Presentation
Acute Coronary
Syndrome
substernal pain on exertion
15-30 min/episode
“dull, squeezing, pressure”
S3/S4
rales
(normal exam does not
exclude ACS)
Tests


Hx consistent with ischemia = most important
EKG
exercise stress test: intermediate risk w/ normal EKG;
looks for reversible ischemia;

catheterize abnormal results
echo: evaluate wall & valve motion, & EF;

normal wall motion excludes MI
EKG: ST depression
NSTEMI
STEMI
chest pain
chest pain
rales
S3
JVD
LBBB
sudden onset dyspnea,
relieved by sitting up
+/-rales,
+/- peripheral edema
S3, JVD
tachycardia
diaphoresis, nausea
Systolic DysFx
CHF
Hypertensive
EKG: ST elevation
CXR
Echo
Troponin I: elevated
BUN: elevated
EKG: repeat if symptoms change
Echo
stress test: 80-85% of max HR to assess ST depression
on EKG; stress test+ = reversible perfusion defect
CAD/angina
Acute Pulmonary
Edema (CHF)
Troponin I: rises 3-4 hr after pain onset, stays positive
1-2 wks
CK-MB: rises 2-4 hr after onset stays positive 1-2 days
(best test of reinfarction); false+ with CHF & renal
failure
Myoglobin: rises at 1-4 hr
chest pain, dyspnea/CHF,
stress test w/ dipyridamole or dobutamine echo
EKG (excludes ischemia & arrhythmia)
CXR (excludes effusion, cardiomegaly,
congestion/vascular fluid overload)
ABG
BNP
Troponin/CK-MB
BUN/Cr: elevated >20:1 (pre-renal azotemia)
CBC: hyponatremia
echo: determine EF, syst/diast dysFx, valve fx
Treatment






ASA (81 mg x2)
Metoprolol (25 mg BID)
Nitroglycerin
ACE-inhibitor
Statin
Morphine

catheterization/angiography

telemetry
 LMW heparin (SC enoxaparin)
 clopidogrel/prasugrel/ticagrelor
chewable ASA (2 x 81 mg)
NTG
statin (LDL goal: <100 mg/dL)
β-blocker (metoprolol)
ACE-I
morphine

cath/angio despite medical intervention
angioplasty/cath or thrombolytics for PCI
clopidogrel/prasugrel/ticagrelor
(DO NOT use heparin)
chewable ASA
NTG
statin (LDL goal: <100 mg/dL)
β -blocker (metoprolol)
ACE-I
angiography when >70% stenosis
ASA +/- clopidogrel/prasugrel/ticargrel
(DO NOT use heparin)
β -blocker (metoprolol)
statin (LDL goal: <100 mg/dL)
ACE-I (if EF <35%)
O2 & elevate head
Furosemide (Lasix) IV 20 mg, double every
20-30 min till urine produced
monitor I/O
NTG paste, IV, or SL
morphine 2-4 mg IV
hemodialysis for refractory cases
transfer to ICU if systolic < 90 mmHg
(DO NOT use β -blockers in acutely ill pt)
ACE-I (or ARB if cough; or alternative is
hydralazine/nitrate if hyperkalemia)
β -blocker (metoprolol, carvedilol)
spironolactone for stage III/IV CHF only
(eplerenone as alternative)
diuretics & digoxin (no mortality benefit)
biventricular pacemaker if QRS >120 ms
IV anti-hypertensives: labetalol, enalaprilat,
Notes
ACS = Hx of chest pain + EKG

