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.
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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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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
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the August 2022 issue of Emergency Medicine Practice: Managing Acute Cardiac Valvular Emergencies in the Emergency Department
Adam Sigal, MD; Stephanie Costa, MD
Abbas Husain, MD; Evan Leibner, MD
August 1, 2022
September 1, 2025
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Date of Original Release: August 1, 2022. Date of most recent review: July 10, 2022. Termination date: August 1, 2025.
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