Cardiology

Acute Coronary Syndromes w/o Persistent ST-Segment Elevation
Acute coronary syndromes refers to any constellation of clinical symptoms compatible with acute myocardial ischemia which may be life-threatening.
It encompasses unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).
Unstable angina is the ischemic discomfort that presents without persistent ST-segment elevation on the ECG and without the presence of cardiac markers in the blood.
Non-ST-segment elevation myocardial infarction is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs.
The patient typically presents with ischemic-type chest pain that is severe and prolonged and may occur at rest or may be caused by less exertion than previous episodes.
Arrhythmias
Arrhythmia is a disorder in which the heart beats irregularly. It may be too slow or too fast.
Bradycardia is having a heart rate of <50 beats/minute that may not affect the hemodynamic status of some patients.
Clinically significant bradycardia is having a heart rate that is inadequate for the patient's current condition and may not be able to support life.
Tachycardia is having serious signs and symptoms that are often demonstrated at ventricular rates of >150 beats/minute.
Signs and symptoms related to rapid heart rate are altered sensorium, angina, shortness of breath, myocardial infarction, hypotension and other signs of shock (eg cold clammy skin, low urine output), heart failure or pulmonary congestion.
Basic Life Support - Adult
Basic life support (BLS) is the fundamental approach to saving lives following cardiac arrest.  Primary aspects of BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillator. Initial recognition and response to heart attack and stroke are also considered part of BLS.
Basic Life Support - Pediatric
Basic life support (BLS) is the fundamental approach to saving lives following cardiac arrest.  Primary aspects of BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillator.
Cardiovascular Disease Prevention
Patients 18 years old and above should receive a risk factor assessment for cardiovascular disease (CVD) at every routine physician visit.
Cardiovascular disease development is closely related to lifestyle characteristics and associated risk factors.
There is an overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a cardiovascular event.
Very high-risk group refers to patients with documented CVD, by invasive or non-invasive testing, and with presence of risk factors.
High-risk patients are those who have already experienced a cardiovascular event or have very high levels of individual risk factors.
Moderate-risk patients require monitoring of risk profile every 6-12 months.
Low-risk patients may be given conservative management, focusing on lifestyle interventions.
Chronic Stable Angina
Chronic stable angina is a clinical syndrome characterized by squeezing, heaviness or pressure discomfort in the chest, neck, jaw, shoulder, back, or arms which is usually precipitated by exertion or emotional stress and relieved by rest or Nitroglycerin.
It is caused by myocardial ischemia that is commonly associated with narrowing of the coronary arteries.
Angina is stable when it is not a new symptom and when there is no deterioration in frequency, duration or severity of episodes.
Dyslipidemia
Dyslipidemia is having an abnormal amount of lipids or fats in the blood.
Lipid profile is obtained from an individual with diabetes mellitus, coronary heart disease, cerebrovascular disease, peripheral arterial disease or other coronary heart disease risk factors or from an individual with family history or clinical evidence of familial hypercholesterolemia.
Plasma lipids are total cholesterol, high-density lipoprotein cholesterol, trigylcerides, and low-density lipoprotein cholesterol.
Evaluation of lipid profile must be performed in parallel with the risk assessment of coronary heart disease.
Heart Failure - Acute
Heart failure is a clinical syndrome caused by cardiac dysfunction usually secondary to myocardial muscle loss or dysfunction.
It is characterized by either left ventricular hypertrophy or dilation or both.
It leads to neurohormonal and circulatory abnormalities.
Acute heart failure is the rapid onset of or change in the signs and symptoms of heart failure.
It arises as a result of deterioration in patients previously diagnosed with heart failure or may also be the first presentation of heart failure.
It is characterized by pulmonary congestion, decreased cardiac output and tissue perfusion.
It is a life-threatening condition that needs immediate medical attention.
Heart Failure - Chronic
Heart failure is a clinical syndrome due to a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at rate commensurate with the requirements of the metabolizing tissues.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm and conduction.
New onset heart failure refers to the first presentation of heart failure.
Transient heart failure refers to the symptomatic heart failure over a limited period of time although long-term therapy may be indicated.
Chronic heart failure is stable, worsening, or decompensated heart failure.
Hypertension
Hypertension is the medical term for high blood pressure. Persistent high blood pressure can lead to increased strain to the heart and arteries that can eventually cause organ damage.
To classify the blood pressure, it must be based on ≥2 properly measured, seated blood pressure readings on each of ≥2 office visits.
Patients who have a blood pressure reading of 140 SBP or 90 DBP or both can be diagnosed as hypertensive patients.
Goals of therapy are to manage hypertension that can maintain the patient's normal blood pressure and identify and treat all reversible risk factors.
Hypertension in Pregnancy
Hypertension in pregnancy is defined as an average diastolic blood pressure of ≥90 mmHg, based on at least 2 measurements, ≥4 hr apart or systolic blood pressure of ≥140 mmHg taken at least 6 hr apart.
Diagnosis of severe hypertension is made when blood pressure is ≥160/110 mmHg.
Measurement should be repeated after 15 min for confirmation.
Hypertensive Crisis
Hypertensive emergency is having severely elevated blood pressure (>180-220 mmHg/120-130 mmHg) that is complicated by progressive target end-organ damage of the central nervous system, heart, kidneys, or the gravid uterus.
There is no definite blood pressure threshold for the diagnosis of hypertensive emergency.
Most target end-organ damage happen with diastolic blood pressure of ≥130 mmHg.
