Cardiac emergenciesCardiac emergencies

Cardiac emergenciesCardiac emergencies BradycardiaBradycardia Acute Coronary Acute Coronary

Syndromes and Acute Syndromes and Acute Myocardial InfarctionMyocardial Infarction

Wide-Complex Wide-Complex Tachycardias and Tachycardias and Ventricular TachycardiaVentricular Tachycardia

Pericardial TamponadePericardial Tamponade Hypertensive CrisisHypertensive Crisis

Cardiogenic ShockCardiogenic Shock Right Ventricle InfarctionRight Ventricle Infarction Acute Mitral RegurgitationAcute Mitral Regurgitation Acute Aortic InsufficiencyAcute Aortic Insufficiency Ventricular Septal Ventricular Septal

RuptureRupture Cardiac RuptureCardiac Rupture PseudoaneurysmPseudoaneurysm

BradycardiaBradycardiadue to sinus node dysfunction or AV block due to sinus node dysfunction or AV block

Clinical Presentation Clinical Presentation syncope, presyncope, fatigue, angina, and syncope, presyncope, fatigue, angina, and

shortness of breath shortness of breath may be asymptomatic may be asymptomatic

BradycardiaBradycardia

sinus rate <60 bpm that does not increase sinus rate <60 bpm that does not increase with activity. with activity.

In sinus arrest, pauses of >3 secs are In sinus arrest, pauses of >3 secs are seen seen

Severe Bradycardia (Heart Rate <40 bpm) Severe Bradycardia (Heart Rate <40 bpm)

Initial Management Initial Management

Assess airway, breathing, and circulation Assess airway, breathing, and circulation

Place a monitor/defibrillator Place a monitor/defibrillator adequate IV access and oxygenation adequate IV access and oxygenation

bradycardia with hemodynamically bradycardia with hemodynamically compromisedcompromised

1.1. atropineatropine0.5–1.0 mg IV. Doses can be repeated q3–5mins up to a total 0.5–1.0 mg IV. Doses can be repeated q3–5mins up to a total dose of 0.04 mg/kg dose of 0.04 mg/kg

2.2. dopaminedopamine 2–20 mg/kg/min, to keep systolic BP >90 mm Hg 2–20 mg/kg/min, to keep systolic BP >90 mm Hg

3.3. transcutaneous pacingtranscutaneous pacing 4.4. epinephrineepinephrine, 2–10 µg/min , 2–10 µg/min 5.5. transvenous pacing transvenous pacing 6.6. have the patient monitored in an ICU have the patient monitored in an ICU 7.7. Stop all medicines that may be causing bradycardia or Stop all medicines that may be causing bradycardia or

hypotension (electrolytes, digoxin level, TSH)hypotension (electrolytes, digoxin level, TSH)

Acute Coronary SyndromeAcute Coronary Syndrome ST-segment–elevation MI (STEMI) ST-segment–elevation MI (STEMI) non–ST-segment MI (NSTEMI) and non–ST-segment MI (NSTEMI) and unstable angina unstable angina

Initial management Initial management symptom recognitionsymptom recognition evaluation of the ECG, and evaluation of the ECG, and triaging to the appropriate reperfusion strategy triaging to the appropriate reperfusion strategy

Clinical Presentation Clinical Presentation The classic symptoms of an MI include an The classic symptoms of an MI include an

intense, left-sided, substernal chest intense, left-sided, substernal chest discomfort radiating to the left arm and an discomfort radiating to the left arm and an impending sense of doom.impending sense of doom.

Chest pain is often prolonged, Chest pain is often prolonged, lasting >20 lasting >20 minsmins, and is not relieved with rest or NTG. , and is not relieved with rest or NTG. The pain may radiate to the jaw, right arm, The pain may radiate to the jaw, right arm, both arms, or back. both arms, or back.

ACSACSDifferentiating STEMI from Differentiating STEMI from

NSTEMI/unstable angina is important, as it NSTEMI/unstable angina is important, as it determines the type of therapy required. determines the type of therapy required.

Differentiating STEMI, NSTEMI, and Differentiating STEMI, NSTEMI, and unstable angina requires unstable angina requires ECG and cardiac ECG and cardiac enzymes.enzymes.

