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so much over the years

Eyal Herzog

The Eugene and Carol Chen Chair of Cardiothoracic SurgeryProfessor and Chief

Ernest G DePuey, MD

Director of Nuclear Medicine

Mount Sinai St Luke’s and Mount Sinai West HospitalsClinical Professor of Radiology

Moshe Flugelman, MD

Director

Jacob Goldstein, MD, FESC

Karen Kan, MD

Mount Sinai St Luke’s Hospital

New York, New York

Medical Resident

Internal Medicine

Mount Sinai St Luke’s and Mount Sinai West HospitalsNew York, New York

Noah Moss, MD

Medical Director of Mechanical Circulatory SupportMount Sinai Hospital

Director of Margarita Camche Smoking Cessation ClinicMount Sinai St Luke’s Hospital

Director of Pulmonary Vascular Disease

Mount Sinai–National Jewish Health Respiratory InstituteAssociate Program Director

Fellowship Training Program

Division of Pulmonary, Critical Care and Sleep MedicineZena and Michael A Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai

Heart disease is the leading cause of death in the world Advances in thetreatment of heart disease are considered among the greatest achievements ofmodern medicine Physicians, nurses, and all health care providers who care forpatients with heart disease consider the cardiac care unit (CCU) the mostexciting place in the hospital

The CCU Book is essentially two books combined into one Most chapters

have two sections: the first is for physicians and other health care providers, andthe second is for patients and their families

The first section of each chapter is aimed toward physicians (interns,residents, fellows, and attendings), medical students, nurses, physician assistants,and other health care providers who rotate or practice in the CCU It is organizedsuch that readers will not need to consult any textbooks regarding the topicsdiscussed and will be able to understand the simplified pathophysiology andmanagement of the disease This includes diagnostic modalities, initial criticalcare management in the CCU, follow-up care in a step-down unit, and plans fordischarge Algorithms and pathways for management are provided for easyimplementation in any health care system

The second part of each chapter covers the same topics previously discussedbut is directed toward the patients and their families The language and themedical terminology are simpler and geared toward the general public

It is my hope that this book will serve as a teaching tool to save the lives ofpatients with heart disease in the CCU

Eyal Herzog

I would like to acknowledge the extraordinary work of LaToya Selby andCandice Francis from my office at Mount Sinai St Luke’s Hospital in NewYork; they are my right hand in assisting my trainees and patients in the hospitaland are also the editing coordinators for this book

Thank you, Eyal Herzog

6 Computed Tomographic Angiography in Acute Cardiac Care

11 Heart Failure with Reduced Ejection Fraction

Yaron Hellman

PATIENT AND FAMILY INFORMATION FOR: HEART FAILURE WITH REDUCED EJECTION FRACTION

12 Heart Failure with Preserved Ejection Fraction

Manpreet Sabharwal, Eyal Herzog, Edgar Argulian

PATIENT AND FAMILY INFORMATION FOR: HEART FAILURE WITH PRESERVED EJECTION FRACTION

13 Mechanical Complications of Myocardial Infarction

Eyal Herzog, Indra Warren

PATIENT AND FAMILY INFORMATION FOR: MECHANICAL COMPLICATIONS OF MYOCARDIAL INFARCTION

14 Cardiogenic Shock Complicating Acute Myocardial Infarction

PATIENT AND FAMILY INFORMATION FOR: CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION

30 Principles of Antiarrhythmic Drug Therapy

Emad F Aziz, Joshua Aziz, May Bakir

PATIENT AND FAMILY INFORMATION FOR: PRINCIPLES OF ANTIARRHYTHMIC DRUG THERAPY

37 Tricuspid and Pulmonic Valvular Disease in the Cardiac Care Unit

Avinoam Shiran

PATIENT AND FAMILY INFORMATION FOR: TRICUSPID AND PULMONIC VALVULAR DISEASE IN THE CARDIAC CARE UNIT

44 Sedation and Analgesia in the Cardiac Care Unit

Louis Brusco, Diana Anca

PATIENT AND FAMILY INFORMATION FOR: SEDATION AND ANALGESIA IN THE CARDIAC CARE UNIT

45 Renal Failure in the Cardiac Care Unit

Karim El Hachem, James Jones, Ira Meisels

PATIENT AND FAMILY INFORMATION FOR: RENAL FAILURE IN THE CARDIAC CARE UNIT

54 Diabetes Mellitus in the Cardiac Care Unit

Rodolfo J Galindo, Mario Rodriguez Rivera, Seyed Hamed Hosseini Dehkordi, Eyal Herzog, Jeanine Albu

