EM E1: CV

How soon should an EKG be ordered if a pt present to the ED w/ CP?

w/in 10 minutes

What is chest wall pain?

somatic, sharp, localized pain, reproducible by palpation, movement

What is pleuritic or respiratory chest pain?

somatic, sharp pain worsened by breathing or coughing

What is visceral chest pain?

poorly localized pain described as aching or heaviness

Which type of pain is precisely located?

Somatic

Which type of pain is imprecisely localized (discomfort, heaviness, or aching)?

Visceral

What are RF for aortic dissection?

middle aged, male gender, HTN, Marfan syndrome

What causes ACS sx?

myocardial ischemia

What are the 3 types of ACS?

unstable angina, NSTEMI, STEMI

Who has a higher incidence of ACS?

males

How do women w/ ACS present?

w/o typical symptoms

*leads to failure to initially dx

What is angina?

sensation of chest pressure or heaviness, reproduced by activities increase myocardial oxygen demand

T/F: In ED, you must assume all angina is unstable until proven otherwise

True

Which type of angina:

Involves episodic pain lasting 5-15 minutes; provoked by exertion & relieved by rest or nitro

Stable angina

Which type of angina:

angina at rest or new-onset exertional angina; increasing frequency or duration or refractory to ntiro

Unstable angina

Pt w/ unstable angina have an inc risk for what?

adverse cardiac event (MI or death)

Which type of angina:

occurs primarily at rest, triggered by smoking, thought to be due to coronary vasospasm

Variant angina (Prinzmetal)

Which type of angina has ST segment elevation that is nearly impossible to differentiate from AMI?

Variant angina (Prinzmetal)

How might an elderly patient with ACS present?

only AMS

What is the preferred biomarker for diagnosis of ACS? (greatest sensitivity/specificity)

Troponin

*detectable after 2-6 hrs, lasts 14 days

CK-MB can also be used to detect an MI. How early does it appear?

detectable w/in 4 hr, peaks 18-24 hrs, subsides day 3 or 4

*level w/in reference range does NOT exclude MI

Which biomarker is the earliest detected (2hrs), and has the highest sensitivity for an MI, but poor specificity?

Myoglobin

What is a super sensitive troponin?

AKA Gen 5 -can detect the smallest of troponin leaks

What do you look for when analyzing a Super Sensitive Troponin?

change (delta) between 2 values

When should Troponins be drawn?

0, 1, and 3 hr

What are you looking for in labs w/ an MI?

CBC -anemia

CMP -K+ and Mag (correct levels if needed)

What pts should automatically get an EKG?

> 45 y/o and is experiencing any form of thoracoabdominal discomfort

What EKG results indicate high probability of MI?

ST elevation > 1 mm in 2 contiguous leads OR presence of new Q-waves

What EKG results that indicate intermediate probability of MI?

ST segment depression, T wave inversion, nonspecific ST-T wave changes

T/F: A normal EKG rules out cardiac event

False

What is the 1st diagnostic test when evaluating a patient with angina in the ED?

EKG

What is PCI used for?

establish coronary reperfusion -more effective than thrombolysis

door-to-ballon = 90 minutes

What is the empirical tx of suspected STEMI?

Morphine, O2, NTG, ASA (chewable)

(MONA)

What are the CI to NTG?

SBP < 90, HR < 60 or > 100, RV infarction, PDE5 inhibitor

How soon should be thrombolytic therapy be initiated for an MI?

30 minutes

(door-to-drug)

What are the preferred thrombolytics for MI?

streptokinase, alteplase, tenecteplase, reteplase

What should you give in addition to ASA & unfractionated heparin to pts with continuing ischemia & pts in whom PCI is planned?

Platelet glycoprotein IIb/IIIa-receptor antagonist

(Eptifibatide, Tirofiban, Abciximab)

What are absolute CI to thrombolytic therapy?

Hx of ICH

Hx of ischemic stroke within the last 3 months

Cerebral vascular malformation/intracranial malignancy

Aortic dissection

Bleeding diathesis/Active bleeding

Significant closed head trauma within the last 3 months

What BP med should be given in tx of MI within first 24 hours?

ACEIs → Captopril

(or ARB)

What is the HEART score used for?

tool to assess CP patients in the ED; evaluates risk of major adverse cardiac events

(higher score = greater 6 week risk)

What are the categories of HEART score?

History, EKG, Age, Risk factors, Troponin

How were pts w/ a HEART score of 0-3 managed?

discharged

How were pts w/ a HEART score of 4-6 managed?

admitted to hospital

How were pts w/ a HEART score of > 7 managed?

candidates for early invasive measures

When should you get another EKG?

ANY change in sx

Total occlusion of the vessel for how long results in irreversible myocardial necrosis?

> 4-6 hours

What type of CHF is the MC form of ischemic heart disease and has a low EF (< 40%)?

Systolic

Which type of CHF has a normal or high EF?

Diastolic

How does isolated left sided HF present?

dyspnea, fatigue, weakness, cough, paroxysmal noctural dyspnea, orthopnea

How does isolated right sided HF present?

peripheral edema, JVD, RUQ pain

What causes high output HF?

anemia, thyrotoxicosis, large atrioventricular shunts, beriberi, Pagets

What are sx that are highly associated w/ CHF?

cough that produces pinky, frothy sputum, peripheral edema, JVD, and tachycardia

What is the diagnostic lab test for CHF?

