Cardiovascular Emergencies Study Guide for the CEN

Endocarditis

Endocarditis is an infection of the lining of the heart that covers the heart valves. It is most common in patients who:

have a history of intravenous drug use
are over 60 years of age
are male
have dental infections

Common complications include sepsis, heart failure due to damaged valves, and emboli. Left untreated, endocarditis can be fatal.

Assessment

Patients frequently present with a list of symptoms, including:

fever
chills
body aches
chest pain while breathing
shortness of breath with activity
fatigue
weakness
red nodules on the fingers or toes
small red spots on the palms or soles
swelling in the feet, legs, or abdomen (if heart failure has occurred)

An ECG and echocardiogram should be obtained to check for vegetation growth on the heart valves and valve damage. A CBC and CMP should also be completed, as well as blood cultures to determine what infectious agent might be growing and whether it is systemic. Auscultation will reveal a heart murmur if valve damage is present. Widened pulse pressures will also indicate the presence of valve damage.

Treatment

Treatment of endocarditis can be complicated. Anticipate a prolonged hospitalization with close monitoring. Intravenous antibiotics often need to be administered for weeks, requiring the insertion of a peripherally inserted central catheter or other type of central line. The patient should remain on a constant telemetry monitor to watch for any dysrhythmias, and vital signs should be monitored closely.

Depending on the degree of valve damage and whether heart failure has occurred, the patient may require open heart surgery to replace the valve. The heart failure usually resolves as the endocarditis is successfully treated and after valve replacement, if necessary.

Heart Failure

Heart failure, also known as congestive heart failure, is a type of heart disease that occurs when the heart can’t pump well enough to supply the body with blood, a condition known as decreased cardiac output. It consists of contractile disorders (systolic heart dysfunction) or filling disorders (diastolic heart failure), both of which are types of left-sided heart failure. With systolic heart failure, the heart is unable to pump enough blood out, while in diastolic heart failure, the heart is too stiff to allow enough blood to return to the heart. In right-sided heart failure, the right side of the heart is too weak to pump deoxygenated blood into the lungs.

Secondary complications can include pulmonary, peripheral, or system/generalized edema due to fluid backing up into the lungs or venous system.

Symptoms include:

crackles/rales in the lungs
shortness of breath/dyspnea
fatigue
peripheral edema
activity intolerance

Heart failure can occur as a result of coronary artery disease, damaged valves, genetic causes, or an unknown etiology. There are four levels of severity in heart failure:

class I—The patient is asymptomatic, and there are no clinical signs of heart failure. Activity level is unrestricted. Prognosis is good.
class II—Symptoms appear with physical exertion but are absent at rest. Mild crackles at the lung bases may be detected through auscultation. Prognosis is good.
class III—Symptoms appear with both physical exertion and rest. The ability to conduct activities of daily living (ADLs) is compromised. Prognosis is fair.
class IV—Severe symptoms, including dyspnea, +4 pitting peripheral edema, and activity intolerance, are present at rest. Some patients may require the use of supplemental oxygen. Prognosis is poor.

Assessment

Patients may complain of generalized fatigue, a wet cough, shortness of breath, and activity intolerance. Evaluate patients for signs of edema, especially in the lower extremities. Auscultate the patient’s lungs carefully and pay close attention to any crackles or rales you hear. Hypotension may be noted if cardiac output is compromised.

An echocardiogram should be performed to evaluate the patient’s heart function and structure. The ejection fraction will be decreased based on the severity of the heart failure. The lab tests for factors like the B-type natriuretic peptide (BNP), a protein secreted by the heart to keep blood pressures stable, will show an increase when heart failure occurs.

Treatment

Treatment consists primarily of medications and lifestyle changes. In acute heart failure, diuretics (often intravenous) such as furosemide or bumetanide will be used to remove excess fluid that is increasing cardiac workload. Long term, patients with heart failure should limit their sodium intake (to minimize fluid retention), check their weight at least once a day, and refrain from participating in strenuous activities if their heart failure is severe. Oral medications used to treat heart failure include diuretic medications, ACE inhibitors, vasodilators, and beta blockers to decrease cardiac workload. Digoxin can increase the contractility of the heart, increasing cardiac output.

A cardiac catheterization may help to determine the underlying cause of the heart failure. Surgical interventions can treat underlying causes such as coronary artery disease and heart valve disease with coronary artery bypass grafting and valve replacements. In extremely severe cases, a left ventricular assist device (LVAD) or heart transplant may be considered.

Hypertension

Hypertension is elevated blood pressure, characterized by an elevated systolic blood pressure or diastolic blood pressure. Stage 1 hypertension occurs when the systolic blood pressure is 130 to 190 mm Hg or the diastolic blood pressure is 80 to 90 mm Hg. Stage 2 hypertension occurs when the systolic blood pressure is over 140 mm Hg or the diastolic blood pressure is over 90 mm Hg.

