Cardiovascular Emergencies

1. Cardiovascular Emergencies By Dr. Z. Samarrae FRCS, FICS ,CABS, DS, MB CHB

2. ACUTE CORONARY SYNDROMES • ACS encompass the following • Stable angina • USA • Myocardial infarction • What is the basic pathology?

3. coronary 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?

4. Coronary 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?

5. Approach 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

6. Ischemia– 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?

7. Physical exam • Usually normal..but look for complications • LVF • Arrythmia • New murmurs---papillary muscle rupture • ---VSD

8. ECG-what it can show? • 50% diagnostic.in MI may see ST elevation • In angina-may seeST 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 ? • ليس العاقل من احتاط للامر اذا وقع ولكن العاقل من احتاط للامر حتى لا يقع • MAY SEE NOTHING • ABSOLUTELY NOTHING-normal ECG does not exclude ischemia • وماذا بعد؟

9. Cardiac 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 وماذا بعد ؟ • Serial reading-mind time since pain onset • NowECG &enzymes are normal, والحين؟ • Admit .

10. Other 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

11. Treatment • MONA • Reperfusion (PCI & Thrombolytics) • B- blockers—reduce infarct size • ACE—stabilize the plaque. • Be ready for complicationليس العاقل من احتاط للامر اذا وقع ولكن العاقل من احتاط للامر حتى لايقع • What is MONA?

12. MONA • 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

13. Reperfusion 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.

14. 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

15. ARRYTHMIAS • 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

16. 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

17. Management 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

18. Hypertensive 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.

19. Patient 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

20. Patient 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

21. 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

22. 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.