Emergency Department Diagnosis and Management of Acute Coronary Occlusion

Publication Date: February 2026 (Volume 28, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 02/01/2029.

Author

Jillian Horning, MD

Assistant Professor, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA

Peer Reviewer

Kestrel Reopelle, MD, PhD

Assistant Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY

Abstract

Acute coronary occlusion is a time-sensitive cardiac emergency that requires early, accurate diagnosis and prompt treatment to restore coronary perfusion, usually by percutaneous coronary intervention. Successful management of these patients demands a highly coordinated effort among emergency medical services, the emergency department, and cardiology. This issue highlights the importance of recognizing distinct electrocardiographic patterns that represent acute coronary occlusion, even in the absence of traditional STEMI criteria, and reviews evidence-based management recommendations.

Case Presentations

CASE 1

A 65-year-old man presents to the ED via EMS with new exertional chest pain that began while shoveling snow…

Upon arrival, the patient complains of ongoing substernal chest pain. His vital signs are normal.
EMS reports that the prehospital ECG did not show STEMI. The patient was administered aspirin and sublingual nitroglycerin en route.
You immediately order a 12-lead ECG, which showed abnormally large T waves by both height and width relative to the QRS size in leads V1 to V3.
You consider the significance of this and whether to activate the cath lab…

CASE 2

A 78-year-old woman presents in triage with severe chest pressure that began 2 hours ago…

She is pale, diaphoretic, and in distress, clutching her chest.
Her vital signs are normal. You obtain an ECG in triage. (See Figure 1.)
You consider what the most appropriate next step in management would be…

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