Table of Contents
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PREFACE
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
Introduction: Cardiac Disease in the Pandemic Era: Teaching an Old Dog New Tricks?
Abstract
Introduction
Emergent Coronary Revascularization
Alternative Approaches to the Management of VF
The Pandemics
Conclusion
References
Cardiovascular Disease and COVID-19
Abstract
INTRODUCTION
Distinguishing Features of Acute Coronary Syndromes
Findings From Different Database Studies
Are Ethnic Differences Important for COVID-19?
Myocardial Injury Severity and Mortality
How Much Myocardial Damage Occurs in COVID-19?
In Whom does Myocardial Damage Occur and How do we Identify it?
Pathological Findings
Global View of Myocardial Infarction (STEMI/NSTEMI) After COVID-19
Diagnostic Strategies
Treatment Strategy: PCI or Fibrinolysis?
Did the Pandemic Process Affect Heart Attacks?
SUMMARY AND CONCLUSIONS
What should be done to Mitigate Pandemic Effects on CVD?
References
Myocardial Damage, Myocarditis, and COVID-19
Abstract
Myocardial injury inflicted by COVID-19
Mechanisms of how SARS-CoV-2 Induces Inflammation and Disease
Myocarditis
Cardiotropic Viruses as the Causes
Fulminant Myocarditis (FM)
Diagnosis
USG/POCUS/Echocardiography
Initial Management
Treatment Strategies for Myocarditis
IV Immune Globulins (IVIG)
Hemodynamic Maneuvers
Conclusions
References
Coagulopathies, Prothrombotic State, Thromboembolism, Bleeding, and COVID-19
Abstract
INTRODUCTION
Laboratory Variables
Troponin and BNP Can Predict the Severity of COVID-19
Pulmonary Thromboembolism (PTE) and COVID-19
Should we Heparinize the Patients with COVID-19?
CONCLUSION
References
Chest Pain and Acute Coronary Syndromes (ACS)
Abstract
INTRODUCTION
Etiology
Pathogenesis
Noncardiac Chest Pain
Medical History
Atypical Presentations
Diagnosis (Physical Examination and Laboratory Examination)
Emergency Conditions
Less Urgent Conditions
Benign (Non-emergency) Diseases
Physical examination
Look
Inspection
Skin Color
Capillary Refill
Neck (jugular) Vein Distention (JVD)
Peripheral/Presacral Edema
Listen
Breathing Sounds
Heart Sounds
Carotid Artery Murmur
Abdominal Auscultation and Palpation
Feel
Pulse
Pulse Deficit
Pulsus Alternans
Pulsus Parvus Et Tardus
Skin
Clubbing
ECG: Key Points
Treatment
High-flow Nasal Oxygen Therapy (HFNOT)
Nitroglycerin
Acute Myocardial Infarction (AMI)
Congestive Heart Failure
Signs and Symptoms
Approach to ACS in Pregnancy
A. Approach Steps to the Patient with Chest Pain in Nature/Outdoor Activities
B. Prehospital Approach To The Patient Suspected of ACS (911/112)
Pre-hospital Intervention Aims
Supplemental O2
Nitroglycerin
Morphine Sulfate
Beta Blockers
Nitrous Oxide
Benzodiazepines (Diazepam, Midazolam)
Lidocaine
Procainamide
Atropine Sulphate
Epinephrine (Adrenaline)
Adenosine
Verapamil
Diltiazem
How was the EMS Management of ACS Changed in The COVID-19 Era?
Thrombolytic Therapy in the Field
C. Approach to the Patient with ACS in the Hospital
STEMI
NSTEMI
Unstable Angina Pectoris (USAP)
Sudden Cardiac Death
Laboratory Markers of ACS
ECG
Left Main Coronary Artery Occlusion
Exercise Test and Risk Assessment
Interpretation
False Positives
Cardiac Enzymes
Cardiac Troponins
High-sensitive Cardiac Troponin T (hs-cTnT)
Pearl Time Zero
Delta TnT Value
B-type Natriuretic Peptide (BNP)
ACS in The Elderly
Is Imaging Performed for AMI?
Coronary CT-angiography (CCTA)
Accuracy Rate
CCTA Advantages
Unstable Angina Pectoris (USAP)
General Management Principles
Low Risk Patients
Killip Classification
Treatment Goals in ACS Management
Emergency Management of USAP
NSTEMI Treatment
Anti-ischemic Treatment in ACS
Dual Antiplatelet Therapy (DAPT)
Prasugrel
Clopidogrel
Is Antiplatelet Therapy Effective on Respiratory Failure in COVID-19?
