Cardiology clinics
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The 12-lead electrocardiogram (ECG) remains the cornerstone of prompt diagnosis of STEMI; Furthermore, the 12-lead ECG provides the primary indication for emergent reperfuison therapy in the STEMI patient. In certain cases, a patient's ECG can resemble STEMI yet manifest ST-segment elevation from a non-coronary-based syndrome; these entities are termed the STEMI mimics and include benign early repolarization, acute pericarditis, and left ventricular aneurysm, to name only a few. In other situations, the patient's ECG makes it difficult or impossible to determine whether STEMI is present, the so-called STEMI confounders and include left bundle branch block pattern, left ventricular hypertrophypattern, and the ventricular paced pattern. The goal with STEMI mimics and confounders is to maximize rapid, accurate diagnosis while avoiding delays in treatment of alternative causes of ST-segment elevation.
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Atrial fibrillation (AF) is the most common tachyarrhythmia encountered in clinical practice. One-third of hospitalizations in the United States are attributed to AF, with increasing rates in the past decade. ⋯ Hallmarks of acute AF management are accurate diagnosis, clinical stabilization, symptom relief through rate or rhythm control, thromboembolic stroke risk modification, and treatment of underlying causes. Meticulous and individualized acute evaluation based on these goals facilitates successful transition to long-term collaborative optimization of outcomes.
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Diagnosis of ST-segment elevation myocardial infarction has long been considered time sensitive. Several other electrocardiogram abnormalities, sometimes referred to as "STEMI-equivalents", should also alert the clinician to conditions similarly requiring aggressive intervention. The de Winter/ST/T complex, ST-segment elevation in lead aVR, Wellens' phenomenon, posterior wall myocardial infarction, and pathologic ST changes in the presence of left bundle branch block and pacemakers are all discussed in this article.
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As the prevalence of systolic heart failure increases, the population of patients in need of advanced therapies becomes larger. As the number of transplants performed each year plateaus, the prevalence of community-dwelling patients with ventricular assist devices (VADs) increases. A broad range of physicians, including emergency physicians, general cardiologists, and generalists, will be exposed to these patients, and must be informed on the disease processes and complications specific to these devices. With an understanding of up-front evaluation and management, these patients may be triaged and stabilized, and will benefit before referral for definitive care by a VAD specialist.
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Hypertensive crises, which include hypertensive emergencies and urgencies, are frequently encountered in the emergency department, and require immediate attention as they can lead to irreversible end-organ damage. Normal blood pressure (BP) regulation is altered during acute rises in BP, leading to end-organ damage. ⋯ Special considerations should be given to hypertensive pregnant patients and patients with postoperative hypertension. Treatment should be individualized to each patient based on the type and extent of end-organ damage, degree of BP elevation, and the specific side effects that each medication could have on a patient's preexisting comorbidities.