Atrial Fibrillation: Diagnosis and Management

Acute Coronary Syndrome (ACS): Diagnosis and Emergency Management

Suspect ACS in any patient with prolonged ischemic chest pain, and obtain a 12-lead ECG within 10 minutes of arrival. Give chewable aspirin 162-325 mg and draw high-sensitivity troponin. ST-segment elevation (STEMI) requires immediate reperfusion: primary PCI within 90 minutes of first medical contact, or fibrinolysis within 30 minutes if timely PCI is unavailable. NSTEMI and unstable angina are managed with dual antiplatelet therapy, anticoagulation, high-intensity statin, and risk-stratified invasive evaluation. Treat pain with nitrates if no contraindication, control blood pressure and heart rate with a beta blocker once stable, and screen for complications such as arrhythmia and acute heart failure.

Stable Angina Pectoris: Clinical Evaluation

Stable angina is characterized by episodic chest discomfort that is predictably provoked by exertion or emotional stress and relieved by rest or nitroglycerin. The initial evaluation involves a thorough history and physical examination, followed by a resting ECG. If the patient can exercise and has a normal resting ECG, an exercise stress test (treadmill ECG) is the preferred initial non-invasive functional test for diagnosing ischemic heart disease. Patients with abnormal resting ECGs or inability to exercise require imaging-based stress testing (e.g., stress echocardiography or nuclear perfusion imaging).

Heart Failure with Reduced Ejection Fraction: Diagnosis and Management

Heart Failure with Reduced Ejection Fraction (HFrEF) is a clinical syndrome characterized by the heart's inability to pump sufficient blood to meet the body's metabolic demands due to impaired systolic function of the left ventricle, typically defined by a left ventricular ejection fraction (LVEF) of 40% or less. Treatment for HFrEF focuses on guideline-directed medical therapy (GDMT) including angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 (SGLT2) inhibitors to reduce mortality and morbidity. Diuretics are used for symptom relief from congestion, and device therapies like implantable cardioverter-defibrillators (ICD) or cardiac resynchronization therapy (CRT) may be indicated for selected patients. Lifestyle modifications, such as dietary sodium restriction and fluid management, are also crucial. Patients commonly present with progressive exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and fatigue due to reduced forward flow. Physical signs may include peripheral edema, jugular venous distension, pulmonary rales (crackles), an S3 gallop, and hepatomegaly, indicating fluid congestion.