Table Of ContentEMERGENCY
CARDIOLOGY
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EMERGENCY
CARDIOLOGY
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AN EVIDENCE BASED GUIDE TO ACUTE CARDIAC PROBLEMS
Second Edition
Karim Ratib MBCHB BSC(HONS) MRCP
Specialist Registrar in Cardiology, University Hospital of North
Staffordshire, Stoke-on-Trent, UK
Gurbir Bhatia MBCHB MD MRCP
Specialist Registrar in Cardiology, University Hospital of North
Staffordshire, Stoke-on-Trent, UK
Neal Uren MD (HONS) FRCP
Consultant Cardiologist, Edinburgh Heart Centre, Royal Infirmary,
Edinburgh, UK
James Nolan MBCHB MD FRCP
Consultant Cardiologist, University Hospital of North Staffordshire,
Stoke-on-Trent, UK
First published in Great Britain in 2003 by Hodder Arnold
This second edition published in 2010 by
Hodder Education, an Hachette UK Company,
338 Euston Road, London NW1 3BH
http://www.hodderarnold.com
© 2011 Karim Ratib, Ghurbir Bhatia, Neal Uren and James Nolan.
All rights reserved. Apart from any use permitted under UK copyright law, this publication
may only be reproduced, stored or transmitted, in any form, or by any means with prior
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accordance with the terms of licences issued by the Copyright Licensing Agency. In the
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Whilst the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. In particular (but
without limiting the generality of the preceding disclaimer) every effort has been made to
check drug dosages; however it is still possible that errors have been missed. Furthermore,
dosage schedules are constantly being revised and new side-effects recognized. For these
reasons the reader is strongly urged to consult the drug companies’ printed instructions
before administering any of the drugs recommended in this book.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN-13 978 0 340 974 223
1 2 3 4 5 6 7 8 9 10
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CONTENTS
Abbreviations vi
CHAPTER 1 Acute Coronary Syndromes 1
CHAPTER 2 Resuscitation 84
CHAPTER 3 Arrhythmias 104
CHAPTER 4 Hypertensive Emergencies 135
CHAPTER 5 Acute Aortic Syndromes 149
CHAPTER 6 Acute Pulmonary Embolism 167
CHAPTER 7 Infective Endocarditis 188
CHAPTER 8 Drug-related Cardiac Problems 203
CHAPTER 9 Pericarditis 218
CHAPTER 10 Cardiac Trauma 225
CHAPTER 11 Cardiac Tamponade 234
Appendices 239
Index 269
ABBREVIATIONS
ACC American College of Cardiology
ACD active and compression–decompression
ACE angiotensin converting enzyme
ACS acute coronary syndrome
ACT activated clotting time
ADP adenosine diphosphate
AF atrial fibrillation
AHA American Heart Association
aPTT activated partial thromboplastin time
ATP adenosine triphosphate
A-V arteriovenous
AV atrioventricular
AVNRT atrioventricular nodal re-entry tachycardia
AVRT atrioventricular re-entry tachycardia
BP blood pressure
BSAC British Society of Antimicrobial Chemotherapy
CABG coronary artery bypass graft
CAD coronary artery disease
cAMP cyclic adenosine monophosphate
CCS Canadian Cardiovascular Society
CCU coronary care unit
CK creatine kinase
CMV cytomegalovirus
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CRP C-reactive protein
CT computed tomography
CTPA computed tomography pulmonary angiography
CVA cerebrovascular accident
DAPT dual antiplatelet therapy
DCC direct current cardioversion
DES drug-eluting stent
DVT deep venous thrombosis
ECG electrocardiogram
EF ejection fraction
vi
ABBREVIATIONS
ELISA enzyme-linked immunoadsorbent assay
EMD electromechanical dissociation
EPS electrophysiological study
ERC European Resuscitation Council
ESR erythrocyte sedimentation rate
ESC European Society of Cardiology
FDP fibrin degradation products
GI gastrointestinal
GP glycoprotein
GRF gelatin–resorcinol–formaldehyde
