An update to this arcticle is pending.
Disease | Differentiating signs and symptoms |
---|---|
Aortic dissection Aortic Aneurysm and Dissection | Sudden intense chest pain Blood pressure may be low and pulses asymmetrical New-onset aortic valve regurgitation Dissection may obstruct the origins of coronary arteries with signs of impending infarction Broad mediastinum on chest x-ray |
Acute pulmonary embolism Pulmonary Embolism | Dyspnoea and tachypnoea as the principal symptoms Chest pain in about half of patients Tachycardia, RBBB, low blood pressure in extensive pulmonary embolism; echocardiography shows right-sided dilatation and increased pulmonary pressure Chest x-ray is often normal PaO2 decreased or normal, PaCO2 decreased or normal D-dimer assay positive; negative result excludes pulmonary embolism with high probability |
Spontaneous pneumothorax, tension pneumothorax Pneumothorax | Dyspnoea, chest pain Quiet breath signs on auscultation Chest x-ray will confirm diagnosis |
Oesophageal tear, perforated ulcer Peptic Ulcer Disease, Helicobacter Pylori Infection and Chronic Gastritis | Chest pain, upper abdominal pain |
Pericarditis Pericarditis, myocarditis Myocarditis | Pain is usually retrosternal and is sharp or tearing in nature The pain is aggravated by inspiration, coughing and changing of position A friction rub may be heard ST-T changes with almost daily alternations |
Pleuritis Pleural Effusions and Thoracentesis | Signs and symptoms of respiratory tract infection Stabbing chest pain, aggravated by inspiration and coughing |
Costochondral pain Tietze's Syndrome and Costochondritis | Pain on palpation Chest wall movements and breathing may aggravate the pain |
Oesophageal inflammationGastro-Oesophageal Reflux Disease or spasm, dyspepsia Dyspepsia | Heartburn, chest pain, upper abdominal pain May be worse in recumbent position and on exertion (reflux) No ECG changes Relief from PPIs |
Early herpes zoster Shingles (Herpes Zoster) | No ECG changes Rash appears within a few days Localised paraesthesia before the appearance of the rash |
Hyperventilation syndrome Hyperventilation | Strong feeling of lack of air Fast and deep breathing Cold limbs with tingling and numbness Dizziness, headache, dry mouth PaCO2 decreased, PaO2 increased or normal |
Depression Recognition and Diagnostics of Depression | Continuous feeling of heaviness in the chest, no correlation to exercise ECG normal |
ECG changes associated with prior Q wave myocardial infarction - an adaptation of the recommendations by the joint ESC/ACCF/AHA/WHF task force | |
---|---|
Adapted from:Eur Heart J 2012;33:2551-2567. | |
1 | Any Q wave in leads V2-V3 HASH(0x2f82cc8) 20 ms or QS complex in leads V2 and V3 |
2 | Q wave HASH(0x2f82cc8) 30ms and HASH(0x2f82cc8) 1 mV deep or QS complex in leads I, II, aVL, aVF or V4-V6 in at least two leads of a contiguous lead grouping (which are I, aVL; V1-V6; II, III, aVF, and V7-V9) |
3 | R wave HASH(0x2f82cc8) 40 ms in V1-V2 and R/S ratio HASH(0x2f82cc8) 1 with a concordant positive T wave in the absence of a conduction defect |
ECG change | To be considered in the differential diagnosis |
---|---|
Source: Porela, Ilva. Sepelvaltimotautikohtauksen diagnostiikka ja epidemiologia (Diagnosis and epidemiology of acute coronary syndrome, In Finnish). In: Airaksinen et al. (eds.) Kardiologia, Kustannus Oy Duodecim, 2016, p. 392. | |
ST elevation | Early repolarisation |
Perimyocarditis | |
Hypertrophic cardiomyopathy | |
Brugada syndrome | |
Pulmonary embolism | |
Left ventricular hypertrophy | |
Hyperkalaemia | |
ST depression | Sympathicotonia |