Ticagrelor
Anticoagulant Treatment
Heparin Dosage
If Primary PCI will be Performed
If Fibrinolytic Treatment will be Ordered
Enoxaparin
Fibrinolytic Therapy
Other Antiischemic Therapy
Oxygen
Nitroglycerin
Morphine Sulfate
Beta Blockers
Esmolol
Calcium Channel Blockers
Benzodiazepines (Diazepam, Midazolam)
Epinephrine (adrenaline)
Dopamine
Ivabradine
Cardiogenic Shock
Signs and Symptoms
Treatment
Medicines to be Used
Dopamine
Norepinephrine
Conclusion
References
Heart Failure and Acute Pulmonary Edema (APEd)
Abstract
Introduction
Etiology Frank-Starling Law
Types and Clinical Presentation
Characteristics of patients with HF
Pathogenesis
Diastolic Dysfunction (DD)
HF Accompanying ACS
Diagnosis, Physical Examination and Findings
Increased Venous Pressure, i.e., Signs of Retrograde Circulatory Failure
Radiological and Laboratory Findings
Telecardiogram
Conventional Chest X-Ray (CXR)
Ultrasonography (USG)/POCUS
Bedside USG/POCUS: Modified LuCUS Protocol
CT
Gadolinium-enhanced Cardiac MRI
ECG
USG/Echocardiography
Pulse Oximeter
Arterial Blood Gases (ABG)
Biochemistry
Complete Blood Count
B-Type Natriuretic Peptide (Brain natriuretic Peptide, BNP) and N-Terminal ProBNP (NT-ProBNP)
Other Blood Tests
Differential Diagnosis
COPD Exacerbations
Right Ventricular AMI
Cardiac Tamponade
Pulmonary Embolism
Pneumonia
ACUTE PULMONARY EDEMA (APEd)
Signs and Symptoms
Left HF Findings
TREATMENT OF LEFT HF/APEd
Follow-up
The First-line Treatment
Fluid Therapy
Ensuring Oxygenation
Oxygenation with High Flow Nasal Cannula (HFNCO)
Non-invasive Ventilation (NIV)
Coronary Revascularization
MONA-FB Treatment
M: Morphine Sulfate
O: (Oxygen)
N: Nitrates, Glycerol Trinitrate
A: Aspirin, Acetylsalicylic Acid (ASA)
F: Furosemide
Update
B: Beta-blocker
ADDITIONAL TREATMENTS
ACE Inhibitors
Digoxin
Vasopressors
Dopamine
Dobutamine
Levosimendan
Milrinon
Istaroxim
Anxiolytic and Sedatives
Renal Replacement Therapy
Treatment in Cardiogenic Shock
Class I Recommendations
Class IIb Recommendations
CONCLUSION
References
Acute Pulmonary Embolism (APE)
Abstract
Case
Diagnosis
“Pre-test Probability” (PTP) for APE
Diagnostic Strategy
ECG Findings for APE
How to Rule out APE?
Lab Biomarkers
D-dimer
POCUS/Bedside USG/Echocardiography
Compression Ultrasonography (CUS)
Ruling out APE with USG
CT Pulmonary Angiography (CTPA)
Emergency Management and Treatment
Low Molecular Weight Heparin (LMWH)
Vitamin K antagonists and the New Oral Anticoagulants (NOAC)
Surgical Embolectomy
Outpatient Treatment of Stable, Low-risk Patients with Verified APE
Clues in APE flowsheet- Summary
References
Hypertension and Aortic Diseases in The Pandemic Era
Abstract
Hypertension: Both Acute and Chronic Disease Of The Emergency Department
Clinical Outcomes of HT
Hypertensive Emergency
Hypertensive Urgency
How can One Discern HT Emergency and Urgency?