PATIENT AND FAMILY INFORMATION FOR: DIABETES MELLITUS IN THE CARDIAC CARE UNIT

55 Lipid Management in the Cardiac Care Unit

Barak Zafrir

PATIENT AND FAMILY INFORMATION FOR: LIPID MANAGEMENT IN THE CARDIAC CARE UNIT

56 Smoking Cessation in the Cardiac Patient

Mary O’Sullivan, Diandra Fortune

PATIENT AND FAMILY INFORMATION FOR: SMOKING CESSATION FOR THE CARDIAC PATIENT

Index

Acute Coronary Syndrome

The practice of medicine is changing at unprecedented speed Today’sreasonable assumption is outlined by tomorrow’s evidence We face a deluge ofdata as we confront the onslaught of acute coronary syndrome (ACS) ACSsubsumes a spectrum of clinical entities, ranging from unstable angina (UA) toST-elevation myocardial infarction (STEMI) The management of ACS isdeservedly scrutinized because it accounts for about 2 million hospitalizationsand a remarkable 30% of all deaths in the United States each year Clinicalguidelines on the management of ACS, which are based on clinical trials, havebeen updated and published.1–3

In this chapter, we describe a novel pathway for the management of ACS inour health care system.4, 5

The pathway has been designated with the acronym PAIN (Priority risk, Advanced risk, Intermediate risk, and Negative/Low risk), which reflects the

patient’s most immediate risk stratification upon admission (Figure 1.1) This

risk stratification reflects the patient’s 30-day risks for death and myocardialinfarction (MI) following the initial ACS event

FIGURE 1.1 The PAIN pathway for the management of acute coronary syndrome ACE, angiotensin

converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; BNP, brain natriuretic peptide; CABG, coronary artery bypass surgery; CHF, congestive heart failure; CCU, coronary care unit; CPK, creatine phosphokinase; CPK-MB, CPK-muscle and brain; ECG, electrocardiogram; INR, international normalized ratio; LBBB, left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; PT, prothrombin time; PTT, partial thromboplastin time.

The pathway is color coded with the “PAIN” acronym (P—red, A—yellow, I

—yellow, N—green), which guides patient management according to thepatient’s risk stratification These colors—similar to the traffic light code—havebeen chosen as an easy reference for the provider about the sequential risk level

of patients with ACS.6

In comparison with the North American and European guidelines for ACS,1–3

elevation)-ACS; A (advanced) and I (intermediate) are equivalent to non–STE-ACS; and N (negative) means that there is no evidence of ACS

is seen in Figure 1.3 All patients should have an electrocardiogram (ECG)

performed within 10 minutes as well as a detailed history and physicalexamination

FIGURE 1.2 Chest pain and chest pain equivalent symptoms.

FIGURE 1.3 Initial assessment of patients with chest pain ACS, acute coronary syndrome; CBC, complete

blood count; CPK, creatine phosphokinase; CPK-MB, CPK-muscle and brain; BNP, brain natriuretic peptide; ECG, electrocardiogram; INR, international normalized ratio; PT, prothrombin time; PTT, partial thromboplastin time.

