1. CARDIAC EMERGENCIES

2. Hypertensive Emergencies Severe hypertension ◦Systolic BP > 200 mm Hg ◦Diastolic BP > 120 If life-threatening organ damage is present, then BP must be reduced quickly to normal levels Rapid BP reductions can cause strokes, renal failure, and myocardial ischemia If life-threatening organ damage is not present, reduce the BP gradually to avoid the side effects

3. Pathophysiology Most organ damage is from arteriolar necrotizing vasculitis (platelet and fibrin deposition) and loss of autoregulation of the blood vessels The most common cause is discontinuation of BP medication Young patients (<30) or black patients may have secondary causes for HTN, such as renal disease, endocrine syndromes, drug- induced catecholamine release, or pregnancy-induced

4. Clinical Features of HTN- induced organ damage Encephalopathy ◦HA, nausea, vomiting, blurred vision, confusion, seizures, coma ◦stroke Pulmonary edema ◦Due to increased afterload, not fluid overload Renal impairment ◦Decreased glomerular filtration rate, blood/protein in the urine Retinopathy Aortic dissection Angina/MI ◦Due to increased afterload and decreased perfusion Pregnancy related ◦Pre-eclampsia/eclampsia

5. Treatment With life-threatening organ damage ◦Close monitoring ◦Sodium nitroprusside (Nipride)  Arteriovenous dilator ◦Gylceryl trinitrate  Arteriovenous dilator  Especially effective when MI/pulm edema co-exist ◦Labetalol  An alpha and beta blocker  Can exacerbate asthma, heart failure, heart block ◦Hydralazine and diazoxide

6. Treatment Without life-threatening organ damage ◦Oral antihypertensives  Sublingual Nifedipine  Beta blockers  ACE inhibitors  Calcium channel blockers ◦Goal is to reduce the diastolic BP to ~100 mm Hg by 24-48 hours

7. Infective Endocarditis Infection of the heart valves or endocardium Usually causes a chronic illness but can be acute when due to a virulent organism Causitive organisms ◦Streptococcus viridans: ~50%...poor dentition ◦Staphylococcus aureus: 20-25%...IV drug use ◦Staphylococcus epidermidis: valve replacement surgery ◦Staphylococcus faecalis: 5%...abortion/genitourinary surgery ◦Gram negative organisms: drug addicts/heart valve replacement ◦Fungi: immunosuppressed patient

8. Infective Endocarditis Etiology ◦Most common in elderly people with degenerative aortic/mitral valve disease ◦Patients with prosthetic valves, rheumatic heart dx, congenital heart dx ◦Abnormal valves are particularly susceptible following dental or surgical procedures

9. Infective Endocarditis Clinical Features ◦CNS: embolic infarction, abscesses, meningitis ◦General infection: low grade fever, lethargy, malaise, anemia, wt loss ◦Cardiac: murmurs, heart failure, aneurysms ◦Late signs: clubbing of digits, splenomegaly ◦Joints: arthralgia, septic arthritis ◦Skin: vasculitic rash ◦Soles of feet: Janeway lesion ◦Eyes: retinal hemorrhages ◦Mucosal: subconjunctival hemorrhage ◦Nail bed: splinter hemorrhages, nailfold infarcts ◦Hands: small, red macular lesions, painful swelling of fingers/toes ◦Kidneys: microscopic hematuria, glomerulonephritis ◦Embolic infarcts and abscesses: lungs, kidneys, CNS…loss of peripheral pulses

10. Infective Endocarditis Diagnosis ◦Mainly clinical ◦Confirmed by anemia, raised ESR or CRP, microscopic hematuria, positive blood cultures, and echocardiography Management ◦ID and treat infection (ATB for ~6 wks) ◦Surgery to replace infected prosthetic valves and native valves if infection/heart failure occurs Prognosis ◦Mortality is ~15% ◦Prophylactic ATB used before procedures in patients with valvular heart disease

11. Pericardial Emergencies Acute pericarditis ◦Due to infection (usually viral), MI, uremia, connective tissue dx, trauma, TB, or neoplasms ◦Clinical features: severe positional (sitting forward relieves) retrosternal chest pain with pericardial rub ◦Diagnosis: concave ST segment elevation…cardiac enzymes may be elevated ◦Management: bed rest, anti-inflammatories, steroids

12. Pericardial Emergencies Pericardial Effusion ◦Due to infection, uremia, MI, aortic dissection, myxedema, neoplasms, radiotherapy ◦Clinical features: cardiac tamponade reducing CO, SOB, pericarditis, venous congestion that increases with inspiration, hypotension with a paradoxical pulse (BP falls >15 mm Hg during inspiration), distant heart sounds ◦Diagnosis: low voltage EKG, CXR shows cardiomegaly, echocardiography ◦Management: pericardial drainage Constrictive pericarditis ◦A progressive fibrotic constriction of the pericardium ◦Surgical removal of the pericardium is the only tx