Managing Acute Cardiac Valvular Emergencies in the Emergency Department -
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Publication Date: August 2022 (Volume 24, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 08/01/2025.

Authors

Adam Sigal, MD

Associate Program Director, Emergency Medicine Residency; Research Director, Department of Emergency Medicine, Reading Hospital, West Reading, PA

Stephanie Costa, MD

Department of Emergency Medicine, Reading Hospital, West Reading, PA

Peer Reviewers

Abbas Husain, MD

Associate Program Director, Associate Professor of Emergency Medicine, Northwell Health, New Hyde Park, NY

Evan Leibner, MD

Assistant Professor of Emergency Medicine, Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; Attending Physician, Emergency Medicine and Cardiac ICU; Director of Simulation Institute for Critical Care Medicine, The Mount Sinai Hospital; New York, NY

Abstract

Valvular heart disease is becoming more prevalent as the United States’ population ages, with aortic and mitral valves most commonly affected. Complications, including syncope, heart failure, dyspnea, and chest pain, can arise from slow progression of stenosis and regurgitation, though acute regurgitation from an ischemic or traumatic event can be life-threatening. Patients with valvular disease may present with cardiogenic shock, and vasoactive agent treatment will depend on determination of the valvular etiology. This issue reviews aortic and mitral valvular disease as potential causes of a patient’s emergency department presentation, including history, diagnostic testing, and physical examination findings that can help guide treatment.

Case Presentations

CASE 1

A 65-year-old woman with a history of coronary artery disease presents complaining of chest pain and sudden onset of feeling short of breath…

The patient had presented to the ED the week before with chest pain and was discharged after normal serial cardiac troponins and serial ECGs, and an unremarkable chest radiograph. The patient reports that 1 week ago, she ran out of her aspirin and clopidogrel.
As you enter the room, you note the patient has an increased work of breathing. Vital signs are: heart rate, 105 beats/min; blood pressure, 100/75 mm Hg; respiratory rate, 28 breaths/min; temperature, 37.4°C; and oxygen saturation, 89% on room air.
Your exam is concerning for new-onset heart failure with pulmonary congestion and jugular venous distention. When you auscultate a new cardiac murmur, you are concerned about an ischemia-induced valvulopathy. You consider what would be the best way to manage this patient….

CASE 2

An 85-year-old woman is brought in by EMS after a syncopal event...

The patient reports that she was reading a book in her house when she lost consciousness, and her family called for help.
On exam, the woman is resting quietly on the stretcher with no complaints. Her vital signs are: heart rate, 75 beats/min; blood pressure, 155/85 mm Hg; respiratory rate, 18 breaths/min; temperature, 37.4°C; and oxygen saturation, 96% on room air.
Your physical exam is significant for a harsh holosystolic murmur in the second right intercostal space.
You wonder whether aortic valve disease is the cause of her syncope, and what therapeutic interventions are needed at this time . . .

CASE 3

A 22-year-old man complaining of chest pain is brought in by EMS from the scene of a motor vehicle accident…

The patient is speaking, but he is clearly in distress.
He is diaphoretic, and his vital signs are: heart rate, 115 beats/min; blood pressure, 85/50 mm Hg; respiratory rate, 18 breaths/min; temperature, 37°C; and oxygen saturation, 96% on room air.
You move him quickly to the resuscitation room, where a chest x-ray shows a widened mediastinum. You hear a diastolic murmur on cardiac auscultation.
You consider how best to correlate the radiologic and physical exam findings . . .

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