• Reduction of cardiac output.• Dizziness, chest pain ,weakness,exertional

dyspnea

Management Management

• Fast rythm----slow it by drugs & electricity• Slow rythm---push it by drugs & electricity• what medicines for fast rhythm? depend

on?• Narrow or wide complex tachycardia.• For narrow complex—CCB• For wide complex tachycar----Amiodarone• For unstable tachycardia---cardioversion

Management of slow rythmManagement of slow rythm

• Atropine for sinus bradycardia

• Pacing for blocks-mobitz 2,complete block

• In emergency —percutaneous pacing

• Later on -----transvenous pacing

• Again treat patient not an ECG

Hypertensive emergenciesHypertensive emergencies

• HTN emergency—target organ damage

• HTN urgency-----no target organ damage

• HTN emergency---Bp reduced min-hrs

• HTN urgency-------Bp reduced in24-48hrs

• Marked reductions should be avoided.

Patient approachPatient approach

• Place patient in a quiet room. • Repeat Bp at the end of interview: 27% show

reduction <critical level at end.• If still high: determine target org.damage.• What is work up needed?• Clinical, lab ,radiological assessment for 3

systems---heart ,CNS,renal.• Heart: chest pain, heart failure, ECG,CXR• Why CXR?• LVF…aortic dissection

Patient evaluationPatient evaluation

• CNS: focality…papilloedema.altered level of conciosness…CT scan…

• Renal : creatinine, urine test: RBC, cast, protienuria..oliguria

• Remember : donot treat Bp reading only

• Drug screen

• Pregnancy tests

Treatment Treatment

• Labetolol ----steady drop in Bp, iv small boluses, or drip titrate to response---in encephalopathy reduce MAP by 25%only and diastolic should be between 100-110

• GTN ----2ND choice

• Trimethaphan(ganglionic blocker) ---for aortic dissection

Conclusions Conclusions

• Mind white coat HTN

• Determine target organ Damage

• Donot treat numbers

• Overzealous Bp reduction to be avoided

• Mind the false concept ---a patient should have a normal Bp before leaving ED.