Clinical Update of Cardiovascular Case

in Emergency Settings

Erika Maharani
Here isRSUP
where
Dr.your presentation
Sardjito Yogyakartabegins
Outline

• Acute Coronary Syndrome

• Acute Heart Failure
• Arrhythmias
Tachyarrhythmias
Bradyarrhythmias
• Cardiac Arrest
Acute Coronary Syndrome
Acute coronary syndrome
(ACS) refers to a spectrum of clinical
presentations ranging from those for ST-
segment elevation myocardial infarction
(STEMI) to presentations found in non–
ST-segment elevation myocardial
infarction (NSTEMI) or in unstable
angina. It is almost always associated
with rupture of an atherosclerotic
plaque and partial or complete
thrombosis of the infarct-related artery.
Pathophysiology
Clinical
Spectrum
Acute
Coronary
Syndrome
Acute
Coronary
Syndrome
Acute
Coronary
Syndrome
 Reperfusion Therapy

Percutaneous Coronary Intervention Anti Thrombotic therapy

(PCI) (Fibrinolytic)
Acute Heart Failure
Acute Heart Failure

▪ Rapid or gradual onset of symptoms and/or signs of HF

▪ Leading cause of hospitalizations in subjects aged >65 years and is
associated with high mortality and rehospitalization rates
▪ In-hospital mortality ranges from 4% to 10%

McDonagh et al. 2021. Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal.
Complex
Pathophysiological
Mechanism of AHF

Braunwald's Heart Disease:

A Textbook of Cardiovascular Medicine
Management of Acute Heart Failure
Clinical Profiles
of Patients with
Acute HF

Int J Heart Fail. 2020 Apr;2(2):91-110

Arrhythmias - Tachycardia
 Tachycardia

• Tachycardia is defined as a rhythm with a heart rate greater than 100 bpm.
• An unstable tachyarrhythmia exists when cardiac output is reduced to the point
of causing serious signs and symptoms.
• Unstable tachyarrhythmia : Chest pain, signs of shock, SOA (short of air),
altered mental status, weakness, fatigue, and syncope.
Macroreentrant and Microreentrant Tachyarrhythmia

Supraventricular
Tachyarrhythmia

Ventricular
Tachyarrhythmia
 QRS Duration during Tachycardia

Narrow QRS complex tachycardia ( QRS duration < 0.12 s)

Supraventricular Tachycardia
Wide QRS complex tachycardia (QRS duration ≥ 0.12 s)
Ventricular Tachycardia DD/ Supraventricular Tachycardia
 Supraventricular Tachycardia

• Reentry phenomenon
• Regular, sudden, paroxysmal onset or cessation, or both
• Up to 250 beats/min
• P waves: seldom seen because rapid rate causes P wave loss in preceding T waves
• QRS complex: normal, narrow (≤0.12 sec usually)
• Palpitations, exercise intolerance
Mechanism of Supraventricular Tachycardia
Mechanism of Supraventricular Tachycardia
Supraventricular Tachycardia: Inisiation
 Ventricular Tachycardia

• Rate: ventricular rate > 150 bpm

• No atrial activity seen, P waves: seldom seen but present
• Regular ventricular
• AV dissociation
• QRS complex: wide and bizarre, “Premature Ventricular Complex (PVC)-like”
complexes >0.12 sec, with large T wave of opposite polarity from QRS
Mechanism of
Ventricular
Tachycardia
Ventricle Tachycardia
Adult Tachycardia with Pulse Algorithm (1)
Adult Tachycardia with Pulse Algorithm (2)
Arrhythmias - Bradycardia
 Bradycardia

• Bradycardia is defined as any rhythm disorder with a heart rate less than 60
beats per minute
• Symptomatic bradyarrhythmias, however, is defined as a heart rate less than
60/min that elicits signs and symptoms, but the heart rate is typically less than
50/min.
ECG Rhythms Classified
as Bradycardia
Adult Bradycardia with Pulse Algorithm
Adult Bradycardia with Pulse Algorithm
Cardiac Arrest
2020 American Heart Association Chains of Survival for IHCA and OHCA
CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital cardiac arrest; and OHCA, out-of-hospital cardiac arrest.
 ACLS Guidelines for Cardiac Arrest Update

• New concept emphasizing high quality, minimally‐interrupted CPR to

maximize blood flow to the brain

• C‐A‐B is the new algorithm, as opposed to the previously taught A‐B‐C

• Recoil of the chest during chest compressions improves oxygenation

• High quality compressions increases survival

 Lethal Arrhythmia in Cardiac Arrest

Shockable Non Shockable

• Ventricle Tachycardia with No Pulse • Pulseless Electrical Activity
• Ventricle Fibrillation • Asystole

V PE
T A

V
F Asistole
Adult Cardiac Arrest
Circular Algorithm
CPR indicates cardiopulmonary
resuscitation; ET, endotracheal; IO,
intraosseous; IV, intravenous; pVT,
pulseless ventricular tachycardia; and
VF, ventricular fibrillation.
Stay SAFE at the frontlines