Cardiovascular emergencies

1. Clinical tips in
Cardiovascular Emergencies
Ahmed Mohsen
Department of cardiovascular Medicine
Cairo university

2. Introduction
• Cardiovascular disease is the most prevalent
disease worldwide.
• It is the leading global cause of death, accounting
for 15 million deaths in 2015 .
• Cardiovascular disease often presents in
emergency situations; prompt treatment is
essential to reduce mortality.

3. • Out-of-hospital cardiac arrest is one of the most
dreadful conditions leading to over 90% mortality
rate
• “Time is gold” has always been The cornerstone
of cardiovascular emergency management ;For
example in patients with STEMI, every 30-minute
delay in door to balloon time translates into 7.5%
relative increase in mortality

4. Leading causes of death

5. Spectrum of Cardiovascular
Emergencies
• 1-Acute chest pain
• 2-Acute dyspnea(acute heart failure)
• 3-Syncope
• 4-Hemodynamic instability
Tachycardia, bradycardia,
Hypotension and shock:
(Cardiac tamponade, cardiogenic shock )
• 5-Hypertensive Emergencies
• 6-Cardiac arrest

6. Acute chest pain Acute dyspnea

7. Syncope

8. Tachyarrhythmia
VT VF

9. Tachyarrhythmia
AF SVT

10. Bradyarrhythmia
Heart block Asystole

11. Hypotension and shock
Cardiac tamponade Cardiogenic shock

12. Hypertensive crisis
Hypertensive urgency Hypertensive emergency

13. Cardiac arrest

14. Case scenario
• A 68- year -old obese man is brought in by ambulance
to the emergency room complaining of abrupt onset
of chest discomfort for the past hour .
• He describes “severe aching ” under the distal aspect
of his sternum with radiation into the inferior left side
of his chest.
• His symptoms started at rest, have been constant, an
worsen when he takes a deep breath.
• He has a history of acid reflux disease, alcoholism,
hyperlipidemia, hypertension, prostate cancer, and
strong family history of myocardial infarction

15. • On examination, the patient appears restless and in
modest distress.
• Vital signs are temperature 37°c, heart ate 112 bpm,
blood pressure 80/ 60 mmHg in the left arm and 85/
65mmHg in the right arm, respirations 26 breaths/min,
and oxygen saturation 90% on room air .
• The patient’s breathing is labored , with normal breath
sounds.
• He has a tachycardic regular rhythm without
murmurs, rubs, o gallops.
• The epigastrium is mildly tender to palpation, and his
stool is negative for occult blood.

16. • What are the priority diagnosis to evaluate?
• What are your next diagnostic steps?

17. Answer:
Chest Pain,
Undifferentiated

18. Summary:
• This 68-year-old man presents with vague
substernal and left-sided chest pain for 1 hour.
• His pain is associated with dyspnea, tachypnea,
and unstable vital signs, including hypotension,
tachycardia, and relative hypoxia.
• He is currently in respiratory distress, and triage
should focus on differentiating between possible
life threatening etiologies of his symptoms that
require urgent attention.

19. This patient has Risk factors for:
• 1-Thromboembolic disease (obesity and
malignancy).
• 2-Cardiovascular disease (obesity, age, gender,
hypertension, hyperlipidemia, and a strong family
history).
• 3-Peptic ulcer disease (acid reflux and
alcoholism).
• As such, the differential should initially be kept
broad, and narrowed once life- threatening
causes are ruled out.

20. Priority differential diagnosis:
• “Can’t miss” diagnoses include:
1- Pulmonary embolism (PE),
2-Acute coronary syndrome (ACS),
3-Aortic dissection
4-Tension pneumothorax
since these are potentially fatal conditions.

21. Next diagnostic steps:
• ECG
• CXR
• Labs (including cardiac biomarkers and ABG)
• Consider contrast enhanced CT of the chest.

22. Approach for Chest Pain
DEFINITIONS:
ACUTE CORONARY SYNDROME (ACS):
• 1-Unstable angina
• 2-Non-ST elevation MI
(NSTEMI)
• 3-ST elevation MI (STEMI)

23. Approach for Chest Pain
DEFINITIONS:
Percutaneous coronary intervention
Catheter-based therapy by
which blood flow is restored
to an occluded coronary artery
by balloon angioplasty or
stenting

24. Differential Diagnosis
• The differential diagnosis of chest pain is
extensive, and although it is usually due to
benign causes, some causes of chest pain may
be life-threatening.
• As such, for each patient presenting with
chest pain, serious causes should be ruled out
before less dangerous conditions are
considered

26. • Non-emergent chest pain evaluated in the primary
care office is most often due to musculoskeletal pain
followed by gastrointestinal issues and is less
commonly due to cardiac causes (most of which are
stable angina).
• Acute chest pain in patients with risk factors for
coronary artery disease will be more likely to be
cardiac in origin (in patients older than 40, up to 50%
of cases will be due to a cardiac cause) .