MC risk factor: HTN

worst risk factor: DM
(also smoking, hyperlipidemia, & family Hx
1st degree relative (<55 male, <65 female))
Ca++-channel blockers used for
symptomatic relief only, not mortality
no O2 unless hypoxic
don’t wait for troponin or CK-MB results
statins can cause increased LFTs & myositis
no O2 unless hypoxic
eptifibitide or abciximab (glycoprotein
IIb/IIIa inhibitor) used if PCI & stent
Takotsubo cardiomyopathy due to
overwhelming emotions; mimics anterior
wall STEMI
1-2 vessel: medical Rx & possible PCI
3 vessel w/ LV dysFx or left main: bypass
ASA only in chronic stable angina
Ranolazine: Na+-channel blocker for
refractory angina cases only
MCC: “I AM in high salty fluid”
Ischemia
Arrhythmia
Medication (most common)
Infection
HTN crisis
Salty food
Fluid overload (iatrogenic)
AICD if low EF despite medical therapy
(lowers mortality)
ACE-I not beneficial in diastolic dysFx
HTN crisis = severe HTN with end-organ
crisis
Cardiomyopathy
Hypertrophic
Obstruction
Cardiomyopathy
Arrhythmia
blurry vision, confusion,
renal insufficiency
SOB worsens on exertion,
improves with rest
rales
+/- peripheral edema
syncope, LOC
chest pain
S4 gallop
sudden death in athletes
palpitations
or nitroprusside (stroke caution: do not lower
BP > 25% 1st few hrs)
damage
CXR: congestion or pulmonary vascular redistribution
echo (alternative MUGA or left heart cath)
β -blocker, ACE-I, spironolactone, diuretics
(for dilated cardiomyopathy)
treat underlying cause (for restrictive card.)
systolic murmur at LLSB: valsalva & standing
(increases); squatting & leg raise (decreases)
echo
left heart catheterization
systolic dysFx: diated cardio.
diastolic dysFx: hypertrophic card.
restrictive card: sarcoidosis, amyloidosis,
hemochr., cancer, endomyocardial fibrosis
EF is preserved
β -blocker (metoprolol)
implantable defibrillator (for syncope)
EKG (if normal, Holter as outpatient, telemetry for
inpatient)
exclude thyroid disease, alcohol, caffeine
NO anticoagulation if present < 48 hr
anticoagulate if risk for stroke (CHAD2)
 cardiomyopathy
 HTN
 age >75
 DM
 prior Stroke/TIA (anticoagulate)
rate control <100 bpm within 30 min
metoprolol (5 mg IV every 5 min 3x, then
oral 50 mg bid, max 200 bid), OR…
diltiazem (0.25 mg/kg, then IV 0.35 mg/kg,
then oral 30 mg qid, max 200 qid)
use digoxin if BP is low or borderline
(digoxin doesn’t lower BP; slow acting)
diuretics, ACE-I, dehydration, & digoxin will
worsen HOCM
hemodynamic instability = chest pain, SOB,
confusion, hypotension (<90 mmHg systolic)
CHAD2 = 0/1: ASA &/or clopidogrel
CHAD2 = 2+: warfarin, rivaroxaban, or
dabigatran (no INR monitoring required, not
reversible)
causes: HTN (MC), CHF, alcohol, cocaine,
thyroid disease, rheumatic fever
(immigrants), dilated atrium
palpitations, +/- chest pain
lightheadedness
EKG: irregularly irregular rhythm, P-waves absent,
normal QRS
(do not measure HR by radial pulse)
echo (detects valve disease & clots)
Troponin/CK-MB
SVT
sudden onset palpitations
SOB, lightheadedness
EKG: narrow QRS tachycardia (>160bpm), P-waves
absent
no physical findings
echo to exclude other pathology
troponin/CK-MB are not useful
telemetry
adenosine
b-blocker (metoprolol or diltiazem)
cardioversion if hemodynamically unstable
Wolf-Parkinson
White Syndrome
palpitations,
lightheadedness, syncope
EKG: small/short P-R, delta waves (early ventricular
depolarization), SVT alternating w/ v-tach
procainamide, amiodarone, flecainide, or
sotalol
electrophysiology (EP) to identify abnormal
conduction tract for ablation
previous EKG
digoxin & Ca++-ch blocker use worsens
symptoms or arrhythmia
Multifocal Atrial
Tachycardia
a/w COPD