Findings Compatible with Hypertensive Emergencies
Hypertensive Urgent Situations
Physical Exam and Evaluation of The Hypertensive Patient
Urgency
Severe Hypertension with Progressive End-organ Damage
Causality of ACE2 Receptors and HT
Impact of HYPERTENSION on The Clinical Presentation of COVID-19
Death Relationship with anti-HT Drugs
Management Principles
Hypertensive Neurological Emergencies (HNE), Acute Ischemic Stroke, Seizures
Seizures
Conclusions
REFERENCES
Aortic Diseases: Abdominal Aortic Aneurysm (AAA) and Dissecting Aortic Aneurysm (DAA)
Abstract
Ruptured AAA
Diagnosis
DISSECTING AORTIC ANEURYSM (DAA)
NON-CRITICAL PRESENTATIONS WITH AORTIC SYNDROMES
Diagnosis and Imaging
Have COVID-19 affected admissions related to AAA/DAA?
POCUS Indirect Sign
Ultrasonography/POCUS
Findings on Non-contrast CT
Findings in Contrast-enhanced CT
Classification of DAA
Treatment
Metoprolol
Labetalol
Esmolol
Treatment with Calcium Channel Blockers
Sodium Nitroprusside
Contraindications for Nitroprusside Infusion
Additional advantages of endovascular repair
Hospitalization and Discharge
Conclusions
References
Supraventricular Arrhythmias and Their Management in the Emergency Setting: PSVT and AF
Abstract
Supraventricular tachycardias
Epidemiology
Symptomatology
Clinical Course And Findings
Evaluation And History
Laboratory
Imaging
Multifocal Atrial Tachycardia (MAT)
Treatment
Valsalva Maneuver And Simplified Modified Valsalva (SMV)
How To Perform The Procedure
Adenosine
Atrial Fibrillation: Classification, Diagnosis and Treatment
Definition
Clinical Status
Differential Diagnosis
Clinical Distinction
Patients with Afl (Flutter)
Multifocal Atrial Tachycardia (MAT)
Differential Diagnosis by ECG
Imaging and Laboratory
Current Management
Rhythm Control And Cardioversion (Conversion To Sinus Rhythm)
Synchronized/Simultaneous Cardioversion
Rate Control
Current Recommendation
Procainamide
Antithrombotic-Antiaggregant Treatment in Patients With AF
Conclusion And Summary
References
Agents Used in the Treatment of Arrhythmias and Advanced Cardiovascular Life Support
Abstract
INTRODUCTION
DRUGS IN ACLS CAN BE EXAMINED UNDER TWO SUBHEADINGS
Extracorporeal CPR (ECPR)
End-Tidal CO2 (ETCO2) Monitoring
How are the Drugs Given?
Vasopressor Use in Cardiac Arrest
Standard Dose Epinephrine
MAGNESIUM
Considerations
SODIUM BICARBONATE
Mechanism of Action
ATROPIN SULPHATE
Mechanism of Action
Considerations
Conclusions
REFERENCES
Electrotherapies: Emergency Defibrillation, Cardioversion, and Transcutaneous Pacing
Abstract
Introduction And Definitions
AUTOMATED EXTERNAL DEFIBRILLATORS
AED Usage
Placement of Pads On AED Devices
Defibrillation Procedure
Biphasic Wave Defibrillators
Resistance in The Chest Cavity - Transthoracic Impedance (TTI)
What is in the defibrillator?
Placement of Defibrillator Paddles
Pediatric Arrests, Differences in AED use and Defibrillation
Defibrillation in patients with Permanent Pacemakers (PPM)
Defibrillation in pregnant women
Synchronous electrical cardioversion (ECV)
Specific Arrhythmias and Recommendations on Cardioversion Doses
Complications of Defibrillation and Cardioversion Procedures
Emergency Application of Transcutaneous Pacemaker
Indications and Procedure
TCP procedure
Steps of TCP Procedure
Overdrive Pacing
TCP Contraindications
Complications of TCP
Conclusions
References
Conclusion
“Nothing will be the same anymore”
Cardiac Care and COVID-19: Perspectives in Medical Practice
Authored by
Ozgur KARCIOGLU
Prof. FEMAT, Department of Emergency Medicine
University of Health Sciences
Istanbul Education and Research Hospital
Fatih, Istanbul
Turkey
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PREFACE
The optimal management of patients with cardiac disease warrants a multifaceted approach undertaken in harmony. The recent decades have witnessed major advances in methods for monitoring and interventions aiming to improve outcomes in this outstanding cause of death worldwide. Other than technological improvements, the medical community is aware that this task can only be achieved via a mutual collaboration of doctors in the pre-hospital phase, hospital emergency departments, intensive care units, social studies, public health professionals, and bystanders.
