Cardiovascular Emergency
Acute
Coronary Syndrome Acute eart Fai!ure Acute Pericarditi" Cardiac #amponade In$ecti%e Endocarditi" Aortic Di""ection Dy"r&yt&mia Deep Vein #&rom'o"i"
De$ine acute coronary "yndrome" (ACS) *nder"tand t&e pat&op&y"io!o+y ,e capa'!e o$ ri"k "trati$ication Aware o$ medication" and "trate+ie" emp!oyed to mana+e ACS *"e 'a"ic princip!e" o$ EC- interpretation and in$arct !oca!i.ation App!y know!ed+e to ca"e "tudie"
Cardiovascular Disease
/0,122,222
American" &a%e one or more $orm" o$ &eart or '!ood %e""e! di"ea"e 324 o$ a!! deat&" are cardio%a"cu!ar di"ea"e
TIME IS MUSCLE
Doe" not predict acute e%ent" Marker o$ e"ta'!i"&ed coronary artery di"ea"e (CAD)
Fi9ed !e"ion : partia!!y occ!uded %e""e! Mi"matc& in o9y+en "upp!y and demand
Precipitant";
< Exercise < Cold < Stress
Duration;
<
=e!ie$;
< Rest < Nitro*l+ceri(e
Clinical Presentation:
I.
'i()tes
*n"ta'!e An+ina ? ACS without a'norma! !e%e!" o$ "erum 'iomarker" $or myocardia! necro"i" 7Ti6Tt6C80M9: NS#EMI ? ACS with po"iti%e marker"
etero+eneou" popu!ation
Atypica! pre"entation Varia'!e a+e Medica! 'urden < rena! in"u$$iciency Percei%ed di$$icu!ty wit& interpretin+
'iomarker"
S#EMI
Comp!ete t&rom'otic occ!u"ion o$ a ma@or epicardia!
artery
Pre"entation;
C&aracteri"tic "ymptom" o$ cardiac i"c&emia
< More .rolo(*ed /(d se1ere s+'.to's < Little res.o(se to (itro*l+ceri(e
Speci$ic EK- c&an+e" on "eria! EK-" E!e%ation o$ "erum marker" $or cardiac in@ury
,;O de4i(itio( o4 AMI
*ncontro!!a'!e
Ma@or Contro!!a'!e
Smokin+ i+& ,P i+& '!ood c&o!e"tero! Dia'ete"
50
Minor Contro!!a'!e
7'e"ity Aack o$ e9erci"e Stre"" Per"ona!ity
51
Cardiovascular Disease
Contro! ri"k $actor" - decrea"e Coronary Artery Di"ea"e and Acute Myocardia! In$arction
/(e'i/6-+.ote(sio(:
core po""e""e" !ipid !aden monocyte" and macrop&a+e" t&at produce !ar+e amount" o$ tiss)e 4/ctor, a potent procoa+u!ant rupture occur" at t&e "&ou!der (t&e @unction o$ t&e p!a>ue and norma! endot&e!ium)
e9po"ed ti""ue $actor comp!e9e" wit& $actor VIIa w&ic& in turn promote" +eneration o$ $actor Ca and t&e production o$ !ar+e amount" o$ t&rom'in circu!atin+ p!ate!et" are acti%ated 'y e9po"ure to co!!a+en, %on Di!!e'rand $actor, t&rom'in adeno"ine dip&o"p&ate, t&rom'o9ane AE and pro"tacyc!in", re!ea"ed 'y dama+ed endot&e!ium, contri'ute to p!ate!et acti%ation and induce %a"o"pa"m
acti%ated p!ate!et" 'ind to one anot&er 'y cro""!inkin+ $i'rino+en to t&eir "ur$ace +!ycoprotein receptor" t&e acti%ation, ad&e"ion and a++re+ation o$ p!ate!et" and t&e acti%ation o$ t&e c!ottin+ ca"cade re"u!t" in an occ!u"i%e t&rom'u" t&rom'u" may partia!!y or $u!!y occ!ude a %e""e! !umen precipitatin+ myocardia! i"c&emia F:necro"i"
