Managing Acute Cardiac Valvular Emergencies in the Emergency Department

Table of Contents

 

About This Issue

When patients present with complaints suspicious for acute coronary syndromes, tachycardia, heart failure, or COPD, it is important to consider a valvular cause. A thorough history and physical examination and targeted diagnostic studies can help narrow the differential. This issue reviews the evidence on the diagnosis and management of cardiac valve emergencies, including:

The key physical examination findings that differentiate aortic valve disease from mitral valve disease.

Whether the valvular dysfunction is new and acute, old and/or chronic, or comorbid with other cardiac or lung conditions.

Interpreting important auscultation findings of murmur sounds, locations, and timing.

Adding point-of-care bedside echocardiography to the laboratory, ECG, and x-ray findings to reveal clues to the etiology.

Using vasoactive agents appropriately for the particular type of valvular dysfunction.

When surgery, ECMO, LVADs, and intra-aortic balloon pumps are indicated and when they are not.

Appropriate management of patients with prosthetic valves.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Aortic Valve Disease
   2. Mitral Valve Disease
   3. Tricuspid and Pulmonary Valve Disease
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
      1. Aortic Stenosis
      2. Aortic Regurgitation
      3. Mitral Stenosis
      4. Mitral Regurgitation
      5. Tricuspid Disease
   2. Physical Examination
      1. Aortic Stenosis
      2. Aortic Regurgitation
      3. Mitral Stenosis
      4. Mitral Regurgitation
10. Diagnostic Testing
    1. Laboratory Testing
    2. Electrocardiogram
    3. Chest X-Ray
    4. Bedside Ultrasound
    5. Echocardiography
11. Treatment
    1. Aortic Stenosis
    2. Aortic Regurgitation
    3. Mitral Stenosis
    4. Mitral Regurgitation
    5. Cardiogenic Shock
12. Special Populations
    1. Patients With Prosthetic Valves
    2. Pregnant Patients
13. Controversies and Cutting Edge
14. Summary
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls for Cardiac Valve Emergencies
17. Case Conclusions
18. Tables and Figures
19. References

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

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….

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 . . .

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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Risk Management Pitfalls for Cardiac Valve Emergencies

1. “This patient has frequent COPD exacerbations.” Do not fail to include valvular pathology in the differential diagnosis. Patients can have diverse pathology, which can present similarly to their chronic conditions. Therefore, it is important to avoid prematurely anchoring on a diagnosis.

5. “The inpatient service can treat the atrial fibrillation.” It is important to manage the patient’s vital signs and symptoms, especially during an acute event, to optimize cardiac functioning. Nonetheless, in certain valve diseases, abnormal vital signs are a compensatory mechanism and should not be treated. Atrial fibrillation should be treated.

6. “The patient crashed when we intubated him.” Anesthesia can acutely worsen a cardiac event due to the vasodilation that is associated with anesthetics. Any use of anesthetics should be carefully considered for timing and preparedness. Pressors and any adjunctive therapies should be prepared prior to using anesthetics.

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. * Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227. (Clinical guidelines) DOI: 10.1161/CIR.0000000000000932

11. NASEMSO Medical Directors Council. National model EMS clinical guidelines. 2019. Accessed July 15, 2021. (Guidelines)

23. * Maheshwari V, Barr B, Srivastava M. Acute valvular heart disease. Cardiol Clin. 2018;36:115-127. (Review) DOI: 10.1016/j.ccl.2017.08.006

27. * Akodad M, Schurtz G, Adda J, et al. Management of valvulopathies with acute severe heart failure and cardiogenic shock. Arch Cardiovasc Dis. 2019;112:773-780. (Review) DOI: 10.1016/j.acvd.2019.06.009

31. * van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136(16):e232-e268. (AHA Scientific Statement) DOI: 10.1016/j.ccc.2014.03.001

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Keywords: aortic, mitral, stenosis, regurgitation, valvular, rheumatic, prolapse, endocarditis, shock, transthoracic, echocardiography, transesophageal, edema, vasoactive, prosthetic