Category: Cardiac

Acute Coronary Syndrome (ACS) – 2025

First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.

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ACS Treatment (Not STEMI going for PPCI)

  • Aspirin 300mg stat
  • Ticagrelor 180mg stat
  • Fondaparinux 2.5mg sc stat. 

Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),

  • Aspirin 300mg stat
  • Clopidogrel 300mg stat

Treatment STEMI going for PPCI

  • Aspirin 300mg stat
  • Plus Either:
    • Ticagrelor 180mg stat (Hx of CVA)
    • Prasugrel 60mg stat (NO Hx of CVA)

Direct admissions to CCU

Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.

As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.

Patients where MI is excluded

If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:

  1. Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
  2. Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.

Atrial Fibrillation/Flutter (ECS 2024)

Before you start 

  • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
  • Stable or Unstable?  – Electricity vs. Drugs
  • Rate/Rhythm control
  • CHADS-VASC vs. ORBIT– Anticoagulation
  • NEW Symptomatic Arrhythmia Clinic [6-8weeks] – referral form attached tho the PDF

Discharge? – If all of following

    • No compromise
    • HR<110 for 2hr
    • No precipitants requiring admission

AF/SVT Clinic – AF/SVT clinic Referral form

  • This clinic is only for:
    • Symptomatic patients with new onset AF /SVT (where the presenting symptoms are definitely due to AF /SVT)
    • And patients have fast ventricular rates.
    • ECG shows AF/SVT

Unstable AF

Haemodynamically UNSTABLE patients

Any of:

    • Shock sBP <90mmHg – poor perfusion
    • Reduced level of consciousness – poor brain perfusion
    • Cardiac Ischaemia – poor heart perfusion
    • Pulmonary Oedema – poor lung perfusion

Emergency DC Cardioversion (DCC) is the mainstay of treatment. Obviously DCC is uncomfortable experience and sedation is preferable, however, if unstable sedation may not be an option.

DC Cardioversion (SYNCRONISED)

    • Consent (best interest if needed)
    • Sedation if possible (may require anaesthetic assistance)
    • DC Cardiaversion
      1. Syncronise (white dots appear over QRS on monitor)
      2. Energy 
        • 1st shock 70J
        • 2nd shock 120J
        • 3rd shock 200J
      3. Charge & Shock (oxygen away, everyone clear!)
      4. Reassess – repeat for further shocks if required

Tachycardia Guide line – Resus Council

Causes/Tests

Causes

It’s essential any Modifiable causes are treated, these include:

    • Haemodynamic stress: Valvular disease/Hypertension/LVD/Thrombus
    • Atrial ischemia: Ischaemic Heart Disease
    • Inflammation: Sepsis/Myocarditis/pericarditis
    • Noncardiovascular respiratory causes: PE/Pneumonia/Lung Cancer
    • Alcohol and drug use: Alcohol/Cocaine/Amphetamine
    • Endocrine disorders: Hyperthyroid/Diabetes/Phaeochromacytoma/Electrolyte prob.
    • Neurologic disorders: Subarachnoid Haemorrhage/Stroke
    • Genetic factors
    • Advancing age

Tests (NEW AF)

  • 12 Lead ECG
  • Bloods: FBC, U&E, Bone profile, Magnesium, LFT, TFT, Clotting, Glucose
  • Others: individualised to the patient.
STABLE – Rate/Rhythm Control

Rate Control

  • First line:
    • β-Blocker – outperforms calcium channel blockers in studies
    • Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
  • Second Line:Consider adding in
    • Digoxin – however, digoxin alone is not effective in patients with increased sympathetic drive. Observational studies have associated digoxin use with excess mortality in AF patients)
    • Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy in patients who do not qualify for non-pharmacological rate control

Rhythm control in ED

“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”

In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.