Diagnosis
Cardiac
@aw, upper 'ack, upper a'domen 'ack May 'e a""ociated wit& "&ortne"" o$ 'reat&, nau"ea, "weatin+
EE
E0
E1
Angina .ec&oris
Fo!!owin+
E/
Sta'!e An+ina
EB
*n"ta'!e An+ina
More $re>uent:"e%ere Can occur durin+ re"t May indicate impendin+ MI =e>uire" immediate treatment and
EH
!ead EK-
Seria! EK-"
< Essential
EMERGENT REPERFUSION . S# depre""ion G5mm, marked "ymmetrica! # wa%e in%er"ion" GE mm, dynamic S#-# c&an+e" wit& pain
UA!NSTEMI LI8ELY
MEDICAL MANAGEMENT =!0 URGENT IMAGING !. Non-dia+no"tic or norma! ECACS LESS LI8ELY
RIS8 STRATIFY
ELECTROCARD O!RAM
NTER.RETAT ON O+ TRO.ON NS
Spectrum
< ;i*-er t-e tro.o(i(6 t-e *re/ter t-e ris>
Fa!"e po"iti%e;
C F, pericarditi", myocarditi", contu"ion, cardiomyopat&y S&ock =ena! in"u$$iciency Pu!monary em'o!i
0 LL . SCORE
+.$.R",/ C(A++
" ""a ""b """ "$
T/E E$ DENCE
Level of Evidence Grading
De!! de"i+ned, randomi.ed, contro!!ed tria!" 7= meta-ana!y"e" in%o!%in+ !ar+e num'er o$ patient" Sma!!er radomi.ed tria!" 7= re%iew" o$ o'"er%ationa!, retro"pecti%e or nonrandomi.ed tria!" E9pert con"en"u", primary nonrandomi.ed 7= o'"er%ationa! data
A 4 C
T/E E$ DENCE
C!a"" I E%idence or +enera! a+reement t&at a "peci$ic procedure or treatmetn i" u"e$u! and e$$ecti%e Con$!ictin+ e%idence or di%er+ence o$ opinion a'out t&e uti!ity or e$$icacy o$ a procedure or treatment Dei+&t o$ e%idence or opinion i" in $a%our o$ uti!ity-e$$icacy *ti!ity-e$$icacy i" !e"" we!! e"ta'!i"&ed 'y e%idence or opinion E%idence or +enera! a+reement t&at a "peci$ic procedure or treatment i" neit&er u"e$u! n e$$ecti%e and may 'e &arm$u! C!a"" II
OXYGEN
Ae%e! C e%idence
23/ Increa"e "upp!y to i"c&emic ti""ue 23.N Su"pect ACS 3O2 Start wit& na"a! cannu!a at 1A:min PR.CA0,"ON+ C7PD
ASPIRIN
C!a"" I, Ae%e! A e%idence
23/
Morta!ity reduction ,!ock" "ynt&e"i" o$ thromboxane A
< In&i'it" p!ate!et a++re+ation < =e!a9e" arteria! tone
23.N
Su"pected ACS
3O2
5/2 m+ c&ewed "!ow!y, t&en H5-0E3 m+ dai!y or pr
CON,RA"N5"CA,"ON
#rue a!!er+y No -I tract 8
UNFRACTIONATED HEPARIN
23/
In&i'it" t&rom'in G ICa, Ca Pre%ent t&rom'u" $ormation o%er ruptured p!a>ue Pre%ent recurrence o$ t&rom'o"i" Pre%ent mura! t&rom'u"
23.N
*A:NS#EMI Dit& tPA Dit& P#CA:"ur+ica! re%a"cu!ari.ation
3O2
IV 'o!u" 7?& )(its!>* i1 to '/xi')' $&&& )(its:, t&en In$u"ion 7#&&& )(its!-r:
23/
Antit&rom'otic, anti Ca Predicta'!e Do not re>uire coa+u!ation te"t monitorin+ Aower incidence o$ t&rom'ocytopenia No p!ate!et acti%ation ,ind" c!ot 'ound t&rom'in
23.N
Su"pected ACS
3O2
Su'cutaneou"!y
PR.CA0,"ON+
=ena! in"u$$iciency Dei+&t G 532 k+
BETA-BLOCKERS (Bb
E!g! &etoprolol$ 'isoprolol$ Atenolol$ etc!