3 P-wave morphologies & normal QRS
same as for a-fib/a-flutter
NO β -blocker (worsens COPD)
EXTREME EMERGENCY
chest pain, confusion, SOB
EKG: wide QRS, reproducibly regular, sustained VT
>30 sec
Troponin/CK-MB
echo
recent MI
loss of pulse
CPR – defib – CPR – epi – CPR – defib after 2 min –
CPR - amiodarone
low systolic < 90 mmHg
lightheadedness
confusion, syncope, SOB
EKG: determine hemodynamic stability
ventricular pacemakers give wide QRS & abnormal Twaves
A-fib/A-flutter
V-Tach
V-fib
Bradycardia
saline bolus if systolic <90 mmHg
check K+. Mg++, Ca++, O2
synchronized cardioversion if unstable
amiodarone, lidocaine, procainamide, &
Mg++ if stable
GIVE CPR!
unsynchronized cardioversion
epinephrine or vasopressin if no response
amiodarone (lidocaine alternative)
if unstable/symptomatic…
atropine (0.5-1.0 mg IV; 3 mg max)
transcutaneous pacemaker
other rate control meds: verapamil, esmolo,
propranolol, atenolol
Cardioversion: a-fib rhythm control
MCC by abnormal AV conduction vagal
maneuvers: carotid massage or valsalva
MCC is previous MI (ischemia), also low
Mg++, Ca++, or O2, high/low K+, cocaine
toxicity, low EF dilated cardiomyopathy
Torsade de Pointes
treat V-tach without pulse the same
if stable/asymptomatic…
Sinus brady, 1st degree AV block, or Mobitz
I = no treatment
Mobitz II or 3rd degree AV block
= pacemaker
Sick Sinus
Syndrome
aka tachy-brady syndrome
Syncope
sudden LOC = cardiac or
neurologic cause
gradual LOC: metabolic
sudden recovery of
consciousness: cardiac
gradual recovery: seizures,
glucose, O2, drug O/D
EKG
Troponin/CK-MB
echo
measure O2, glucose, Na+, Ca++
MRI for brainstem causes
head CT & echo w/o murmur findings are useless
Valvular Heart
Disease
dyspnea
CHF
edema
murmurs
congenital/rheumatic fever
echo (best initial assessment)
catheterization (most accurate test)
Aortic/Mitral
Regurgitation
dyspnea, rales, edema
pacemaker if slow (>3 sec pause)
b-blocker if fast
echo (best test)
EKG: AR will show LVH (SV1 + RV5 >35 mm)
CXR: enlarged LA & LV
AR: diastolic decrescendo murmur @ LLSB
MR: pansystolic @ axilla that radiates
Aortic Stenosis
angina a/w CAD
syncope
CHF (worse prognosis)
Mitral Stenosis
young immigrant
a-fib, dysphagia, hoarseness,
early onset stroke
Mitral Valve
Prolapse
Pericarditis
Pericardial
Tamponade
Constrictive
Pericarditis
Peripheral Artery
Disease
palpitations
atypical chest pain
incidental finding
chest pain: relieved by
sitting up, worse on
inspiration
SOB, lightheadedness
dyspnea, hypotension, JVD
tachycardia
sudden loss of pulse
edema, JVD, Kussmaul’s
sign
enlarged liver & spleen
ascities
“angina of the calves”
pain in legs relieved by rest
decreased peripheral pulses
echo (best test)
stress test & angiography (due to CAD)
EKG: biphasic P-waves in V1 & V2
CXR: “double bubble”, L mainstem bronchus pushing
up, straightened L heart border
TEE & L heart cathetherization is best test
echo (best test)
mid-systolic click w/ late systolic murmur
EKG & CXR will be normal
friction rub on auscultation
EKG: ST elevation in all leads except AVR,
PR segment depression
vasovagal episode
telemetry
endocarditis PPx if valve was replaced
ACE-I/ARBs decreased afterload
no ABX PPx before dental procedures unless
valve was replaced
surgery: AR EF <50% or LVESD >55mm,
MR EF <60% or LVESD >45mm
no treatment if asymptomatic
surgical replacement if symptomatic
balloon valvulopasty if pt too ill
diuretics (fluid overload)
digoxin or β -blocker (HR control)
balloon valvuloplasty (or alternative: valve
replacement)
β -blocker for palpitations & chest pain
no treatment if asymptomatic
no endocarditis PPx
treat underlying cause
NSAIDS (ibuprofen & naproxen)
