Chest pain electrocardiogram: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(27 intermediate revisions by 10 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Chest pain}}
{{Chest pain}}
{{CMG}}  
{{CMG}}{{AE}}{{Aisha}}
 
Please help WikiDoc by adding more content here.  It's easy!  Click  [[Help:How_to_Edit_a_Page|here]]  to learn about editing.


==Overview==
==Overview==
The key findings to look for on EKG is [[ST elevation]] which is characteristic of [[myocardial infarction]]. Diffuse ST elevation may point to the diagnosis of [[pericarditis]]. Serial EKG's should be obtain to evaluate for continued or progression of myocardial injury over time.
The key findings to look for on an [[ECG]] is the [[ST elevation]] which is characteristic of [[myocardial infarction]]. However, The major challenge is the differential between [[NSTE-ACS]] and non-cardiac [[chest pain]]. Diffuse [[ST elevation]] may point to the [[diagnosis]] of [[pericarditis]]. A serial [[ECG]] should be obtained to evaluate for continued or progression of [[myocardial]] injury over time.


==Electrocardiogram==
==Electrocardiogram==
* [[Electrocardiogram]] is usually required for initial evaluation.
 
* [[ST elevation]] should require further urgent evaluation for reperfusion therapy.
== 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/ SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref> ==
* Salient findings on ECG are:
{| class="wikitable"
** New ST elevation (>1 mm) or Q waves on ECG (MI)
|-
** ST depression >1 mm or ischemic T waves (unstable angina)
| Colspan="1" style="text-align:center; background: LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| Bgcolor="LightGreen"|<nowiki>"</nowiki>'''1''' In [[patients]] presented with [[chest pain]] and non diagnostic [[ECG]], performing serial [[ECG]] is recommended, especially in [[patients]] with high clinical suspicion of [[ACS]], persistent [[symptoms]], or clinical [[condition]] deterioration, .'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence C-EO]])<nowiki>"</nowiki>''
|-
| Colspan="2" style="text-align:center; background: LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| Bgcolor="LightGreen"|<nowiki>"</nowiki>'''2'''  In [[patients]] with [[chest pain]] and evidence of [[ischemia]] on [[ECG]], treatment should be done based on the guideline of [[STEMI]], [[NSTE-ACS]]'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence C-EO]])<nowiki>"</nowiki>''
|-
| Colspan="2" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| Bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3'''  In [[patients]] with [[chest pain]] and nondiagnostic [[ECG]] and evidence of intermediate to high clinical suspicion of [[ACS]], leads V7-V9 should be taken for evaluation of  [[posterior STEMI]]'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence B-NR]])<nowiki>"</nowiki>''
|}
 
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |
|-
|}
[[Electrocardiogram|An electrocardiogram]] is usually required for the initial evaluation of chest pain.
It is very useful for the [[diagnosis]] of several etiologies of chest pain such as:
 
