(BQ) Part 1 book Emergencies in cardiology presents the following contents: Cardiovascular collapse, chest pain, shortness of breath, acute coronary syndromes, acute heart failure, valve disease, infective endocarditis, aortic dissection,...
4—A true life-threatening emergency Memorizing these conditions may help Call immediately for assistance Try to remain calm and quickly assess ABC Once the problem has been dealt with remember to reassess- other problems may have been forgotten or missed in the heat of the moment 3—These patients need to be assessed very quickly, because they can rapidly deteriorate Consider senior help/advice 2—These conditions require careful assessment and correction but are less likely to become life-threatening emergencies 1—These conditions are non-urgent, or cover general guidance OXFORD MEDICAL PUBLICATIONS Emergencies in Cardiology Second edition Published and forthcoming titles in the Emergencies in… series: Emergencies in Anaesthesia Edited by Keith Allman, Andrew McIndoe, and Iain H Wilson Emergencies in Cardiology Edited by Saul G Myerson, Robin P Choudhury, and Andrew Mitchell Emergencies in Clinical Surgery Edited by Chris Callaghan, J Andrew Bradley, and Christopher Watson Emergencies in Critical Care Edited by Martin Beed, Richard Sherman, and Ravi Mahajan Emergencies in Nursing Edited by Philip Downing Emergencies in Obstetrics and Gynaecology Edited by S Arulkumaran Emergencies in Oncology Edited by Martin Scott-Brown, Roy A.J Spence, and Patrick G Johnston Emergencies in Paediatrics and Neonatology Edited by Stuart Crisp and Jo Rainbow Emergencies in Palliative and Supportive Care Edited by David Currow and Katherine Clark Emergencies in Primary Care Chantal Simon, Karen O’Reilly, John Buckmaster, and Robin Proctor Emergencies in Psychiatry Basant K Puri and Ian H Treasaden Emergencies in Clinical Radiology Edited by Richard Graham and Ferdia Gallagher Emergencies in Respiratory Medicine Edited by Robert Parker, Catherine Thomas, and Lesley Bennett Head, Neck and Dental Emergencies Edited by Mike Perry Medical Emergencies in Dentistry Nigel Robb and Jason Leitch Emergencies in Cardiology Saul G Myerson Consultant Cardiologist, John Radcliffe Hospital, Honorary Senior Clinical Lecturer, University of Oxford Oxford Robin P Choudhury Wellcome Trust Senior Clinical Fellow Clinical Director, Oxford Acute Vascular Imaging Centre Honorary Consultant Cardiologist John Radcliffe Hospital, Oxford Andrew R J Mitchell Consultant Cardiologist, Jersey General Hospital 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press, 2010 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2006 Euromedice edition published 2007 Second edition published 2010 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available Typeset by Cepha Imaging Private Ltd., Bangalore, India Printed in China on acid-free paper by Asia Pacific Offset Limited ISBN 978–0–19–955438–6 10 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations The authors and publishers not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding v Preface Acute cardiology problems often need quick, appropriate diagnosis and treatment With the increasing complexity and rapidly-changing nature of available therapies, knowing which to use and in what situation can be difficult This book provides an easily accessible guide to diagnosing and managing acute cardiovascular problems and is designed for busy medical and cardiology teams, with expert advice in a clear, concise format The familiar Oxford Handbook style, with bullet-point information for speed and clarity, is combined with an integral cross-referencing system, enabling rapid access to the necessary information This second edition incorporates much of the feedback received from the first edition, and includes updated sections throughout, with significantly expanded sections on myocardial infarction, heart failure, and cardiac problems in pregnancy There is a new chapter on cardiac drugs and a separate chapter for infective endocarditis The layout is even clearer than before, with improved text, several new illustrations, algorithms and ECG’s and additional practical procedure guidance including exercise ECG interpretation and intra-aortic balloon pumps The first section of the book is symptom based and is designed to help clinch the diagnosis with suggestions of the key points in the history, physical findings and investigations and extensive cross-referencing to specific cardiac conditions later in the book The second section “Specific conditions” describes the presentation, investigation and management of all the common (and some uncommon) acute cardiac problems The chapter authors have used their specialist knowledge to guide management in all areas, including potentially challenging problems such as arrhythmias (and implantable defibrillators), cardiac issues in pregnancy, cardiac problems around the time of surgery, adults with congenital heart disease, and cardiac trauma The final section deals with “practical issues”, with clear descriptions of how