Missed MI ~ 2% missed infarction rate –25% had missed ST elevation –15% had Hx of nitroglycerin use –25% died or potentially lethal outcome!
Angina vs. MI Heart muscle –death in MI –Ischemia in angina Stable vs. Unstable Angina
Presentation of Angina Angina –Established character, timing, duration of CP –Transient, reproducible, predictable –Easily relieved by rest or SL NTG –Reduced coronary flow through fixed atherosclerotic plaques Unstable Angina –Angina deviating from normal pattern –Rest angina > 20 min –New-onset angina, previously undiagnosed –Increasing angina or change in class
Evaluation Detailed history Physical ECG/repeat ECG CXR Labs
Risk Stratify While this is recommended, exactly how to do it is controversial. There are several scoring systems. They each pros and cons. How risk stratification is will vary from institution to institution. TIMI score GRACE Braunwald Risk Stratification
Risk Stratify High/Moderate = admission to r/o MI –ASA –SL NTG for pain x3 then paste if pain free –NTG gtt if pain continues –IV heparin –B-blockade Low = provocative testing –From department –Low-risk obs pathway