| 🫀 Acute STEMI / Acute Myocardial Infarction |
- Central crushing chest pain, pressure or tightness.
- Radiation to left/right arm, neck, jaw, back or epigastrium.
- Sweating, nausea, vomiting, breathlessness or collapse.
- May be atypical in older adults, women, diabetes and CKD.
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- 12-lead ECG: ST elevation, new posterior MI pattern, or STEMI equivalent.
- Troponin supports diagnosis, but do not delay reperfusion in clear STEMI.
- U&E, FBC, glucose, lipids/HbA1c later.
- Echo if shock, murmur, heart failure or diagnostic uncertainty.
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- Immediate cardiology/cath-lab pathway for primary PCI if eligible.
- Aspirin loading unless contraindicated.
- Second antiplatelet and anticoagulation according to local ACS/PCI protocol.
- GTN for pain if BP allows and no contraindication.
- Morphine/antiemetic if severe pain.
- Oxygen only if hypoxaemic/shocked.
- High-intensity statin and secondary prevention after acute stabilisation.
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| 🩺 NSTEMI / Unstable Angina |
- Chest pain at rest, new-onset severe angina, or crescendo angina.
- May have dyspnoea, diaphoresis, nausea or syncope.
- NSTEMI has troponin rise; unstable angina does not.
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- ECG: ST depression, T-wave inversion or may be normal.
- Serial high-sensitivity troponins and dynamic change.
- Risk stratification using GRACE or local pathway.
- Echo if heart failure, murmur or LV function assessment needed.
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- Aspirin loading unless contraindicated.
- Anticoagulation and second antiplatelet according to cardiology/local pathway.
- GTN for pain if BP allows.
- High-intensity statin.
- Early invasive angiography for high-risk features, recurrent pain, dynamic ECG changes, heart failure or instability.
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| 💧 Cardiac Tamponade |
- Hypotension, raised JVP and muffled heart sounds: Beck’s triad.
- Tachycardia, dyspnoea, pulsus paradoxus.
- May follow malignancy, pericarditis, trauma, cardiac procedure or post-MI rupture.
- Can cause obstructive shock or PEA arrest.
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- Urgent bedside echocardiography: pericardial effusion with chamber collapse.
- ECG: low voltage or electrical alternans may occur.
- CXR may show enlarged globular heart in chronic effusion.
- Do not delay treatment in peri-arrest tamponade.
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- Urgent cardiology/cardiothoracic/ICU involvement.
- IV fluids may temporarily support preload.
- Avoid unnecessary positive-pressure ventilation if possible before drainage, as it may worsen preload.
- Urgent pericardiocentesis or surgical drainage depending on cause and stability.
- Treat underlying cause.
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| 🩸 Aortic Dissection |
- Sudden severe tearing chest, back or interscapular pain.
- Pain may migrate.
- Pulse deficit, BP difference between arms, syncope or neurological deficit.
- Risk factors: hypertension, Marfan/Ehlers-Danlos, bicuspid aortic valve, pregnancy, cocaine, known aneurysm.
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- CT angiography aorta is first-line if stable.
- TEE if unstable or CT unsuitable.
- ECG/troponin may mislead if coronary involvement.
- CXR may show widened mediastinum but can be normal.
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- Immediate senior/cardiothoracic/vascular discussion.
- Analgesia and controlled BP/heart rate reduction.
- IV beta-blocker first-line to reduce shear stress if no contraindication.
- Add vasodilator only after rate control if needed.
- Type A dissection = emergency surgery.
- Complicated Type B may need endovascular/surgical intervention; uncomplicated Type B often medical management.
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| 🫁 Massive / High-Risk Pulmonary Embolism |
- Sudden dyspnoea, pleuritic chest pain, syncope or collapse.
- Hypotension, shock, tachycardia and hypoxia.
- May have signs of DVT.
- Raised JVP/right heart strain in massive PE.
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- CTPA if stable enough.
- Bedside echo may show RV dilatation/strain in unstable patients.
- ECG: sinus tachycardia common; S1Q3T3 is uncommon.
- Troponin/BNP may support risk stratification.
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- ABCDE, oxygen if hypoxaemic, IV access and ICU/cardiology input.
- Anticoagulation if no contraindication.
- Systemic thrombolysis for PE with haemodynamic instability unless contraindicated.
- Consider catheter-directed therapy or surgical embolectomy if thrombolysis contraindicated or unsuccessful.
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| ⚡ Ventricular Tachycardia |
- Palpitations, dizziness, chest pain, syncope or cardiac arrest.
- Broad-complex regular tachycardia, usually >120 bpm.
- Assume broad-complex tachycardia is VT until proven otherwise, especially with structural heart disease.
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- 12-lead ECG if stable.
- Check potassium, magnesium, calcium, troponin and drug causes.
- Echo after stabilisation to assess structural disease.
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- Unstable VT: synchronised DC cardioversion.
- Pulseless VT: defibrillation and ALS cardiac arrest algorithm.
