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STEMI / Acute Coronary Syndrome – Quick Consult
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Last Updated / Reviewed: June 2022
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Key History
Key Physical Exam
Risk Factors for MI/ACS
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
- Classic: substernal chest pain radiating to left arm, neck, jaw
- Associated symptoms of shortness of breath, diaphoresis, nausea or
vomiting
- Atypical presentations – 1/3 of patients do not have chest pain on
presentation
– especially women, diabetics and elderly
- Pain onset typically crescendo vs. sudden
- Pain onset usually with exertion although may occur at rest
- Dizziness
- Dyspnea
- Elderly patients and diabetics may present only with nausea, vomiting,
diaphoresis,
or dyspnea
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- Fatigue
- Impending sense of doom, anxiety
- Indigestion
- Pain can vary in intensity
- Pain in arms, shoulder, epigastrum or neck
- Palpitations
- Posture changes or breathing does not change the intensity of the pain
- Sensation described as squeezing, burning, heaviness, tightness, band
around chest
or stabbing
- Syncope
- Vague discomfort
- Weakness
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- Typically normal
- Cold clammy skin
- Hypertension or hypotension
- May find signs of abnormal lipid metabolism – xanthelasma, xanthoma
- May find signs of diffuse vascular disease – diminished peripheral
pulses, carotid
bruit
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- New systolic ejection murmur – if papillary muscle ruptured
- Peripheral or central cyanosis
- S4 heart sound
- Signs of congestive heart failure
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- CAD
- Diabetes
- Family history (especially of MI or acute coronary syndrome before age
55)
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- Cocaine use
- HTN
- Hypercholesterolemia
- Smoking
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Cardiopulmonary
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Abdominal
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Infectious
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- Cholecystitis
- Cholelithiasis
- Esophageal rupture
- Esophagitis
- Gastritis
- Gastroesophageal reflux
- Hiatal hernia
- Mallory-Weiss syndrome
- Pancreatitis
- Peptic ulcer disease
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Musculoskeletal
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Other
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ECG Criteria for Acute MI
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STEMI: New ST elevation at the J point in at least 2 contiguous leads of ≥2 mm
(0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2-V3, and/or of ≥1 mm
(0.1 mV) in other contiguous chest leads or the limb leads
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Posterior MI: New ST depression in ≥2 precordial leads (V1-V4)
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LBBB with Acute MI (Sgarbossa or Modified Sgarbossa Criteria)
- ST elevation ≥1 mm and concordant with the QRS complex (5 points)
- ST depression ≥1 mm in lead V1, V2, or V3 (3 points)
- ST elevation ≥5 mm and discordant with the QRS complex (2 points)
(Modified criteria replaces this 5 mm criterion with a proportion: ST
elevation/S-wave amplitude of ≤ -0.25)
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Troponin is the preferred biomarker for diagnosis of MI.
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Failure to diagnose myocardial infarction is one of the leading causes of litigation
against medical practitioners.
- Consider atypical presentations in women, elderly and diabetic patients.
- Cardiac risk factors are not helpful to predict acute MI for the patient presenting
with acute chest pain.
- Beware the non-specific ECG. The non-specific change may be a normal variant or a new
ECG change indicating the presence of an acute coronary syndrome.
- Do not use a GI cocktail as a test to rule out the presence of ACS.
- Do not use the failure to respond to nitroglycerin as a test to rule out the presence
of ACS.
- Intermediate or indeterminate troponin levels are not normal. Repeat the test or get
a cardiology consult.
- Always get old ECGs for comparison if available.
- Consider cardiology consult when diagnosis is questionable.
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