Moffitt Cardiology Morning Report 8/18: Chest pain in a young person

Take-home pearl: the electrocardiographically silent part of the heart is in the distribution of the LCx and OM vessels. If concerned about ACS, you should get a POSTERIOR ECG (leads V7-9) to make sure this territory is not involved. This should be done for ACS rule out, not just when you see ST-depressions in V1-V3.

Other clinical pearls from YY:

  • If concerned about myopericarditis vs ACS on differential, you should try to rule out pericardial effusion before starting heparin since sometimes this can worsen an existing effusion.
  • CT coronary is a good test for ruling out coronary abnormalities, as long as you can beta-block their heart rate adequately for a high quality gated study

Differential diagnosis for chest pain in a young person


  • Ischemia
    • CAD (think of Type I DM, family history of early CAD)
    • Drug
    • Vasospasm
    • Coronary anomaly
    • Coronary aneurysm (think Kawasaki – pathophys is thrombus with distal emboli)
    • Myocardial bridge
    • Large vessel vasculitis (expect to see some systemic/non-cardiac manifestations by the time if affects the coronaries)
    • Coronary emboli (valvular lesions, cardiac mass, PFO/ASD)
    • Coronary dissection (think of 3rd trimester of pregnancy as the classic association)
  • Pericarditis
  • Pump
    • Myocarditis
    • Takotsubo
  • Arrhythmia


  • Aortic disease (e.g. dissection, think about connective tissue diseases)
  • PE
  • MSK
  • GI
  • Anxiety (dx of exclusion)

Evernote link:


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