“ECG ⊕” Chest Pain Syndromes

• This pages describes the “chest pain” syndromes that may present with ECG changes (“ECG ⊕”)

Culprit vs. Bystander ⚡

• “Culprit” ⚡: refers to ECG findings of chest pain resulting from a primary cardiac issue of the myocardium (many) or pericardium (pericarditis), secondary cardiac issue related to strain (PE), & diffuse vs. focal supply-demand mismatch. In supply-demand mismatch, ischemic chest pain is being driven by an uncontrolled extra-cardiac issue (e.g. severe anemia, hypoxia, acute pulmonary hypertension) rather than a cardiac issue, & tachycardia is often a strong clue. Supply-demand ECG changes can be thought of as those that would be seen in a ⊕ stress test, because they quite literally account for ischemic chest pain related to supply-demand mismatch: they are simply being caught out “in the wild” rather than in a cardiologist’s stress lab

• “Bystander” ⚡: refers to ECG findings completely unrelated to symptoms, with the ECG findings being related to baseline repolarization issues vs. artifact

“Can’t Miss,” Initial Work-Up 🚨

• ECG: intent is to catch OMIs, but there are 2 important caveats. First, ECG ⊖ OMIs should be considered if the story is very compelling for unrelenting ischemia (i.e. consider electrocardiographically silent posterior wall OMI). Second, the ECG may shed light on another “ECG ⊕ chest pain” syndrome (see DDx). CXR: pneumothorax. CT chest w/ IV contrast: pulmonary embolism → infarction, aortic dissection, pneumonia. Echocardiogram: partly for further OMI work-up, partly for pericardium assessment, & partly for evaluation of evolving endocarditis

Role of Stress Testing 💨

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• Not All Waves Are Factual