EMERGENCY MEDICINE Volume 38, Issue 11 | June 7, 2021

Cardiac Emergencies: Part 1 of 3

Acute Coronary Syndrome aneurism, Prinzmetal angina, and Takotsubo cardiomyopathy;
type 2 NSTEMI — presents with other changes on electrocardi-
John C. Perkins Jr, MD, Associate Professor of Emergency, ography (ECG) such as T-wave inversions and ST depressions;
Family, and Internal Medicine, and Assistant Director of can be caused by pulmonary embolism (PE), catastrophic neuro-
the Emergency Medicine Residency Program, Virginia Tech logic emergencies, subarachnoid hemorrhage, aortic dissection,
Carilion School of Medicine, Roanoke, VA hypertensive emergencies, sepsis, hypotension, and hypoxia
Acute coronary syndrome (ACS): includes ST-segment elevation Coronary artery plaques: traditional stress tests assess for obstruc-
myocardial infarction (STEMI), non-ST-segment elevation myo- tive lesions with a focus on size, but identifying which plaques are
cardial infarction (NSTEMI), and unstable angina; chest pain — is likely to rupture on the basis of composition is more likely to pre-
one of the top complaints in any emergency department (ED); vent progression to STEMI with transmural infarction; addressing
accounts for 8 to 9 million ED visits per year (1 in 3 patients pres- myths — catheterization and stress tests often detect only plaques
ents with chest pain); has an admission rate of ≈30%; cost for ACS growing intraluminally, but intraluminal obstruction often occurs in
evaluation is $10 to $12 billion per year; miss rates — in the 1980s late disease; plaques can grow into the vessel wall without occlud-
to 1990s, rate of missing the diagnosis of ACS was 2%; current ing the lumen (require detection by ultrasonography); highest cal-
missed diagnoses are often due to atypical presentations in older cium content may not correlate with the highest risk, because low
adults, patients with diabetes, and female patients, or in patients calcium content indicates unstable plaque (large plaques are often
believed to be too young for ACS; missed ACS represents ≈$1 in the most stable); angina symptoms may not precede major cardiac
every $3 paid in ED ligation; mortality of missed patients who are events; stenting may not prevent future ACS events
sent home with a myocardial infarction (MI) is 10% to 25% com- Cap and calcification: cap contains inflammatory molecules; cas-
pared with <5% for patients admitted with STEMI and even less cade of MI begins with exposure of inflammatory debris inside
for those admitted with NSTEMI the plaque to the blood and initiation of the inflammatory cascade;
Myocardial infarction: is an acute myocardial injury defined stable calcified plaques contain a thick fibrous cap that separates
by elevation of myocardial biomarkers in acute ischemia; inflammatory debris from the lumen and blood, thus reducing
STEMI — is a transmural infarction that results in a permanent likelihood of rupture; thinner caps are more likely to rupture;
infarction and remodeling of myocardial tissue; presents with coronary computed tomography (CT) angiography assesses for
biomarkers associated with ST-segment changes dependent on calcification but is the least effective tool for evaluating plaque
sex and limb leads; presents as a 2-mm ST-segment elevation composition; intracoronary ultrasonography is uncommon but is
in precordial leads V1, V2, and V3 vs 1 mm in other leads; also the best way to identify vulnerable plaques; cardiac catherization
varies on the basis of morphology and distribution; chest pain is is not ideal for determining composition
not mandatory but its absence is atypical; may present with only American Heart Association (AHA) risk stratification: is used
weakness in older, diabetic, or immunocompromised patients; to evaluate patients with chest pain for ACS risk; during initial
dyspnea is more common than chest pain in older adults; evaluation, consider whether the patient is currently having
NSTEMI — the type 1 pathophysiology is cardiac in nature with an MI by using serial troponin levels and repeating ECG and
ischemia in a coronary artery causing nontransmural ischemia whether the patient requires further risk stratification
and troponin leak; type 2 is caused by systemic pathologies lead- Risk factors for MI: traditional ones include older age, diabetes,
ing to supply-demand mismatch in myocardial tissues and sub- hypertension, hypercholesterolemia, obesity, and smoking; risk
sequent troponin leak factors in the ED differ and begin with patient history, followed
Unstable angina: a term falling out of favor; patients with positive by family history of coronary artery disease (CAD), male sex,
findings for high-sensitivity troponin are now considered to have older age, and an increasing number of traditional risk factors;
NSTEMI; patients were previously considered to have unstable AHA low-risk category — no history of CAD, normal findings
angina because measurement of high-sensitivity troponin was on ECG and hemodynamics, no dysrhythmia, and normal tro-
unavailable or subtle troponin leakage was not detectable ponin value; pleuritic, reproducible, or positional chest pain are
Differential diagnosis: STEMI — conditions causing ST-segment low-risk features along with chest pain persisting continuously;
elevations other than thrombosis or embolic events in a coro- AHA high-risk category — diaphoresis and vomiting associated
nary artery include myocarditis, pericarditis, left ventricular with chest pain, radiation to one or both arms, and any exertional