GTN glyceryl trinitrate
HIT heparin-induced thrombocytopenia
IABP intra-aortic balloon counterpulsation
IAC interposed abdominal compression
ICD implantable cardioverter defibrillator
IE infective endocarditis
IHD ischaemic heart disease
IMH intramural haematoma
INR international normalized ratio
IPG impedance plethysmography
IRA infarct-related artery
IRAD International Registry of Acute Aortic Dissection
IV intravenous
IVDU intravenous druge user
JVP jugular venous pressure
LAD left anterior descending (artery)
LIMA left internal mammary artery
LMWH low molecular weight heparin
LSD lysergic acid diethylamide
LVF left ventricular failure
MACE major adverse cardiac event
MEN multiple endocrine neoplasia
MI myocardial infarction
MIC minimum inhibitory concentration
MRI magnetic resonance imaging
MRSA methecillin resitant staphyloccocus aureus
NICE National Institute for Health and Clinical Excellence
NPCT non-penetrating cardiac trauma
NSTEACS non-ST elevation ACS
NSTEMI non-ST elevation MI
PAU penetrating atherosclerotic ulceration
vii
ABBREVIATIONS
PCI percutaneous coronary intervention
PE pulmonary embolism
PEA pulseless electrical activity
PLS posterior leucoencephalopathy syndrome
po per os (orally)
PTCA percutaneous transluminal coronary angioplasty
PTD percutaneous thrombolytic device
PTFE polytetrafluoroethylene
SBP systolic blood pressure
SC subcutaenous
SLE systemic lupus erythematosus
STEMI ST elevation MI
SVT supraventricular tachycardia
TCAD tricyclic antidepressant
TIA transient ischaemic attack
TOE transoesophageal echocardiogram (echocardiography)
tPA tissue plasminogen activator
TVR target vessel revascularization
UA unstable angina
UFH unfractionated heparin
V/Q ventilation/perfusion
VF ventricular fibrillation
VT ventricular tachycardia
WCC white cell count
WPW Wolff–Parkinson–White (syndrome)
viii
CHAPTER 1
ACUTE CORONARY SYNDROMES
Epidemiology 1 Revascularization strategies 36
Definitions 2 in NSTEACS
Pathophysiology 3 Bleeding risk in ACS 38
Diagnosis 6 Adjunctive medical therapy 40
Initial treatment 17 Complications of ACS 54
Treatment of ST elevation MI 19 Early peri-infarction arrhythmias 65
Primary PCI 20 Late post-infarction arrhythmias 76
Thrombolysis 23 Recovery and rehabilitation 77
Treatment of non-ST 31 Key points 79
elevation ACS Key references 80
Risk scores in NSTEACS 33
EPIDEMIOLOGY
Coronary heart disease is the most common cause of death in the United
Kingdom. In total, 220 000 deaths were attributable to ischaemic heart
disease in 2007. It is estimated that the incidence of acute coronary
syndrome (ACS) is over 250 000 per year.
Sudden death remains a frequent complication of ACS: approximately
50 per cent of patients with ST elevation myocardial infarction (STEMI)
do not survive, with around two-thirds of the deaths occurring shortly
after the onset of symptoms and before admission to hospital. Prior to
the development of modern drug regimes and reperfusion strategies,
hospital mortality after admission with ACS was 30–40 per cent. After the
introduction of coronary care units in the 1960s, outcome was improved,
predominantly reflecting better treatment of arrhythmias. Current therapy
has improved outcome further for younger patients who present early in
the course of their ACS. The last decade has seen a significant fall in the
overall 30-day mortality rate. Most patients who die before discharge do
so in the first 48 hours after admission, usually due to cardiogenic shock
consequent upon extensive left ventricular damage. Most patients who
survive to hospital discharge do well, with 90 per cent surviving at least
1 year. Surviving patients who are at increased risk of early death can be
identified by a series of adverse clinical and investigational features, and
their prognosis improved by intervention.
EPIDEMIOLOGY 1
