Cardiovascular System Emergency Cases
Case 1: Acute Coronary Syndrome
NSTEMI, STEMI, Unstable Angina
Case Scenario
A 62-year-old male presents to the emergency department with sudden-onset, severe, central chest pain that began while resting. The pain is pressure-like, lasts longer than 20 minutes, and radiates to the left arm and jaw. He reports nausea, sweating, and shortness of breath. He has a history of hypertension, type 2 diabetes, and smoking. He denies fever, trauma, or recent illness.
Decision Point 1: Based on the initial presentation, what is the most critical first step?
History Taking
- Pain characteristics: Onset, duration, location, quality, radiation.
- Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, dizziness, syncope.
- Cardiac risk factors: Diabetes, smoking, hypertension, dyslipidemia, family history.
- Previous episodes: Angina, known CAD, or use of nitrates.
- Rule out red flags: Tearing pain → dissection; pleuritic pain → PE
- Review medications and allergies, and functional status.
Examination
- ABC approach: Assess Airway, Breathing, Circulation.
- Attach cardiac monitor and defibrillator pads.
- Vitals: HR, BP, RR, SpO₂, capillary refill.
- Focused Exam: Cardiac (murmurs, gallops), Pulmonary (crackles for edema).
- Look for signs of right heart failure or volume overload.
Investigations
- 12-lead ECG: Within 10 mins. Look for ST-segment elevation.
- Cardiac troponin (high sensitivity): Repeated after 1–3 hours.
- Chest X-ray: Rule out alternate causes.
- Blood tests: CBC, renal panel, electrolytes, coagulation, glucose, lipids.
- Consider bedside echocardiography if unstable.
Decision Point 2: The patient's ECG shows ST-segment elevation in leads II, III, and aVF. Which medication should be used with extreme caution or avoided?
Management
- Continue ABC monitoring and support.
- Administer Aspirin 300 mg PO (chewed).
- Administer P2Y12 inhibitor (e.g., ticagrelor or clopidogrel).
- Give oxygen only if SpO₂ < 90%.
- Start Nitroglycerin (sublingual or IV) if BP is stable and no RV infarct.
- Begin anticoagulation (e.g., unfractionated heparin or enoxaparin).
- Administer high-intensity statin (e.g., atorvastatin 80 mg).
- Give morphine if pain remains severe.
- Activate catheterization lab for primary PCI (goal: within 90 minutes).
- Admit to Cardiac Care Unit (CCU) post-intervention.
Key Findings
Important Positives:
- Chest pain at rest > 20 mins, radiating to jaw/arm.
- Associated nausea, dyspnea, diaphoresis.
- Key risk factors present.
- ECG: ST-segment elevation.
- Elevated troponin.
Important Negatives:
- No fever/cough (less likely pneumonia).
- No pleuritic pain (less likely PE).
- No tearing pain or unequal pulses (less likely dissection).
Clinical Pearl
In suspected ACS, "time is myocardium." The single most important initial action is a 12-lead ECG to identify STEMI and activate the cath lab. Every minute of delay leads to further irreversible heart muscle damage.
Case 2: Hypertensive Crisis
Emergency vs. Urgency
Case Scenario
A 54-year-old female presents to the ED with a sudden-onset, severe headache, blurred vision, nausea, and shortness of breath. She has a history of chronic hypertension but has been non-compliant with her medications. On arrival, her blood pressure is 232/126 mmHg. She appears distressed, with crackles on auscultation and papilledema on fundoscopy.
Decision Point 1: The presence of papilledema and crackles on auscultation signifies what?
History Taking
- Symptom onset and severity: headache, chest pain, dyspnea, nausea, vomiting, vision changes.
- Neurological symptoms: confusion, seizures, weakness, altered mental status.
- Review history of hypertension: duration, compliance, previous hypertensive crises.
- Medication adherence: missed doses, or overuse of over-the-counter drugs (e.g., NSAIDs).
- Substance use: cocaine, amphetamines.
- Screen for pregnancy in females of reproductive age.
Examination
- ABCDE approach: Airway, Breathing, Circulation, Disability, Exposure.
- Circulation: BP (in both arms), HR, perfusion status, cap refill.
