Cardiology in the ER: A Practical Guide

339 Pages·2019·9.013 MB·English

by  Carlos Jerjes-Sánchez

Cardiology in the ER
A Practical Guide
Carlos Jerjes-Sánchez
123
Cardiology in the ER
Carlos Jerjes-Sánchez
Cardiology in the ER
A Practical Guide
Carlos Jerjes-Sánchez
Instituto de Cardiología y Medicina Vascular
TecSalud, Hospital Zambrano Hellion
Escuela de Medicina y Ciencias de la Salud
Tecnológico de Monterrey
San Pedro Garza García
Nuevo León
México
ISBN 978-3-030-13678-9 ISBN 978-3-030-13679-6 (eBook)
https://doi.org/10.1007/978-3-030-13679-6
© Springer Nature Switzerland AG 2019
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For my beloved family, my dear wife Alicia
and my two dear children, Carlos and Alicia,
thank you for accompanying me in this life
and to the time we have spent together
Preface
The book Cardiology in the ER attempts to link advances made in the management
of patients with cardiovascular emergencies. The main characteristic of the last
decade was the acquisition of new knowledge and technologic advances to improve
patients’ care in the emergency room. In this book, we cover the broad spectrum of
cardiovascular emergencies and highlight a practical approach to patient assessment
and therapy.
The book was enriched with our 30-year experience in treating cardiovascular
emergencies at large cardiology hospitals in Mexico, from 1982 to 1995 in the
emergency room department in the Cardiology Hospital, National Medical Center,
IMSS, Mexico City, and from 1996 to 2010 in the emergency room department in
the Cardiology Hospital No. 34, IMSS, Monterrey City. In both hospitals, I had the
opportunity to perform the first fast-track programs in cardiology hospitals on
ST-elevation myocardial infarction and submassive and massive pulmonary embo-
lism patients to perform systemic thrombolysis in <30 minutes and <90 minutes,
respectively. Also, I had active participation in patient care and decision-making in
the setting of different cardiovascular emergencies in all these years.
Cardiology in the ER provides a current and comprehensive update of the most
frequent clinical presentation symptoms (dyspnea, chest pain, and syncope) and
acute cardiovascular events. The clinical spectrum of the acute vascular syndromes
(acute coronary syndromes, acute aortic syndromes, and acute pulmonary embo-
lism), cardiac tamponade, cardiogenic shock, hypertensive crisis, arrhythmias, as
well as acute heart failure, cardiac arrest, and prosthetic valve dysfunction is fully
explored. Finally, the chapter related to pacemaker emergencies presents current
knowledge and gives to the emergency room physician a quick review of the com-
plications, clinical diagnostic keys, high clinical suspicion signs, and possible treat-
ments. Additionally, a brief section about the basis of pacing is included.
Our contribution is targeted to a broad group of physicians, including cardiolo-
gists, internists, and first-contact physicians involved in the emergency room patient
care. In addition, it serves as a resource for medical students, interns, residents, and
fellows.
vii
viii Preface
A deep recognition to all coauthors for their contributions that made this book
possible; especially Dr. David Rodriguez for the excellent coordination.
We hope that this book enables physicians to make the best decisions for their
patients in the field of cardiovascular emergencies. It is my profound hope that
Cardiology in the ER will in some measure improve the quality of care for all
patients in the emergency room. Finally, thanks to all those patients whom we were
able to help but especially to those whom we could not.
San Pedro Garza Gar cia, Carlos Jerjes-Sánchez, MD, FCCP,
Nuevo León, Mexico FACC, MHSMC, FESC
Contents
1 Chest Pain in the ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 High-Clinical Suspicion for Cardiac-Related Causes of CP
in the ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4 Chest Pain and Risk Factors for Acute Coronary Syndromes . . . . . 2
1.4.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4.3 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4.4 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5 Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.1 Chest X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.2 Echocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5.3 Immediate Exercise Stress Echocardiogram . . . . . . . . . . . . 8
1.5.4 Cardiac Computed Tomography (CCT)
and Other Imaging Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6.1 Cardiac Biomarkers in the Context of Acute Coronary
Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6.2 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6.3 Clinical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7 Additional Clinical Practice Takeaway . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 Dyspnea in the ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3 High-Clinical Suspicion for Dyspnea of Cardiac Origin . . . . . . . . . 16
2.3.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.3.3 Dyspnea Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
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2.3.4 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3.5 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4 Imaging Diagnosis Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4.1 Chest X-Ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4.2 Echocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4.3 Cardiac Computed Tomography . . . . . . . . . . . . . . . . . . . . . 24