Ae%e! A e%idence
23/
Anti-arr&yt&mic Anti-i"c&emic Anti-&yperten"i%e Decrea"ed myocardia! rupture at one week in S#EMI
23.N
Dit&in 5E &our" o$ AMI ACS and e9ce"" "ympat&etic acti%ity
3O2
Intra%enou" 7ra!
7Meto.rolol:
A4+O(0,.:
S&ock ,radycardia ypoten"ion Se%ere a"t&ma Acute C F:pu!monary edema
R.(A,"$.:
A"t&ma : "e%ere C7PD eart '!ock" Se%ere PVD IDDM E9treme a+e
23/
Irre%er"i'!e in&i'itor o$ ADP-receptor
23.N
S#EMI, ASA "en"iti%ity *A:NS#EMI i+& ri"k patient c&aracteri"tic"
PR.CA0,"ON+
A!!er+y #&rom'ocytopenia i+& ri"k -I '!eed (CV "ur+ica! procedure anticipated)
< Sto. 'i(i')' $ d/+s .rior
GPIIb&III# INHIBITORS
C!a"" I Ae%e! A e%idence i( ./tie(ts 3it- .l/((ed PCI i( #%0%@ -o)rs6 ASA /(d C!a"" IIa, Ae%e! A e%idence I( -i*- ris> ./tie(ts 3it-o)t .l/((ed PCI6 ASA /(d -
23/
23.N
3O2
ACS, re$ractory "ymptom" *r+ent PCI Dit& ASA and *F F:- PCI ,o!u"; 5H2 mc+:k+ i% 7'/xi')' 3ei*-t #%&>*: In$u"ion; E mc+:k+:min 7half 3it- re(/l i(s)44icie(c+:
EPTIFIBATIDE (In'()r("in
PR.CA0,"ON+
Acti%e '!eedin+ wit&in 02 day" Stroke or &ead in@ury wit&in 02 day" ,!eedin+ diat&e"i" IN= GE.2 P!ate!et" J 522,222 Ma@or "ur+ery or trauma wit&in / week" *ncontro!!ed #N (S,P G E22, D,P G552) yper"en"iti%ity
NITROGLYCERINE
Ae%e! C e%idence
23/
Decrea"e" i"c&emic pain
< Ve(odil/tio(!decre/sed .relo/d < Dil/tes coro(/r+ /rteries 7eli'i(/tes 1/sos./s': < I(cre/ses coro(/r+ coll/ter/l 4lo3
23.N
I"c&emic c&e"t pain For E1-1H &r a$ter AMI
< Rec)rre(t ./i( < ;+.erte(sio( < C;F
NITROGLYCERINE
3O2
Su'!in+ua!
< #a'!et"; 2.0m+ > 3 minute" < Spray; 2.1 m+ > 3 minute"
IV In$u"ion < Start 52-E2 mc+:min < Increa"e 'y 3-52 mc+:min >3-52 minute"
PR.CA0,"ON+
A%oid &ypoten"ion .6treme caution wit& R$ infarction Interaction wit& "i!dena$i! (Via+ra)
MORPHINE
23/
=educe i"c&emic pain =educe an9iety =educe e9ten"ion
Ae%e! C e%idence
23.N
7n+oin+ pain o$ in$arction Acute pu!monary edema S,P G I2 mm +
MORPHINE
3O2
Sma!! increment" IV < # 0 A '* .r(6 to eli'i(/te ./i(
PR.CA0,"ON+
A!!er+y Nau"ea and %omitin+ ypoten"ion =e"piratory depre""ion
ACE-INHIBITORS
..g. +amipril$ Enalapril$ Captopril Ae%e! A e%idence
7A(terior i(4/rct6 EF @&B:
23/
=educe
23.N
Dit&in E1 &our" AMI Su"pected or known CAD
ACE-INHIBITORS
3O2
7ra!
