0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54
408 Coronary Syndromes, Acute■Pulmonary edema, most likely related to ischemia
■New or worsening MR murmur
■S3 or new/worsening rales
■Hypotension
■Tachycardia
■Bradycardia
■Age >75 (age >70 but not >75 is intermediate risk)
■Physical exam should also aim to exclude other precipitants of
angina, e.g. uncontrolled HTN, thyrotoxicosis, aortic stenosis, hyper-
trophic cardiomyopathytests
■Basic blood tests:
➣Differentiate UA from NSTEMI by presence of cardiac enzy-
mes
Troponins (TnT or TnI)
More sensitive and specific that CK-MB
Low sensitivity in first 6 hours after symptom onset
Useful for selection of therapy / risk stratification
Detects recent MI up to 2 weeks after onset
CK-MB
Prior standard and still acceptable
Less sensitive than troponins
Less specific in setting of skeletal muscle disease
Better ability to detect early re-infarction
Myoglobin
Highly sensitive
Rapid release kinetics-detects MI early
Very low specificity in setting of skeletal muscle disease limits
value for ruling out MI
➣High risk: TnT or TnI >0.1 ng/ml
➣Intermediate risk: Tn >0.01 but <0.1 ng/ml
➣Low risk: normal troponin
■Specific diagnostic tests
➣12-lead electrocardiogram (ECG)
➣Important for risk assessment of UA and NSTEMI and exclusion
of STEMI
High-risk features:
Transient ST changes of≥0.05 mV with angina at rest
LBBB or RBBB, new or presumed new
Sustained VT