Educational Objectives Faculty Disclosure

The goal of this program is to improve the evaluation, risk strati- In adherence to ACCME Standards for Commercial Support,
fication, and management of cardiac emergencies, including acute Audio Digest requires all faculty and members of the planning
coronary syndrome, right ventricle failure, and pulmonary embo- committee to disclose relevant financial relationships within
lism. After hearing and assimilating this program, the clinician the past 12 months that might create any personal conflicts of
will be better able to: interest. Any identified conflicts were resolved to ensure that this
1. Differentiate between the subcategories of acute coronary educational activity promotes quality in health care and not a
syndrome on the basis of clinical presentation and etiology proprietary business or commercial interest. For this program,
members of the faculty and planning committee reported nothing
2. Evaluate chest pain in the emergency department with an
to disclose.
emphasis on cardiac plaque composition as it relates to
myocardial infarction
3. Identify low-risk patients appropriate for discharge by using
the HEART Score or HEART Pathway decision tool
4. Evaluate and manage patients in the emergency department
with right ventricle failure while avoiding common pitfalls
5. Identify which patients with pulmonary embolism are the best
candidates to send home by using clinical decision tools
and imaging strategies

EM-38-11
 Audio Digest Emergency Medicine 38:11
component with chest pain; gastric pathology — reproducible Goch A et al. The clinical manifestation of myocardial infarction in
chest wall tenderness to palpitation occurs in 10% of patients elderly patients. Clin Cardiol. 2009;32:E46-51; doi: 10.1002/clc.20354;
with ACS; patients with ACS may improve with gastrointesti- Kwong JC et al. Acute myocardial infarction after laboratory-confirmed
nal cocktail and those with gastric pathology may improve with influenza infection. N Engl J Med. 2018;378:345-353; doi: 10.1056/NEJ-
sublingual nitroglycerin; main misdiagnosis for ACS is gastro- Moa1702090; Lee JM et al. Prognostic implications of plaque characteris-
esophageal reflux disease (GERD), with 20% of ACS patients tics and stenosis severity in patients with coronary artery disease. J Am Coll
Cardiol. 2019;73:2413-2424; doi: 10.1016/j.jacc.2019.02.060; Libby P.
describing their chest pain as indigestion or burning and 50% Mechanisms of acute coronary syndromes and their implications for ther-
reporting an increase in belching; inferior ACS and circumflex apy. N Engl J Med. 2013;368:2004-2013; doi: 10.1056/NEJMra1216063.
pathology often present with a gastric component
Nontraditional risk factors: 10% of MI patients lack traditional Right Heart Failure
risk factors and instead present with end-stage renal disease, HIV,
lupus, rheumatoid arthritis, heavy alcohol use, pregnancy, or sys- Matthew A. Roginski, MD, MPH, Assistant Professor of
temic infection; MI may be more common during and up to 1 wk Medicine, Department of Emergency Medicine, Dartmouth
after influenza, community-acquired pneumonia, or COVID-19 Geisel School of Medicine, Lebanon, NH
infection owing to the inflammatory nature of these diseases
Misinterpretation of ECG: computer interpretation — failing to Right ventricle (RV) failure: patients present with shortness of
recognize ischemic changes or dependence on computer inter- breath, fatigue, chest pain, syncope, and “unwell” feeling; is chal-
pretation is a major cause of medical malpractice claims for lenging to diagnose in the emergency department (ED); normal
ACS; studies suggest computer interpretation is 69% sensitive physiology — RV receives the same cardiac output as the left ven-
for STEMI and that 75% of STEMIs diagnosed by computer tricle (LV) at 20% of the pressure; normal RV motion squeezes up
interpretation are erroneous; there is no accepted standard for longitudinally and relaxes downward; LV dictates motion of sep-
computer interpretation given the wide range of models and tum; pathologic physiology — massive pulmonary embolism (PE)
algorithms for interpreting ECG; sensitivity — 20% to 30% of causes an acute obstruction in the outflow tract, backing up the
patients with ACS have normal or nonspecific findings on ECG; blood and causing the thin-walled RV to balloon out while pushing
sensitivity of ECG increases with repeated tests; ECG should be into the LV; causes tricuspid annular dilatation, which results in
repeated in response to any changes in symptomology; perform- further backflow into the liver and body; presentation — patient is
ing ECG every 15 to 20 min is reasonable hypotensive with RV overload from acute PE or acute heart failure
Stress testing: is required in high-risk patients with chest pain; resulting from underlying damage to the heart; can cause sepsis
