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Abbreviations: CABG: coronary artery bypass graft; ECG: electrocardiogram; LAD: left anterior descending; LBBB: left bundle branch block; MI: myocardial infarction; PCI: percutaneous coronary intervention; S3: third heart sound; S4: fourth heart sound; VSD: ventricular septal defect

Characterize the symptoms:

Chest pain or chest discomfort

❑ Sudden onset
❑ Sensation of heaviness, tightness, pressure, or squeezing
❑ Duration> 20 minutes
❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium
❑ No relief with rest
❑ Worse with time
❑ Worse with exertion

Dyspnea
Weakness
Palpitations
Nausea
Vomiting
Sweating
Loss of consciousness
Fatigue

 
 
 
 
 
 
Obtain a detailed history:

❑ Age
❑ Baseline blood pressure
❑ Previous episodes of chest pain
❑ Previous PCI or CABG
❑ Cardiac risk factors

Hypertension
Diabetes
Hypercholesterolemia
Smoking
Obesity

❑ List of medications
❑ Family history of premature coronary artery disease


Identify possible triggers:
❑ Physical exertion
❑ Air pollution or fine particulate matter
❑ Antecedant infection
❑ Heavy meal
Cocaine

Marijuana
 
 
 
 
 
 
 
Examine the patient:

Vital signs
Blood pressure

Blood pressure lower than baseline, suggestive of:
❑ Discrepancy between arms (suggestive of aortic dissection)
❑ Narrow pulse pressure (suggestive of heart failure)

Heart rate

Tachycardia (suggestive of heart failure)
Bradycardia (suggestive of heart block or bradyarrhythmias)

Pulses
Femoral pulse (if a patient is to undergo PCI)

❑ Strength
Bruits

Skin
Xanthelasma (suggestive of dyslipidemia)
Xanthoma (suggestive of dyslipidemia)
Edema (suggestive of heart failure)
Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock)

Heart
Heart sounds

S3 (suggestive of heart failure)
S4 (associated with conditions that increase the stiffness of the ventricle)

Murmurs

Aortic regurgitation: early diastolic high-pitched sound best heard at the left sternal border (suggestive of aortic dissection with propagation to the aortic arch)

Pericardial friction rub (suggestive of pericarditis)

Lungs
Rales (suggestive of heart failure)

 
 
 
 
 
 
Order labs and tests:

EKG
❑ Biomarkers

❑ Troponin I
❑ CK-MB

EchocardiographyCreatinine
Glucose
Hemoglobin
❑ Multislice CT coronary imaging (rule out CAD as cause of pain in patients with low to intermediate likelihood of CAD and when troponin and ECG are inconclusive)[1]
MRI (integrate imaging of function, perfusion and necrosis)[2]


 
 
 
Identify cardinal findings of Unstable angina/ NSTEMI :

Chest pain or chest discomfort

❑ Sudden onset
❑ Sensation of heaviness, tightness, pressure, or squeezing
❑ Duration> 20 minutes
❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium
❑ No relief with medications
❑ No relief with rest
❑ Worse with time
❑ Worse with exertion
❑ Associated symptoms of palpitations, nausea, vomiting and sweating

Characteristic ECG changes consistent with unstable angina/ NSTEMI

❑ No changes
❑ Non specific ST / T wave changes
❑ Flipped or inverted T waves
❑ ST depression (carries the poorest prognosis)
Increase in troponin and / or CK MB
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out life threatening alternative diagnoses:

Aortic dissection
(suggestive findings: back pain, |interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms)
Pulmonary embolism
(suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT)
Cardiac tamponade
(suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus)
Tension pneumothorax
(suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound)

Esophageal rupture
(suggestive findings: vomiting, subcutaneous emphysema)
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial treatment:
❑ Administer 162 - 325 mg of non enteric aspirin
❑ Orally, crushed or chewed, OR
❑ Intravenously

❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90%

❑ Caution in COPD patients: maintain an oxygen saturation between 88% and 92%

❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure
Contraindicated in heart failure , prolonged or high degree AV block , reactive airway disease , high risk of cardiogenic shock and low cardiac output state

Metoprolol IV, 5 mg every 5 min, up to 3 doses
Carvedilol IV, 25 mg, two times a day

❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
Contraindicated in suspected right ventricular MI , recent use of phosphodiesterase inhibitors , decreased blood pressure 30 mmHg below baseline
❑ Administer IV morphine if needed

❑ Initial dose 4-8 mg
❑ 2-8 mg every 5 to 15 minutes, as needed

❑ Administer 80 mg atorvastatin
❑ Monitor with a 12-lead ECG all the time

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine if the patient has any of the following indications that require immediate angiography and revascularization:

❑ Hemodynamic instability or cardiogenic shock
❑ Severe left ventricular dysfunction or heart failure
❑ Recurrent or persistent rest angina despite intensive medical therapy
❑ New or worsening mitral regurgitation or new VSD
❑ Sustained VT or VF

❑ Prior PCI within past 6 months or CABG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to angiography
 
Low risk
Initial conservative strategy
 
High risk
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Administer ONE of the following antiplatelet agents (before or at the time of PCI):
P2Y12 receptor inhibitors

Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg

Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
❑ IV GP IIb/IIIa inhibitors

Abciximab
❑ Loading dose 0.25 mg/kg IV bolus
❑ Maintenance dose 0.125 mg/kg/min
Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus
❑ Another 180 mcg/kg IV bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <50 mL/min
❑ Avoid in hemodialysis patients
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <30 mL/min

Administer ONE of the following anticoagulant therapy:
Unfractionated heparin

If GP IIb/IIIa receptor antagonist is planned
❑ 50- to 70-U/kg IV bolus
If no GP IIb/IIIa receptor antagonist is planned
❑ 70- to 100-U/kg bolus

Bivalirudin

❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion
❑ Additional bolus of 0.3 mg/kg if needed
❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min
 
Administer one of the following antiplatelet agents:

Clopidogrel

❑ Loading dose (300 mg)
❑ Maintenance dose for up to 12 months (75 mg)

Ticagrelor

❑ Loading dose (180 mg)
❑ Maintenance dose for up to 12 months (90 mg twice daily)
 
Administer one of the following antiplatelet agents:

Before PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min

At the time of PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or
❑ Prasugrel (60 mg)

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
 
 
 
 
 
 
 
 
 
Coronary artery bypass grafting (CABG)[3]
It is usually preferred for:
❑ Patients with left main or left main equivalent disease
❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction
❑ Diabetic patients
 
 
 
 
 


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Administer ONE of the following antiplatelet agents (before or at the time of PCI):
P2Y12 receptor inhibitors

Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg

Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
❑ IV GP IIb/IIIa inhibitors

Abciximab
❑ Loading dose 0.25 mg/kg IV bolus
❑ Maintenance dose 0.125 mg/kg/min
Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus
❑ Another 180 mcg/kg IV bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <50 mL/min
❑ Avoid in hemodialysis patients
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <30 mL/min

Administer ONE of the following anticoagulant therapy:
Unfractionated heparin

If GP IIb/IIIa receptor antagonist is planned
❑ 50- to 70-U/kg IV bolus
If no GP IIb/IIIa receptor antagonist is planned
❑ 70- to 100-U/kg bolus

Bivalirudin

❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion
❑ Additional bolus of 0.3 mg/kg if needed
❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min

G01=

Consider urgent CABG if the coronary anatomy is not amenable to PCI and one of the following:

❑ Ongoing and recurrent ischemia
Cardiogenic shock
❑ Severe heart failure
❑ Other high risk features





Unstable angina/ NSTEMI Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts


 
 
 
 
 
 
 
Examine the patient:

Vitals
Pulse

Tachycardia
❑ Unequal pulse (suggestive of aortic dissection)
❑ Should be measured in all extremities

