1. A.Abdi,M.D

2. Initial Diagnosis Symptoms ECG Cardiac Biomarkers

3. CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN (ADAPTED FROM ROSEN’S, EMERGENCY MEDICINE) CHARACTERISTICSUGGESTIVE OF ANGINALESS SUGGESTIVE OF ANGINA TYPE OF PAINDULL PRESSURE/CRUSHING PAIN SHARP/STABBING DURATION2-5 MIN, <20 MINSECONDSTO HOURS/CONTINUOUS ONSETGRADUALRAPID LOCATION/CHEST WALL TENDERNESS SUBSTERNAL, NOT TENDER TO PALP. LATERAL CHEST WALL/TENDER TO PALP. REPRODUCIBALITYWITH EXERTION/ACTIVITY WITH BREATHING/MOVING AUTONOMIC SYMPTOMSPRESENT USUALLYABSENT

4. Assessing Likelihood of ACS High LikelihoodIntermediate Likelihood Low Likelihood Chest or left arm discomfort similar to prior angina Transient murmur, hypotension, or heart failure New ST changes Elevated Enzymes Chest or left arm as primary symptom Age > 70 Male gender Diabetes Known Vascular Dz. Q-waves on ECG No enzyme elevation Suggestive symptoms Recent cocaine Pain reproducible with palpation Minimal ECG changes Normal ECG No enzyme elevation

5. Cardiac Biomarkers

6. Risk Stratification UA or NSTEMI - Evaluate for Invasive vs. conservative treatment - Directed medical therapy Based on initial Evaluation, ECG, and Cardiac markers - Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy STEMI Patient? YESNO

18. 51-year-old male with bicuspid aortic valve, aortic insufficiency and hypertension who had an episode of chest pain 2 days prior to this tracing.

19. The patient is an elderly female with a known history of left bundle branch block who presented to the emergency ward with shortness of breath

20. A 52-year-old man. What is his chief complaint? What is the rhythm disturbance?

21. A 43-year-old man diagnosed with lateral subendocardial ischemia based on ST depressions in aVL. Do you agree?

22. A 47-yr-old man with double trouble

23. A 41-yr-old man with chest discomfort. What is the most likely diagnosis?

24. Subtle syncopation. 54-year-old morbidly obese male with an acute inferior MI. What is the rhythm?

25. 64-year-old male with chest pain.

26. 89-year-old man with a history of severe congestive heart failure. What is the rhythm? What is the possible significance of rsR' in V6?

27. What is the ECG diagnosis in this recording with baseline movement?

28. 54-year-old man with rest chest pain

29. Middle-aged man with chest pain after a motor vehicle accident with blunt trauma to the chest. The ECG is diagnostic of which condition

30. 70 year old woman with ECG showing which of the following major diagnoses?