CHEST DISCOMFORT

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H a r r i s o n ’ s P r i n c i p l e o f I n t e r n a l M e d i c i n e , 2 0 E d . C h a p t e r 1 1

3 CATEGORIES CAUSES OF CHEST DISCOMFORT

1. Myocardial Ischemia
2. Other Cardiopulmonary causes
• Pericardial Disease
• Aortic Emergencies
• Pulmonary Conditions
3. Non-Cardiopulmonary causes
EPIDEMIOLOGY & NATURAL HISTORY
GI Causes
• Most common diagnoses
Cardiopulmonary conditions
• <10%
Myocardial Infarction (MI)
• 2% to 6% of px with Chest Discomfort of presumed
non-ischemic etiology who are discharged from the
ED are later deemed to have had a missed MI
o Have a 30-day risk of death
o Double that of their counterparts who are
hospitalized.

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MYOCARDIAL ISCHEMIA/INJURY CLASSIFICATION OF MI
1. Type 1 MI
Angina Pectoris • Results from Acute Coronary Thrombosis
• Chest discomfort caused by Myocardial Ischemia 2. Type 2 MI
• Primary clinical concern in chest discomfort • Occurs secondary to other imbalances of
• Imbalance between myocardial oxygen supply & demand
o Myocardial oxygen REQUIREMENTS Non-atherosclerotic that can lead to Coronary Obstruction
o Myocardial oxygen SUPPLY 1. Congenital Abnormalities Of The Coronary Vessels
Affects oxygen CONSUMPTION 2. Myocardial Bridging
1. Increases In Heart Rate 3. Coronary Arteritis
2. Ventricular Wall Stress 4. Radiation-Induced Coronary Disease
3. Myocardial Contractility Extreme Myocardial Oxygen Demand & Impaired
Affects oxygen SUPPLY Endocardial Blood Flow
1. Coronary Blood Flow • can precipitate myocardial ischemia in Px w/ or
2. Coronary Arterial Oxygen Content w/out underlying Obstructive Atherosclerosis
Myocardial Infarction 1. Aortic Valve Disease
• irreversible cellular injury the results when 2. Hypertrophic Cardiomyopathy
myocardial ischemia is sufficiently severe and 3. Idiopathic Dilated Cardiomyopathy
prolonged in duration (20 min)
Atheromatous Plaque
• most common cause of Ischemic Heart Disease CHARACTERISTICS OF ISCHEMIC CHEST
Stable Ischemic Heart Disease (SIHD) DISCOMFORT
• results from the gradual atherosclerotic narrowing of Angina Pectoris “Angina”
the coronary arteries • Highly similar clinical characteristics between SIHD,
Stable Angina UIHD, MI, or Unstable Angina
• characterized by ischemic episodes that are typically o Except in the differences in PATTERN &
precipitated by a superimposed INCREASE in oxygen DURATION of symptoms
demand during physical exertion Characteristic of Myocardial Ischemia (Table 11-1)
• Relieved upon RESTING • Quality
Stable > Unstable Ischemic Heart Disease (UIHD) o Aching
o Heavy
• when rupture or erosion of one or more
o Squeezing
atherosclerotic lesions triggers coronary thrombosis
o Crushing
• classified clinically by:
o Constricting
o Presence or absence of detectable
o Minority
myocardial injury
▪ May be extremely vague
o Presence or absence of ST-segment
▪ Mild tightness
elevation in ECG
▪ Merely an uncomfortable feeling
• Symptoms may also occur predominantly because of
▪ Numbness
o Increased myocardial oxygen DEMAND
▪ Burning sensation
▪ Intense psychological stress
• Site of discomfort
▪ Fever
o Retrosternal (usually)
o DECREASED oxygen delivery
o Radiation is common
▪ Anemia
▪ Ulnar surface of Left Arm
▪ Hypoxia
(generally)
▪ Hypotension
▪ Both arms
Acute Coronary Atherothrombosis
▪ Neck
• Intracoronary thrombus may be partially obstructive
▪ Jaw
o generally leading to myocardial ischemia in
▪ Shoulders
the ABSENCE of ST-segment
Stable Angina
Unstable Angina
• Usually begins GRADUALLY
• Marked by ischemic symptoms at rest, with minimal
• Reaches its maximal intensity over a period of
activity or in an accelerating pattern
minutes before dissipating within several minutes
• no detectable myocardial injury
with REST or with NITROGLYCERIN
Non-ST Elevation MI (NSTEMI)
• Occurs predictably at characteristic level of
• there is evidence of myocardial necrosis
o Exertion
ST Elevation MI (STEMI)
o Stress
• Transmural Myocardial Ischemia
Unstable Angina
o When the coronary thrombus is acutely and
• chest discomfort that occurs with progressively
completely occlusive
lower intensity of physical activity or EVEN AT REST
o ST-segment elevation on the ECG
MI
Acute Coronary Syndrome (ACS)
• More severe chest discomfort
• Covers:
• Prolonged (usually ≥30 min)
o Unstable Angina
• NOT RELIEVED BY REST
o STEMI
o NSTEMI
• Ischemia precipitated by ACUTE CORONARY
ATHEROTHROMBOSIS

