1. Chest pain

3. Chest pain is difficult to interpret

5. Case 1: ECG

10. The importance of a history Swap JAMA 2005 1.9 Worse than previous angina or similar to previous MI 1.8 Described as pressure 2.0 Associated with nausea or vomiting 2.3 Radiation to left arm 2.4 Associated with exertion 4.1 Radiation to both arms or shoulder 4.7 Radiation to R arm or shoulder Positive likelihood ratio Pain Descriptor

11. The importance of a history Swap JAMA 2005 0.8 Not associated with exertion 0.3 Reproducible with palpation 0.3 Described as sharp 0.3 Described as positional 0.2 Describes as pleuritic Positive likelihood ratio Pain Descriptor

13. Markers of myocardial injury

15. PTCA, percutaneous transluminal coronary angioplasty. 5.0%- 6.5% 13%-15% 30% Pre-CCU Era CCU Era Reperfusion Era Improvement in Mortality

17. ECG

24. ECG

38. Case # 5 A 52-year-old man telephones his physician to report a 4-week history of episodic left-sided chest pain lasting 3 to 5 minutes, often occurring at rest, and resolving spontaneously. He is unsure whether the episodes are related to meals. He has not had any shortness of breath, orthopnea, exertional dyspnea, nausea or vomiting. History is significant for hyperlipidemia. Patient has been sedentary for the past several years until 3 months ago when he began exercising. The patient is experiencing significant stress related to his job; he is also in the midst of a divorce. During the course of the phone interview, the patient is asked to determine whether he feels any pain while pressing on his chest over the lateral aspects of the sternum. The patient reports that this maneuver does vaguely reproduce his pain.