Thanks to Tyler for presenting an interesting case of 81M with CV risk factors who p/w chest pain with found to have sub-millimeter ST elevations and marked troponin elevation due to ACS versus hypertensive emergency – cath pending!
1. We use a combination of the history, EKG and troponin to help diagnose ACS. Scoring systems usually rely on at least two of three being positive, but atypical presentations with a marked derangement in only one of the three parameters do occur.
2. The differential diagnosis of ST elevations includes acutely life threatening causes, but less severe diagnoses are possible – see below.
3. Prior EKGs are extremely helpful in the assessment of acute chest pain. Look for evidence of ischemia (Q waves), cardiomyopathy (LVH) or conduction system disease (LBBB)
- > 1mm STE in 2 contiguous leads as measured from the J point.
- Except in V2-V3
- > 2mm in men
- > 1.5 mm in women
Prior EKG’s can have very important clues to the current presentation. Assess for the prior EKG for:
- Old ischemia
- Q waves
- Poor R wave progression (anterolateral MI)
- Persistent ST elevation (aneurysm)
- Non-specific T wave changes
- Low voltages
- Axis shift (right axis shift from lateral MI)
- Conduction system disease (LBBB)