- Stable VT: IV amiodarone according to ALS/local protocol.
- Correct hypokalaemia/hypomagnesaemia and treat ischaemia.
- ICD assessment if recurrent/sustained VT or high-risk structural disease.
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| 🫀 Acute Heart Failure / Pulmonary Oedema |
- Severe breathlessness, orthopnoea and paroxysmal nocturnal dyspnoea.
- Crackles, hypoxia, pink frothy sputum.
- Raised JVP, peripheral oedema or cool peripheries.
- May be triggered by ACS, arrhythmia, hypertension, valve disease or fluid overload.
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- CXR: pulmonary oedema, pleural effusions, cardiomegaly.
- ECG and troponin if ACS suspected.
- BNP/NT-proBNP supports heart failure diagnosis.
- Echo to assess LV function, valves and complications.
- ABG/VBG if severe respiratory distress.
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- Sit upright.
- Oxygen if hypoxaemic.
- CPAP/NIV if severe respiratory distress or persistent hypoxia.
- IV nitrates if hypertensive and BP allows.
- IV diuretics if fluid overloaded.
- Treat trigger: ACS, arrhythmia, hypertensive emergency, valve disease or renal failure.
- Inotropes/vasopressors only with senior/ICU/cardiology input if cardiogenic shock.
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| 📈 Hypertensive Emergency |
- Severe hypertension with acute end-organ damage.
- Symptoms may include chest pain, dyspnoea, headache, confusion, visual symptoms or neurological deficit.
- Complications: ACS, pulmonary oedema, aortic dissection, stroke, encephalopathy, AKI, papilloedema.
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- Confirm BP using correct cuff and repeat measurements.
- ECG, U&E/creatinine, urinalysis, troponin if chest pain.
- CXR if pulmonary oedema.
- CT head if neurological symptoms.
- Fundoscopy if hypertensive encephalopathy suspected.
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- Admit for monitored BP reduction.
- Use IV antihypertensive therapy according to the emergency and local policy.
- Avoid rapid excessive BP reduction except in specific conditions such as aortic dissection.
- Treat the organ injury: ACS, pulmonary oedema, stroke, AKI or dissection.
- Seek specialist input for pregnancy, dissection, stroke, phaeochromocytoma or renal failure.
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| 🐢 Unstable Bradycardia / High-Grade AV Block |
- Bradycardia with hypotension, syncope, shock, heart failure or chest pain.
- May be caused by inferior MI, complete heart block, hyperkalaemia, hypothermia, beta-blockers, calcium-channel blockers or digoxin.
- ECG may show sinus bradycardia, Mobitz II, complete heart block or slow AF.
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- 12-lead ECG.
- U&E including potassium, magnesium and calcium.
- Glucose, troponin if ACS suspected.
- Drug levels if digoxin/toxicity suspected.
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- Follow ALS bradycardia algorithm.
- Atropine if symptomatic bradycardia.
- If ineffective or high-risk features: transcutaneous pacing, isoprenaline/adrenaline infusion or temporary pacing depending on local protocol.
- Treat reversible causes: hyperkalaemia, hypoxia, drug toxicity, MI.
- Permanent pacemaker may be required for persistent high-grade block.
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| 💓 Fast Atrial Fibrillation / SVT with Instability |
- Palpitations, breathlessness, chest pain, dizziness or syncope.
- Unstable signs: shock, syncope, myocardial ischaemia or heart failure.
- AF is irregularly irregular; SVT usually regular narrow-complex tachycardia.
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- 12-lead ECG.
- U&E, Mg, thyroid function later if new AF.
- Troponin if chest pain/ischaemia suspected.
- Echo if structural disease or heart failure.
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- Unstable tachyarrhythmia: synchronised DC cardioversion.
- Stable SVT: vagal manoeuvres then adenosine if appropriate.
- Stable AF: rate control with beta-blocker/diltiazem/digoxin depending on LV function and context.
- Consider anticoagulation according to stroke/bleeding risk and duration/onset.
- Treat triggers: sepsis, PE, thyrotoxicosis, alcohol, electrolyte disturbance.
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| 🧱 Cardiogenic Shock |
- Hypotension with poor tissue perfusion due to cardiac pump failure.
- Cold clammy peripheries, oliguria, confusion, raised lactate.
- May follow large MI, mechanical complication, severe valve disease, myocarditis or arrhythmia.
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- ECG and troponin.
- Bedside echo: LV/RV function, valves, tamponade, VSD, MR.
- ABG/VBG lactate, U&E, LFT, FBC, clotting.
- CXR for pulmonary oedema.
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- Urgent cardiology and ICU involvement.
- Treat cause: PCI for MI, cardioversion for arrhythmia, surgery for mechanical complication.
- Careful fluids only if hypovolaemia/RV infarct suspected.
- Vasopressors/inotropes under ICU/cardiology guidance.
- Consider mechanical circulatory support in selected cases.
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