2.4.4 Ventilation/Perfusion Lung Scan . . . . . . . . . . . . . . . . . . . . . 24
2.5 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.5.1 Cardiac Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.5.2 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.6 Additional Clinical Practice Takeaway . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3 Suspected Cardiovascular Syncope in the ER . . . . . . . . . . . . . . . . . . . 31
3.1 The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.3 Syncope Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.1 Presyncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.2 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.3 Main Clinical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 34
3.5.4 Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.6 Multimodal Diagnosis Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.7 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.7.1 Differential Diagnosis of Cardiac Syncope . . . . . . . . . . . . . 38
3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.8.1 Neurally Mediated Syncope . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.8.2 Orthostatic Hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.8.3 Cardiac Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.9 Additional Clinical Practice Takeaways . . . . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4 Optimizing the Use of Biomarkers in the ER . . . . . . . . . . . . . . . . . . . . 43
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.2 The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.2.1 Pre-analytical Operating Characteristics . . . . . . . . . . . . . . . 44
4.2.2 Analytical Operating Characteristics . . . . . . . . . . . . . . . . . . 45
4.2.3 Clinical Operating Characteristics . . . . . . . . . . . . . . . . . . . . 45
4.2.4 Principles for the Proper Use of Cardiac Biomarkers
at the ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.3 Cardiac Troponins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.3.1 Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.3.2 Pre-analytical Considerations . . . . . . . . . . . . . . . . . . . . . . . 47
4.3.3 Analytical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.3.4 Clinical Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Contents xi
4.3.5 Clinical Conditions Associated with Increased
Expression of cTn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4.3.6 Diagnostic Algorithms and Prediction Scores . . . . . . . . . . . 51
4.3.7 Foresight, Challenges, and Limitations at the ER . . . . . . . . 52
4.4 Natriuretic Peptides, Cardiac Stress, and Heart Failure . . . . . . . . . . 52
4.4.1 Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4.4.2 Pre-analytical Considerations . . . . . . . . . . . . . . . . . . . . . . . 53
4.4.3 Analytical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4.4 Clinical Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.4.5 Clinical Conditions Associated with Increased
Expression of NP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.4.6 Diagnostic Algorithms and Prediction Scores . . . . . . . . . . . 56
4.4.7 Foresight, Challenges, and Limitations at the ER . . . . . . . . 57
4.5 D-Dimer and Endogenous Fibrinolysis Activation . . . . . . . . . . . . . 57
4.5.1 Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.5.2 Pre-analytical Considerations . . . . . . . . . . . . . . . . . . . . . . . 58
4.5.3 Analytical Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.5.4 Clinical Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.5.5 Clinical Conditions Associated with Increased
Expression of DD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.5.6 Diagnostic Algorithms and Prediction Scores . . . . . . . . . . . 62
4.5.7 Foresight, Challenges, and Limitations at the ER . . . . . . . . 62
4.6 Bayesian Reasoning and Clinical Decision-Making . . . . . . . . . . . . 62
4.6.1 Rules of Decision-Making Based on Probabilities . . . . . . . 64
4.6.2 Pretest Probability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.6.3 Posttest Probability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.6.4 Clinical Practice Takeaway . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.7 Suggested Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5 Acute Coronary Syndromes in the ER . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.1 The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.2 Classification and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.3 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5.5 High Clinical Suspicion in ACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.6 Risk Stratification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
5.7 Other Risk Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5.7.1 Clinical Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
5.7.2 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.8 Multimodal Diagnosis Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.8.1 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.8.2 Chest X-Ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.9 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
5.9.1 Echocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89