====[[Acute coronary syndromes|Acute coronary syndrome]]====
 
*A standard 12 lead [[ECG]] is recommended in all patients with chest pain within 10 minutes of presentation if acute coronary syndrome is suspected. <ref name="pmid3661390">{{cite journal |vauthors=Slater DK, Hlatky MA, Mark DB, Harrell FE, Pryor DB, Califf RM |title=Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings |journal=Am. J. Cardiol. |volume=60 |issue=10 |pages=766–70 |date=October 1987 |pmid=3661390 |doi=10.1016/0002-9149(87)91020-4 |url=}}</ref><ref name="pmid3920520">{{cite journal |vauthors=Brush JE, Brand DA, Acampora D, Chalmer B, Wackers FJ |title=Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction |journal=N. Engl. J. Med. |volume=312 |issue=18 |pages=1137–41 |date=May 1985 |pmid=3920520 |doi=10.1056/NEJM198505023121801 |url=}}</ref>
*Findings on an [[ECG]] suggestive of [[ACS]] include <ref name="pmid3970650">{{cite journal |vauthors=Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L |title=Acute chest pain in the emergency room. Identification and examination of low-risk patients |journal=Arch. Intern. Med. |volume=145 |issue=1 |pages=65–9 |date=January 1985 |pmid=3970650 |doi= |url=}}</ref><ref name="O'GaraKushner2013">{{cite journal|last1=O'Gara|first1=Patrick T.|last2=Kushner|first2=Frederick G.|last3=Ascheim|first3=Deborah D.|last4=Casey|first4=Donald E.|last5=Chung|first5=Mina K.|last6=de Lemos|first6=James A.|last7=Ettinger|first7=Steven M.|last8=Fang|first8=James C.|last9=Fesmire|first9=Francis M.|last10=Franklin|first10=Barry A.|last11=Granger|first11=Christopher B.|last12=Krumholz|first12=Harlan M.|last13=Linderbaum|first13=Jane A.|last14=Morrow|first14=David A.|last15=Newby|first15=L. Kristin|last16=Ornato|first16=Joseph P.|last17=Ou|first17=Narith|last18=Radford|first18=Martha J.|last19=Tamis-Holland|first19=Jacqueline E.|last20=Tommaso|first20=Carl L.|last21=Tracy|first21=Cynthia M.|last22=Woo|first22=Y. Joseph|last23=Zhao|first23=David X.|title=2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction|journal=Journal of the American College of Cardiology|volume=61|issue=4|year=2013|pages=e78–e140|issn=07351097|doi=10.1016/j.jacc.2012.11.019}}</ref>, [[ST elevation]], [[ST depression]] and a new [[left bundle branch block]] ([[LBBB]])
*It is important to note that a normal [[ECG]] does not rule out the presence of an acute [[myocardial infarction]] as an [[ECG]] can show a hyper-acute [[T wave]] <ref name="pmid11992348">{{cite journal |author=Somers MP, Brady WJ, Perron AD, Mattu A |title=The prominant T wave: electrocardiographic differential diagnosis |journal=Am J Emerg Med |volume=20 |issue=3 |pages=243–51 |year=2002 |month=May |pmid=11992348 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735675702921935}}</ref><ref name="ACS_Clin_NA">Smith SW, Whitwam W. "Acute Coronary Syndromes." ''Emerg Med Clin N Am'' 2006; '''24(1)''': 53-89. PMID 16308113</ref> <ref name="ECG_Noncardiac">"The clinical value of the ECG in noncardiac conditions." ''Chest'' 2004; '''125(4)''': 1561-76. PMID 15078775</ref> as an early presentation.
*If an initial [[ECG]] is non-diagnostic and there is still a high clinical suspicion of an [[MI]], a repeat [[ECG]] should be conducted.
*It is helpful to have precious [[ECG]]<nowiki/>s of a [[patient]] to determine if observed findings are new.
 
Shown below is an [[ECG]] demonstrating clear [[ST elevation]] in the right [[precordial lead]]s depicting [[STEMI]]. A [[coronary angiography]] revealed a proximal [[right coronary artery]] occlusion. <ref name="urlST elevation myocardial infarction electrocardiogram - wikidoc">{{cite web |url=https://www.wikidoc.org/index.php/ST_elevation_myocardial_infarction_electrocardiogram |title=ST elevation myocardial infarction electrocardiogram - wikidoc |format= |work= |accessdate=}}</ref>
[[Image:STEMI 20 a.jpg|center|500px|<ref>http://en.ecgpedia.org/wiki/Main_Page</ref>]]
 
 
'''For more ECG examples of ST elevation myocardial infarction click [[ST elevation myocardial infarction ECG examples|here]]'''
 
====[[Pericarditis]]====
 
*ECG findings in patients with [[Pericarditis|pericarditi]]<nowiki/>s may mirror that seen in [[acute myocardial infarction]] and carrying changes may be seen as the disease progresses.
*Findings on an [[ECG]] suggestive of [[pericarditis]] at different levels include: <ref name="urlPericarditis electrocardiogram - wikidoc">{{cite web |url=https://www.wikidoc.org/index.php/Pericarditis_electrocardiogram |title=Pericarditis electrocardiogram - wikidoc |format= |work= |accessdate=}}</ref>
*Stage I: [[ST elevation]] in all leads; PTa depression (depression between the end of the [[P wave]] and the beginning of the [[QRS]] complex)
*Stage II: Pseudonormalization (transition)
*Stage III: Inverted [[T waves]]
*Stage IV: Normalization
 