stress testing that focuses on plaque composition or likelihood of and reductions in myocardial oxygen, contractility, and cardiac
rupture is superior to testing examining size and amount of lumi- output; RV becomes overloaded; can result in death
nal obstruction; 5% to 15% of ED patients with chest pain and Diagnosis in ED: assess the patient’s medical history for pulmo-
negative findings on a stress test in the past 3 yr have positive nary hypertension and RV failure; echocardiography or point-
cardiac biomarkers, require cardiac catheterization, or die <31 of-care ultrasonography — evaluate RV size, function, and
days after ED visit; stress testing is inadequate to rule out ACS, septal flattening; RV shape is abnormal and probing RV in the
even if the patient recently had a negative result on a stress test; wrong direction can cause grossly distended RV on axis view
the COURAGE trial randomized patients with positive results or minimal RV visibility; normally, width of the RV is less than
on stress testing to revascularization vs medical treatment and width of the LV and the tricuspid annulus moves longitudinally
found no significant differences in mortality, nonfatal MI, nonfa- (ie, Tricuspid Annular Systolic Plane Excursion [TAPSE] scor-
tal stroke, or hospitalization for ACS; meta-analyses have found ing system); RV width greater than LV width and lack of RV
no benefit to invasive and medical therapy vs medical therapy longitudinal motion on TAPSE indicate positive findings; from
alone after a positive result on stress testing, which suggests that a parasternal short-axis view, pathologic patients have a D-sign
hospitalizing such patients does not improve health outcomes where the RV is the same size as the LV with high pressure and
HEART Score and HEART Pathway risk stratification: HEART volume pushing the RV into the LV
Score — patients with a score ≤3 have risk for major adverse car- Management: target euvolemia; hypotension causes death in
diac events such as death, revascularization, or MI in 30 days patients with PE and they are at risk for sphincter-tightening
of <2%; evaluates troponin levels, ECG, age, history, and risk intubation; aggressively treat tachydysrhythmias; physiol-
factors; limitations of the score include calculating a score <3 in ogy — dilated RV has high filling pressure and does not fill if
the setting of elevated troponin levels or dynamic ECG changes patient is acutely hypovolemic or hypotensive; providing too
because all other factors are negative; risk factors are only help- much fluid without forward flow can increase dilation of RV,
ful if the patient’s preexisting conditions are diagnosed; HEART pushing it into the LV and reducing cardiac output; hyperten-
Pathway — expands on the HEART Score by evaluating troponin sive and hypervolemic — administer furosemide (Lasix) if the
and ECG outcomes at 0 and 3 h; patients with a low risk score have patient is hypervolemic and norepinephrine if hypotensive; for
risk for 30-day major adverse cardiac event of <1% (ie, lower than intravascularly hypovolemic patients presenting with diarrhea,
that predicted by the HEART Score); caveats — the HEART Path- urinary tract infection, or septic shock, administer small aliquots
way or HEART Score should be adopted as a standard within an of fluid, start norepinephrine, and reassess based on bolus; strive
institution to ensure consistent evaluations; both were designed to for euvolemia; norepinephrine is preferred because it is the most
identify low-risk patients who can be discharged from the hospital frequently used vasopressor with known dosages and it increases
to an outpatient setting; they are not intended for high-risk patients peripheral vascular resistance without increasing pulmonary vas-
or for older patients with concurrent medical problems cular resistance (unlike phenylephrine)
Treating tachydysrhythmia: differs from sinus tachycardia, which
Suggested Readings
requires treating the underlying cause; atrial fibrillation patients
Amsterdam EA et al. Testing of low-risk patients presenting to the with ventricular tachycardia, supraventricular tachycardia, or
emergency department with chest pain: a scientific statement from rapid ventricular rate require immediate rhythm control via car-
the American Heart Association. Circulation. 2010;122:1756-1776. dioversion and amiodarone; these patients have imminent risk of
doi: 10.1161/CIR.0b013e3181ec61df; Anderson JL, Morrow DA. Acute death from low cardiac output
myocardial infarction. N Engl J Med. 2017;376:2053-2064; doi: 10.1056/
Intubation: assess blood pressure every 1 to 2 min in peri-intu-
NEJMra1606915; Brady W, de Souza K. The HEART score: a guide to its
application in the emergency department. Turk J Emerg Med. 2018;18: bation period to diagnose hypotension immediately and begin
