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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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is first medical contact to device ≤ 120 min?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 










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[1]
❑ For moderate MS repeat echocardiography every 1-2 years[1]
❑ 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[2]
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. 1.0 1.1 "2008 Focused update incorporated into the ACC/AH... [Circulation. 2008] - PubMed - NCBI".
  2. "Effect of hydroxymethylglutaryl coenzyme-a reduc... [Circulation. 2010] - PubMed - NCBI".