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EMERGENCY CARDIOLOGY This page intentionally left blank EMERGENCY CARDIOLOGY - 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 permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS. 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 Commissioning Editor: Caroline Makepeace Project Editor: Sarah Penny Production Controller: Kate Harris Cover Designer: Lynda King Indexer: David Bennett Typeset in Minion Pro 9.5pt by MPS Limited, A Macmillan Company Printed and bound in India by Replika Press Pvt Ltd What do you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com 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