STABLE – Stroke Prevention

Anticoagulation

AF increases the chance of Stroke by 5x (and those recently diagnosed are least likely be on any form of protection)

  • ESC/NICE recommends using the CHADS-VASc to assess stroke risk and ORBIT to assess bleeding risk
  • There are currently significant delays getting to “New AF” clinic as well as to GP’s, making assessment of Stroke risk in ED more important than ever

CHADS-VASc outcome recommendations

    • Males (0), Female (1) – No anticoagulation recommended
    • Males (1) – Consider anticoagulation (DOAC) in light of bleed risk
    • ALL (≥2) – Anticoagulation recommended (DOAC)- Trust DOAC guide,  NICE/CKS
    • Use Apixaban where first line, significantly cheaper. If using alternative please document reasons.

ORBIT outcome recommendations

    • Modifiable risks – Address ALL modifiable risk factors
    • Most will benefit from anticoagulation – but discuss personalised risk with patients

Contraindications to Anticoagulation inc:

    • Active serious bleeding (where the source should be identified and treated)
    • Associated comorbidities (e.g. severe thrombocytopenia <50 platelets/lL, severe anaemia under investigation, etc.)
    • Recent high-risk bleeding event such as intracranial haemorrhage (ICH).

 

STABLE – Comorbidities

Cardiovascular risk factors

    • Life Style
      • Obesity: Risk of AF, Recurrence of AF and Stoke all increase with BMI
      • Alcohol: Alcohol excess both increases the risk of AF and of Bleeding, so patient should support to reduce aldol intake is recommended
      • Caffeine: It is unlikely caffeine consumption causes AF. Habitual caffeine use may reduce the risk of developing AF. But increases the symptoms
      • Exercise: Moderate cardiavasclar exercise is protective, however higher rates of AF are seen in elite athletes and vigorous physical activity
    • Specific conditions- patient should follow up with GP/Clinic (treatment may start in ED)
      • Hypertension
      • Heart Failure
      • Coronary artery disease
      • Diabetes Mellitus
      • Sleep Apnoea
STABLE – CARE

Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

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Acute Heart Failure (AHF) – ESC

Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.

AHF Triggers

there are many triggers for AHF, which if recognized and treated with help improve outcomes

  • Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension
  • Respiratory: PE, COPD
  • Infection: Pneumonia, Sepsis, Infective endocarditis
  • Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds
  • Increased Sympathetic Drive: Stress
  • Metabolic: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
  • Cerebrovascular Insult

ESC Guide – 2021 Heart Failure

Presentations

Decompensated Heart Failure

Isolated Right Vent-Failure

Pulmonary Oedema

Cardiogenic Shock

Managment

Treatment – Time Matters!!!

  • Mortality increased by 1%/hour IV treatment not started

Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)

Oxygen
  • Not all patients should be given Oxygen ESC suggest maintain SaO2 >90%
  • Early NIV is suggested if any of:
    • RR >25bpm or SaO2 <90% despit oxygen
    • Signs type 2 respiratory failure

Metanalysis suggests early NIV may reduce need for intubation and improve mortality

NIV Guide-HERE

Diuretic

Vasodilator

Inotropes

Hypomagnesaemia

Classification

  • Normal: 1.1-0.7
  • Mild: 0.69-0.5 – No symptoms or non-specific symptoms, such as lethargy, muscle cramps, or muscle weakness
  • Severe: <0.5 – Severe neurologic symptoms such as nystagmus, tetany, seizures, and cardiac arrhythmias

Signs/Symps (normally <0.5)

  • MSK: Muscle Twitch, Tremor, Tetany, Cramps
  • CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
  • CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
  • BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia

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Syncope – ESC 2018

  • Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery.
  • Common ED Complaint: 1.7% of all attendances
  • Difficult Diagnosis: less than 50% get a diagnosis in ED
  • Mortality & Serious Outcome: 0.8% mortality & 10.3% serious outcome @ 30 days

Ask 3 Questions!

  1. Is this Syncope?
  2. What is the underlying cause?
  3. What is the best Follow-Up for this patient?

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