The differential diagnosisThe differential diagnosis

aortic dissection, aortic dissection, pericarditis, pericarditis, esophagitis, esophagitis, myocarditis, myocarditis, . .

pneumonia, pneumonia, cholecystitis, cholecystitis, pancreatitis, and pancreatitis, and pulmonary pulmonary

embolismembolism

The ECGThe ECG The ECG triages patients in three groups: ST-The ECG triages patients in three groups: ST-

segment elevation, ST-segment depression, and segment elevation, ST-segment depression, and nondiagnostic or normal ECG nondiagnostic or normal ECG

ST-segment deviation of at least 1 mm in two ST-segment deviation of at least 1 mm in two contiguous leads is considered significant. contiguous leads is considered significant.

A new left bundle-branch block should also raise A new left bundle-branch block should also raise concern of an acute MI. concern of an acute MI.

ST-segment depression of 1 mm and T wave ST-segment depression of 1 mm and T wave inversions in two contiguous leads suggests an inversions in two contiguous leads suggests an unstable angina/NSTEMI syndrome. unstable angina/NSTEMI syndrome.

ST segment depression or elevation (leads I, aVL, V4-V6), flattening of the T wave (leads I, aVR, aVL, V5, V6), or T wave inversion (I, V2-V4).

ST segment and T wave changes that are consistent with ST segment and T wave changes that are consistent with subendocardial ischemiasubendocardial ischemia include ST segment depression (V3-V6), and include ST segment depression (V3-V6), and

T wave flattening or inversionT wave flattening or inversion

J point and ST segment elevation are the hallmarks of J point and ST segment elevation are the hallmarks of acute myocardial infarctionacute myocardial infarction

Initial management Initial management O2 and ASAO2 and ASA for all patients for all patients nitratesnitrates should be rapidly delivered for control of should be rapidly delivered for control of

chest discomfort. chest discomfort. If the heart rate is >65 bpm and the systolic BP If the heart rate is >65 bpm and the systolic BP

is >110 mm Hg, is >110 mm Hg, beta blockersbeta blockers should be used should be used as well. as well.

MorphineMorphine may be given for analgesia as well as may be given for analgesia as well as relief from pulmonary congestion.relief from pulmonary congestion.

Patients with STEMI or new left bundle-branch Patients with STEMI or new left bundle-branch block benefit from early reperfusion with block benefit from early reperfusion with fibrinolytics or angioplastyfibrinolytics or angioplasty

Wide-Complec Tachycardia & VTWide-Complec Tachycardia & VT

VTs are responsible for the majority of cases of VTs are responsible for the majority of cases of sudden cardiac death and are divided into sudden cardiac death and are divided into sustained and nonsustained VT sustained and nonsustained VT

The differential diagnosis The differential diagnosis bundle-branch block bundle-branch block SVT with aberrant conduction SVT with aberrant conduction AF with preexcitation AF with preexcitation HyperkalemiaHyperkalemia

Findings suggestive of VT include Findings suggestive of VT include

(a) AV dissociation, (a) AV dissociation, (b) fusion/capture beats, (b) fusion/capture beats, (c) left bundle-branch block with right-axis (c) left bundle-branch block with right-axis

deviation, and deviation, and (d) positive or negative concordance of QRS in (d) positive or negative concordance of QRS in

ECG leads V1–V6. ECG leads V1–V6.

symptomssymptoms Slow VT (rate, 100–Slow VT (rate, 100–

150) may be well 150) may be well tolerated with minimal tolerated with minimal or no symptoms. or no symptoms.

if it persists for hours if it persists for hours or longer, however, or longer, however, they develop they develop HF and, HF and, potentially, potentially, cardiogenic shock.cardiogenic shock.