to perform common practical cardiac procedures It also includes a chapter on the art of ECG recognition with a library of example ECGs to help pattern recognition We hope that you enjoy the new edition of the book and use it to enhance the care of your patients We welcome further suggestions for alterations and inclusions in future editions This page intentionally left blank vii Contents Contributors ix Symbols and abbreviations xi 10 11 12 13 14 15 16 17 18 19 Part I Presentation: making the diagnosis Cardiovascular collapse Chest pain Shortness of breath Syncope Palpitation 13 19 23 33 Part II Specific conditions Acute coronary syndromes Acute heart failure Valve disease Infective endocarditis Arrhythmias Aortic dissection Pericardial disease Pulmonary vascular disease Systemic emboli Cardiac issues in pregnancy Adult congenital heart disease Perioperative care Cardiac drugs: effects and cardiotoxicity Miscellaneous conditions 39 67 93 121 137 189 203 213 227 235 253 291 309 347 viii CONTENTS Part III Practical issues 20 Practical procedures 21 ECG recognition Index 431 359 383 342 CHAPTER 18 Cardiac drugs: effects and cardiotoxicity Recreational drugs with cardiac effects in overdose Cocaine Clinical features • Euphoria, agitation, paranoia • Sweating, hyperthermia, convulsions • Tachycardia, hypertension, chest pain, pulmonary oedema • Coronary/carotid spasm—can be severe enough to cause MI/stroke • Intracerebral haemorrhage • The patient may be violent and have a high pain threshold Investigations • ECG—ST segment elevation/depression if coronary ischaemia, supraventricular and ventricular arrhythmias • Bloods—U&Es, CK, arterial blood gases Management • Cooling if core temperature >41°C; aim for 200mmHg systolic / 130mmHg diastolic) Check BP in both arms (?aortic dissection) and in the legs (?coarctation) • Fundoscopy (retinal haemorrhages, exudates, or papilloedema) • Full neurological examination (focal abnormalities) • Examine for renal bruits (?renal artery stenosis) Investigations • 12 lead ECG (?LV hypertrophy, atrial arrhythmias) • CXR (cardiomegaly) • FBC (microangiopathic haemolytic anaemia), U&E, glucose, clotting studies (DIC) • Urinalysis (haematuria) • Further laboratory investigations (according to working diagnosis) include cardiac troponin, thyroid hormones, urine collections for catecholamines Management • Patients are usually admitted to hospital for bed rest and monitoring • Initial aim of BP management is to lower systolic pressure by 10% in the first hour and then by a further 15% in the next few hours • Treatment can usually be commenced orally with a beta-blocker • (e.g atenolol) or long-acting calcium antagonist (e.g amlodipine) • IV antihypertensive therapy may be required if oral therapy is not effective, e.g nitrates, nitroprusside, labetalol (see Box 19.2) • In the longer term, a combination of beta-blockers, calcium-channel blockers, ACE-inhibitors, and other antihypertensives are often necessary to normalize BP HYPERTENSIVE EMERGENCIES Box 19.1 Hypertensive emergencies in specific conditions Aortic dissection (b p.196) A more rapid reduction in BP is required with a target systolic pressure of RA Symptoms and signs (clubbing, rash, ‘tumour plop’—similar to S3) similar to endocarditis, malignancy, and collagen vascular disease Blood test may reveal anaemia, iCRP, iESR Echocardiography is normally diagnostic (Fig 19.1) Myxomas generally have a broad base but some are pedicled Management is with surgical excision Follow-up echocardiography is required as inadequate excision can lead to recurrence Papillary fibroelastomas Often detected as small incidental lesions on the aortic and mitral valve Fragments may embolize leading to coronary or cerebral obstruction (b p.228) Surgery is generally indicated to improve prognosis but small rightsided lesions may be monitored Others • Rhabdomyoma (most common p cardiac neoplasm in children) • Fibroma (most commonly resected childhood tumour) • Haemangiomas • Cardiac lipomas • AV nodal tumours (small cystic mass—a cause of sudden cardiac death) CARDIAC TUMOURS Fig 19.1 Transoesophageal echocardiography demonstrating a large myxoma attached to the septum between the right atrium (RA) and left atrium (LA) Fig 19.2 Transoesophageal echocardiography revealing a mobile fibroelastoma attached to the aortic valve LA, left atrium, LV left ventricle 353 354 CHAPTER 19 Miscellaneous conditions Malignant tumours Metastatic cardiac tumour Much more common than primary cardiac tumours Tachycardia, arrhythmias, heart failure in a patient with carcinoma should raise the suspicion May present with pericardial effusion and/or tamponade Associated malignancies include malignant melanoma, leukaemia, lymphoma, carcinoma of the stomach, liver, colon, rectum, and ovary Sarcomas Extremely rare May occur in any part of the heart but most commonly involve the RA Includes angiosarcoma, osteosarcoma, leiomyosarcoma, rhabdomyosarcoma Management is with a combination of surgery, chemotherapy, and radiotherapy Outcome is generally poor with median survival