Skill Checkup: Man With a History of Type 2 Diabetes Complicated by Peripheral Neuropathy Presents With New Dyspnea

Alanna Morris, MD


January 27, 2022

The ECG is the key investigative tool in the initial evaluation and triage of patients in whom an acute coronary syndrome is suspected. Expert medical societies and organizations, including the American College of Cardiology (ACC) and the American Heart Association (AHA), have highlighted the importance of obtaining a 12-lead ECG in a timely fashion (≤ 10 min of presentation) in their recommendations for the evaluation and diagnosis of chest pain. The symptoms of acute myocardial infarction can be subtle; thus, an ECG should be performed on any patient who is older than 45 years and is experiencing any form of thoracoabdominal discomfort, including new epigastric pain or nausea.

Guidelines also recommend performing serial ECGs upon presentation to evaluate progression and assess changes with and without pain.

In addition to ECG, high-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, which enables more accurate detection and exclusion of myocardial injury. After initial measurement at presentation, serial measurement of cardiac troponins 3-6 hours after symptom onset is recommended. In patients with initial negative levels, additional measurements beyond the 6-hour mark should be obtained.

When there is a low to average likelihood of coronary artery disease and when cardiac troponin and/or ECG results are inconclusive, multidetector CT coronary angiography may be considered as an alternative to invasive angiography to exclude an acute coronary syndrome.

Measurement of B-type natriuretic peptide or N-terminal pro B-type natriuretic peptide is not recommended for diagnosis of myocardial infarction; however, these biomarkers are useful for risk stratification and prognostication in patients with acute myocardial infarction who may have congestive heart failure.

Endomyocardial biopsy is not recommended for the diagnosis of myocardial infarction but may be used in the setting of myocarditis, cardiomyopathy, and heart failure.

An ECG is ordered for this patient and shows convex ST-segment elevation > 1 mm in two anatomically contiguous leads and the presence of new Q waves.


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