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MECHANISMS OF CARDIAC PAIN DISEASES OF THE AORTA
ACUTE AORTIC SYNDROME
• spectrum of acute aortic diseases related to
disruption of the media of the aortic wall
• Chest discomfort that is:
o often severe
o sudden in onset
o sometimes described as “tearing” in quality
• Ascending Aortic Syndromes
o Pain in the midline of anterior chest
• Descending Aortic Syndromes
o Most often pain in the BACK
• Dissection that begins in ASCENDING > DESCENDING
o Pain in the front of the chest that extends
toward the back, between the shoulder
blades
Acute Aortic Dissection
• Less common cause of chest discomfort
• Involves a tear in the AORTIC INTIMA
o results in separation of the MEDIA and
creation of a separate “false” lumen
Penetrating Ulcer
• ulceration of an aortic atheromatous plaque that
extends through the INTIMA and into AORTIC MEDIA
OTHER CARDIOPULMONARY CAUSES o potential to initiate an intramedial
dissection or rupture into the ADVENTITIA
Intramural Hematoma
PERICARDIAL & OTHER MYOCARDIAL DISEASES • occur due to either rupture of
Inflammation of Pericardium
o VASA VASORUM
• Infectious or Noninfectious
o Penetrating Ulcer (less common)
• Causes Acute or Chronic pain
• an aortic wall hematoma with
• Insensitive to Pain o no demonstrable intimal flap
o Visceral Surface o no radiologically apparent intimal tear
o Most of Parietal Surface o no false lumen
Pericarditis Proximal Aortic Dissection
• Principally associated with Pleural Inflammation • Dissections that involve the Ascending aorta (type A
• Pleuritic pain exacerbated by: in the Stanford nomenclature)
o Breathing • High risk for major complications:
o Coughing 1. Compromise of the AORTIC OSTIA of the
o Changes in position coronary arteries
• Often referred to Shoulder & Neck ▪ resulting in MI
o overlapping sensory supply of the central 2. Disruption of the AORTIC VALVE
diaphragm via the PHRENIC nerve with ▪ causes Acute Aortic Insufficiency
somatic sensory fibers originating in the C3- 3. Rupture of the hematoma into the
C4 segments pericardial space
Acute inflammatory and other non-ischemic myocardial ▪ Leads to Pericardial Tamponade
diseases can also produce chest discomfort Nontraumatic Aortic Dissections
Takotsubo (Stress-related) Cardiomyopathy • Very rare in the absence of HYPERTENSION or
• symptoms often start abruptly with chest pain & SOB conditions associated with deterioration of the
• triggered by an EMOTIONALLY or PHYSICALLY elastic or muscular components of the AORTIC
STRESSFUL even MEDIA
• May mimic Acute MI o Pregnancy
o ST-segment elevation o Bicuspid Aortic Disease
o Elevated BIOMARKERS of myocardial injury o Inherited Connective Tissue Diseases
Acute Myocarditis (Marfan and Ehlers-Danlos syndromes)
• Highly varied symptoms Aortic Aneurysms
• Chest discomfort may either originate from: • most often asymptomatic
o Inflammatory injury of the MYOCARDIUM • Thoracic Aortic Aneurysms
o Due to severe increases in wall stress o can cause chest pain and other symptoms
related to poor ventricular performance by compressing adjacent structures
o Pain:
▪ Steady
▪ Deep
▪ Occasionally severe
Aortitis
• Rare cause of chest or back discomfort in the
ABSENCE of Aortic Dissection