PR.CA0,"ON+
Pre+nancy Symptomatic &ypoten"ion ,i!atera! rena! artery "teno"i" An+ioedema A!!er+y
,R.A,1.N,
Pro!on+ed:recurrent pain GEmm S# depre""ion Po"iti%e cardiac marker" G5mm tran"ient S# e!e%ation emodynamic in"ta'i!ity =e$ractory i"c&emia
PR.+.N,A,"ON
=e"t painG E2 minute" GEmm S# depre""ion Deep # wa%e in%er"ion (G3mm) GEmm # wa%e in%er"ion in G3 !ead" Po"iti%e cardiac marker"
,R.A,1.N,
,R.A,1.N,
=e"t pain New on"et or cre"cendo pain Non"peci$ic or norma! EKNorma! or 'order!ine po"iti%e cardiac marker" Increa"ed 'a"e!ine ri"k (DM, pre%iou" AMI,CA,-, recent PCI)
PR.+.N,A,"ON
Sin+!e "&ort duration pain New on"et or cre"cendo pain Non"peci$ic:norma! EK- C E Norma! cardiac marker" C E No &i+& ri"k $eature"
,R.A,1.N,
reperfusion:
"N#E=VEN#I7N
FIBRINOLYTICS
Ae%e! A e%idence
23/
P!a"mino+en acti%ator" De+rade t&e occ!u"i%e t&rom'u"
23.N
2",3"N !7 1"N0,.+ O% PR.+.N,A,"ON I"c&emic type c&e"t pain EK- compati'!e
< ST ele1/tio( C %'' i( %= co(ti*)o)s le/ds < (e3 L999 < tr)e .osterior i(4/rct
CON,RA"N5"CA,"ON+
A4+O(0,.: L/c> o4 cle/r i(dic/tio(s Acti1e i(ter(/l 2leedi(* Rece(t tr/)'/6 '/Dor s)r*er+6 i(ter(/l 2leedi(*
73it-i( %3ee>s:
S)s.ected /ortic dissectio( Peric/rditis Pre1io)s -e'orr-/*ic stro>e Ot-er stro>es 3it-i( o(e +e/r 8(o3( i(tr/cr/(i/l (eo.l/s'
R.(A,"$.:
Rece(t tr/)'/6 '/Dor s)r*er+6 i(ter(/l 2leedi(* 7%0@ 3ee>s: Se1ere )(co(trolled -+.erte(sio( 7C #E&!##& '';*: C)rre(t )se o4 /(tico/*)l/(ts 7INR C %0A: I(tr/cere2r/l ./t-olo*+ 7ot-er t-/( stro>e: 8(o3( 2leedi(* di/t-esis Acti1e .e.tic )lcer dise/se Pre*(/(c+ No(co'.ressi2le 1/sc)l/r .)(ct)res 8(o3( -+.erse(siti1it+ to /*e(t A*e C F$ +e/rs Prolo(*ed 7C #& 'i()tes: tr/)'/tic CPR
FIBRINOLYTICS
3O2
,trepto-inase
- Deri%ed $rom 'eta-&emo!ytic Streptococcu" cu!ture" - Sma!!er in$arct", e!der!y, underwei+&t - 5.3 mi!!ion unit" o%er 5 &our )issue (lasminogen Activator t(A - Natura!!y occurrin+ en.yme - ,etter wit& !ar+e in$arct - i+&e"t incidence o$ IC - 53 m+ IV 'o!u" - 2.B3 m+:k+ o%er ne9t 02 min (32 m+) - 2.32 m+:k+ o%er ne9t /2 min (03 m+)
FIBRINOLYTICS
)enecteplase ")./#
< Sin+!e 'o!u" < Dei+&t 'a"ed do"in+
+eteplase
< -enetica!!y modi$ied t-PA < Not wei+&t 'a"ed < #wo 'o!u"e" o$ 52 unit", 02 minute" apart