ACSx presentation and management

A.Abdi,M.D

Initial DiagnosisSymptomsECGCardiac Biomarkers

CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN (ADAPTED FROM ROSEN’S, EMERGENCY MEDICINE)

CHARACTERISTICSUGGESTIVE OF ANGINALESS SUGGESTIVE OF ANGINA

TYPE OF PAINDULL PRESSURE/CRUSHING PAIN

SHARP/STABBING

DURATION2-5 MIN, <20 MINSECONDSTO HOURS/CONTINUOUS

ONSETGRADUALRAPID

LOCATION/CHEST WALL TENDERNESS

SUBSTERNAL, NOT TENDER TO PALP.

LATERAL CHEST WALL/TENDER TO PALP.

REPRODUCIBALITYWITH EXERTION/ACTIVITY

WITH BREATHING/MOVING

AUTONOMIC SYMPTOMSPRESENT USUALLYABSENT

Assessing Likelihood of ACSHigh LikelihoodIntermediate

LikelihoodLow Likelihood

•Chest or left arm discomfort similar to prior angina

•Transient murmur, hypotension, or heart failure

•New ST changes

•Elevated Enzymes

•Chest or left arm as primary symptom

•Age > 70

•Male gender

•Diabetes

•Known Vascular Dz.

•Q-waves on ECG

•No enzyme elevation

•Suggestive symptoms

•Recent cocaine

•Pain reproducible with palpation

•Minimal ECG changes

•Normal ECG

•No enzyme elevation

Cardiac Biomarkers

Risk Stratification

UA or NSTEMI- Evaluate for Invasive vs. conservative treatment

- Directed medical therapy

Based on initialBased on initialEvaluation, ECG, andEvaluation, ECG, and

Cardiac markersCardiac markers

- Assess for - Assess for reperfusionreperfusion

- Select & - Select & implement implement reperfusion reperfusion therapytherapy

- Directed medical - Directed medical therapytherapy

STEMI Patient?

YESYES NONO

51-year-old male with bicuspid aortic valve, aortic insufficiency and hypertension who had an episode of chest pain 2 days prior to this tracing.

The patient is an elderly female with a known history of left bundle branch block who presented to the emergency ward with shortness of breath

A 52-year-old man. What is his chief complaint? What is the rhythm disturbance?

A 43-year-old man diagnosed with lateral subendocardial ischemia based on ST depressions in

aVL. Do you agree?

A 47-yr-old man with double trouble

A 41-yr-old man with chest discomfort. What is the most likely diagnosis?

Subtle syncopation. 54-year-old morbidly obese male with an acute inferior MI. What is the rhythm?

64-year-old male with chest pain.

89-year-old man with a history of severe congestive heart failure. What is the rhythm? What is the possible

significance of rsR' in V6?

What is the ECG diagnosis in this recording with baseline movement?

54-year-old man with rest chest pain

Middle-aged man with chest pain after a motor vehicle accident with blunt trauma to the chest. The ECG is diagnostic of which condition

70 year old woman with ECG showing which of the following major diagnoses?