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PULMONARY CONDITIO NS NONCARDIOPULMONARY CAUSES
Pulmonary and pulmonary-vascular conditions
• Causes chest discomfort in conjunction with
DYSPNEA GASTROINTESTINAL CONDITIONS
• Symptoms are PLEURITIC in nature • most common cause of nontraumatic chest
discomfort
PULMONARY EMBOLISM Esophageal Disorders
• Sudden onset of DYSPNEA & CHEST DISCOMFORT • May simulate angina in the character and location of
• Pleuritic in pattern the pain
• Possible Mechanisms: GERD & Disorders of Esophageal Motility
1. Involvement of the pleural surface of the • Common and should be considered in the
lung adjacent to a resultant pulmonary differential diagnosis of chest pain
infarction Acid Reflux
2. Distention of the pulmonary artery • Burning discomfort
3. Right ventricular wall stress and/or Esophageal Spasm
subendocardial ischemia related to acute • Pain is intense, squeezing discomfort
pulmonary hypertension • Retrosternal
Small Pulmonary Emboli • Relieved by Nitroglycerin or Dihydropyridine CCBs
• Pain is often LATERAL & PLEURITIC (like angina)
• Caused by either of the 3 mechanisms PUD
Massive Pulmonary Emboli • Pain is EPIGASTRIC in location
• Severe SUBSTERNAL PAIN • May radiate into the chest
• May mimic MI Hepatobiliary Disorders
• Involves 2nd & 3rd mechanism • may mimic acute cardiopulmonary diseases
• may also be associated with • Pain localizes to the RUQ of the abdomen
o Syncope o May be felt in the Epigastrium
o Hypotension o May radiate to the Back and Lower Chest
o signs of Right Heart Failure Pain is steady
• Lasts several hours and subsides spontaneously
PNEUMOTHORAX • without symptoms between attacks
Primary Spontaneous Pneumothorax Pancreatitis
• rare cause of chest discomfort • Epigastric pain that radiates to the Back
• Risk Factors:
o Male Sex
o Smoking MUSCULOSKELETAL & OTHER CAUSES
o Family History • Chest discomfort caused by disorders involving chest
o Marfan Syndrome wall or nerves of neck or upper limbs
• Symptoms Tietze’s Syndrome
o Mild Dyspnea • Costochondritis causing tenderness of the
o Sudden in onset costochondral junctions
Secondary Spontaneous Pneumothorax Cervical Radiculitis
• Px with underlying Lung disorders • manifest as a prolonged or constant aching
o COPD discomfort in the upper chest and limbs
o Asthma Other Causes
o Cystic Fibrosis • Compression of the BRACHIAL PLEXUS by the cervical
• More severe symptoms ribs
Tension Pneumothorax • Tendinitis or Bursitis involving the left shoulder may
• Caused by trapped intrathoracic air that precipitates mimic the radiation of angina
hemodynamic collapse
EMOTIONAL & PSYCHIATRIC CONDITIONS
OTHER PULMONARY PARENCHYMANL, PLEURAL, • 10% who present with acute chest discomfort have a
OR VASCULAR DISEASE PANIC DISORDER or related condition
Pleurisy APPROACH TO THE PATIENT
• Knifelike pain that is worsened by INSPIRATION or
COUGHING
• Involvement of Pleura in Pneumonia or Malignancy
Chronic Pulmonary Hypertension
• can manifest as chest pain that may be very similar
to angina in its characteristics
• suggesting right ventricular myocardial ischemia in
some cases.
Reactive airways diseases
• cause chest tightness associated with breathlessness
rather than pleurisy

