William J. Brady, MD

December 31, 2006

Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.

December 31, 2006

A 54-year-old man with a history of type 2 diabetes, hypertension, and coronaryartery disease with angina presents to the physician’s office withchest pain. The pain began 3 hours earlier and is associated with diaphoresisand dyspnea. Examination results are unremarkable, except for diaphoresis.A 12-lead ECG reveals normal sinus rhythm with large R waves and horizontalST-segment depression in leads V1 through V3. The patient is given nitroglycerin,aspirin, heparin, morphine, and a &#946-blocker for noninfarction acutecardiac ischemia and transferred to the local emergency department (ED).

December 31, 2006

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.

December 31, 2006

A42-year-old man with a history of hypertension presents to an outpatientclinic with chest pain that began the day before, after he had worked outat his health club. The discomfort increases when he walks and worsenssomewhat with inspiration. No associated symptoms are noted. Results of aphysical examination are normal; no chest wall tenderness is evident. Becausecertain features of the presentation suggest an acute coronary syndrome, a12-lead ECG is obtained, which is shown here.

December 31, 2006

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

December 31, 2006

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductivecough that began earlier in the day. The pain is constant and does notdiminish with rest; it worsens somewhat with deep inspiration and has localizedto the left chest. The patient has had no nausea, vomiting, or abdominal pain.He has been immobile for several years secondary to spinal cord disease buthas no history of cardiopulmonary disease.

November 01, 2006

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma. The patient could have a non-STEMI ACS for which conservative treatment will suffice--or he could have a STEMI in an electrocardiographically "silent" area and need acute reperfusion therapy.

November 01, 2006

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma.

September 01, 2006

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning.

July 01, 2006

56-year-old man presents with substernal chest pain, diaphoresis, and weakness of 1 hour's duration. He had taken a sublingual nitroglycerin tablet that had been prescribed for his wife.