47-51; doi: 10.1016/j.tjem.2018.04.004; DeVon HA et al. Typical and norepinephrine; prior to intubation, if the patient is normoten-
atypical symptoms of acute coronary syndrome: time to retire the terms? sive, start infusion of norepinephrine at 5 to 10 mcg/min because
J Am Heart Assoc. 2020;9:e015539. doi: 10.1161/JAHA.119.015539; induction will cause hypotension; any intubation agents that
Durazzo M et al. Non-cardiac chest pain: a 2018 update. Minerva Car- maintain the blood pressure semi-neutral, such as etomidate, ket-
dioangiol. 2018;66:770-783; doi: 10.23736/S0026-4725.18.04681-9; amine, or fentanyl, can be used but propofol should be avoided
 Audio Digest Emergency Medicine 38:11
Suggested Readings findings and basic metabolic panel scores are indicative of low-
Harjola VP et al. Contemporary management of acute right ventricular risk patients who do not require hospitalization; the American
failure: a statement from the Heart Failure Association and the Work- College of Emergency Physicians criteria endorse use of any of
ing Group on Pulmonary Circulation and Right Ventricular Function of the 3 clinical decision tools and do not require assessment of
the European Society of Cardiology. Eur J Heart Fail. 2016;18:226-241; troponin or pro–brain natriuretic peptide
doi: 10.1002/ejhf.478; Olsson KM et al. Decompensated right heart Imaging: echocardiography and ultrasonography are useful for
failure, intensive care and perioperative management in patients with evaluating PE; some studies suggest that right-sided echocar-
pulmonary hypertension: updated recommendations from the Cologne diography should be mandatory to evaluate for signs of heart
Consensus Conference 2018. Int J Cardiol. 2018;272S:46-52; doi: strain, but this is not feasible for most institutions and would
10.1016/j.ijcard.2018.08.081; Panchal AR et al. An update to the Amer- make outpatient management more difficult; CT is less sensi-
ican Heart Association guidelines for cardiopulmonary resuscitation and tive than ultrasonography but is indicative of right-heart strain
emergency cardiovascular care. Circulation. 2019;140:e881-e894; doi: if the patient has a right ventricle–to–left ventricle ratio of 1;
10.1161/CIR.0000000000000732. some suggest performing bilateral duplex ultrasonography on all
patients because some will have recurrent venous thromboembo-
Can This Patient With Pulmonary Embolism Go Home? lism within 7 days of anti-coagulation (ie, it is the next PE that
Mark C. Bisanzo, MD, Associate Professor, The University causes mortality), but this is not part of any criteria
of Vermont Larner College of Medicine, Burlington, VT Pitfalls: patients require close follow-up; patient education is
critical to ensure patients understand follow-up guidelines, other
Pulmonary embolism (PE): was traditionally a dangerous, comor- potential workups needed, who to follow up with, and precau-
bid diagnosis in older, sicker patients; has been transformed into tions related to use of anti-coagulant agents; consider patient-
a diagnosis that can be made in younger, healthier patients pre- centered factors such as stability, proximity to health care, and
senting with chest pain and shortness of breath by using D-dimer likelihood of following advice
followed by computed tomography (CT) pulmonary angiogra-
Suggested Readings
phy; sending patients home — studies show one-third of patients
with deep vein thrombosis (DVT) have silent PE with good out- Emergency Department Patients With Chest Pain Writing Panel; Rybicki
comes; thus, speaker suggests that DVT patients without short- FJ et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/
ness of breath or chest pain do not require additional tests; other SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of
studies show a high volume of false positives for PE by radiolo- cardiovascular imaging in emergency department patients with chest
pain: a joint document of the American College of Radiology Appro-
gists using CT data and the overuse of D-dimers
priateness Criteria Committee and the American College of Cardiology
Clinical decision tools: most commonly used are the Hestia cri- Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;13(2):
teria, the Pulmonary Embolism Severity Index (PESI), and the e1-e29. doi:10.1016/j.jacr.2015.07.007; Moumneh T et al. Risk strati-
simplified PESI (sPESI); tools consider patient factors and how fication of pulmonary embolism. Crit Care Clin. 2020;36:437-448; doi:
an individual hemodynamically responds to PE; patients with 10.1016/j.ccc.2020.02.002; Stein PD et al. Silent pulmonary embolism
low risk scores are deemed to have acceptable 30-day mortality in patients with deep venous thrombosis: a systematic review. Am J Med.
and can be sent home; new studies suggest that negative troponin 2010;123:426-431; doi: 10.1016/j.amjmed.2009.09.037.

