Jeremy Joslin, MD

ABSTRACT: Atypical clinical presentations in the quality, intensity, and radiation of pain are common in patients with acute coronary syndromes. Women with an acute myocardial infarction (AMI) are more likely to have atypical symptoms, such as dyspnea, than men. A history of acute anxiety or a psychiatric diagnosis does not preclude the possibility of an acute coronary event in a patient with chest pain. The clinical response to a GI cocktail, sublingual nitroglycerin, or chest wall palpation does not reliably identify the source of pain. Over-reliance on tests with poor sensitivity, such as the ECG, or on the initial set of cardiac biomarkers will miss many patients with MI. Serial troponin levels obtained at 3- to 6-hour intervals are recommended to evaluate the extent of myocardial damage. Coronary angiography that detects mild non-obstructive disease does not exclude the possibility of sudden plaque rupture and acute coronary occlusion.