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HISTORY Fleeting Pain
• Quality • Lasting only seconds
• Location (including Radiation) • Rarely ischemic in origin
• Pattern (onset & duration) Pain that is CONSTANT in intensity
• Provoking or Alleviating factors • prolonged period
• Associated symptoms • unlikely ischemic if it occurs in the absence of other
clinical consequences (ECG, biomarkers, etc.)
QUALITY OF PAIN Morning Onset
• Never sufficient to establish a diagnosis • May occur in Myocardial Ischemia and Acid Reflux
Myocardial Ischemic Pain
• Pressure or tightness PROVOKING & ALLEVIATING FACTORS
• Some Px may deny any “pain” and rather complains Myocardial Ischemic pain
of DYSPNEA or vague sense of ANXIETY • usually prefer to rest, sit, or stop walking
• Ask about the similarity of discomfort to previous “Warm-up Angina”
definite ischemic symptoms • some Px experience relief from angina as they
• Unusual for Angina to be sharp knifelike, stabbing, or continue at the same (or greater) level of exertion
pleuritic Musculoskeletal Etiology
o Px sometimes use “sharp” to convey • Alterations in the intensity of pain with changes in
intensity rather than quality. position or movement of the upper extremities and
Pleuritic Discomfort neck
• Suggestive of PULMONARY EMBOLISM or Pulmonary Pericarditis
parenchymal processes. • Pain is often worse in SUPINE
• Massive Pulmonary Embolism or Pericarditis • Relieved by sitting UPRIGHT & LEANING forward
o Less frequently have a steady pressure or GERD
aching similar to myocardial ischemia • May be exacerbated by alcohol, some foods
“Tearing” or “Ripping” Pain • Exacerbated in RECLINED position
• Acute Aortic Dissection • Relief with SITTING
• Or severe knifelike pain Exacerbation by eating
Burning • GI etiology
• Acid reflux or PUD o PUD
• May also occur in Myocardial Ischemia ▪ Symptomatic 60-90 min after meal
Esophageal Pain o Cholecystitis
• Ca be a severe squeezing discomfort identical to o Pancreatitis
angina, particularly with SPASM Postprandial Angina
• Occurs in the setting of Severe Coronary
LOCATION OF DISCOMFORT Atherosclerosis
• Px may present with aching in sites of radiated pain • Results from redistribution of blood flow to the
as their only symptoms of ischemia splanchnic vasculature after eating
Substernal radiating to Neck, Jaw, Shoulder, or Arms Nitroglycerin
• Typical Myocardial Ischemia • Relieves Angina & Esophageal Spasm
• May also occur in EPIGASTRIUM • > 10 min delay of relief is either:
Radiation to Both Arms o Not caused by ischemia
• High association with MI o Caused by severe ischemia (ACUTE MI)
Highly Localized Pain
• Ex. Demarcated by the tip of 1 finger ASSOCIATED SYMPTOMS
Symptoms that accompany Myocardial Ischemia
• Highly unusual for Angina
o Diaphoresis
Retrosternal
o Dyspnea
• Consider esophageal pain
o Nausea
• GI conditions usually present with pain intense in
o Fatigue
ABDOMEN or EPIGASTRIUM with possible radiation
o Faintness
to chest
o Eructation
Angina
• May exist in isolation (Anginal equivalent)
• Rare in pain that occurs SOLELY above MANDIBLE or
o Particularly in Women & Elderlies
below EPIGASTRIUM
Dyspnea
Severe pain radiating to the BACK
• Suggests cardiopulmonary etiology
• Particularly between shoulder blades
Sudden onset of significant RESPIRATORY DISTRESS
• Acute Aortic Syndrome
• Pulmonary Embolism
Radiation to the TRAPEZIUS ridge
• Spontaneous Pneumothorax
• Characteristic of pericardial pain
Hemoptysis
• Does not usually occur with angina
• Pulmonary Embolism
• Severe Heart Failure
PATTERN
o blood-tinged frothy sputum
Myocardial Ischemic
Syncope
• usually builds over minutes and is exacerbated by
• Hemodynamically significant Pulmonary Embolism
activity and mitigated by rest
• Aortic Dissection
Pain that REACHES ITS PEAK INTENSITY IMMEDIATELY
• Ischemic Arrhythmias
• Aortic Dissection
• Pulmonary Embolism
• Spontaneous Pneumothorax
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Nausea & Vomiting PULMONARY
• GI disorders Examination of Lungs to localize pulmonary causes
• may also occur in MI • pneumonia, asthma, or pneumothorax
o Inferior MI Left Ventricular Dysfunction
o Due to activation of the vagal reflex • from severe ischemia/infarction as well as acute
o Stimulation of left ventricular receptors as valvular complications of MI
part of the Bezold-Jarisch reflex Aortic Dissection
• can lead to PULMONARY EDEMA
PAST MEDICAL HISTORY o indicator of high risk
Assessment for Risk Factors of
• Coronary Atherosclerosis CARDIAC
• Venous Thromboembolism Jugular Venous Pulse
• Connective tissue diseases (Marfan Syndrome) • often normal in Acute Myocardial Ischemia
o Acute Aortic Dissection • have characteristic patterns in:
o Spontaneous Pneumothorax o Pericardial Tamponade
• Elicit clues of DEPRESSION & prior PANIC ATTACKS o Right Ventricular Dysfunction
Cardiac Auscultation
PHYSICAL EXAMINATION • may reveal a 3rd/4th (more common) heart sound
o Myocardial Systolic or Diastolic Dysfunction
GENERAL STEMI with Mechanical Complications
Acute MI/Acute Cardiopulmonary Disorders • Murmurs of mitral regurgitation or
• often appear anxious, uncomfortable, pale, cyanotic, • Ventricular-septal defect
or diaphoretic Murmur of Aortic Insufficiency
Levine’s Sign • may be a PROXIMAL AORTIC DISSECTION
• Px massaging or clutching their chests may describe complication
their pain with a clenched fist held against the Pericardial Friction Rubs
sternum • Pericardial Inflammation