add colchicine to reduce recurrence risk
alternative is prednisone for symptoms
pulsus paradoxus (>10 mmHg with inspiration)
CXR: enlarged heart shadow
CT: pericardial effusion
echo: effusion pressing on right heart: RA & RV
diastolic collapse is the first sign
EKG: low voltage, QRS electrical alternans
fluids prevent/reverse tamponade
thoracocentesis
pericardial window placement
cardiac catheterization: pressure equalization
of all chambers in diastole
S3 “pericardial knock”
CXR: fibrosis, thickening, calcification
Chest CT/MRI shows more detail
surgical removal is best
diuretics & salt restriction prevents build-up
ankle/brachial index (ABI): ankle pressure >10%
lower than brachial (ABI <0.9) = obstruction
lower extremity Doppler
STOP SMOKING!
ASA (or clopidogrel)
Cilostazol
exclude cardiac & neurologic causes
 MI
 ventricular arrhythmia
 aortic stenosis
 HOCM
 seizure
 brainstem stroke
 increased venous return (squatting or legs
raised) increases all murmur intensities
(except MVP & HOCM)
 decreased venous return (sudden standing
or valsalva) decreases left-sided murmur
(except MVP)
 handgrip increases afterload; worsens
regurgitations, improves HOCM
due to any cause of dilated cardiomyopathy
louder with squatting & leg raised
softer with valsalva & standing
worsens with hand grip ( afterload)
DO NOT use ACE-I or ARB (worsens)
MS can cause LA enlargement & a-fib w/
pressure on esophagus & recurrent laryngeal
nerve.
improves with squatting & leg raised
worsens with valsalva & standing
MCC: viral infection
also fever, recent lung infection
renal failure
chest wall trauma
SLE, RA, Wegner’s
recent MI, cancer of chest organs
Hx of tobacco smoking
Hx of HTN, DM, hyperlipidemia
pain with exertion, spinal stenosis worse
smooth, shiny skin (severe)
Abdominal
Aortic Aneurysm
USS: all men age >65 who have ever smoked
Thoracic Aortic
Aneurysm
chest pain radiates to the
back
Heart Disease &
Pregnancy
peripartum cardiomyopathy
w/ LV dysFx
pleuritic chest pain that
changes with respiration
dyspnea, fever, cough,
sputum
sudden onset pleuritic chest
pain
recent surgery
chest pain radiates to back
chest tender on palpation
epigastric pain, burning
Pneumonia
Pulmonary
Embolus
Aortic dissection
Costochndrtis
GERD
Hypotension
systolic < 90 mmHg
Dehydration
Sepsis
angiography
Fever
Orthostasis
CXR: wide mediastinum
CT angiogram, MRA, TEE (90-95% sensit/specif)
angiogram with catheter is most accurate
Eisenmenger’s leads to pulmonary HTN
(blood volume increases by 50% in pregnancy)
CXR
oximeter
ABG
sputum culture
ACE-I for BP
Statin (LDL goal: <100 mg/dL)
tight glucose control in diabetics
AAA >5.0 cm = surgical repair
AAA <5.0 cm = USS in 6 months
b-blocker (labetalol) decreases pulse pressure
nitroprusside
surgical repair
Mitral stenosis
Aortic stenosis
ABX prophylaxis
CT pulmonary angiogram
CXR, oximeter, ABG
CXR: wide mediastinum
none
repeat BP manually
CT angiogram, MRA, TEE
improves with antacids
position feet up/head down
IVF 250-500 mL NS bolus over 15-30 min
BUN: Cr ratio >15-20:1
low urine Na+ (<20)
high urine Osm (>500)
CBC: leukocytosis
Blood cultures
BP normalizes lying flat
Tilt-table test
Premature
Ventricular
Contractions
(PVCs)
incidental finding
EKG: alternating normal QRS with wide, premature
PVCs
no specific treatment
30 heart block
recent MI
EKG: bradycardia, canon A waves
atropine for symptoms
pacemaker for all pt
RV infarct
recent MI
EKG: inferior wall MI
right-sided EKG: V4 STEMI
Valve Rupture
Septal Rupture
recent MI, new murmur
rales/congestion
recent MI, new murmur
increased O2 sat in RV
walking downhill, but not uphill
balloon pump in some pt
balloon pump in some pt
Tx first, Dx later.