CARDIAC EMERGENCIES

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CARDIAC EMERGENCIES
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Hypertensive Emergencies

• Severe hypertension
• Systolic BP gt 200 mm Hg
• Diastolic BP gt 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

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Pathophysiology

• 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 (lt30) or black patients may have
  secondary causes for HTN, such as renal disease,
  endocrine syndromes, drug-induced catecholamine
  release, or pregnancy-induced

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Clinical Features of HTN-induced organ damage

• Encephalopathy
• HA, nausea, vomiting, blurred vision, confusion,
  seizures, coma
• stroke
• Pulmonary edema
• Due to increased afterload, not fluid overload
• Renal impairment
• Decreased glomerular filtration rate,
  blood/protein in the urine
• Retinopathy
• Aortic dissection
• Angina/MI
• Due to increased afterload and decreased
  perfusion
• Pregnancy related
• Pre-eclampsia/eclampsia

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Treatment

• 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

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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

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Infective Endocarditis

• 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/genitourin
  ary surgery
• Gram negative organisms drug addicts/heart
  valve replacement
• Fungi immunosuppressed patient

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Infective Endocarditis

• 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

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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,
  CNSloss of peripheral pulses

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Infective Endocarditis

• 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
  patients with valvular heart disease

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Pericardial Emergencies

• 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 elevationcardiac
  enzymes may be elevated
• Management bed rest, anti-inflammatories,
  steroids

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Pericardial Emergencies

• 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 gt15 mm Hg during
  inspiration), distant heart sounds
• Diagnosis low voltage EKG, CXR shows
  cardiomegaly, echocardiography
• Management pericardial drainage
• Constrictive pericarditis
• A progressive fibrotic constriction of the
  pericardium
• Surgical removal of the pericardium is the only tx