BNP

When is BNP falsely elevated?

ESRD

What CXR findings indicate CHF?

cardiomegaly, Kerley B lines, pleural effusion, interstitial edema

What indicates successful management of BP & cardiac filling pressure in CHF?

marked improvement in respiratory status

-seen long before any significant diuresis

What analgesic should be avoided in treatment of CHF?

NSAIDs

(ASA is okay)

What is the 1st line tx for CHF?

Loop diuretic (Furosemide), Nitrates, ASA, Inotropic agents

Why is Digoxin not used for emergency management of CHF?

delayed absorption and diminished efficacy at times of inc sympathetic tone

Patients with hypotension presenting with CHF are treated w/ which inotropic agents?

Dopamine & Dobutamine

What murmurs warrant a cardio eval & Echo?

diastolic murmur or a new murmur with symptoms at rest

What is the MCC of mitral stenosis?

Rheumatic heart disease

How does mitral stenosis present?

exertional dyspnea, mid-diastolic rumbling crescendo murmur, followed by a loud opening snap

What is the tx of mitral stenosis?

Intermittent diuretics, tx afib, anticoagulation

What are common causes of mitral regurgitation?

MVP, MI, rheumatic heart disease, CAD, collagen-vascular disease

How does mitral regurgitation present?

dyspnea, high pitched holosystolic murmur, active apical impulse, thrill at the apex

What is the 1st sx of chronic mitral regurgitation?

Exertional dyspnea (afib)

What will be seen on CXR/EKG of mitral regurgitation?

LV & LA enlargement, LVH

What is the tx for asymptomatic mitral regurgitation?

None

What are sx of mitral valve prolapse?

atypical CP, palpitations, fatigue, exertional dyspnea, midsystolic click

± pectus excavatum, scoliosis, straight thoracic spine

What is the pt education for mitral valve prolapse?

avoid alcohol, tobacco, and caffeine, can give ASA (80-325mg)

What are common causes of aortic stenosis in adults?

degenerative heart disease, calcific aortic stenosis, rheumatic heart disease

What is the MCC of aortic stenosis in children?

congenital

What is the TRIAD of sx associated w/ aortic stenosis?

syncope, angina, dyspnea

How does aortic stenosis present?

harsh systolic ejection murmur, paradoxical splitting of S2, syncope in the setting of a new systolic murmur, pulse lag

What meds should be used with caution in patients with aortic stenosis?

Nitrates

What is the MCC of acute aortic regurgitation?

Infective endocarditis

*2nd = aortic dissection

What are sx of aortic regurgitation?

dyspnea, pink frothy sputum, systemic emboli, tachycardia

+ fever and chills (endocarditis)

+"tearing" CP that radiates btwn shoulder blades (dissection)

What is the tx for aortic regurgitation?

acute: O2, nitroprusside, dobutamine

chronic: vasodilators - ACEI or nifedipine

What are sx of dilated cardiomyopathy?

CHF symptoms

*sx dictate therapy

What are EKG findings with dilated cardiomyopathy?

LA & LV enlargement

What are sx of hypertrophic cardiomyopathy?

dyspnea on exertion, chest pain, palpitations, syncope, FH of cardiac death, sudden death in the young athlete

What is the tx for hypertrophic cardiomyopathy?

BB, avoid vigorous exercise

What are sx of restrictive cardiomyopathy?

CHF sx, S3, rales, JVD, Kussmaul, hepatomegaly, edema

What is the tx for restrictive cardiomyopathy?

Diuretics & ACEIs

*sarcoidosis → cortiosteroids

*hemochromatosis → chelation

What are sx of pericarditis?

sharp precordial or retrosternal CP, may radiate to the back or left arm, relieved when patient leans forward while sitting, pericardial friction rub

What are EKG findings of pericarditis?

diffuse ST elevation & PR depression

What is the initial test of choice for pericarditis?

TEE

What is the tx for pericarditis?

- No pericardial effusion: d/c

- Small/med pericardial effusion: admit & serial echos

- Large pericardial effusion: pericardiocentesis/pericardial window

What is the MCC of pericardial effusion?

malignancy

What is Beck's triad?

*assoc w/ tamponade

JVD, hypotension, muffled heart sounds

What is the testing is done for cardiac tamponade?

Echo = test of choice

EKG = electrical alternans (pathognomonic)

What is the tx for tamponade?

pericardiocentesis

What are common causes of restrictive pericarditis?

trauma, pericardiotomy, fungal or TB pericarditis, CRF

How does restrictive pericarditis present?

+JVD, Kussmaul sign, paradoxical pulse, pericardial "knock" at the apex, hepatomegaly, ascites, edema, chest pain, SOB, fatigue

What are EKG findings of restrictive pericarditis?

low-voltage QRS complexes, inverted T-waves

What is the tx for severe restrictive pericarditis?

Pericardiectomy

What is the classic presentation of a pulm embolism?

(doesn’t usually present like this)

abrupt pleuritic CP, SOB, hypoxia

What is Virchow's triad?

*for blood clots

hypercoagulability, endothelial damage, venous stasis

What is the gold standard test for pulmonary embolism?

Pulmonary CTA