27. History
Chest pain analysis
• Onset, course duration
• Site and radiation
• Character and duration
• Precipitating and relieving
factors
• Associated symptoms
• Severity
Risk factors and type of patient
• DM
• Hypertension
• Smoking
• Obesity
• Family history
• Age
• Prior similar attacks
• Prolonged Immobilization
• Recent surgery
• Oral contraceptive pills

28. History suggestive of MI
Chest pain analysis
• Site: Retrosternal
• Radiation :left or right shoulder or both ,back,
lower jaw, epigastrium
• Character: Compressing, heaviness, Burning
• Duration: More than 20 minutes
• Precipitating factors: Physical or emotional stress
• Relieving factors: Rest or SL nitrates
• Associated symptoms: Vomiting, sweating
dyspnea and syncope

29. History suggestive of MI
Risk factors and type of patient
• DM
• Hypertension
• Smoking
• Obesity
• Family history
• Age
• Prior similar attacks

30. Important tips
• Normal ECG does not rule out ACS
• Do not allow patient presenting to ER at night with
acute chest pain to go home
• Presentations may be atypical in the elderly, women,
and diabetics.
• Up to one-third of these patients may not experience
classic ischemic chest pain with myocardial infarction
(MI).
• They can present with dyspnea(angina equivalent) or
fatigue, syncope, arrhythmia, acute HF or even silent
infarction.
• Epigastric pain may be sign of inferior infarction

31. History suggestive of aortic dissection
Chest pain analysis
• Sudden tearing chest
pain refer to the
back in interscapular
region
• Severe pain from
the start
Risk factors and type of patient
• Usually male patient
,smoker with
uncontrolled
hypertension
• Marfan syndrome

32. Important tip
• The possibility of aortic dissection should be
excluded in every patient with ACS as
antiplatelet and anticoagulant as well as
thrombolytic therapy are contraindicated and
will be catastrophic in patients with aortic
dissection

33. History suggestive of pneumothorax
Chest pain analysis
• Pleuritic chest pain:
stitching localized chest
pain that increase with
cough or deep
inspiration or positional
pain
• Associated with severe
dyspnea
Risk factors and type of patient
• Spontaneous
pneumothorax classically
occurs in tall patients,
those with cystic fibrosis,
α1-antitrypsin deficiency,
following trauma to the
chest, or iatrogenically
• Patient with long history
of chest problems(COPD,
BA)

34. Important tip
• Any patient with chest pain and normal ECG
should have a CXR to look for pneumothorax
or wide mediastinum

35. History suggestive of pulmonary
embolism
Chest pain analysis
• Typical chest pain
or
• Pleuritic chest pain:
stitching localized chest
pain that increase with
cough or deep inspiration
or positional pain
• Associated with severe
unexplained dyspnea
Risk factors and type of patient
• Prolonged
Immobilization
• Recent surgery
• Oral contraceptive
pills
• Malignancy
• Pregnancy

36. Important tip
• Any patient with unexplained dyspnea with
normal CXR should be considered pulmonary
embolism until proved otherwise

37. Less urgent causes of chest pain that
may mimic MI include the following
• Pericarditis (pain is typically better when leaning forward, and may
be pleuritic)
• Myocarditis (may be preceded by a recent flulike illness)
• Pneumonia (may be associated with fevers, chills, cough, and
leukocytosis)
• Peptic ulcer (pain is more epigastric, is reproducible, and may be
associated with peritoneal signs if perforated)
• Pancreatitis
• Cholecystitis
• Musculoskeletal pain (always a diagnosis of exclusion).

38. Physical Exam
1-Vital signs
• Assessment of the vital signs is essential in the early evaluation of
chest pain.
• Pulmonary embolism:
Tachycardia and tachypnea may be early signs of a pulmonary
embolism, even if the patient is not hypoxic.
• Aortic dissection:
• Blood pressure differential of >20 mmHg between the arms is
suggestive of an aortic dissection.

39. Precordial examination
• 1-ACS:
S4 or mitral regurge murmur
2-Aortic dissection:
Aortic regurge murmur
• 3-Pneumothroax:
Distant heart sound

40. Chest examination
1-Acute coronary syndrome:
• Final bilateral basal crepitation if complicated
with heart failure
2-Pneumothorax:
• Unilateral bulge or limited chest expansion
• Hyper-resonance by percussion
• Diminished breath sounds

41. Important tips
• The physical examination may be completely
normal in a patient with life-threatening chest
pain.
• As such, a normal exam may be falsely
assuring, and diagnostic testing should be
done.