Non-ACS chest pain should be excluded urgently These conditions includeaortic dissection, pericarditis and pericardial effusion, pulmonary emboli, aorticstenosis, and hypertrophic cardiomyopathy If any of these emergency conditions

is suspected, we recommend immediately obtaining an echocardiogram or acomputed tomography (CT) scan and treating accordingly

Our recommended initial laboratory tests include complete blood count, basicmetabolic panel, cardiac markers (to include creatine phosphokinase [CPK],CPK-muscle and brain [CPK-MB], and troponin), brain natriuretic peptide(BNP), prothrombin time, partial thromboplastin time, international normalized

INITIAL MANAGEMENT OF PRIORITY PATIENTS

Priority patients are those with symptoms of chest pain or chest pain equivalentlasting longer than 30 minutes with one of the following ECG criteria for acuteMI:

1 Group (1): New ST-elevation at the J point in at least two contiguous leads:

≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3and/or ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads

2 Group (2): New left bundle branch block (LBBB) or

3 Group (3): Acute posterior wall MI (ST-segment depression in leads V1–V3)

The initial treatment of these patients includes obtaining an intravenous line;providing oxygen; treating patients with oral aspirin (chewable 325 mg stat) and

a loading dose of one of the following agents: ticagrelor (180 mg), clopidogrel(600 mg), or prasugrel (60 mg); and giving high-dose statin (atorvastatin 80 mgpo) We also recommend considering a bolus of IV heparin (1 mg/kg to amaximum dose of 4000 units) and nitroglycerin if it will not delay the transfer of

the patient to the Cardiac Catheterization Laboratory (Figure 1.4).

LBBB, left bundle branch block; MI, myocardial infarction.

The key question for further management of these patients is the duration ofthe patients’ symptoms For patients whose symptoms exceed 12 hours, presence

of persistent or residual chest pain determines the next strategy If there is noevidence of continued symptoms, these patients will generally be treated asthough they had been risk stratified with the advanced risk group

For patients whose symptoms are less than 12 hours or with ongoing chestpain, the decision for further management is based on the availability of on-siteangioplasty (percutaneous coronary intervention [PCI]) capability or the ability

to transfer the patient to a PCI-capable hospital for immediate PCI within 120minutes, and the clinical condition of the patient Patients presenting to a PCI-capable hospital or patients presenting to a non–PCI-capable hospital but whocan be transferred to a PCI-capable hospital with an expected “first door toballoon” time of less than 120 minutes should be transferred immediately to the

for this group of patients (Figure 1.5) Furthermore, patients with cardiogenic

shock should be transferred immediately to the cardiac catheterization laboratoryeven if they present to a non–PCI-capable hospital and anticipated time totransfer is more than 120 minutes

FIGURE 1.5 Advanced management of priority myocardial infarction patients MI, myocardial infarction;

PCI, percutaneous coronary intervention.

In our health care system, a single call made by the emergency departmentphysician to the page operator activates the MI team, which includes thefollowing healthcare providers:

1 The interventional cardiologist on call (who is considered the team leader

2 The director of the Coronary Care Unit (CCU)

Patients with priority MI should be admitted to the CCU (Figure 1.6) All

patients should have an echocardiogram to evaluate left ventricle systolic anddiastolic function and to exclude valvular abnormality and pericardialinvolvement We recommend a CCU stay of 24 to 48 hours to excludearrhythmia or mechanical complications For patients with no evidence ofmechanical complications or significant arrhythmia, secondary prevention drugsshould be started, including aspirin, one of the additional antiplatelet drugs(ticagrelor, clopidogrel, or prasugrel) a high-dose statin, a beta-blocker, and anangiotensin converting enzyme (ACE) inhibitor, or an angiotensin receptorblocker (ARB) Aldosterone blocking agents should be considered for patientswith diabetes or LV ejection fraction less than 40%

FIGURE 1.6 Coronary care unit management and secondary prevention for patients with priority

myocardial infarction ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker; CCU, coronary care unit.

Most patients can be discharged within 48 hours with recommendation forlifestyle modification, including exercise, weight and diet control, smokingcessation, and cardiac rehabilitation Secondary prevention drugs should becontinued on discharge

MANAGEMENT OF ADVANCED RISK ACUTE CORONARY SYNDROME

Typical anginal symptoms are required to be present in patients who will beenrolled into the advanced or intermediate risk groups

We recommend that patients be admitted to the CCU and be treated withaspirin; ticagrelor or clopidogrel; anticoagulation, including either intravenousheparin or low molecular weight heparin; a beta-blocker; and a statin; considerglycoprotein IIb–IIIa inhibitor or nitroglycerin if there are no contraindications

(Figure 1.8).