Simplified Cardiology Cases Management Handbook

Initial Assessment and Risk Stratification

Every cardiology patient requires immediate hemodynamic assessment and risk classification to guide management intensity and urgency. 1

Clinical Criteria for High-Risk Presentation

Cardiogenic shock indicators: SBP <90 mm Hg for 30 minutes, lactate >2 mmol/L, or need for vasopressors/inotropes to maintain blood pressure 1
Hemodynamic instability: Cardiac index <1.8 L/min/m² without support, cardiac power output <0.6W, or pulmonary artery pulsatility index <1.0 1
Acute coronary syndrome signs: New ST-segment changes ≥0.05 mV, elevated troponin >2x upper limit normal, or ongoing chest pain with ischemic ECG changes 1

Immediate Triage Decisions

Direct to cardiac catheterization lab: Patients with ST-elevation MI, cardiogenic shock with cardiac power output <0.6W, or refractory ischemia despite medical therapy 1
Admit to cardiac intensive care unit: Any patient meeting cardiogenic shock criteria, hemodynamic instability, or high-risk features requiring invasive monitoring 1
Standard telemetry admission: Stable angina, controlled heart failure, or low-risk acute coronary syndrome without high-risk features 1

Acute Coronary Syndrome Management

Patients with suspected ACS require immediate ECG within 10 minutes, dual antiplatelet therapy, and risk-based invasive strategy selection. 1, 2

Immediate Interventions (First 24 Hours)

Antiplatelet therapy: Aspirin 162-325 mg loading dose plus clopidogrel 300-600 mg loading dose (avoid in planned urgent CABG within 5 days) 1, 3
Anticoagulation: Unfractionated heparin or low-molecular-weight heparin initiated immediately 1
Anti-ischemic therapy: Sublingual nitroglycerin 0.4 mg every 5 minutes x3 for ongoing chest pain, then IV nitroglycerin if pain persists (avoid if SBP <90 mm Hg or RV infarction) 1
Beta-blockers: Oral metoprolol or carvedilol within 24 hours UNLESS signs of heart failure, low-output state, or cardiogenic shock risk factors present 1

Invasive Strategy Timing

Emergent (<2 hours): STEMI with symptom onset <12 hours, cardiogenic shock, or electrical/hemodynamic instability 1, 2
Urgent (2-24 hours): NSTEMI with refractory ischemia, hemodynamic instability, or high-risk features (elevated troponin, dynamic ST changes, GRACE score >140) 1
Early invasive (24-72 hours): NSTEMI with intermediate risk features, diabetes, renal insufficiency, or reduced ejection fraction <40% 1

Post-PCI Management

Continue dual antiplatelet therapy: Aspirin 81 mg daily indefinitely plus clopidogrel 75 mg daily for minimum 12 months 3
Statin therapy: High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) initiated before discharge 1
ACE inhibitor/ARB: Start within 24 hours if LVEF ≤40%, heart failure signs, anterior MI, or diabetes (hold if SBP <100 mm Hg) 1
Cardiac rehabilitation referral: Mandatory Class I recommendation for all post-PCI patients to improve outcomes and reduce mortality 4

Cardiogenic Shock Protocol

Cardiogenic shock requires immediate invasive hemodynamic monitoring with pulmonary artery catheter to phenotype shock and guide mechanical circulatory support decisions. 1

Hemodynamic Phenotyping

LV-dominant shock: Cardiac power output <0.6W, pulmonary artery pulsatility index >1.0, right atrial pressure <15 mm Hg, PCWP >15 mm Hg 1
RV-dominant shock: Cardiac power output <0.6W, pulmonary artery pulsatility index <1.0, right atrial pressure >15 mm Hg, PCWP <15 mm Hg 1
Biventricular shock: Cardiac power output <0.6W, pulmonary artery pulsatility index >1.0, right atrial pressure >15 mm Hg, PCWP >15 mm Hg 1

