In Cardiology, one of the most feared diagnosis is a STEMI. Here are my thoughts as a cardiology fellow!
Part 2: Differential Diagnoses & Clinical Work-Up
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Part 2: Differential Diagnoses & Clinical Work-Up
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#MedTwitter #MedEd #CardioTwitter #IMG
In the work-up for acute chest pain, it is important to consider multiple differential diagnoses (both cardiac and non-cardiac).
Here are some of the common etiologies:
1) Pericarditis
2) Myocarditis
3) Stress Cardiomyopathy
4) Acute Aortic Dissection
5) Pulmonary Embolism
Here are some of the common etiologies:
1) Pericarditis
2) Myocarditis
3) Stress Cardiomyopathy
4) Acute Aortic Dissection
5) Pulmonary Embolism
Pericarditis:
- Chest pain that is worse when the patient is supine and improves w/ sitting upright or slightly forward
- Diffuse ST segment elevation is the hallmark; can also be seen in acute MI with LM or 'wrap-around' LAD
- PR-segment depressions
- TTE can show lack of RWMA
- Chest pain that is worse when the patient is supine and improves w/ sitting upright or slightly forward
- Diffuse ST segment elevation is the hallmark; can also be seen in acute MI with LM or 'wrap-around' LAD
- PR-segment depressions
- TTE can show lack of RWMA
Myocarditis:
- Insidious onset/associated viral infections
- TTE is less helpful to differentiate from acute MI b/c can see segmental LV dysfunction with both
- Cardiac MRI: patchy distribution of delayed enhancement in epicardium & mid-myocardium w/ sparing of endocardium
- Insidious onset/associated viral infections
- TTE is less helpful to differentiate from acute MI b/c can see segmental LV dysfunction with both
- Cardiac MRI: patchy distribution of delayed enhancement in epicardium & mid-myocardium w/ sparing of endocardium
Stress Cardiomyopathy:
- Following acute/emotional stress
- Present with typical chest pain, ischemic ECG, troponin elevation, and new onset RWMA
- Can see apical ballooning
- More common in women & older adults
- Often requires LHC to rule out epicardial disease
- Following acute/emotional stress
- Present with typical chest pain, ischemic ECG, troponin elevation, and new onset RWMA
- Can see apical ballooning
- More common in women & older adults
- Often requires LHC to rule out epicardial disease
Acute Aortic Dissection:
- Sharp, tearing chest pain
- Can have new neurological symptoms (carotid involvement)
- Should be evaluated before anti-thrombotic/platelet therapy
- CXR: Widened mediastinum
- TTE: dissection flap in aorta
- CT Chest w/ contrast: Test of choice
- Sharp, tearing chest pain
- Can have new neurological symptoms (carotid involvement)
- Should be evaluated before anti-thrombotic/platelet therapy
- CXR: Widened mediastinum
- TTE: dissection flap in aorta
- CT Chest w/ contrast: Test of choice
Pulmonary Embolism:
- Shortness of breath with pleuritic chest pain
- Can use an ECHO to rule out wall motion abnormalities and can identify right ventricular dilatation and dysfunction
- CTA is the test of choice
- Important to evaluate clinical context
- Shortness of breath with pleuritic chest pain
- Can use an ECHO to rule out wall motion abnormalities and can identify right ventricular dilatation and dysfunction
- CTA is the test of choice
- Important to evaluate clinical context
Work-Up:
- EKG is the 1st test (should obtain within 10 minutes); if have a STEMI or new LBBB should have emergent reperfusion treatment with PCI/fibrinolysis
- Evaluate for presence of heart failure
- Can have mechanical complications (acute MR or VSD) w/ new systolic murmur
- EKG is the 1st test (should obtain within 10 minutes); if have a STEMI or new LBBB should have emergent reperfusion treatment with PCI/fibrinolysis
- Evaluate for presence of heart failure
- Can have mechanical complications (acute MR or VSD) w/ new systolic murmur
EKG:
- Requires elevation of 1-mm or more in two or more contiguous leads with reciprocal ST-depressions in contralateral leads
- New LBBB may indicate acute large anterior wall MI involving the LAD
- RBBB: may challenge interpretation of ST-elevation in V1-V3
- Requires elevation of 1-mm or more in two or more contiguous leads with reciprocal ST-depressions in contralateral leads
- New LBBB may indicate acute large anterior wall MI involving the LAD
- RBBB: may challenge interpretation of ST-elevation in V1-V3
Troponins:
- Can also be elevated in HF, Aortic dissection, HCM, PE, cardiac contusion, among others
- High-sensitivity troponin: Can measure as early as 1-3 hours w/o compromising sensitivity or negative predictive value
- CK-MB: No longer used, peaks in 24 hours
- Can also be elevated in HF, Aortic dissection, HCM, PE, cardiac contusion, among others
- High-sensitivity troponin: Can measure as early as 1-3 hours w/o compromising sensitivity or negative predictive value
- CK-MB: No longer used, peaks in 24 hours
When diagnosing acute chest pain, the EKG and ECHO are two of your most important initial tests.
Consider various differential diagnoses in conjunction with the patient's story and labs!
Stay tuned for part 3 for medical management for STEMI. Comment below ๐
Consider various differential diagnoses in conjunction with the patient's story and labs!
Stay tuned for part 3 for medical management for STEMI. Comment below ๐
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