![]() 10 The physical examination can be completely normal in ACS and is more helpful in ruling in or out diagnoses such as CHF, aortic dissection, and pneumothorax. The Multicenter Chest Pain Study, found ACS in 22% of patients who had stabbing chest pain, 13% with pleuritic chest pain and in 7% of patients with reproducible chest pain. Pleuritic chest pain and reproducible chest pain are uncharacteristic in the presentation of ACS, 9 but, unfortunately, not entirely sensitive for excluding ACS. Symptoms associated with higher risk of MI include radiation of pain to the upper extremities (particularly radiation to both arms) and pain associated with diaphoresis or nausea and vomiting. Peripheral arterial disease, diabetes, renal insufficiency.Historical factors that increase the likelihood of ACS: 6,7 Atypical features, such as dyspnea, weakness, vomiting, epigastric discomfort, shoulder, neck, or jaw pain, should NOT exclude ACS from your differential. It is important to note, however, that not all patients with NSTE-ACS will have chest pain as their chief complaint, especially the elderly, diabetics and women. The classic teaching is that the patient with unstable angina presents with chest pain/pressure that lasts > 10 minutes, is more severe than prior pain episodes, may occur at rest or is now occurring with much less exertion. 5įigure 2: Pathophysiology of ACS 5 INITIAL EVALUATION On the other hand, subtotal occlusion or transient blood flow disruption that spares the myocardium from necrosis, (no troponin leakage), defines unstable angina. If this occurs but the patients ECG does not develop ST-segment elevation, the patient is diagnosed with NSTEMI. 3,4 This leads to edema and necrosis of myocardium and subsequent troponin leakage. 3 The thin fibrous cap of this plaque is prone to rupture, leading to thrombus formation that can occlude the vessel or send off emboli to occlude a microvessel. The varying degrees of coronary obstruction and the overall risk profile of the patient complicates the final disposition in the emergency department, making management of NSTE-ACS patients both frustrating and exciting.įigure 1: Classification of ACS PATHOPHYSIOLOGYĪ vulnerable atherosclerotic plaque is present in the coronary vessels long before the patient presents to the emergency department with physical complaints. NSTE-ACS management is not as straightforward. These patients should be rushed to the catheterization lab or given thrombolytic therapies (in hospitals not equipped with a cath lab) to restore flow to the occluded coronary artery. The treatment of the patient with STEMI is straightforward. Approximately 780,000 people in the United States will experience Acute Coronary Syndrome (ACS) and 70% of these people will have NSTE-ACS. 1,2 ST-depression, transient ST-elevations and T-wave inversions may be present in UA and NSTEMI, but it is the presence of elevated cardiac biomarkers that distinguish NSTEMI from UA. NSTE-ACS is the umbrella term defining the continuum between Unstable Angina (UA) and Non-ST-elevation Myocardial Infarction (NSTEMI). Chest pain from myocardial ischemia can be subdivided into ST-Elevation Myocardial Infarction (STEMI) or Non-ST-Elevation ACS (NSTE-ACS). BACKGROUNDĪCS is an term that defines a spectrum of conditions involving acute myocardial ischemia and/or infarction. In this post, we will explore definitions, risk stratification instruments, and the existing evidence for various treatment options for patients with unstable angina and NSTEMI. You wonder, could it be unstable angina or NSTEMI? What is the best treatment option for these patients? The next steps in the care for this patient are less clear-cut than the patient with STEMI. On his ECG you do notice some subtle ST-segment and T-wave changes. ![]() In fact, more commonly you are greeting the patient with chest pain who looks quite well and is wondering whether or not his pain is just heartburn from last nights lasagna. This patient needs the cath lab, and fast! But unfortunately, emergency medicine is not always so simple. Thankfully, in this situation, you know exactly what to do. You can see tombstone ST-segments from across the room. The patient looks bad, he’s sweaty and pale, and the ECG looks equally bad. You walk into the room of a patient with the chief complaint “chest pain” and catch a glimpse of the ECG as it prints from the machine. Authors: Sushant Kapoor, DO (EM/IM Resident Physician, Christiana Care) and Eli Zeserson, MD (EM Attending Physician, Christiana Care) // Edited by: Jamie Santistevan, MD EM Admin and Quality Fellow / University of Wisconsin), Brit Long, MD SAUSHEC / USAF) and Alex Koyfman, MD EM Attending Physician, UTSW / Parkland Memorial Hospital) INTRODUCTION ![]()
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