Sandbox/MS

Abbreviations: CABG: coronary artery bypass graft; ECG: electrocardiogram; LAD: left anterior descending; LBBB: left bundle branch block; MI: myocardial infarction; PCI: percutaneous coronary intervention; S3: third heart sound; S4: fourth heart sound; VSD: ventricular septal defect

Characterize the symptoms: ❑ 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 rest ❑ Worse with time ❑ Worse with exertion ❑ Dyspnea ❑ Weakness ❑ Palpitations ❑ Nausea ❑ Vomiting ❑ Sweating ❑ Loss of consciousness ❑ Fatigue
Obtain a detailed history: ❑ Age ❑ Baseline blood pressure ❑ Previous episodes of chest pain ❑ Previous PCI or CABG ❑ Cardiac risk factors ❑ Hypertension ❑ Diabetes ❑ Hypercholesterolemia ❑ Smoking ❑ Obesity ❑ List of medications ❑ Family history of premature coronary artery disease Identify possible triggers: ❑ Physical exertion ❑ Air pollution or fine particulate matter ❑ Antecedant infection ❑ Heavy meal ❑ Cocaine ❑ Marijuana
Examine the patient: Vital signs ❑ Blood pressure ❑ Blood pressure lower than baseline, suggestive of: ❑ Discrepancy between arms (suggestive of aortic dissection) ❑ Narrow pulse pressure (suggestive of heart failure) ❑ Heart rate ❑ Tachycardia (suggestive of heart failure) ❑ Bradycardia (suggestive of heart block or bradyarrhythmias) Pulses ❑ Femoral pulse (if a patient is to undergo PCI) ❑ Strength ❑ Bruits Skin ❑ Xanthelasma (suggestive of dyslipidemia) ❑ Xanthoma (suggestive of dyslipidemia) ❑ Edema (suggestive of heart failure) ❑ Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock) Heart ❑ Heart sounds ❑ S3 (suggestive of heart failure) ❑ S4 (associated with conditions that increase the stiffness of the ventricle) ❑ Murmurs ❑ Aortic regurgitation: early diastolic high-pitched sound best heard at the left sternal border (suggestive of aortic dissection with propagation to the aortic arch) ❑ Pericardial friction rub (suggestive of pericarditis) Lungs ❑ Rales (suggestive of heart failure)
Order labs and tests: ❑ EKG ❑ Biomarkers ❑ Troponin I ❑ CK-MB ❑ Echocardiography ❑ Creatinine ❑ Glucose ❑ Hemoglobin ❑ Multislice CT coronary imaging (rule out CAD as cause of pain in patients with low to intermediate likelihood of CAD and when troponin and ECG are inconclusive) ❑ MRI (integrate imaging of function, perfusion and necrosis)

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

Proceed to angiography

Low risk Initial conservative strategy

High risk Initial invasive strategy

Administer ONE of the following antiplatelet agents (before or at the time of PCI): ❑ P2Y12 receptor inhibitors ❑ Clopidogrel 600 mg ❑ Ticagrelor 180 mg ❑ Prasugrel 60 mg Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding ❑ IV GP IIb/IIIa inhibitors ❑ Abciximab ❑ Loading dose 0.25 mg/kg IV bolus ❑ Maintenance dose 0.125 mg/kg/min ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus ❑ Another 180 mcg/kg IV bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min ❑ Decrease infusion by 50% if creatinine clearance <50 mL/min ❑ Avoid in hemodialysis patients ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min ❑ Decrease infusion by 50% if creatinine clearance <30 mL/min Administer ONE of the following anticoagulant therapy: ❑ Unfractionated heparin ♦ If GP IIb/IIIa receptor antagonist is planned ❑ 50- to 70-U/kg IV bolus ♦ If no GP IIb/IIIa receptor antagonist is planned ❑ 70- to 100-U/kg bolus ❑ Bivalirudin ❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion ❑ Additional bolus of 0.3 mg/kg if needed ❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min

Administer one of the following antiplatelet agents: ❑ Clopidogrel ❑ Loading dose (300 mg) ❑ Maintenance dose for up to 12 months (75 mg) ❑ Ticagrelor ❑ Loading dose (180 mg) ❑ Maintenance dose for up to 12 months (90 mg twice daily)

Administer one of the following antiplatelet agents: Before PCI ❑ P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg), or ❑ Ticagrelor (180 mg), or ❑ IV GP IIb/IIIa inhibitors ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min, or ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min At the time of PCI ❑ P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg), or ❑ Ticagrelor (180 mg), or ❑ Prasugrel (60 mg) ❑ IV GP IIb/IIIa inhibitors ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min, or ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min

Coronary artery bypass grafting (CABG) It is usually preferred for: ❑ Patients with left main or left main equivalent disease ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction ❑ Diabetic patients

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Administer ONE of the following antiplatelet agents (before or at the time of PCI):
❑ P2Y12 receptor inhibitors

❑ Clopidogrel 600 mg

❑ Ticagrelor 180 mg

❑ Prasugrel 60 mg

Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
❑ IV GP IIb/IIIa inhibitors