VITAL SIGNS ABDOMINAL

Significant Tachycardia & Hypotension • Rare in purely Acute Cardiopulmonary problems
• Indicates important hemodynamic consequence except in
• Rapid survey for severe conditions o Chronic Cardiopulmonary Disease
o Acute MI with cardiogenic shock o severe RIGHT VENTRICULAR DYSFUNCTION
o Massive Pulmonary Embolism leading to hepatic congestion
o Pericarditis with Tamponade Vascular Pulse Deficits
o Tension Pneumothorax • may reflect CHRONIC ATHEROSCLEROSIS
Acute Aortic Emergencies o Increases the likelihood of Coronary Artery
• Usually presents with severe HYPERTENSION Disease
• Hypotension may also occur IN Aortic Dissection
o Coronary Arterial Compromise • Complications may cause Acute Limb Ischemia with
o Dissection into the PERICARDIUM loss of the pulse and pallor, particularly in the upper
Sinus Tachycardia extremities
• Important manifestation of SUBMASSIVE Venous Thromboembolism
PULMONARY EMBOLISM • Unilateral lower-extremity swelling
Low-grade Fever
• Non-specific

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MUSCULOSKELETAL CARDIAC TROPONIN
Pain in Costochondral and Chondrosternal articulations • Preferred biomarker for MI
• may be associated with localized swelling, redness, o superior cardiac tissue-specificity compared
or marked localized tenderness with Creatine Kinase MB
• Pain on palpation • measured in suspected ACS at presentation
o well localized o repeated in 3-6 h
o deep palpation may elicit pain in the o testing after 6 h
absence of costochondritis ▪ when there is uncertainty
Sensory Deficit regarding the onset of pain
• indicative of Cervical Disk Diseases ▪ when stuttering symptoms have
occurred
• not necessary of advisable if without suspicion of
ELECTROCARDIOGRAPHY ACS
• Should be obtained within 10 mins of presentation o unless for risk stratification (Pulmonary
• Primary goal is to identify embolism or HF)
o ST-segment elevation diagnostic of MI • concentration below detection in Px presenting >2h
o Candidates for immediate interventions to of symptoms
restore flow in the occluded coronary artery o sufficient to exclude MI (99%)
• Poor sensitivity for ischemia (20% in some studies) MI
Indicative of higher risk of death or RECURRENT ISCHEMIA • acute myocardial injury that is marked by a rising
• ST-segment DEPRESSION & SYMMETRIC T-wave and/or falling patter
inversions (at least 0.2mV) in the ABSENCE of STEMI o at least one value exceeding the 99th
Evaluation of suspected ACS percentile reference limit—and that is
• ECGs every 30-60 min caused by ischemia
ECG with Right-sided Lead-placement
• Px clinically suspected of Ischemia D-DIMER TEST
Abnormal in ST-segment & T-wave • aid in exclusion of Pulmonary Embolism
• Pulmonary Embolism
o Sinus Tachycardia B-TYPE NATRIURETIC PEPTIDE
o Or RIGHTWARD SHIFT of the ECG axis • aid in diagnosing HF
▪ S-wave in Lead I • prognosis of
▪ Q-wave & T-wave in Lead III o ACS
• Ventricular Hypertrophy o Pulmonary Embolism
• Acute & Chronic Pericarditis
• Myocarditis INTEGRATIVE DECISION-AIDS
• Electrolyte Imbalance Use to estimate either:
• Metabolic Disorders 1. Probability of a final diagnosis of ACS
• Hyperventilation associated with panic disorder 2. Probability of major cardiac events during short-term
ST-segment Elevation follow-up
• Distinguishing Pericarditis from Acute MI Identify Low clinical probability of ACS who are candidates
o presence of diffuse lead involvement not for:
corresponding to a specific coronary 1. Early provocative testing for ischemia
anatomic distribution and PR-segment 2. Discharge from the ED
depression Goldman & Lee Decision-aid
• ECG
• Risk indicators
CHEST RADIOGRAPHY
• Routine in acute chest discomfort o Hypotension
o Pulmonary Rales
• Selectively in Px evaluated with subacute or chronic
o Known ischemic heart disease
pain
• Categorized Px into 4 categories ranging from a <1%
• Most useful for identifying pulmonary processes
to a >16% probability of a major cardiovascular
o Pneumonia
complication
o Pneumothorax
ACI-TIPI
ACS
• Acute Cardiac Ischemia Time-Insensitive Predictive
• Often unremarkable
Instrument
• Pulmonary edema may be evident
• Combines the ff to define a probability of ACS:
Aortic Dissection
o Age
• Widening of the mediastinum
o Sex
Westermark’s Sign
o chest pain presence
• Pulmonary embolism (mostly)
o ST-segment abnormalities
• Pericardial Calcification in Chronic Pericarditis
Figure 11-3
• Recently developed decision-aid
CARDIAC BIOMARKER S • Common elements
• Focus on detecting myocardial injury 1. Symptoms typical for ACS
• Detected by presence of circulating proteins 2. Older age
released by damaged myocardial cells 3. Risk factors for or known atherosclerosis
• Initial biomarkers may be in normal range even in 4. Ischemic ECG abnormalities
STEMI 5. Elevated cardiac troponin levels