At rates <200, At rates <200, symptoms of symptoms of decreased cardiac decreased cardiac output are generally output are generally present, including present, including dyspnea, light-dyspnea, light-headedness, headedness, syncope, or syncope, or cardiac cardiac arrest. arrest.

nonsustained ventricular nonsustained ventricular tachycardia (VT)tachycardia (VT)

Treatment Pulseless VT or VF Treatment Pulseless VT or VF ACLS protocols immediate electrical defibrillation (360j)ACLS protocols immediate electrical defibrillation (360j) CPR should be started immediatelyCPR should be started immediately rapid assessment of the airway rapid assessment of the airway the patient should be intubated, and the patient should be intubated, and IV access IV access The cardiac rhythm is briefly assessed between shocks. The cardiac rhythm is briefly assessed between shocks. Administer epinephrine, 1 mg IV q3–5 mins, or Administer epinephrine, 1 mg IV q3–5 mins, or

vasopressin (Pitressin), 40 U IV once. vasopressin (Pitressin), 40 U IV once. Lidocaine (1.0–1.5 mg/kg IV, repeat in 3–5mins to Lidocaine (1.0–1.5 mg/kg IV, repeat in 3–5mins to

maximum dose, 3 mg/kg) maximum dose, 3 mg/kg)

continued pulseless VTcontinued pulseless VT

amiodarone (Cordarone, Pacerone) (300 mg IV, amiodarone (Cordarone, Pacerone) (300 mg IV, repeat at 150 mg) Procainamide (Procan SR, repeat at 150 mg) Procainamide (Procan SR, Procanbid, Pronestyl, Pronestyl-SR), 20–30 Procanbid, Pronestyl, Pronestyl-SR), 20–30 mg/min, can also be considered. mg/min, can also be considered.

If hyperkalemia is even suspected, calcium and If hyperkalemia is even suspected, calcium and bicarbonate should be administered bicarbonate should be administered immediately.immediately.

Treatment Stable VTTreatment Stable VTdivided into monomorphic and polymorphic VTdivided into monomorphic and polymorphic VT

Polymorphic VT with a prolonged QT interval should raise concern Polymorphic VT with a prolonged QT interval should raise concern of torsades de pointesof torsades de pointes

administering 4 g MgSO4, administering 4 g MgSO4, overdrive pacing, overdrive pacing, isoproterenol (Isuprel), and isoproterenol (Isuprel), and LidocaineLidocaine Persistent torsades de pointes is usually unstable and may require Persistent torsades de pointes is usually unstable and may require

defibrillation. defibrillation.

Polymorphic VT with normal baseline QT interval and monomorphic Polymorphic VT with normal baseline QT interval and monomorphic VT with a poor ejection fraction are both treated with amiodarone, VT with a poor ejection fraction are both treated with amiodarone, 150 mg IV over 10 mins, or lidocaine, 0.5–0.75 mg/kg IV push, as 150 mg IV over 10 mins, or lidocaine, 0.5–0.75 mg/kg IV push, as well as correcting electrolyte disorders and/or ischemia.well as correcting electrolyte disorders and/or ischemia.

Pericardial TamponadePericardial TamponadeCardiac tamponade occurs with an Cardiac tamponade occurs with an

increase in intrapericardial pressure due to increase in intrapericardial pressure due to accumulation of fluid in the pericardial accumulation of fluid in the pericardial space, which is characterized by space, which is characterized by

(a) elevation of intrapericardial pressure, (a) elevation of intrapericardial pressure, (b) limitation of RV diastolic filling, and (b) limitation of RV diastolic filling, and (c) reduction of stroke volume and cardiac (c) reduction of stroke volume and cardiac

output.output.

Clinical Findings Clinical Findings Beck's triad may be seen in this setting; it Beck's triad may be seen in this setting; it

consists of consists of (a) a decline in systemic arterial pressure, (a) a decline in systemic arterial pressure, (b) elevation of systemic venous pressure, (b) elevation of systemic venous pressure,

and and (c) a small, quiet heart. (c) a small, quiet heart.

Management Management

Percutaneous pericardiocentesis Percutaneous pericardiocentesis should be done by trained personnel with should be done by trained personnel with

hemodynamic monitoring and hemodynamic monitoring and echocardiographic guidance. echocardiographic guidance.

