STEMI RMA male in his mid 40’s presented with 20 minutes of chest pain in the middle of the night. He had no previous cardiac disease. After looking at his first ECG, you see there is sinus rhythm with left bundle branch block (LBBB).

ECG RMHere’s a formula – and an app – to help you catch this easy-to-miss diagnosis

A 37-year-old man presented to the emergency department with severe respiratory distress. He reported a history of hypertension, diabetes and end-stage renal failure for which he received hemodialysis three times per week. However, he admitted to missing his last two dialysis sessions.

titleA 39-year old female presents to our emergency department with complaints of “worsening of heartburn”. The patient states that for several months she has had episodic indigestion and chest discomfort. She has been taking antacids for several weeks as prescribed by her family doctor without improvement.

"I think my child has swan flu!” You pause and try your hardest to maintain that poker face you’ve perfected. “I saw it on the news,” she continues, “and then my daughter was at Disney World running around with all these swans yesterday. I think they were contagious!”
What does the EKG show? What should you do next?
Although these CDRs summarize what you should be looking for, regarding history, physical examination and diagnostic criteria that put your patients at risk for ACS, they come up short on real-world application. The value, in my opinion, is knowing what those risky elements are, as opposed to actually calculating a TIMI score.
Chest pain is a diagnostic dilemma for the emergency physician. Data from the United States suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed. Information obtained from the history, the initial 12-lead ECG, and a single set of cardiac markers does not have sufficient sensitivity to identify those patients who are safe for early discharge.
A hemodynamically stable middle-aged male presents to your ED with non-pleuritic chest pain and multiple cardiac risk factors. Your diagnostic evaluation includes includes a Troponin-I which unfortunately returns at 0.5 ng/mL, although no ECG changes are noted.
A 40-year-old male presents to the ED after a syncopal episode. In his past medical history he relates a history of frequent debilitating “dizzy spells”. After reviewing his ECG your interpretation/advice is...

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