 Welcome to ACS Part 1. In this section we'll discuss the presentations of acute coronary syndromes. ACS or acute coronary syndromes really mean a few different clinical diagnosis. They are all caused by blocked coronary arteries. It can cause irreversible damage to the myocardial cells or myocardial infarction. If the myocardial infarction shows SD elevation on the ECG, it is known as ST elevation MI or STEMI. And if it does not show ST elevation on the ECG, it's known as a non-STEMI. ACS also include ischemia to the myocardium, that is decreased blood supply to the myocardial cells that does not lead to myocardial cell death. Why is a acute coronary syndrome bad? ACS is associated with high mortality and therefore we want to diagnose it early. In this part, we'll talk about the history and the physical you want to do in a patient with chest pain, with an eye towards looking for acute coronary syndrome. For ACS, the history is the most important. We'll first go through the risk factors for ACS and the different component for the presentation. There are some main risk factors for developing acute coronary syndrome. These are the risk factors for developing coronary artery diseases in general. They include smoking, diabetes, hypertension, family history of coronary artery disease, particularly if younger people are affected. It also includes high cholesterol. Even though the risk factors increase the chance of coronary artery disease, you do not need to have any of these risk factors to have an acute coronary syndrome. This is important. Let's go through the different part of the presentation. Patients usually present with chest pain. You want to find out everything about this pain. What is its quality? Is it stabbing, sharp, pressure, crushing? Where is the pain? Have the patient point to where the pain is mostly felt. The severity of the pain? Ask the patient to rate the pain on a scale of 1 to 10. What was the onset of the pain? Both the time of the onset and what the patient was doing. How long did the pain last? Is it the first time the patient has been having this kind of pain or have they felt it before? And if so, what kind of frequency have they been experiencing this pain? If they have any history of coronary artery disease before, is it similar to any of the pain they have experienced relating to that? We also need to find out if the pain radiates to anywhere. For example, jaw, shoulders, arm, or back. We also want to know what makes the pain better or worse. Is the pain pleuritic? As in, is the pain worse when the patient takes in a big breath? Is the pain positional? Is the pain different if the patient is lying down versus sitting up? Is the pain worse or better with exercise? Is the pain better or worse with rest? We also want to ask about associated symptoms. They include shortness of breath, diaphoresis, nausea, and presyncope. A history that's worrisome for ACS will include retrosternal chest pressure, radiation to both arms or shoulders, exertional pain that's better with rest, pain that is not pleuritic or positional, association with nausea or diaphoresis, and particularly if the patient has had previous MI or ACS before and the patient tells you this pain is exactly the same, that increases the possibility of this being an acute coronary syndrome. However, patients can also have atypical ACS symptoms. In terms of the chest pain description, the patient can have very mild discomfort. It may not even be in the chest at all. It could be isolated in the shoulder, arm, jaw, or epigastric area, really anywhere but the chest region. They may not have the chest discomfort at all and may only have shortness of breath or diaphoresis. The patient might describe the pain as sharp or similar to heartburn. It may even be pleuritic or reproducible on palpation. The pain may not be worse with exertion and may not get better with rest. Because patients can have these very atypical symptoms, we want to have a very low threshold of investigating patients. If not, we will miss them. We see more atypical symptoms in the elderly, women, and diabetics. In terms of physical examination, the patients can present in a range of symptoms from sick to well-looking. The sick patient might present in full cardiac arrest or have unstable vitals including hypotension or hypertension, brady or tachycardia, or tachypnea, or they can look well with no obvious complaints. Specifically on the cardiac exam, you want to elicit the S1 and S2, any other extra heart sounds, presence of murmurs, you would also look for increased JVP as well. On the respiratory exam, you want to listen for crackles and the presence of breath sounds. In summary, we discussed the presentations of ACS. Remember that ACS include myocardial infarction with or without SD elevation on EKG and myocardial ischemia and that history is key in diagnosis of patients with ACS. While the typical symptoms will be very helpful for us, patients can often have atypical symptoms, in particular in the elderly, female, and patients with diabetes. In part two, we'll discuss using the ECG to diagnose patients with ACS. Hope you find this useful. Thank you for watching.