Pharmacologic Management by Phenotype

LV-dominant with high afterload: Nitroprusside, milrinone, or dobutamine to reduce afterload and improve cardiac output 1
RV-dominant shock: Inhaled pulmonary vasodilators (nitric oxide or epoprostenol), minimize positive pressure ventilation, correct acidosis and hypoxemia 1
Refractory shock: Consider mechanical circulatory support if cardiac power output remains <0.6W despite optimal medical therapy 1

Mechanical Circulatory Support Indications

Percutaneous ventricular assist device: LV-dominant shock with cardiac index <2.2 L/min/m², lactate elevation, contraindications to other MCS 1
Venoarterial ECMO: Biventricular failure, RV-dominant shock with severe pulmonary hypertension, or risk of pulmonary hemorrhage with forced perfusion 1
Absolute contraindications: Anoxic brain injury, irreversible end-organ failure, prohibitive vascular access, or DNR status 1

Target Outcomes for MCS

30-day mortality: <1% 1
Complete heart block requiring pacemaker: <5-10% depending on device 1
Symptomatic improvement: >90% achieving ≥1 NYHA class improvement 1

Heart Failure Management

Heart failure patients require guideline-directed medical therapy optimization before discharge and enrollment in multidisciplinary disease management programs. 1, 5

Guideline-Directed Medical Therapy (HFrEF)

Quadruple therapy foundation: ACE inhibitor/ARB/ARNI + beta-blocker + mineralocorticoid receptor antagonist + SGLT2 inhibitor initiated before hospital discharge 5
Beta-blocker selection: Carvedilol, metoprolol succinate, or bisoprolol titrated to target doses (avoid in decompensated state) 1
Diuretic management: Loop diuretics for volume overload, titrate to euvolemia, monitor electrolytes and renal function 1

Multidisciplinary Care Team Structure

Core team members: Cardiologist, heart failure nurse, pharmacist, dietician, social worker, and palliative care specialist 1
Nurse-led case management: Medication reconciliation, symptom monitoring, weight tracking, and patient education on daily basis 1, 6
Pharmacist role: Medication optimization, drug interaction monitoring, and adherence counseling 1

Monitoring and Follow-Up

Post-discharge contact: Telephone follow-up within 3 days, clinic visit within 7-14 days 1
Self-monitoring education: Daily weights (report gain >2-3 lbs in 24 hours or >5 lbs in week), symptom diary, blood pressure tracking 1
Readmission prevention: Case management reduces cardiovascular events by 5 per 1000 individuals per year (NNT=200 to prevent 1 event annually) 6

Hypertrophic Cardiomyopathy

HCM patients require comprehensive 3-generation family history, genetic counseling, and referral to specialized HCM centers for invasive septal reduction therapy decisions. 1

Initial Diagnostic Evaluation

Physical examination maneuvers: Valsalva, squat-to-stand, passive leg raising to assess dynamic LVOT obstruction 1
Comprehensive family history: Document 3 generations for HCM diagnosis, unexplained sudden death, or cardiac events in relatives 1
Baseline testing: ECG, transthoracic echocardiography with provocation maneuvers, and cardiac MRI for tissue characterization 1

Septal Reduction Therapy Criteria

Indications: LVOT gradient ≥50 mm Hg at rest or with provocation, NYHA class III-IV symptoms despite maximal medical therapy 1
Center requirements: Procedures performed only at comprehensive or primary HCM centers meeting outcome benchmarks 1
Target outcomes: 30-day mortality <1%, symptomatic improvement >90%, residual LVOT gradient <50 mm Hg in >90% 1

Referral Indications to HCM Center

Complex management decisions: Genetic counseling, primary prevention ICD decision-making, sports participation counseling 1
Advanced procedures: Septal reduction therapy, catheter ablation for ventricular tachycardia, heart transplant evaluation 1
Shared decision-making: Full disclosure of risks/benefits for all treatment options including both surgical myectomy and alcohol septal ablation 1

