![]() Today, however, it has been more persistent and severe than usual. She has never been evaluated by a doctor for it, as it typically resolves within 10 to 15 minutes with rest and relaxation techniques. ![]() She has had several episodes of similar pain in the past, typically associated with emotional distress or exertion. It started 3 hours prior to presentation during an argument with her husband, and she describes it as “squeezing,” localized to her left chest, with radiation to the neck and jaw. You wonder if you should activate the cath lab, or if a bedside echo might help.Īn 82-year-old woman presents to the ED with chest pain. His ECG shows 4-mm anterior ST-segment depressions. Chest x-ray confirms your clinical suspicion of pulmonary edema. He has bibasilar crackles and visibly increased work of breathing. His heart rate is 110 bpm and blood pressure is 90/40 mm Hg. He has a history of hypertension, diabetes, and coronary artery disease, with baseline stable angina. He also notes dyspnea and lightheadedness. However, the pain didn’t resolve with rest and has been worsening since onset, and is currently 9/10 in severity. Initially, it felt similar to his usual episodes of angina, with left-sided pressure radiating to his left arm. Your intern asks if she can go home since her troponin is low and she looks well.Ī 69-year-old man presents to the ED with chest pain that began an hour prior to presentation, while he was walking home from the store. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL). In the ED, her vital signs are within normal limits and her exam is unremarkable. Her only past medical history is hypertension. The pain is located in the center of her chest, and she describes it as a “pressure” sensation. Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest. Opening CasesĪ 76-year-old woman presents to the ED with chest pain. Issues surrounding special patient populations are addressed, and new diagnostic and therapeutic modalities are discussed. In this review, current national management guidelines for NSTEMI are summarized as they pertain to the ED, and the evidence base supporting them is considered. Non–ST-segment elevation myocardial infarction (NSTEMI) is twice as common as ST-segment elevation myocardial infarction (STEMI), and lack of clarity surrounding the best management of this condition can contribute to adverse outcomes. A quarter of these patients will be diagnosed with acute coronary syndromes, but among those, nearly half will have nondiagnostic electrocardiograms. Anterior STEMI on ElectrocardiogramĬhest pain is the second most common complaint in emergency departments, with 6.4 million visits annually in the United States. HEART Score for Suspected Acute Coronary Syndromesįigure 1. Clinical Features of Type 1 and Type 2 Myocardial Infarction ![]() American Heart Association/ American College of Cardiology Classes of Recommendation and Levels of Evidence
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