Respiration

Tachypnea (suggestive of left sided heart failure or pulmonary edema)

Blood pressure

Hypertension (systolic blood pressure ≥ 180 mm Hg, or diastolic blood pressure ≥ 120 mmHg)
❑ Measured by the physician
❑ Measured in both arms
❑ Measured with appropriate cuff size (small cuffs gives falsely high readings)

Pulse oximetry
Eye

Abnormal extra-ocular movements
Pupils not reactive to light
Abnormal findings on ophthalmoscopic exam

Neck
❑ Elevated jugular venous pressure (suggestive of heart failure)
Carotid bruits (suggestive of aortic stenosis and astherosclerotic vessels)
Respiratory examination
❑ Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles)
❑ Auscultation (rales, reduced breath sounds, egophony) (all suggestive of pulmonary edema)
Cardiovascular examination
❑ Auscultation (abnormal sounds, murmurs) (suggestive of acute heart failure or previous heart disease)
❑ Abdominal aorta (e.g., size, bruits) (suggestive of aortic dissection)
❑ Pedal pulses (e.g., pulse amplitude)
Abdominal examination
❑ looking for pulsatile masses, tenderness, bruits (suggestive of aortic dissection or renal artery involvement precipitating acute renal failure)
Neurological examination
Full neurological examination searching for laterlaizing signs (suggestive of cerebrovascular accident)
Glasgow coma scale
❑ Test cranial nerves with notation of any deficits
❑ Deep tendon reflexes with notation of any pathologic reflexes (e.g., Babinksi)

Clonus
Hyperactive reflexes

❑ Sensation (e.g., by touch, pin, vibration, proprioception)

 
 



 
 
 
 
 
 
 
 
 
 
Identify cardinal signs and symptoms that increase the pretest probability of hypertensive crisis:

❑ Acute severe elevation in blood pressure (usually systolic blood pressure greater >160 mm Hg or diastolic blood pressure >100 mm Hg) with or without end-organ damage like
Cerebral infarction
or
Intracerebral hemorrhage
or
Subarachnoid hemorrhage
or
Hypertensive encephalopathy
or
Acute left ventricular failure
or
Myocardial infarction
or
Aortic dissection
or
Acute pulmonary edema
or
Acute renal failure
or
Hypertensive retinopathy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
With evidence of end-organ damage
 
 
 
Without evidence of end-organ damage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypertensive emergency
 
 
 
Hypertensive urgency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify alarming signs and symptoms:
Tachycardia
Hypotension
Loss of consciousness
Tachypnea
 
 
 
❑ Consider admission for observation
or
❑ Consider treatment on outpatient basis
 
 
 


 
 
 
 
 
Identify cardinal findings that suggest any of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure the blood pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BP ≥ 180/120
 
BP < 180/120
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any evidence of end organ damage?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify alarming signs and symptoms:
Tachycardia
Hypotension
Loss of consciousness
Tachypnea
 
❑ Consider admission for observation
❑ Consider treatment as an outpatient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Stage A Stage B Stage C Stage D
❑ No symptoms
❑ Patient at risk of developing mitral stenosis
❑ Mild valve doming during diastole
❑ Normal transmitral flow velocity
❑ No symptoms
❑ Progressive mitral stenosis
❑ Valve area > 1.5 cm²
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Increased transmitral flow velocities
❑ Diastolic pressure half-time < 150 ms
❑ Mild to moderate left atrial enlargement
❑ Normal pulmonary pressure at rest
❑ Asymptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement
❑ Symptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement


 
 
 
 
Classify mitral stenosis based on TTE:
❑ Valve anatomy
❑ Valve hemodynamics gradient
❑ Hemodynamic consequences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage A
 
