Atypical Presentations of ACS
  • Diaphoresis
  • Unexplained Fatigue
  • N and V 
  • Upper Abdominal Discomfort
  • Exertional symptoms

  • Typical Chest Pain: see Chest Pain for details
  • Pretest Probability of CAD or established CAD : see Chest Pain for details
  • Risk Stratification for short term / long term risk of death or MI: see Chest Pain for details
    • TIMI or GRACE Score or Based on Clinical Characters in a patient with established CAD 
    • TIMI Score Note: Predicts 14 day All cause Mortality Risk, new or recurrent MI, severe recurrent ischemia requiring fluctuation.  

    • GRACE Score: Predicts In-hospital, 6 month to 3 year mortality
      • Some feel it works better than TIMI to predict prognosis in a patient with established ACS  

    • With established CAD, alternatively to TIMI or GRACE score for risk stratification, the following information for risk stratification. 
  • Selection of patients for Early Invasive vs. Initial Conservative Strategy 
    • High risk and often intermediate risk score by any of the above risk stratification: needs to be managed with early invasive strategy until further risk stratification with cardiac cath. 
    • Low risk patient: may be managed with initial conservative strategy while doing further risk stratification i.e ECHO or Stress Test 
  • Management (Early Invasive vs Initial Aggressive Strategy): (Start Clopidogrel Based on CURE Trial 2001)

  • NSTEMI - ACS (see the difference in strategy compared to UA/NSTEMI Circulation 2012
    • Ischemia-guided or delayed invaise therapy is preferred term over initial conservative strategy
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

ACS Questions: 

73 y/o F is presenting to ER and office a symptom of intermittent N and V for 2 - 3 weeks. Does have symptoms of UTI, and CT was done which shows  thickening of the esophagus. Patient has DM, CAD, HLD, HTN. 2 weeks back when patient presented with N and V. Patient does not have any abdominal pain. Which of the following is  NOT the diff Dx. 

1. UTI
2. DM with Gastroparesis
3. Reflux Esophagitis 
4. ACS 
5. Pneumonia 
6. Cholelithiasis 
7. Pancreatitis. 

1 week later patient presents to ER with CP of 2 hrs, and EKG shows the following. Patient is taken to cath lab. Stenosis of Proximal LAD (100%), and L-CX (80%) is seen, and patient has DES placement done.