Acknowledgments
Dr. Perkins was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with current social-distancing
guidelines during the COVID-19 pandemic. Dr. Roginski and Dr. Bisanzo were recorded virtually at the Vermont Emergency Medicine
Update, held January 27-29, 2020, in Stowe, VT, and presented by the Larner College of Medicine at the University of Vermont. For infor-
mation on future CME activities from the Larner College of Medicine at the University of Vermont, please visit med.uvm.edu/cme/home.
Audio Digest thanks the speakers and the Larner College of Medicine at the University of Vermont for their cooperation in the production
of this program.

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 Audio Digest Emergency Medicine 38:11
Cardiac Emergencies: Part 1 of 3
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1. In which of the following groups is the diagnosis of acute coronary syndrome (ACS) LEAST likely to be missed owing to
atypical presentation?
(A) Women (C) Patients with diabetes
(B) Obese patients **** (D) Older adults

2. Which clinical symptom of ST-segment elevation myocardial infarction (STEMI) is the most common in older patients?
(A) Chest pain (C) Weakness/fatigue
(B) Dyspnea **** (D) Syncope

3. Which of the following is an accurate statement about coronary artery plaques?

(A) Plaques with a thick fibrous cap are the most likely to rupture
(B) Coronary computed tomography angiography is effective for assessing plaque composition
(C) A high calcification score correlates with high risk for acute coronary syndrome
(D) Catheterization and stress tests may miss plaques that do not occlude the lumen ****

4. Which of the following is NOT a traditional risk factor for myocardial infarction?
(A) Hypercholesterolemia (C) Male sex ****
(B) Smoking (D) Diabetes

5. Patients with acute coronary syndrome (ACS) are often misdiagnosed with _______, which is the most common source of
noncardiac chest pain.
(A) Gastroesophageal reflux disease (GERD) **** (C) Pulmonary embolism
(B) Costochondritis (D) Anxiety or panic attacks

6. What is the primary difference between the HEART Score and the HEART Pathway for risk stratification of patients with
chest pain?
(A) The HEART Pathway is intended for use in high-risk patients
(B) The HEART Pathway evaluates troponin levels and electrocardiography outcomes at 2 time points *****
(C) The HEART Score has higher sensitivity and greater negative predictive value for acute coronary syndrome (ACS)
(D) The HEART Score does not consider age or history of ACS

7. Which is the preferred vasopressor for managing hypotension in patients with right ventricle (RV) failure?
(A) Dopamine (C) Phenylephrine
(B) Vasopressin (D) Norepinephrine ****

8. Which intubation agent should be avoided in the management of patients with right ventricle failure?
(A) Etomidate (C) Propofol ****
(B) Ketamine (D) Fentanyl

9. Approximately what percentage of patients with deep vein thrombosis have silent pulmonary embolism that does not
require additional management?
(A) 14% (C) 33% ****
(B) 26% (D) 50%

10. The American College of Emergency Physicians (ACEP) recommends the use of which of the following to stratify risk in
patients in the emergency department with pulmonary embolism?
(A) Clinical decision tool ****
(B) Clinical decision tool, echocardiography, and pro–brain natriuretic peptide
(C) Clinical decision tool and troponin levels
(D) Troponin levels and echocardiography

Answers to Audio Digest Emergency Medicine Volume 38, Issue 10: 1-B, 2-B, 3-D, 4-C, 5-A, 6-C, 7-D, 8-B, 9-A, 10-C

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