Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department
- Guy S Reeder, MD
Guy S Reeder, MD
- Section Editor — Coronary Disease
- Professor of Medicine
- Mayo Medical School
- Eric Awtry, MD
Eric Awtry, MD
- Associate Professor of Medicine
- Boston University School of Medicine
- Simon A Mahler, MD, MS
Simon A Mahler, MD, MS
- Associate Professor of Emergency Medicine
- Wake Forest School of Medicine
- Section Editors
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The clinical presentation of myocardial ischemia is most often acute chest discomfort. The goal of emergency department evaluation is to determine the cause of the chest discomfort and promptly initiate appropriate therapy. It is essential that initial assessment and management be rapid but methodical and evidence-based.
Diagnostic evaluation emphasizes distinguishing among the following potential causes of chest pain:
●Acute coronary syndrome (myocardial infarction or unstable angina)
The diagnosis of acute coronary ischemia depends upon the characteristics of the chest pain, specific associated symptoms, abnormalities on electrocardiogram (ECG), and levels of serum markers of cardiac injury. A patient with a possible acute coronary syndrome (ACS) should be treated rapidly. Thus, initial management steps must be undertaken before or during the time the diagnosis is being established.
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- GENERAL PRINCIPLES
- IMMEDIATE ED INTERVENTIONS
- DETERMINING WHO NEEDS AN ELECTROCARDIOGRAM
- ECG ASSESSMENT
- Initial interpretation and criteria for ischemia
- Localization of ischemia
- Importance of serial ECGs
- LBBB or pacemaker
- CLINICAL PRESENTATION
- Ischemic chest pain
- Historical features increasing likelihood of ACS
- Associated symptoms
- Noncardiac chest pain
- ATYPICAL SYMPTOMS
- PHYSICAL EXAMINATION
- CARDIAC BIOMARKERS
- ST elevation
- Non-ST elevation
- - Diagnosis and treatment
- - Risk stratification
- Cardiac arrhythmias during ACS
- Disposition of patient without STEMI
- - High-risk patient
- - Low and moderate risk patient
- IMPACT OF MISSED DIAGNOSIS
- REST AND STRESS IMAGING TESTS
- SUMMARY AND RECOMMENDATIONS