Hypertensive-CrisisHypertensive-Crisis

ClassificationClassification hypertensive emergencies, urgencieshypertensive emergencies, urgenciesThe distinction is important because it The distinction is important because it

dictates how rapid BP should be lowered, dictates how rapid BP should be lowered, whether the patient will need ICU whether the patient will need ICU monitoring, and whether parenteral or PO monitoring, and whether parenteral or PO medications can be used medications can be used

Hypertensive Emergency Hypertensive Emergency accelerated or malignant HTN and hypertensive accelerated or malignant HTN and hypertensive

encephalopathy encephalopathy Accelerated or malignant HTNAccelerated or malignant HTN is characterized by is characterized by

severe elevation of BP with retinopathy, renal failure, severe elevation of BP with retinopathy, renal failure, and other target organ damage. Retinal exudates, and other target organ damage. Retinal exudates, hemorrhages, arteriolar narrowing, and spasm are seen hemorrhages, arteriolar narrowing, and spasm are seen in accelerated HTN, whereas papilledema is seen in in accelerated HTN, whereas papilledema is seen in malignant HTN. malignant HTN.

Hypertensive encephalopathyHypertensive encephalopathy is a condition in which is a condition in which markedly elevated BP causes cerebral edema, resulting markedly elevated BP causes cerebral edema, resulting in headache, papilledema, vision complaints, seizures, in headache, papilledema, vision complaints, seizures, altered mental status, and other neurologic symptoms.altered mental status, and other neurologic symptoms.

Hypertensive Urgencies Hypertensive Urgencies

Hypertensive urgencies present with Hypertensive urgencies present with markedly elevated BP markedly elevated BP without evidence of without evidence of acute end-organ damage acute end-organ damage

Management of Hypertensive Management of Hypertensive EmergenciesEmergencies

The patient should be admitted to an ICU The patient should be admitted to an ICU setting. setting.

In general, it is recommended In general, it is recommended to reduce to reduce the mean arterial pressure by no more the mean arterial pressure by no more than 20–25% than 20–25% or to reduce the diastolic or to reduce the diastolic pressure to 100–110 mm Hg within pressure to 100–110 mm Hg within minutes to several hours. minutes to several hours.

Drugs of choiceDrugs of choice

Sodium Nitroprusside Sodium Nitroprusside IV starting at doses of 0.25 µg/kg/min and IV starting at doses of 0.25 µg/kg/min and titrated q5mins to 10 µg/kg/min. titrated q5mins to 10 µg/kg/min.

Nitroglycerin Nitroglycerin The usual initial dose is 5–15 µg/min. The usual initial dose is 5–15 µg/min. Max 100 µg/minMax 100 µg/min

Hypertensive Encephalopathy Hypertensive Encephalopathy The goal of treatment should be to lower The goal of treatment should be to lower

mean arterial pressure by approximately mean arterial pressure by approximately 20% of diastolic pressure to 100 mm Hg 20% of diastolic pressure to 100 mm Hg (whichever is greater) in the first hour. (whichever is greater) in the first hour.

The agents of choice are SNP and The agents of choice are SNP and labetalol. labetalol.

CNS depressants, such as clonidine CNS depressants, such as clonidine (Catapres), should be avoided. (Catapres), should be avoided.

acute stroke and intracranial acute stroke and intracranial hemorrhage statehemorrhage state

If systolic pressure is >230 mm Hg or diastolic pressure If systolic pressure is >230 mm Hg or diastolic pressure is >140 mm Hg on two separate readings 5 mins apart, is >140 mm Hg on two separate readings 5 mins apart, start start nitroprussidenitroprusside..

If systolic pressure is 180–230 mm Hg, diastolic If systolic pressure is 180–230 mm Hg, diastolic pressure is 105–140 mm Hg, or mean arterial pressure pressure is 105–140 mm Hg, or mean arterial pressure is 130 mm Hg, start IV labetalol, esmolol, or other easily is 130 mm Hg, start IV labetalol, esmolol, or other easily titratable IV antihypertensive.titratable IV antihypertensive.

If systolic pressure is <180 mm Hg and diastolic If systolic pressure is <180 mm Hg and diastolic pressure is <105 mm Hg, defer antihypertensive pressure is <105 mm Hg, defer antihypertensive treatment.treatment.

If ICP monitoring is available, cerebral perfusion If ICP monitoring is available, cerebral perfusion pressure should be kept >70 mm Hg (cerebral perfusion pressure should be kept >70 mm Hg (cerebral perfusion pressure = mean arterial pressure – ICP).pressure = mean arterial pressure – ICP).

