What is the initial management approach for a patient presenting with a heart condition?

Initial Management of Heart Conditions

Begin with a thorough history focusing on cardiac and non-cardiac disorders that might cause or accelerate heart disease, followed immediately by a 12-lead ECG, basic laboratory tests, and echocardiography to determine the specific cardiac pathology and guide treatment. 1, 2

Step 1: Immediate Clinical Assessment

History Taking

• Document chest pain characteristics: location, quality (pressure, squeezing, heaviness), duration, radiation to left arm/jaw/neck, and precipitating/relieving factors 1, 2
• Assess dyspnea patterns: at rest, with exertion, orthopnea, paroxysmal nocturnal dyspnea 2
• Obtain complete medication history: current/past use of alcohol, illicit drugs, chemotherapy agents, and alternative therapies 1
• Review cardiovascular risk factors: hypertension, diabetes, hyperlipidemia, smoking history, family history of premature coronary disease 2
• Evaluate functional capacity: ability to perform routine and desired activities of daily living 1

Physical Examination

• Measure vital signs: blood pressure (including orthostatic changes), heart rate, respiratory rate, oxygen saturation 1
• Assess volume status: jugular venous pressure, peripheral edema, pulmonary rales 1
• Calculate body mass index: measure weight and height 1
• Evaluate for signs of hypoperfusion: cool extremities, narrow pulse pressure, altered mental status 1

Step 2: Mandatory Initial Testing

Electrocardiogram

• Obtain 12-lead ECG immediately in all patients—this is non-negotiable 1, 3, 2
• A completely normal ECG has >90% negative predictive value for excluding left ventricular systolic dysfunction 3
• Look specifically for: ST-segment elevation (indicating acute MI requiring immediate reperfusion), new left bundle branch block, arrhythmias, Q waves, and ischemic changes 1

Laboratory Tests

Order the following panel immediately: 1, 2

• Complete blood count
• Serum electrolytes (including calcium and magnesium)
• Blood urea nitrogen and serum creatinine
• Fasting blood glucose (or glycohemoglobin)
• Lipid profile
• Liver function tests
• Thyroid-stimulating hormone

Chest Radiograph

• Obtain PA and lateral chest X-ray to assess for cardiomegaly, pulmonary congestion, and pleural effusions 1, 3
• Important caveat: Cardiomegaly can be absent on chest X-ray even in chronic heart failure, so do not rely on this alone 3

Step 3: Echocardiographic Assessment

• Perform two-dimensional echocardiography with Doppler during initial evaluation to assess: 1, 3

  • Left ventricular ejection fraction
  • Left ventricular size and wall thickness
  • Valve function
  • Diastolic filling patterns
  • Presence of left ventricular thrombus

• Timing: This should be done within 48 hours of presentation for most patients, or immediately if diagnosis is uncertain or hemodynamic instability exists 1

Step 4: Risk Stratification and Additional Testing

For Suspected Coronary Disease

• Coronary arteriography is indicated for patients with angina or significant ischemia unless contraindications to revascularization exist 1
• Consider stress testing (exercise ECG, stress echocardiography, or nuclear perfusion imaging) for patients with known or suspected coronary disease without angina 1, 2
• Coronary CT angiography is reasonable for low-to-moderate risk patients to evaluate for obstructive coronary disease 1, 2

For Suspected Heart Failure

• Measure BNP or NT-proBNP when diagnosis is uncertain: BNP <35 pg/mL or NT-proBNP <125 pg/mL makes chronic heart failure unlikely 3
• Maximal exercise testing with respiratory gas exchange is reasonable to determine if heart failure is the cause of exercise limitation or to identify high-risk patients for advanced therapies 1

For Suspected Acute Myocardial Infarction

• If ST-segment elevation or new left bundle branch block is present, initiate reperfusion therapy immediately—do not wait for cardiac biomarkers 1
• Initiate continuous ECG monitoring immediately to detect life-threatening arrhythmias 1

Step 5: Screening for Specific Etiologies

Consider targeted screening based on clinical suspicion: 1

• Hemochromatosis
• Sleep-disordered breathing
• HIV infection
• Rheumatologic diseases
• Amyloidosis
• Pheochromocytoma
• Thyroid disease

Common Pitfalls to Avoid

• Do not assume chest pain is always cardiac: Many patients with coronary disease present with atypical symptoms, and many with chest pain have non-cardiac causes 1, 2
• Do not rely solely on chest X-ray: Cardiomegaly may be absent despite significant cardiac dysfunction 3
• Do not dismiss the diagnosis with a normal echocardiogram alone: Consider diastolic dysfunction, which requires specific Doppler assessment 3
• Do not delay treatment waiting for biomarkers: In acute presentations with ECG changes, treatment should begin immediately 1
• Recognize sex differences: Women may present with different symptom patterns than men and often have more frequent angina despite less extensive coronary disease 1, 2

Immediate Treatment Considerations

For Acute Heart Failure

• Initiate oxygen therapy if oxygen saturation <90% 1
• Consider non-invasive ventilation for patients with respiratory distress 1
• Start vasodilators and/or diuretics based on blood pressure and degree of congestion 1

For Acute Myocardial Infarction

• Hemodynamically stable patients: Give 5 mg lisinopril orally within 24 hours, followed by 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg daily for at least 6 weeks 4
• Patients with low systolic blood pressure (≤120 mmHg): Initiate with 2.5 mg 4