- Disability: Neurological exam — pupils, limb power, reflexes, GCS.
- Cardiac exam: S3 gallop, displaced apex beat (LVH), murmurs.
- Lung exam: Basal crackles (pulmonary edema), signs of CHF.
- Fundoscopy: Papilledema, flame hemorrhages (hypertensive retinopathy).
Decision Point 2: What is the primary goal for blood pressure reduction in the first hour?
Management
- Admit to ICU or high-dependency unit.
- Continuous BP monitoring with arterial line.
- Begin IV antihypertensive therapy (e.g., Labetalol, Nicardipine).
- Aim: reduce BP by max 25% in 1st hour.
- After 1st hour, gradually reduce BP to 160/100 mmHg over next 2–6 hrs.
- Identify and treat underlying cause.
- Transition to oral antihypertensives over 24–48 hours.
Clinical Pearl
The key difference between a hypertensive emergency and urgency is the presence of acute end-organ damage. Emergencies require immediate IV medication and ICU admission, while urgencies can be managed with oral medications over 24-48 hours.
Case 3: Acute Heart Failure (AHF)
Decompensation of Chronic Heart Failure
Case Scenario
A 68-year-old man with known ischemic cardiomyopathy (LVEF ≈ 30 %), HTN, DM, and CKD-3 presents to the ER with 12 hours of suddenly worsening dyspnea, orthopnea, and a frothy cough. He feels "full" despite taking his usual furosemide. A chest x-ray shows signs of pulmonary edema.
Decision Point 1: Which lab test is most useful to rapidly support the diagnosis of AHF and differentiate it from other causes of dyspnea?
History & Etiology
- Presentation: Usually acute decompensation of preexisting heart failure (ADHF).
- ADHF Precipitants: Uncontrolled hypertension, new cardiac ischemia, arrhythmias, infections, medication nonadherence, or volume overload.
- Classic Symptoms: Acute dyspnea, orthopnea, and a cough, which may produce frothy sputum.
- Hypoperfusion Symptoms: Profound weakness, fatigue, or altered mental status.
Examination
Classification (Perfusion & Congestion)
Patients are categorized as "Warm" (well-perfused) or "Cold" (hypoperfused), and "Dry" (not congested) or "Wet" (congested). Most (~95%) are **"Warm and Wet."**
Key Physical Signs
- Signs of Congestion (Wet): Jugular venous distention (JVD), coarse crackles/rales on auscultation, S3 gallop, peripheral edema.
- Signs of Hypoperfusion (Cold): "Cold" extremities, clammy/mottled skin, suggesting impending cardiogenic shock.
- Diagnostic Triad: The combination of JVD, lung crackles, and an S3 gallop makes AHF highly probable.
Decision Point 2: Your patient is well-perfused with crackles in both lungs and significant peripheral edema. How would you classify them?
Management
"LMNOP" Mnemonic for stable ("Warm and Wet") patients:
- Loop diuretics (IV Furosemide) to remove excess fluid.
- Modify medications (hold beta-blockers if unstable).
- Nitrates (for vasodilation to reduce preload and afterload).
- Oxygen (only if SpO₂ < 90%).
- Positioning (sit the patient upright to reduce preload).
Hemodynamically Unstable ("Cold and Wet"): Requires respiratory support (often NIPPV) and inotropic agents.
Key Findings & Differential Diagnosis
Important Positives:
- Classic triad (JVD, S3 gallop, bibasilar crackles).
- Significantly elevated BNP/NT-proBNP.
- CXR evidence of pulmonary edema.
Important Negatives:
- A low BNP/NT-proBNP makes AHF highly unlikely.
Key Mimics of AHF:
- Pneumonia: Clues are fever, focal consolidation on CXR.
- Pulmonary Embolism (PE): Pleuritic chest pain, elevated D-dimer.
- ARDS: Known trigger (sepsis, trauma), "white-out" on CXR without cardiomegaly.
- ACS: Significant troponin trend, ECG changes.
Clinical Pearl
BNP (or NT-proBNP) is a powerful tool in diagnosing AHF. The heart releases it in response to stretching. A low BNP level is a critical finding that makes AHF highly unlikely and should prompt an immediate search for mimics like PE or pneumonia.