❑ Abciximab

❑ Loading dose 0.25 mg/kg IV bolus

❑ Maintenance dose 0.125 mg/kg/min

❑ Eptifibatide

❑ Loading dose 180 mcg/kg IV bolus

❑ Another 180 mcg/kg IV bolus after 10 minutes

❑ Maintenance dose 2 mcg/kg/min

❑ Decrease infusion by 50% if creatinine clearance <50 mL/min

❑ Avoid in hemodialysis patients

❑ Tirofiban

❑ Loading dose 25 mcg/kg

❑ Maintenance dose 0.15 mcg/kg/min

❑ Decrease infusion by 50% if creatinine clearance <30 mL/min

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Administer ONE of the following anticoagulant therapy:
❑ Unfractionated heparin

♦ If GP IIb/IIIa receptor antagonist is planned

❑ 50- to 70-U/kg IV bolus

♦ If no GP IIb/IIIa receptor antagonist is planned

❑ 70- to 100-U/kg bolus

❑ Bivalirudin

❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion

❑ Additional bolus of 0.3 mg/kg if needed

❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min

G01=

Consider urgent CABG if the coronary anatomy is not amenable to PCI and one of the following:

❑ Ongoing and recurrent ischemia
❑ Cardiogenic shock
❑ Severe heart failure
❑ Other high risk features

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: ❑ Cerebral infarction ❑ Intracerebral hemorrhage ❑ Subarachnoid hemorrhage ❑ Hypertensive encephalopathy ❑ Acute left ventricular failure ❑ Myocardial infarction ❑ Aortic dissection ❑ Acute pulmonary edema ❑ Acute renal failure ❑ Hypertensive retinopathy

Measure the blood pressure

BP ≥ 180/120

BP < 180/120

Does the patient have any evidence of end organ damage?

❑ Continue with the complete diagnostic approach of chronic hypertension

Yes

No

Hypertensive emergency

Hypertensive urgency

Identify alarming signs and symptoms: ❑ Tachycardia ❑ Hypotension ❑ Loss of consciousness ❑ Tachypnea

❑ Consider admission for observation ❑ Consider treatment as an outpatient

Click here for complete management of hypertensive crisis

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 ❑ For moderate MS repeat echocardiography every 1-2 years ❑ 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

Continue with the summary for mitral stenosis intervention below

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 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

Continue with the summary for mitral stenosis intervention below

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?

Continue with the complete diagnostic approach below

Stroke ❑ Suspect in case of: ❑ Sudden weakness or paralysis - face, arm or leg ❑ Speech or visual difficulties ❑ Altered level of consciousness ❑ Sudden severe headache

Atrial fibrillation ❑ Suspect in case of palpitations ❑ Order an ECG immediately looking for ❑ Irregularly irregular rhythm, and ❑ Absent P waves

Pulmonary embolism ❑ Suspect in case of: ❑ Acute onset of exertional dyspnea or dyspnea at rest ❑ Pleuritic or substernal chest pain ❑ Hemoptysis

Pulmonary hypertension ± right sided heart failure ❑ Suspect in case of severe dyspnea ❑ Increased jugular venous pressure immediately ❑ Hepatomegaly ± pulsatile liver

Click here for stroke resident survival guide

Click here for atrial fibrillation resident survival guide

Click here for pulmonary embolism resident survival guide

Click here for Pulmonary hypertension resident survival guide, or Click here for Acute heart failure resident survival guide

Summary of Recommendations for Mitral Stenosis Intervention

• PMBC is recommended for symptomatic patients with sever mitral stenosis (MVA ≤ 1.5 cm², stage D) and favorabale valve morphology in the absence of contraindications (Class I, level of evidence A)
  
• Mitral valve surgery is indicated in severely symptomatic patients (NYHA class III/IV) with severe mitral stenosis (MVA ≤ 1.5 cm², stage D) who are not high risk for surgery and who are not candidates for or failed previous PMBC (Class I, level of evidence B)
  
• Concomitant mitral valve surgery is indicated for patients with severe mitral stenosis (MVA ≤ 1.5 cm², stage C or D) undergoing other cardiac surgery (Class I, level of evidence C)
  
• PMBC is reasonable for asymptomatic patients with very severe mitral stenosis (MVA ≤ 1 cm², stage C) and favourable valve morphology in the absence of contraindications (Class IIa, level of evidence C)
  
• Mitral valve surgery is reasonable for severely symptomatic patients with severe mitral stenosis (MVA ≤ 1.5 cm², stage D) provided that there is other operative indications (Class IIa, level of evidence C)
  
• PMBC may be considered for asymptomatic patients with mitral stenosis (MVA ≤ 1.5 cm², stage C) and favourable valve morphology who have new onset of atrial fibrillation in the absence of contraindications (Class IIb, level of evidence C)
  
• PMBC may be considered for symptomatic patients with MVA > 1.5 cm² if there is evidence of hemodynamically significant mitral stenosis during exercise (Class IIb, level of evidence C)
  
• PMBC may be considered for severely symptomatic patients (NYHA III/IV) with severe mitral stenosis (MVA ≤ 1.5 cm², stage D) who have suboptimal valve anatomy and aren't candidates for surgery or at high risk for surgery (Class IIb, level of evidence C)
  
• Concomitant mitral valve surgery may be considered for patients with moderate mitral stenosis (MVA 1.6 - 2.0 cm²) undergoing other cardiac surgery (Class IIb, level of evidence C)
  
• Mitral valve surgery and excision of the left atrial appendage may be considered for patients with severe mitral stenosis (MVA ≤ 1.5 cm², stage C and D) who have recurrent embolic events while receiving adequate anticoagulation (Class IIb, level of evidence C)