Cardiovascular
What you must know
Cardiovascular items cluster into four buckets: ischemia, pump failure, rhythm, and vascular catastrophe. For ischemia, the diagnosis rests on symptoms plus ECG plus troponin; ST elevation in two contiguous leads defines STEMI and drives immediate reperfusion. NSTEMI is managed with aspirin, a P2Y12 inhibitor, anticoagulation, and risk-stratified catheterization. For heart failure, separate HFrEF (EF 40% or less) from HFpEF (EF 50% or more with diastolic dysfunction). HFrEF has four mortality-reducing pillars: renin-angiotensin blockade (ACEi/ARB/ARNI), an evidence-based beta-blocker (carvedilol, metoprolol succinate, bisoprolol), a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Loop diuretics relieve congestion but do not prolong life.
Rhythm: rate versus rhythm control in atrial fibrillation; anticoagulation is driven by CHA2DS2-VASc (score 2 or more in men, 3 or more in women), never by aspirin alone when anticoagulation is indicated. Vascular: aortic dissection is a think-it-or-miss-it diagnosis - abrupt tearing chest or back pain with a pulse deficit or widened mediastinum; control heart rate and blood pressure with a beta-blocker before adding a vasodilator.
Traps
- Expecting classic crushing chest pain; women, older adults, and patients with diabetes often present with dyspnea, nausea, or syncope.
- Giving a non-dihydropyridine calcium channel blocker or a beta-blocker to a patient with decompensated heart failure or high-grade AV block.
- Chasing an ACE inhibitor cough with an antihistamine instead of switching drug class; angioedema mandates immediate discontinuation.
- Treating pericarditis with an NSAID and omitting colchicine, which reduces recurrence.
Rule of thumb
New S3, elevated JVP, and pulmonary edema with EF under 40%: give a loop diuretic for congestion and start or titrate the four pillars as the patient becomes euvolemic.