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 Contrast-enhanced CT
• Can detect focal areas of myocardial injury in the
acute setting
Coronary CT Angiography
• Sensitive for detection of OBSTRUCTIVE CORONARY
DISEASE especially in:
o Proximal third of the Major Epicardial
Coronary Arteries

MRI
Cardiac Magnetic Resonance (CMR)
• Structural and Functional evaluation of the heart and
the vasculature of the chest
• Can be a modality in pharmacologic stress perfusion
imaging
• Gadolinium-enhanced CMR
o Early detection of MI
o define areas of myocardial necrosis
PROVOCATIVE TESTING FOR ISCHEMIA accurately
Exercise Electrocardiography “Stress Testing” o delineate patterns of myocardial disease
• For completion of risk stratification of Px who have that are often useful in discriminating
undergone an initial evaluation ISCHEMIC from NON-ISCHEMIC myocardial
• Has not revealed a specific cause of chest discomfort injury
• useful modality for cardiac structural evaluation of
• Low or selectively Intermediate risk of ACS
Px
• Safe in Px without High-risk findings after 8-12 hours
o Elevated cardiac troponin levels in the
of observation
absence of definite CAD
• Low-risk Px
o Underwent exercise testing in the first 48 hr
o Without evidence of ISCHEMIA
▪ 2% rate of cardiac events
o With evidence of ISCHEMIA
▪ 15% rate of cardiac events
• CONTRAINDICATION
o Ongoing chest pain
Pharmacological Stress Testing
• For those unable to undergo exercise testing
• With either
o Nuclear Perfusion imaging
o Echocardiography

OTHER NONINVASIVE STUDIES

ECHOCARDIOGRAPHY
• Not routine in chest discomfort
• Indicated in Px with
o Uncertain Diagnosis
o Nondiagnostic St Elevation
o Ongoing Symptoms
o Hemodynamic Instability
• Detection of abnormal regional wall motion provides
evidence of possible ISCHEMIC DYSFUNCTION
• Diagnostic in
o Mechanical complications of MI
o Pericardial Tamponade
Transthoracic Echocardiography
• Poor sensitivity for AORTIC DISSECTION
• Intimal flap may sometimes be detected in
ASCENDING AORTA

CT ANGIOGRAPHY
• appears to enhance the speed to disposition of
patients with a low-intermediate probability for ACS
• Major strength is its negative predictive value
• Can exclude
o Aortic Dissection
o Pulmonary Embolism
o Pericardial Perfusion

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