42. Diagnostic Testing
1-ECG:
• An ECG should be obtained within 10 minutes of arrival to
the ED to rule out acute MI
2-CXR:
(Wide mediastinum, pneumothorax)
3-Echocardiography:
(RWMAs or dissection flap)
4-CT:
(Triple rule out, CT aortography, CT pulmonary
angiography, CT coronary angiography)
5-Labs:
D-dimer and cardiac enzymes ,ABG

43. STEMI
Anterior STEMI Inferior STEMI

44. Lateral STEMI Posterior STEMI

45. STEMI equivalent
Dewinter Wellen

46. `
RBBB LBBB

47. NSTEMI
Normal ST depression

48. Pulmonary embolism

49. CXR
Aortic dissection

50. CXR
Pneumothorax

51. CT
Aortic dissection

52. CT
Aortic dissection

53. CT
Pulmonary embolism

54. Echo
Aortic dissection

55. Important tips
• Do not wait for cardiac enzymes in patients
with STEMI
• D-dimer is a good negative test but it should
be only used in patients with low or
intermediate probability of pulmonary
embolism
• First set of cardiac enzymes may be normal
and you ask for serial cardiac enzymes

56. Management of ACS
• 1-Loading dose of dual antiplatelet therapy :
4 tablets Acetyl salicylic acid(4 tablet Aspocid 75mg)
and
4 tablets Clopidgrel ( 4 tablet Plavix 75 mg)
or
2 tablet Ticagrelor( 2 tablets of Birlique 90 mg)
• 2-Pain relief by morphia or SL nitrates(Dinitra 5 mg SL
tab)

57. Management of ACS
• 3-Reperfusion or revascularization
 STEMI
Patients with STEMI should immediately proceed to PCI, and patients
with STEMI who cannot receive PCI within 120 minutes should be
considered for thrombolysis (with an agent such as streptokinase or
alteplase), whereas lytic agents are contraindicated in NSTEMI.
 NSTEMI
For NSTEMI, if not high-risk, PCI can be delayed for up to 72 hours,
and patients with high-risk NSTEMI (persistent chest pain, heart
failure, or electrical instability) should proceed immediately to PCI.
4-Anticoagulation,ACEI, Betablocker ,statins and PPI

58. Management of aortic dissection
• Patients with aortic dissection are typically emergently
treated with IV beta-blockers (which decrease heart rate,
blood pressure, and shear force of blood along the arterial
wall) and afterload reduction with nitroprusside.
• Type A dissections (involving the ascending aorta to the
left subclavian artery) are typically managed with
immediate surgery
• Type B dissections (involving the descending aorta distal to
the left subclavian artery) may be initially managed
medically with surgery reserved for patients with refractory
pain or evidence of end-organ hypoperfusion.

59. Management of pneumothorax
In the case of simple, uncomplicated pneumothorax:
• patients are typically monitored closely with serial
CXR, and 100% oxygen may be empirically
administered to increase the rate of absorption.
Patients with tension pneumothorax
• Usually unstable on presentation, and require a needle
thoracotomy to the 2nd intercostal space,
midclavicular line.
• This immediately relieves the pressure, and a chest
tube may be placed surgically immediately thereafter.

60. Management of pulmonary embolism
• Parenteral and oral anticoagulation
• Thrombolytic therapy(If there is hemodynamic
instability or shock)
• Ogygen

61. Tachyarrhythmia
• Any patient presenting with tachyarrhythmia
and hemodynamically unstable you must go
synchronized DC cardioversion

62. Bradyarrhythmia
• You can give up to 3 mg atropine(0.5mg every 5 minutes)
• Always suspect hyperkalemia and if so you should give
anti-hyperkalemic measures
 Slow IV calcium gluconate over 15 minutes
 100 cc glucose 25% with 10 units of rapid acting insulin)
 Nebulizer with beta agonist (farcoline)
 Lasix
 Sodium bicarbonate if there is acidosis)
• Refer for possible temporary or permanent pacemaker

63. ECG in hyperkalemia

64. Cardiac tamponade

65. Hypertensive crisis

68. Management of hypertensive crisis

69. Management of hypertensive crisis

70. Important tips
• SL nifidipine (Epilat) is absolutely
contraindicated and no longer used as it can
lead to acute severe lowering of BP with
subsequent cerebral hypoperfusion and
stroke
• Lasix is not used in hypertensive urgency, it is
used only in hypertensive emergency in form
of acute pulmonary edema

71. Cardiac arrest

72. Cardiac arrest
You should follow BLS and ALS algorithm
putting in mind the difference between:
• 1-Shockable rhythms(VF or pulseless VT):
you should give non-synchronized DC
cardioversion
• 2-Non-Shockable rhythms(Bardy-Asystole)

73. Thank you

74. COMPREHENSION QUESTIONS
• 1-A 68-year-old man with no medical history presents
to a rural emergency department with chest pain for
the past 30 minutes.
• The ECG shows ST elevation in V3–V6 and I, and aVL.
• The hospital is not equipped for PCI, and the closest
hospital that performs PCI is 3 hours away.
• Vital signs are HR 110 bpm, BP 150/84 mmHg, RR 18
per minute, and O2 saturation 98% on room air (RA).
• In addition to aspirin and IV heparin, what is the most
appropriate next step?