For nearly a year, our lives have changed like never before. The current WHO clinical guide documents cite that ‘there is no current evidence to recommend any specific anti-COVID-19 treatment for patients with confirmed COVID-19’.
In order to overcome the pandemic with minimized global losses, the scientific community, healthcare facilities, professional organizations, chambers, and state institutions should work in coordination and unison. Most importantly, only a coordinated approach with all targeted masses reached via awareness programmes and campaigns can create a real difference in this pandemic era.
This project, of the book ‘Cardiac Care and COVID-19: Perspectives in Medical Practice’ is intended to encompass the advancements regarding diagnoses and treatment modalities for cardiac diseases in general and emergency cardiac conditions to be more specific, with respect to pandemic conditions. Apart from up-to-date descriptions of the problem and delineation of management principles, case examples were also used to highlight complex issues for a concrete understanding of the medical practitioner.
The ultimate objective is to provide a reference source with up-to-date information on the management of cardiac emergencies and resuscitation in the COVID-19 era. We aim to conduct a brief overview of epidemiological features of cardiac emergencies and their sociodemographic factors, measures to be taken for prevention, together with diagnostic and therapeutic procedures to pursue in the pandemic era.
CONSENT FOR PUBLICATION
Not applicable.
CONFLICT OF INTEREST
The author declares no conflict of interest, financial or otherwise.
ACKNOWLEDGEMENTS
Declared none.
Ozgur KARCIOGLU
Prof. FEMAT, Department of Emergency Medicine
University of Health Sciences
Istanbul Education and Research Hospital
Fatih, Istanbul
Turkey
Introduction: Cardiac Disease in the Pandemic Era: Teaching an Old Dog New Tricks?
Ozgur KARCIOGLU
Abstract
Nowadays, cardiac diseases, both developed de novo and acute exacerbations of chronic conditions, remain the most prominent death cause for the middle-aged and elderly, mostly in the developed, industrialized countries.
Since the end of 2019, COVID-19 pandemics have changed our lifestyles fundamentally, and maybe we will never find a way to return to the world of 2019. This catastrophic change had its impact on almost every aspect of our lives, including how we will manage cardiac arrest patients, how to perform perform cardiopulmonary resuscitation (CPR), ACLS, etc. A net effect is that protecting ourselves will take priority (more than before) in all procedures we pursue. Thus we can conclude that new generations should incorporate self-protecting behavior and techniques to benefit the patients in the most fruitful ways.
High-quality CPR cardiopulmonary resuscitation is among the most prominent issues to save humanity from the high burden of cardiac events. Relatively novel techniques such as mechanized devices for CPR, extracorporeal membrane oxygenation (ECMO), and therapeutic temperature management promise the highest possible solution to improve survival rates, in conjunction with urgent coronary angiography with revascularization.
Pandemics can be overcome not by the heroic behaviors of a few people but by the solidarity of society. The medical community should find the best solutions to help those in need with cardiac diseases even in pandemic conditions since this pandemic will not go away like magic. The aim of this book is to support patients and their next of kin, as well as health care workers, those who have dedicated themselves to healthy well-being with their relentless endeavor.
Keywords: Cardiac arrest, Cardiac arrhythmias, Cardiopulmonary resuscitation, COVID-19 pandemics, Defibrillation, Treatment.
References
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[http://dx.doi.org/10.1016/j.ccl.2018.03.009] [PMID: 30293608]Cardiovascular Disease and COVID-19
Ozgur KARCIOGLU
Abstract
Cardiovascular disease (CVD) has long been the leading cause of global morbidity and mortality. However, with the COVID-19 pandemic, which has been the focus of attention all over the world since the end of 2019, this issue has gained different importance. The presence of CVD leads to more severe COVID-19 and an increased probability of mortality. In addition, both CVD and COVID-19 pave the way to myocardial injury, which also boosts the morbidity and death toll. Another point is the possible deprivation of usual healthcare received by cardiac patients (CVD and others) because of the shifted emphasis of the hospital and prehospital medical services on COVID-19. As the public can foresee that the pandemic will not disappear rapidly soon, healthcare organization faces a challenge to be redesigned radically. The objective of this chapter is to analyze CVD, myocardial injury, and other cardiac diseases resulting from COVID-19 itself, together with the impact of the pandemics on the usual healthcare of cardiac patients.
Keywords: Acute myocardial infarction, Cardiovascular disease, Coronavirus, COVID-19, Diagnosis, Treatment.
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