Over time, an elevated blood pressure can result in organ damage, especially to the kidneys and to the arteries and veins that comprise the circulatory system, increasing the risk of stroke. In a hypertensive crisis, the patient’s systolic blood pressure is more than 180 mm Hg and/or the diastolic blood pressure is over 120 mm Hg with acute end-organ damage, which includes:

hypertensive encephalopathy
acute pulmonary edema
stroke
acute renal failure
eclampsia
aortic dissection

Assessment

First, take the patient’s blood pressure. If the systolic blood pressure is higher than 180 mm Hg or the diastolic blood pressure is over 120 mm Hg and the patient has evidence of acute end-organ damage, the patient is experiencing a hypertensive crisis that requires emergency treatment. Symptoms include

headache
changes in vision
dizziness
chest pain
shortness of breath
decreased urine output
altered mental status

If the hypertension has a sudden onset, you will also need to determine the underlying cause of the patient’s hypertension so that you can address it. Lab work, including a CBC and CMP, should be drawn to evaluate organ function, and an ECG should be promptly obtained to evaluate the patient’s heart rhythm.

Treatment

Treating a hypertensive crisis requires prompt intervention, usually using intravenous medications. The exact medication selected will vary depending on the type of acute end-organ damage that the patient is experiencing. Common drugs include nitroglycerin, nitroprusside, and nicardipine. The general goal is to lower the blood pressure by 20 to 25 percent within one hour, to 160 mm Hg/100 mm Hg within two to six hours, and gradually to normal parameters over the next 24 to 48 hours.

It is important to note that if the patient’s systolic blood pressure is greater than 180 mm Hg or their diastolic blood pressure is greater than 120 mm Hg, without signs of end-organ dysfunction, immediate intervention is not required. In fact, it can be dangerous to cause a sudden decrease in blood pressure under those circumstances. In these cases, oral medications are commonly prescribed, including:

diuretics
beta blockers
ACE inhibitors
calcium channel blockers
angiotensin II receptor blockers (e.g., losartan, irbesartan)
alpha blockers
vasodilators

Lifestyle changes include minimizing sodium intake, increasing exercise, and losing weight.

Pericardial Tamponade

Pericardial tamponade occurs when fluid fills the pericardium surrounding the heart and eventually prevents the heart from filling properly, causing diminished cardiac output. It can worsen quickly over time and is fatal without intervention.

Assessment

The three classic physical symptoms of pericardial tamponade are:

hypotension
jugular vein distension
muffled heart noises

The patient may experience tachycardia and tachypnea and have a decrease in their blood pressure when breathing deeply. Peripheral pulses can be weak or absent. The defining test is an echocardiogram to confirm the presence of the pericardial tamponade, but a chest X-ray, CT, or ECG should also be obtained in most cases.

Treatment

The immediate treatment is to perform pericardiocentesis to drain the fluid surrounding the heart using a needle. This can be performed blindly or with the guidance of an ultrasound or fluoroscopy. If the fluid persists, a pericardial window surgical procedure may be performed to allow the fluid to freely drain into the patient’s chest cavity. The underlying cause for the fluid also needs to be addressed, whether it is hemorrhage or another cause.

Pericarditis

Pericarditis is an inflammation of the thin sack surrounding the heart. A common symptom is stabbing chest pain that improves when leaning forward and worsens when lying flat, coughing, swallowing, or breathing. In most cases, it results from a viral, bacterial, or fungal infection. Restrictive pericarditis prevents the heart from expanding normally and can lead to heart failure and fluid retention in severe cases. Fluid may also accumulate between the thin layers of the pericardium, which is known as a pericardial effusion.

Assessment

Auscultate the heart carefully and listen for a friction rub, which is a harsh, grating sound that is most commonly associated with pericarditis. The patient may complain of sharp, stabbing chest pain, especially while taking a deep breath, coughing, or lying flat. The pain will improve when they sit up or lean forward. The diagnostic tests will include:

chest X-ray
ECG
echocardiogram
CT scan
cardiac catheterization
lab work, including an erythrocyte sedimentation rate (ESR) and C-reactive protein levels

The C-reactive protein levels can be elevated due to the inflammation.

Treatment

Treatment for pericarditis is primarily focused on medication. The first line of treatment is a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen or high-dose aspirin to relieve pain and control inflammation. Other medications will also be administered to treat any underlying viral, bacterial, or fungal infection. If symptoms persist for more than two weeks, the next step is to administer colchicine, a potent anti-inflammatory medication. A steroid such as prednisone may also be administered.

In cases of restrictive pericarditis, a diuretic may be necessary to rid the body of excess fluid and a surgical procedure called a pericardiectomy may be needed to remove a portion of the restricted pericardium. A pericardial effusion may need to be drained using pericardiocentesis.