Acute Coronary Syndrome Differential Diagnoses
- Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD more...
As many as half of all cases of ACS are clinically silent in that they do not cause the classic symptoms of this syndrome. Consequently, ACS goes unrecognized by the patient. Maintain a high index of suspicion for ACS, especially when evaluating women, patients with diabetes, older patients, patients with dementia, and those with a history of heart failure.
Although ST-segment and T-wave changes are associated with CAD, alternative causes of these findings are left ventricular aneurysm, pericarditis, Prinzmetal angina, early repolarization, Wolff-Parkinson-White syndrome, and drug therapy (eg, with tricyclic antidepressants, phenothiazines).
Increasing public awareness of the typical and atypical presentations of ACS is of the utmost importance for optimal and timely treatment. Many patients do not recognize that their symptoms are cardiac in origin and therefore may delay seeking medical help. Guidelines from the European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA) recommend that patients with established CAD call emergency medical services if they have chest pain that does not resolve after they take a sublingual nitroglycerin tablet.
In patients presenting to the ED with chest pain, a structured diagnostic approach that includes time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appeared both safe and diagnostically efficient in a study by Scheuermeyer et al. However, some patients with ACS may be discharged for outpatient stress testing on the index ED visit.
Hypertensive Emergencies in Emergency Medicine
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|Age ≥65 years||1|
|At least 3 risk factors for coronary heart disease||1|
|Previous coronary stenosis ≥50%||1|
|Use of aspirin in previous 7 days||1|
|At least 2 anginal episodes in the previous 24 hours||1|
|ST-segment elevation on admission ECG||1|
|Elevated levels of serum biomarkers||1|
|Note: Event rates significantly increased as the TIMI risk score increased in the test cohort in the TIMI IIB study. Rates were 4.7% for a score of 0/1, 8.3% for 2, 13.2% for 3, 19.9% for 4, 26.2% for 5, and 40.9% for 6/7 (P < .001, χ2 test for the trend). The pattern of increasing event rates with increasing TIMI risk score was confirmed in all 3 validation groups (P < .001).|