75. • A. Administration of full-dose thrombolysis, and transfer to
the nearest PCI capable hospital for angiography
• B. Administration of full-dose thrombolysis, and
subsequent transfer only if patient is unstable
• C. Administration of half-dose thrombolysis, and transfer to
the nearest PCI capable hospital for immediate PCI
• D. Medical management with the addition of clopidogrel

76. • 1 A.
• Patients who present to a hospital not equipped
for PCI who are more than 120 minutes from the
nearest PCI-capable hospital should be given
thrombolysis unless contraindicated.
• Angiography can then be performed, and PCI
carried out if reperfusion is not complete.
• Trials of half-dose lytic and immediate PCI (called
“facilitated PCI”) have not shown favorable
results, and this strategy is not advocated.

77. • 2 -A 70-year-old woman with a history of hypertension,
coronary artery disease, and smoking presents with
tearing chest pain across the chest that radiates to the
back for the past 1 hour.
• Vitals are HR 100 bpm , BP 190/110 mmHg, RR 18 per
minute, and O2 saturation 97% on RA.
• A chest CT with contrast shows an aortic dissection
extending 1 cm distal to the left subclavian artery to 2
cm superior to the renal arteries.
• What is the most appropriate management strategy?

78. • A. Immediate surgery
• B. Administration of IV labetalol, nitroglycerine,
and surgery when stable
• C. Administration of IV heparin, IV metoprolol,
and continued monitoring
• D. Administration of IV heparin, IV nitroprusside,
IV metoprolol, and continued monitoring
• E. Administration of IV metoprolol, IV
nitroprusside, and continued monitoring

79. • 2 E.
• This patient has a type B aortic dissection, which may
be managed medically with IV metoprolol and IV
nitroprusside.
• Intravenous labetalol does not reduce shear force of
blood along the arterial wall as well as metoprolol, and
• nitroglycerine is generally considered inferior to
nitroprusside for afterload reduction.
• Surgery is not required unless the aneurysm continues
to extend or there are complications, and IV heparin is
contraindicated.

80. • 3 An 18-year-old man presents with chest pain
and dyspnea with deep breathing for the past
1 hour. Vitals are stable. CXR shows a small
pneumothorax involving 10% of area of the
left lung.
• What is the most appropriate management
strategy?

81. • A. Needle thoracotomy of the 2nd left
intercostal space, midclavicular line
• B. Placement of a chest tube
• C. 100% oxygen and serial CXR over the next
24 hours
• D. Albuterol inhaler, 100% oxygen, and chest
physical therapy

82. • 3 C.
• This young man has a simple, uncomplicated
pneumothorax, which may be monitored with
serial CXR for stability.
• No urgent intervention is required, and 100%
oxygen may help it resorb.
• Needle thoracotomy and chest tube are
therapies reserved for tension pneumothorax.

83. • 4 A 45-year-old man with a history of
hypertension and lung cancer presents with
pleuritic chest pain, and left calf swelling after
a 4-hour plane flight.
• He is tachycardic, hypoxic, but otherwise
stable.
• What is the most appropriate next step in
management?

84. • A. Obtain a left lower extremity venous
ultrasound
• B. Obtain a chest CT scan with contrast
• C. Obtain a bedside transthoracic
echocardiogram
• D. Check a d -dimer
• E. Empiric administration of IV unfractionated
heparin

85. • 21.4 B.
• This patient likely has a pulmonary embolism,
caused by a left lower extremity deep-vein
thrombosis (DVT).
• The next best step is to obtain a chest CT with
contrast to confirm the diagnosis.
• In patients with renal insufficiency, a venous
ultrasound to confirm a DVT may be sufficient
to infer a diagnosis, but is less ideal.

86. • A bedside echocardiogram is typically unnecessary
unless the right heart needs to be assessed in a patient
with signs of hemodynamic instability.
• A d-dimer is reasonable to rule out a PE in a patient
with low to intermediate probability for PE; however,
this may be falsely elevated in this patient with lung
cancer.
• IV heparin should not be administered without a
diagnosis if this can be avoided.