Stage B
 
Stage C
 
Stage D
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Yearly follow up is recommended with history and physical examination in asymptomatic patients with mild MS
❑ For mild MS repeat echocardiography every 3-5 years[4]
❑ For moderate MS repeat echocardiography every 1-2 years[4]
❑ The onset of symptoms require medical therapy and re-evaluation of the stage as the patient may also need intervention in moderate and severe disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The presence of symptoms is an indication for intervention

Indications for pharmacotherapy:
❑ Alleviate symptoms before surgery
❑ Control symptoms precipitated by intercurrent illness or during pregnancy
❑ Persistent symptoms after intervention
Medications:
Diuretics: used to relieve symptoms of pulmonary vascular congestion (shortness of breath, orthopnea and paroxysmal nocturnal dyspnea) and in case of right sided heart failure
Beta blockers: useful to control exertional symptoms as it decreases heart rate and cardiac output during exercise, thus decreasing the rise in transmitral gradient
Digoxin: used in case of right or left ventricular systolic dysfunction and also during atrial fibrillation (not the first line)
Statin therapy: slower progression of rheumatic mitral stenosis[3]
Antithrombotic recommendations:
Consider anticoagulation therapy in MS patients with:
AF
❑ Prior embolic event
❑ Left atrial thrombus
Long term oral anticoagulation (2.0-3.0 INR)

Prevention of endocarditits:
No longer require antimicrobial prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify mitral stenosis based on the following findings on TTE:
❑ Valve anatomy
❑ Valve hemodynamics gradient
❑ Hemodynamic consequences
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage A

❑ Patient at risk of developing mitral stenosis
❑ Mild valve doming during diastole
❑ Normal transmitral flow velocity
 
Stage B

❑ Progressive mitral stenosis
❑ Valve area > 1.5 cm²
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Increased transmitral flow velocities
❑ Diastolic pressure half-time < 150 ms ❑ Mild to moderate left atrial enlargement
❑ Normal pulmonary pressure at rest
 
Stage C

❑ Asymptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement
 
Stage D

❑ Symptomatic severe mitral stenosis
❑ Valve area ≤ 1.5 cm² (≤ 1 cm² in severe mitral stenosis)
❑ Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets
❑ Diastolic pressure half-time ≥ 150 ms (≥ 220 ms with very severe mitral stenosis)
❑ Elevated pulmonary artery systolic pressure > 30 mmHg
❑ Severe left atrial enlargement
 
 
 
 


 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of mitral stenosis

Mid diastolic murmur
❑ Low-pitched diastolic rumble
❑ Associated with an opening snap
❑ Best heard at the cardiac apex
❑ Radiating to the axilla
❑ Increases with lying down, raising the legs and with exercise
❑ Decreases with valsalva maneuver and amyl nitrate
❑ Reduced pulse pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings of decompensated mitral stenosis that require urgent management?
Tachycardia
Hypotension
Severe dyspnea
Loss of consciousness
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the complication of mitral stenosis that is causing decompensation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Suspect in case of:
❑ Sudden weakness or paralysis - face, arm or leg
❑ Speech or visual difficulties
Altered level of consciousness
❑ Sudden severe headache
 

❑ Suspect in case of palpitations
❑ Order an ECG immediately looking for
❑ Irregularly irregular rhythm, and
❑ Absent P waves
 

❑ Suspect in case of:
❑ Acute onset of exertional dyspnea or dyspnea at rest
❑ Pleuritic or substernal chest pain
Hemoptysis
 

❑ Suspect in case of severe dyspnea
❑ Increased jugular venous pressure immediately

Hepatomegaly ± pulsatile liver

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Summary of Recommendations for Mitral Stenosis Intervention

  1. "http://eurheartj.oxfordjournals.org/content/32/23/2999.full.pdf" (PDF). External link in |title= (help)
  2. "http://eurheartj.oxfordjournals.org/content/32/23/2999.full.pdf" (PDF). External link in |title= (help)
  3. 3.0 3.1 "ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI".
  4. 4.0 4.1 "2008 Focused update incorporated into the ACC/AH... [Circulation. 2008] - PubMed - NCBI".