Left Ventricular Failure with Left Ventricular Failure with Pulmonary EdemaPulmonary Edema

LV failure with pulmonary edema requires LV failure with pulmonary edema requires rapid reduction in BP with SNP or NTG. rapid reduction in BP with SNP or NTG. Small doses of loop diuretics may be Small doses of loop diuretics may be added.added.

Preeclampsia and Eclampsia Preeclampsia and Eclampsia

IV hydralazine and labetalol are the most IV hydralazine and labetalol are the most common antihypertensives used. common antihypertensives used.

NTGNTG

ACE inhibitors are contraindicated in ACE inhibitors are contraindicated in pregnancy.pregnancy.

Management of Hypertensive Management of Hypertensive UrgencyUrgency

Mean arterial pressure should not be Mean arterial pressure should not be decreased by more than 15–20%. decreased by more than 15–20%.

Oral antihypertensives may be used to Oral antihypertensives may be used to control BP in 3–4 hrs. control BP in 3–4 hrs.

Patients may be discharged to home with Patients may be discharged to home with close follow-up. close follow-up.

MedicationsMedications Hypertensive UrgencyHypertensive Urgency

Captopril (Capoten) at doses of 6.25–25 mg has Captopril (Capoten) at doses of 6.25–25 mg has an onset in 15–30 mins and lasts 4–6 hrs. an onset in 15–30 mins and lasts 4–6 hrs.

Clonidine at doses of 0.1 mg may be given every Clonidine at doses of 0.1 mg may be given every hour hour

Short-acting nifedipine should be avoided in Short-acting nifedipine should be avoided in treating hypertensive crises.treating hypertensive crises.

Short-acting nifedipine (Procardia) has been Short-acting nifedipine (Procardia) has been shown to cause sudden severe hypotension, shown to cause sudden severe hypotension, myocardial ischemia/MI, and decreased cerebral myocardial ischemia/MI, and decreased cerebral perfusion. perfusion.

Cardiogenic ShockCardiogenic Shock

Cardiogenic shock is estimated to occur in Cardiogenic shock is estimated to occur in approximately 7.2% of patients who approximately 7.2% of patients who present with an MI and has a mortality rate present with an MI and has a mortality rate ranging from ranging from 50–80%.50–80%.

Management Cardiogenic ShockManagement Cardiogenic Shock

diuresis with furosemide (Lasix) improves diuresis with furosemide (Lasix) improves oxygenation. Start furosemide at 20 mg IVoxygenation. Start furosemide at 20 mg IV

Vasopressors are very useful in Vasopressors are very useful in cardiogenic shockcardiogenic shock

Inotropes and Vasopressors Inotropes and Vasopressors norepinephrinenorepinephrine If systolic BP is <70 mm Hg, start at 2 µg/min and titrate to 20 If systolic BP is <70 mm Hg, start at 2 µg/min and titrate to 20

µg/min to achieve a mean arterial pressure of 70 mm Hg. µg/min to achieve a mean arterial pressure of 70 mm Hg.

dopaminedopamine If systolic BP is 70–90 mm Hg, start At 2–5 µg/kg/min, If systolic BP is 70–90 mm Hg, start At 2–5 µg/kg/min,

dopamine increases cardiac output and renal blood flow dopamine increases cardiac output and renal blood flow through beta- and dopamine-specific receptors, respectively. At through beta- and dopamine-specific receptors, respectively. At 5–20 µg/kg/min, dopamine has alpha-adrenergic stimulation 5–20 µg/kg/min, dopamine has alpha-adrenergic stimulation leading to vasoconstriction.leading to vasoconstriction.

dobutaminedobutamine With systolic BP >90 mm Hg, is the preferred agent. With systolic BP >90 mm Hg, is the preferred agent.

Dobutamine is started at 2.5 µg/kg/min and slowly titrated to 15 Dobutamine is started at 2.5 µg/kg/min and slowly titrated to 15 µg/kg/min (usual maximum dose is 10 µg/kg/min). µg/kg/min (usual maximum dose is 10 µg/kg/min).

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Periksa Kolesterol (LDL-C ) Setiap Periksa Kolesterol (LDL-C ) Setiap 6 bulan sekali6 bulan sekali

Aktivitas FisikAktivitas Fisik

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