![]() Findings suggestive of NSTEMI include transient ST elevation, ST depression, or new T wave inversions. ST-elevation or anterior ST depression should be considered a STEMI until proven otherwise and treated as such. A normal ECG does not exclude ACS and NSTEMI. An ECG should be performed as soon as possible in patients presenting with chest pain or those with a concern for ACS. History, ECG, and cardiac biomarkers are the mainstays in the evaluation. Signs of heart failure should increase concern for ACS but are, again, nonspecific findings. Clues such as back pain with aortic dissection or pericardial friction rub with pericarditis may point to an alternative diagnosis for a patient’s chest pain, but no such exam finding exists that indicates ACS as the most likely diagnosis. Physical Exam for ACS and NSTEMI is often nonspecific. While all patients presenting with ACS are more likely to present with typical symptoms than atypical symptoms, the likelihood of atypical presentations increases with age over 75, women and those with diabetes, renal insufficiency, and dementia. Atypical symptoms may include a stabbing or pleuritic pain, epigastric or abdominal pain, indigestion, and isolated dyspnea. ![]() Risk factors for ACS include male sex, older age, family history of coronary artery disease, diabetes, personal history of coronary artery disease, and renal insufficiency. Sudden onset of unexplained dyspnea with or without associated symptoms is also a common presentation. The pain may be associated with dyspnea, nausea or vomiting, syncope, fatigue, or diaphoresis. The pain generally lasts more than 10 minutes and may radiate to either arm, the neck, or the jaw. The “typical” presentation of NSTEMI is a pressure-like substernal pain, occurring at rest or with minimal exertion.
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