Pearls:

Remember who is more likely to present atypically and still have ACS.

Look at your ECGs anatomically and methodically.

One ECG begets another.

There are over 6 million visits to the Emergency Department (ED) and Urgent Care (UC) for chest pain every year. We have a lot of tools to help us evaluate chest pain including ECGs, troponins, chest x-rays, d-dimers, the HEART score, etc, but we still make a lot of mistakes.

Mistake #1: Expecting a typical presentation of crushing substernal chest pain that radiates to the arm with other associated symptoms.

The evidence shows us that the atypical presentation is actually more typical.



1 in 10 patients will have very atypical symptoms.



In one large study, ⅓ of the patients diagnosed with MI had no chest pain.



Think about diaphoresis, sudden generalized weakness, vague abdominal complaints or vague neuro symptoms like presyncope or dizziness as an MI in disguise.

Mistake #2: Minimizing women’s symptoms and not recognizing atypical presentations.

Parikh NI, et al. Reproductive Risk Factors and Coronary Heart Disease in the Women's Health Initiative Observational Study. Circulation. 2016 May 31;133(22):2149-58. PMID 27143682



Women are less likely to present acutely and are more likely to minimize their symptoms when they describe them.





They are more likely to have vaguer complaints.





They are more likely to be seen in the ED and have their symptoms minimized by the provider.

Mistake #3: Thinking anyone is too young or too old for ACS.

One in ten MIs in the United States occurs in patients aged 40 or younger.



Elderly are more likely to present atypically

Mistake #4: Reading all 12 ECG leads at the same time.

Start with II, III and aVF. Look for an inferior MI.



Then look at v1, v2, v3 for and anterior and anteroseptal MI.



Then look at v4, v5 v6 and look for an anterolateral MI



Then look specifically at I and aVL for a high lateral MI.



Then look at aVR.



If aVR is elevated and you have diffuse ST depression elsewhere, this is significant left main disease and this patient is at high risk of infarcting in front of you.





If aVR is up and you have some subtle changes in v1, v2, v3, think about a posterior or right sided MI.



Compare it to an old ECG

Mistake #5 : Only getting 1 ECG.

In someone with CP, repeat it in 5 or 10 minutes.



In someone who came in which chest pain and you are about to send them home, repeat the EKG just before you discharge them.



One ECG begets another.

Be concerned about pseudonormalization. EKGs don’t change for the hell of it. Either the patient had an angioplasty and got better, or they are getting worse.