Hyperventilation | |
Microvascular angina | |
Left ventricular hypertrophy | |
Digoxin | |
Post tachyarrhythmia | |
Mitral prolapsed | |
T wave changes | Normal variant |
Hyperventilation | |
Increased intracranial pressure | |
An electrolyte disturbance | |
Acute cor pulmonale (pulmonary embolism) | |
Takotsubo cardiomyopathy | |
Q wave | Left ventricular hypertrophy (Lead V1) |
Hypertrophic cardiomyopathy | |
Right ventricular pressure and volume overload | |
Pneumothorax | |
Duchenne muscular dystrophy | |
Abnormal position of the heart (Leads II, III and aVF) | |
Myocarditis | |
Left anterior fascicular block (right sided chest leads) |
Modified from: Eskola et al. Epävakaa angina pectoris ja sydäninfarkti ilman ST-nousua (NSTEMI): vaaran arviointi ja ennuste. [Unstable angina pectoris and non-ST elevation myocardial infarction (NSTEMI): assessment of danger and prognosis] (In Finnish). Publication: Airaksinen et al. (ed.) Kardiologia. Duodecim Publishing Company Ltd., 2016, p. 404. *The timing of angiography indicated in the table is in accordance with the most recent European guideline. It is important to follow the guidelines locally agreed on. | |
Risk category | Risk assessment criteria and urgency of angiography* |
---|---|
High risk | Very high risk: angiography < 2 h |
| |
High risk: angiography < 24 h | |
| |
Medium risk: angiography within 3 days (72 hours) | |
| |
Low risk | None of the above mentioned signs of danger |
No repeating chest pain during observation | |
No changes suggesting ischaemia on ECG |
Absolute contraindications | Relative contraindications |
---|---|
Ischaemic stroke or SAH treated in preceding 6 months | TIA in preceding 6 months |
Cerebral haemorrhage or stroke of unknown origin at any time previously | Anticoagulant therapy |
Central nervous system neoplasms or blood vessel anomalies, untreated aneurysm in a cerebral blood vessel | Pregnancy or within 1 week post partum |
Major trauma, head injury or major surgery within preceding 3 weeks or neurosurgical operation within preceding 1 month | Systolic BP >180 mmHg or diastolic BP > 110 mmHg, refractory to treatment |
Gastrointestinal bleeding within one month | Infective endocarditis |
Known bleeding disorder (coagulation disorder, anaemia, thrombocytopenia) | Active peptic ulcer |
Confirmed or suspected aortic dissection | Prasugrel or ticagrelor therapy, especially in patients who have just received a loading dose |
Recent intervention (liver biopsy, lumbar puncture) | Prolonged or traumatic resuscitation |
Drug | Initial dose | |
---|---|---|
Tenecteplase
| Single i.v. bolus dose according to weight | |
weight < 60 kg | 30 mg | |
60-69 kg | 35 mg | |
70-79 kg | 40 mg | |
80-89 kg | 45 mg | |
HASH(0x2f82cc8) 90 kg | 50 mg | |
Reteplase | 10 units × 2 i.v. bolus doses given 30 minutes apart | |
Drug | Intravenous dose |
---|---|
Adapted from the source: Eur Heart J 2008;29:2909-2945 | |
Amiodarone | 150 mg over 10 minutes. Supplemental bolus doses of 150 mg may be given over 10-30 minutes for recurrent arrhythmias, but limited to 6-8 supplemental boluses in any 24 hour period. A maintenance infusion of 1 mg/min for 6 hours followed by 0.5 mg/minute may be necessary after the initial dose. |
Metoprolol | 2.5-5 mg at an interval of 2-5 minutes, up to 3 doses |
Digoxin | 0.25 mg every other hour, up to 1.0 mg, patient-specific assessment! |
Atropine | Rapid bolus dose of at least 0.5 mg, repeated up to a total dose of 1.5-2.0 mg (0.04 mg/kg) |
Isoprenaline | 0.05-0.1 µg/kg/min, up to 2 µg/kg/min. The dose should be adjusted to heart rate and rhythm. |