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
- CAD (think of Type I DM, family history of early CAD)
- 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)
- Aortic disease (e.g. dissection, think about connective tissue diseases)
- Anxiety (dx of exclusion)