Cardiovascular Disease
Acute coronary syndromes
Obtain a 12-lead ECG within 10 minutes. STEMI mandates immediate reperfusion (PCI preferred); NSTEMI and unstable angina are managed with risk stratification using troponin trend, ECG changes, and a validated score. High-sensitivity troponin must rise or fall - a single elevated value in a patient with CKD or sepsis is not automatically MI. Watch for mechanical complications after inferior MI (papillary muscle rupture, VSD) and for right ventricular infarction, where nitrates cause hypotension.
Heart failure
For HFrEF, four drug classes improve mortality: renin-angiotensin system inhibition (ARNI preferred), evidence-based beta blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor. Do not start beta blockers during acute decompensation. HFpEF is treated with SGLT2 inhibitors, diuretics for congestion, and aggressive comorbidity control. Diurese with loop diuretics; monitor potassium and renal function.
Arrhythmia and valves
Anticoagulate atrial fibrillation by CHA2DS2-VASc (strongly at ≥2 in men, ≥3 in women). DOACs are preferred except with mechanical valves or moderate-severe mitral stenosis, where warfarin is required. Severe aortic stenosis presents with angina, syncope, or dyspnea. Hypertrophic cardiomyopathy murmurs increase with Valsalva and standing. Pericarditis gives positional pain, diffuse ST elevation with PR depression; treat with NSAIDs plus colchicine.
Worked example
A 70-year-old with hypertension, diabetes, prior TIA, and new atrial fibrillation has a CHA2DS2-VASc of 6 - anticoagulation is indicated, and a DOAC is appropriate in the absence of a mechanical valve.