First Aid Algorithms: Cardio

Ischemic Chest Pain

  • Scenario: A patient presents with substernal chest pain that radiates to the left arm and is associated with nausea and diaphoresis

    • Very first thing to do is get EKG

      • Any ST-segment elevation in 2 contiguous leads = STEMI; load with ASA and clopidogrel, revascularization if within 90 minutes; anything on the other side of that gets thrombolytics; both cases will get BB, morphine, oxygen, ASA, and nitrates (you don’t want them to B MOANing in pain)

      • ST-segment depressions/nonspecific T wave abnormalities

        • Get troponin and CK-MB

          • Positive findings = NSTEMI; treat with heparin/LWMH and aspirin with clopidogrel

          • Negative findings with symptoms that do not resolve with rest = unstable angina; get a stress test and load with aspirin and clopidogrel; give statin and beta blocker during hospital course

            • If positive for reversible ischemia, send for coronary angiography

          • Negative findings with symptoms that resolve with rest, risk factors and evidence for CAD = Stable angina; give aspirin, beta blockers, nitrates, and send for stress test; follow same rules if positive for reversible ischemia

          • Negative findings with symptoms that resolve with rest and no risk factors for CAD = coronary vasospasm; give CCBs and beta blockers

Post-MI Complications

  • Scenario: Following a MI which was revascularized, the patient now has a change in clinical status

    • Still always begin with EKG and troponin levels

      • Fever, pleuritic chest pain, global ST-elevation and pericardial effusion 1-6 weeks later = Dressler’s syndrome; just need to give NSAIDs and colchicine

      • A waves, right-sided MI 1 day later = Third degree AV block; temporary pacemaker and atropine

      • Significant anterior infarct or severely diminished ejection fraction: ventricular aneurysm; need to give anticoagulants

Cardiac Non Ischemic Chest Pain

Pulmonary Chest Pain

  • Scenario: A patient has chest pain not characteristic of cardiac chest pain

    • Acute onset, shortness of breath, sinus tachycardia: get CT angiogram and V/Q scan; this follows the pattern of pulmonary embolism; get BNP and troponin just to rule out MI and treat with anticoagulants

GI Chest Pain

Cardiogenic Shock

  • Classic scenario of cardiogenic shock: Patient has hypotension, tachycardia, dyspnea, and cool extremities

    • Obtain CBC, CMP, troponin, lactate, BNP, EKG, TTE, CXR

Cardiomyopathy

  • Scenario: A patient presents with dyspnea, orthopnea, lower extremity swelling

    • Obtain CBC, CMP, troponin, lactate, BNP, EKG, TTE, CXR

      • On TTE, dilated ventricles with diminished or normal EF = dilated cardiomyopathy

        • History of recent pregnancy: DCM from peripartum causes

        • History of doxorubicin use or cocaine/meth use: DCM due to toxins

        • Tachycardia with RVR: DCM from hyperthyroidism

        • Travel to South America, fever and malaise: DCM likely from Chagas

      • TTE showing impaired filling, and patient also has ascites, hepatomegaly, pulmonary edema, S3, JVD, low voltage EKG: these all suggest restrictive cardiomyopathy; get MRI and endomyocardial biopsy

        • Accompanying systemic sclerosis symptoms: RCM from scleroderma

        • Congo red stain: RCM from light chain amyloidosis

        • Eosinophilic granule proteins: RCM from endocardial fibrosis; treat with diuretics for edema

        • Non-caseating granulomas and AV block on EKG: RCM from sarcoidosis

        • Iron deposits and bronze diabetes: RCM from hemochromatosis

Arrhythmias

Pericardial

Valve

Syncope

  • Scenario: Patient experiences a transient loss of consciousness

    • EKG is still the first thing to be done, along with CXR

    • Existing arrhythmia or new murmur: syncope from arrhythmia; will want to get TTE or Holter if TTE fails to reveal

    • Accompanying Beck triad: syncope from pericardial effusion

    • Dyspnea, chest pain, tachycardia, hypoxia: syncope from PE

    • Evidence of orthostatic vitals

      • Dehydration signs: syncope from hypovolemia

      • Use of beta blockers, vasodilators, CCBs: syncope from medication

    • Prodrome of warmth, nausea, and diaphoresis followed by the loss of consciousness

      • Voiding of bladder and bowel, coughing, prolonged standing, then prodrome: vasovagal syncope; educate on counterpressure maneuvers

      • Carotid massage like wearing a tight collar before prodrome: carotid sinus syndrome

HTN

HLD