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Publication Date: January 2020 (Volume 22, Number 1)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 01/01/2023.
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Chest pain is the second most common complaint in emergency departments, with 6.4 million visits annually in the United States. A quarter of these patients will be diagnosed with acute coronary syndromes, but among those, nearly half will have nondiagnostic electrocardiograms. Non–ST-segment elevation myocardial infarction (NSTEMI) is twice as common as ST-segment elevation myocardial infarction (STEMI), and lack of clarity surrounding the best management of this condition can contribute to adverse outcomes. In this review, current national management guidelines for NSTEMI are summarized as they pertain to the ED, and the evidence base supporting them is considered. Issues surrounding special patient populations are addressed, and new diagnostic and therapeutic modalities are discussed.
Excerpt From This Issue
A 76-year-old woman presents to the ED with chest pain. She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest. Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. The pain is located in the center of her chest, and she describes it as a “pressure” sensation. Her only past medical history is hypertension. In the ED, her vital signs are within normal limits and her exam is unremarkable. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL). Your intern asks if she can go home since her troponin is low and she looks well...
A 69-year-old man presents to the ED with chest pain that began an hour prior to presentation, while he was walking home from the store. Initially, it felt similar to his usual episodes of angina, with left-sided pressure radiating to his left arm. However, the pain didn’t resolve with rest and has been worsening since onset, and is currently 9/10 in severity. He also notes dyspnea and lightheadedness. He has a history of hypertension, diabetes, and coronary artery disease, with baseline stable angina. His heart rate is 110 bpm and blood pressure is 90/40 mm Hg. He has bibasilar crackles and visibly increased work of breathing. Chest x-ray confirms your clinical suspicion of pulmonary edema. His ECG shows 4-mm anterior ST-segment depressions. His initial troponin is still pending. You wonder if you should activate the cath lab, or if a bedside echo might help...