Acute coronary syndrome resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Patient Presentation

Initial Evaluation and Orders

Important
Follow up with all pending tests and lab results as soon as these become available. For information on evaluating the results go to the apppropriate section on this page.

History and Symptoms

  • History of Present Illness:
    • Chest pain history; ask about onset, duration, nature, intensity, location, progression, radiation (to arm, neck, jaw= acute coronary syndrome, or back=aortic dissection), aggravating (pleurtic and pericarditis chest pain worsens with respiration) and relieving factors (relieved by nitrates), constant or intermittent. Ask about any precipitating factors (trauma, physical strain, emotional distress).
    • Ask if pain is associated with (head to toe). Headache, confusion, fever, photophobia, vision changes, bleeding, nausea, vomiting, apetite, weight loss, shortness of breath, palpitations, cough, sputum, abdominal pain, bowel symptoms, urinary symptoms.
  • Social History: History of smoking, alcohol use, illicit drug use.
  • Family History: Family history of premature coronary artery disease in a first degree male relative <55 years of age, or a first degree female relative <65 years old. Family history of myocardial infarction, hypertension, diabetes, stroke, or hypercoagulable state.
  • Medications: Obtain a list of home medications.
  • Allergies: Obtain a history of allergic reactions.

Physical Examination

  • General
    • Check for alertness, and orientation with time, place, and person
    • Patient leaning forward can point towards pericarditis
  • HEENT:
  • Cardiovascular:
    • Vital signs
      • Pulse Rate (rate, rhythm. volume, quality, symmetry, all 4 limbs. Aortic dissection- Diminution or absence of pulses)
      • Blood pressure (check for symmetry in all the limbs)
    • Inspection: Check for displacement of the apex.
    • Palpation: Confirm the findings of inspection (cardiac apex), musculo-skeletal tenderness, crepitus (esophageal rupture,subcutaneous emphysema), feel for any thrill (possible regurgitation), heave (right ventricular hypertrophy)
    • Auscultation:
  • Respiratory:
    • Inspection: Observe for symmetry of chest movement, evidence of flail chest, tracheal deviation (pneumothorax).
    • Palpation : Check for muscle tenderness, tracheal deviation, and chest wall movement.
    • Percussion: Percuss all lung fields for dullness (effusion), or hyperresonance to percussion on the affected side (pneumothorax).
    • Auscultation: Decreased breath sounds (effusion and tension pneumothorax), crackles (pleural effusion) rales (heart failure).
  • Extremities: Check for pedal edema.

Differential Diagnosis

EKG Findings

Electrocardiogram in Unstable angina / NSTEMI


ST Depression in a patient with unstable angina

Electrocardiogram in STEMI

  • ≥2 mm of ST segment elevation in 2 contiguous precordial leads
  • ≥1mm in other leads (2 contiguous)
  • An initial Q wave or abnormal R wave
  • Additionally, new left bundle branch block and those with a true posterior MI are considered STEMI
  • Specific types of STEMI:
    • Anterior STEMI: ST elevation in the precordial leads + I and aVL (Left anterior descending artery)
    • Posterior STEMI: ST elevations in II, III and aVF, reciprocal ST depressions in V1-V3, may have component of inferior ischemia (Left Circumflex artery)
    • Inferior STEMI: ST elevation in II, III and aVF. When inferior MI is suspected a R - sided precordial leads is useful (ST elevation). Reciprocal changes in I and aVL (Right coronary artery or Left circumflex artery)

Chest X Ray Findings

Laboratory Findings

Management

Other Diagnostic Work-up