Transcript CARDIAC EMERGENCIES - AJA University of Medical Science

CARDIAC EMERGENCIES
Severe hypertension
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Systolic BP > 200 mm Hg ◦
Diastolic BP > 120 ◦
If life-threatening organ damage is present,
then BP must be reduced quickly to normal
levels
Rapid BP reductions can cause strokes, renal
failure, and myocardial ischemia
If life-threatening organ damage is not
present, reduce the BP gradually to avoid the
side effects
Hypertensive Emergencies
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Most organ damage is from arteriolar
necrotizing vasculitis (platelet and fibrin
deposition) and loss of autoregulation of the
blood vessels
The most common cause is discontinuation of
BP medication
Young patients (<30) or black patients may
have secondary causes for HTN, such as
renal disease, endocrine syndromes, druginduced catecholamine release, or
pregnancy-induced
Pathophysiology
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Encephalopathy
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Pulmonary edema
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Renal impairment
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Retinopathy
Aortic dissection
Angina/MI
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Pregnancy related
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HA, nausea, vomiting, blurred vision, confusion, ◦
seizures, coma
stroke ◦
Due to increased afterload, not fluid overload ◦
Decreased glomerular filtration rate, blood/protein in the ◦
urine
Due to increased afterload and decreased perfusion ◦
Pre-eclampsia/eclampsia ◦
Clinical Features of HTNinduced organ damage
With life-threatening organ damage 
Close monitoring ◦
Sodium nitroprusside (Nipride) ◦
Arteriovenous dilator 
Gylceryl trinitrate ◦
Arteriovenous dilator 
Especially effective when MI/pulm edema co-exist 
Labetalol ◦
An alpha and beta blocker 
Can exacerbate asthma, heart failure, heart block 
Hydralazine and diazoxide ◦
Treatment
Without life-threatening organ damage 
Oral antihypertensives ◦
Sublingual Nifedipine 
Beta blockers 
ACE inhibitors 
Calcium channel blockers 
Goal is to reduce the diastolic BP to ~100 mm ◦
Hg by 24-48 hours
Treatment
Infection of the heart valves or 
endocardium
Usually causes a chronic illness but can be 
acute when due to a virulent organism
Causitive organisms 
Streptococcus viridans: ~50%...poor dentition
Staphylococcus aureus: 20-25%...IV drug use
Staphylococcus epidermidis: valve replacement
surgery
Staphylococcus faecalis:
5%...abortion/genitourinary surgery
Gram negative organisms: drug addicts/heart
valve replacement
Fungi: immunosuppressed patient
Infective Endocarditis
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Etiology 
Most common in elderly people with ◦
degenerative aortic/mitral valve disease
Patients with prosthetic valves, rheumatic heart ◦
dx, congenital heart dx
Abnormal valves are particularly susceptible ◦
following dental or surgical procedures
Infective Endocarditis
Clinical Features
CNS: embolic infarction, abscesses, meningitis
General infection: low grade fever, lethargy, malaise,
anemia, wt loss
Cardiac: murmurs, heart failure, aneurysms
Late signs: clubbing of digits, splenomegaly
Joints: arthralgia, septic arthritis
Skin: vasculitic rash
Soles of feet: Janeway lesion
Eyes: retinal hemorrhages
Mucosal: subconjunctival hemorrhage
Nail bed: splinter hemorrhages, nailfold infarcts
Hands: small, red macular lesions, painful swelling of
fingers/toes
Kidneys: microscopic hematuria, glomerulonephritis
Embolic infarcts and abscesses: lungs, kidneys,
CNS…loss of peripheral pulses
Infective Endocarditis
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Diagnosis 
Mainly clinical ◦
Confirmed by anemia, raised ESR or CRP, ◦
microscopic hematuria, positive blood cultures,
and echocardiography
Management 
ID and treat infection (ATB for ~6 wks) ◦
Surgery to replace infected prosthetic valves ◦
and native valves if infection/heart failure
occurs
Prognosis 
Mortality is ~15% ◦
Prophylactic ATB used before procedures in ◦
Infective
Endocarditis
patients
with valvular heart disease
Acute pericarditis 
Due to infection (usually viral), MI, uremia,
connective tissue dx, trauma, TB, or neoplasms
Clinical features: severe positional (sitting
forward relieves) retrosternal chest pain with
pericardial rub
Diagnosis: concave ST segment
elevation…cardiac enzymes may be elevated
Management: bed rest, anti-inflammatories,
steroids
Pericardial Emergencies
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Pericardial Effusion
Due to infection, uremia, MI, aortic dissection,
myxedema, neoplasms, radiotherapy
Clinical features: cardiac tamponade reducing CO, SOB,
pericarditis, venous congestion that increases with
inspiration, hypotension with a paradoxical pulse (BP
falls >15 mm Hg during inspiration), distant heart
sounds
Diagnosis: low voltage EKG, CXR shows cardiomegaly,
echocardiography
Management: pericardial drainage
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Constrictive pericarditis
A progressive fibrotic constriction of the pericardium ◦
Surgical removal of the pericardium is the only tx ◦
Pericardial Emergencies
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