Chronic Coronary Disease

Patients with stable coronary disease require comprehensive risk factor modification, optimal medical therapy, and functional testing to guide revascularization decisions. 1, 7

Medical Therapy Optimization

Antiplatelet therapy: Aspirin 81 mg daily (clopidogrel 75 mg if aspirin intolerant) 7
Statin therapy: High-intensity statin targeting LDL <70 mg/dL (consider <55 mg/dL in very high-risk patients) 1
Blood pressure control: Target <130/80 mm Hg using ACE inhibitor or ARB as first-line agent 1
Diabetes management: Metformin first-line, add SGLT2 inhibitor or GLP-1 receptor agonist if additional ASCVD risk factors present 1

Functional Testing Strategy

Exercise stress testing: First-line for patients with normal baseline ECG, not on digoxin, able to exercise 8
Stress imaging: Myocardial perfusion imaging or stress echocardiography if baseline ECG abnormalities, unable to exercise, or need to localize ischemia 8
Coronary CT angiography: Viable noninvasive option for initial evaluation of stable symptomatic coronary disease 5

Revascularization Decision-Making

Invasive strategy: Refractory angina despite optimal medical therapy, high-risk stress test features, or LVEF <40% with viable myocardium 7
Conservative strategy: Stable symptoms controlled on medical therapy, low-risk stress test, or patient preference after shared decision-making 7

Cardiac Amyloidosis

Cardiac amyloidosis requires multidisciplinary team approach with early diagnosis, accurate phenotyping (AL vs ATTR), and disease-specific therapy to improve survival and quality of life. 1

Diagnostic Algorithm

Clinical suspicion triggers: Heart failure with preserved ejection fraction, increased wall thickness on echo, low-voltage ECG despite thick walls, neuropathy 1
Serum free light chain testing: Essential first step to exclude AL amyloidosis before proceeding with nuclear imaging 1
Pyrophosphate (PYP) scan: Grade 2-3 cardiac uptake confirms ATTR-CM if serum free light chains negative 1
Endomyocardial biopsy: Reserved for equivocal cases or when AL amyloidosis suspected despite negative screening 1

Multidisciplinary Team Composition

Core specialists: Cardiology, hematology, neurology, nephrology, gastroenterology, genetics, palliative care 1
Support staff: Heart failure nurses, pharmacists, dieticians for comprehensive symptom management 1

Treatment Goals

Primary objectives: Improved survival and maximized quality of life through individualized disease journey 1
Disease-specific therapy: AL amyloidosis requires hematology-directed chemotherapy; ATTR-CM requires TTR stabilizers or silencers 1

Systems of Care and Quality Metrics

Regionalized cardiac care networks with dedicated shock teams and standardized protocols improve outcomes through early diagnosis, multidisciplinary care, and selective mechanical support use. 1

Shock Team Structure

Activation criteria: Any patient meeting cardiogenic shock hemodynamic criteria or high-risk ACS features 1
Team composition: Interventional cardiologist, cardiac intensivist, cardiac surgeon, perfusionist, heart failure specialist 1
Response time: Team mobilization within 30 minutes of activation for optimal outcomes 1

STEMI Systems of Care

Prehospital 12-lead ECG: Transmission to receiving facility reduces door-to-balloon time and improves outcomes 1
Direct transfer protocols: Bypass non-PCI capable facilities for STEMI patients when transfer time <120 minutes 1
Post-cardiac arrest care: Comprehensive structured approach including targeted temperature management, coronary angiography, and multiorgan support 1

Quality Improvement Targets

Door-to-balloon time: <90 minutes for STEMI patients presenting to PCI-capable facility 1
Cardiac rehabilitation enrollment: >70% of eligible post-MI and post-PCI patients referred before discharge 4
Guideline-directed medical therapy: >90% of HFrEF patients discharged on quadruple therapy or documented contraindications 5

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