Hypertensive urgency refers to patients with severely elevated blood pressure (>180/110-120 mmHg) but with little or no evidence of acute end-organ damage.
The clinical differentiation between hypertensive emergencies and urgencies is dependent on the presence of target end-organ damage rather than the level of blood pressure.
Infective Endocarditis
Infective endocarditis is microbial infection of the endovascular structures of the heart.
It often presents in an occult fashion and early diagnosis depends on a high index of clinical suspicion especially in patients with congenital heart disease, prosthetic valves or previous infective endocarditis.
The established diagnosis of infective endocarditis is demonstrated by a positive blood culture and involvement of the endocardium detected during sepsis or systemic infection. It may also be established if there is involvement of the endocardium detected during sepsis or systemic infection but blood culture is negative.
Intracerebral Hemorrhage
Intracerebral hemorrhage is the sudden burst of blood into the brain tissue itself.
It causes sudden onset of focal neurological deficit.
The focal neurologic findings are related to the anatomic location, size and speed of development of intracerebral hemorrhage.
Neurological deficit usually progresses over a minute to an hour.
Rapid recognition and diagnosis of intracerebral hemorrhage are essential because of its frequently rapid progression.
Ischemic Stroke
Ischemic stroke occurs when a blood vessel supplying the brain is obstructed.
Consider stroke in any patient presenting with sudden focal neurological deficit or any alteration in level of consciousness.
Rapid evaluation is essential for sure of time-sensitive treatments.
Determine if patient's symptoms are due to stroke and exclude stroke mimics (eg migraine, hypertensive encephalopathy, hypoglycemia, seizures or post-ictal paresis); identify other conditions requiring immediate intervention and determine the potential causes of stroke.
Myocardial Infarction w/ ST-Segment Elevation
Myocardial infarction is death of cardiac myocytes (necrosis) caused by prolonged ischemia. The term acute "usually" refers to the time 6 hours to 7 days following pathologic appearance of the infarct.
The patient may experience ischemic-type chest discomfort with accompanying symptoms of nausea, vomiting, dyspnea, diaphoresis, lightheadedness, dizziness, syncope, fatigue and weakness.
Rapid diagnosis and risk stratification of chest pain patients is important to identify acute myocardial infarction patients who will benefit from reperfusion therapy.
Ideally, patient diagnosed with myocardial infarction should begin treatment within 30 minutes of arrival to hospital.
Peripheral Arterial Disease
Peripheral arterial disease includes a range of vascular syndromes caused by atherosclerosis and thromboembolic pathophysiological processes that alter the normal structure and function of the aorta, its visceral arterial branches and the arteries of the lower extremity.
Individuals at risk for lower extremity peripheral arterial disease should undergo review of vascular symptoms and comprehensive vascular examination to assess walking impairment, claudication, ischemic rest pain &/or the presence of nonhealing wounds.
Patients with peripheral arterial disease may be symptomatic or asymptomatic. Symptoms may range from claudication presenting as exertional leg pain to critical limb ischemia presenting as rest pain, ulceration or gangrene.
Pulmonary Arterial Hypertension
Pulmonary arterial hypertension is a syndrome resulting from restricted flow through the pulmonary arterial circulation resulting in increased pulmonary vascular resistance and ultimately leading to right heart failure.
It is a part of the spectrum of pulmonary hypertension, which is hemodynamic and pathophysiological condition defined as an increase in mean pulmonary arterial pressure ≥25 mmHg at rest.
Typical symptoms include progressive dyspnea on exertion, palpitations, fatigue, weakness, angina, syncope and abdominal distention.
Rheumatic Fever - Acute
Acute rheumatic fever is an autoimmune response to a previous group A beta-hemolytic streptococcal (GAS) infection causing acute generalized anti-inflammatory response primarily affecting the heart.
It often presents in patients 5-14 years of age and uncommon before 3 years and after 21 years of age.
Patients presenting with acute rheumatic fever are severely unwell, in extreme pain and requires hospitalization.
Venous Thromboembolism - Management
Deep vein thrombosis is a frequent manifestation of venous thromboembolism in which there is a blood clot blocking a deep vein.
Clinical findings are important to the diagnosis of deep vein thrombosis but are poor predictors of the presence or severity of thrombosis.
Pulmonary embolism is the blockage of the blood vessels in the lungs usually due to blood clots from the veins, especially veins in the legs and pelvis.
Dyspnea, pleuritic chest pain, syncope or tachypnea occur in most cases of pulmonary embolism.
Massive pulmonary embolism has the prime symptom of dyspnea and systemic arterial hypotension that requires pressor support is the predominant sign.
Venous Thromboembolism - Prevention
Venous thromboembolism is comprised of pulmonary embolism and deep venous thrombosis and is associated with significant morbidity and mortality.
Decision on which type of prophylaxis must be individualized for each patient.
All patients admitted for major trauma, surgery or acute medical illness should be assessed for risk of venous thromboembolism and bleeding before starting prophylaxis for venous thromboembolism.
Early mobilization and leg exercises for any patient recently immobilized is recommended. Immobilized patients should also be adequately hydrated.
Intermittent pneumatic compression devices periodically compress calf &/or thighs and stimulate fibrinolysis. It has been shown to be effective in prophylaxis of asymptomatic deep venous thrombosis in surgical patients.
Graduated compression stockings may be used for deep venous thrombosis prophylaxis in surgical patients with no contraindication for use.