[[Image:Stadia pericarditis.png|center|500px|<ref>http://en.ecgpedia.org/wiki/Main_Page</ref>]]
 
====[[Aortic dissection|Acute aortic dissection]]====
 
*[[ECG]] findings in [[aortic dissection]] are usually non-specific. Possible findings include: <ref name="EvangelistaIsselbacher2018">{{cite journal|last1=Evangelista|first1=Arturo|last2=Isselbacher|first2=Eric M.|last3=Bossone|first3=Eduardo|last4=Gleason|first4=Thomas G.|last5=Eusanio|first5=Marco Di|last6=Sechtem|first6=Udo|last7=Ehrlich|first7=Marek P.|last8=Trimarchi|first8=Santi|last9=Braverman|first9=Alan C.|last10=Myrmel|first10=Truls|last11=Harris|first11=Kevin M.|last12=Hutchinson|first12=Stuart|last13=O’Gara|first13=Patrick|last14=Suzuki|first14=Toru|last15=Nienaber|first15=Christoph A.|last16=Eagle|first16=Kim A.|title=Insights From the International Registry of Acute Aortic Dissection|journal=Circulation|volume=137|issue=17|year=2018|pages=1846–1860|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031264}}</ref><ref name="HirataWake2010">{{cite journal|last1=Hirata|first1=Kazuhito|last2=Wake|first2=Minoru|last3=Kyushima|first3=Masahiro|last4=Takahashi|first4=Takanori|last5=Nakazato|first5=Jun|last6=Mototake|first6=Hidemitsu|last7=Tengan|first7=Toshiho|last8=Yasumoto|first8=Hiroshi|last9=Henzan|first9=Eisei|last10=Maeshiro|first10=Masao|last11=Asato|first11=Hiroaki|title=Electrocardiographic changes in patients with type A acute aortic dissection|journal=Journal of Cardiology|volume=56|issue=2|year=2010|pages=147–153|issn=09145087|doi=10.1016/j.jjcc.2010.03.007}}</ref>
 
* Non-specific ST-segment changes
* Evidence of [[acute myocardial infarction]] in %5 of type A
* [[Left ventricular hypertrophy]]
* [[Sinus bradycardia]]
 
*: Abnormal [[ECG]] may result from [[hypertensive]] changes, compromise of [[coronary]] Ostia, or preexisting [[coronary artery disease]].
**[[ECG]] may lead to a delay in the [[diagnosis]] as some [[clinicians]] usually follow the [[diagnosis]] of [[Coronary heart disease|coronary artery disease]] due to its more common prevalence.
 
===Exercise ECG===
 
====Contraindications====
There are conditions that may render the exercise ECG useless for assessing acute coronary syndromes such as:
*Abnormal ST changes on resting ECG;
*Digoxin;
*Left bundle branch block;
*Wolff-Parkinson-White pattern;
*Ventricular paced rhythm (not useful for establishing ischemia);
*Unable to achieve ≥5 METs or unsafe to exercise;
*High-risk unstable angina or acute myocardial ischemia;
*Uncontrolled heart failure;
*Significant cardiac arrhythmias or high risk for arrhythmias caused by QT prolongation;
*Severe aortic stenosis;
*Severe hypertension (eg, ≥200/110mmHg);
*Acute illness.<ref name="pmid34709928">{{cite journal| author=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK | display-authors=etal| title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 144 | issue= 22 | pages= e368-e454 | pmid=34709928 | doi=10.1161/CIR.0000000000001030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34709928  }} </ref>


==References==
==References==
Line 20: Line 92:
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Signs and symptoms]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Mature chapter]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Needs content]]

Latest revision as of 20:45, 29 November 2022

Chest pain Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chest pain from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Chest Pain in Pregnancy

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Chest pain electrocardiogram On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chest pain electrocardiogram

CDC on Chest pain electrocardiogram

Chest pain electrocardiogram in the news

Blogs on Chest pain electrocardiogram

to Hospitals Treating Chest pain electrocardiogram

Risk calculators and risk factors for Chest pain electrocardiogram

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

The key findings to look for on an ECG is the ST elevation which is characteristic of myocardial infarction. However, The major challenge is the differential between NSTE-ACS and non-cardiac chest pain. Diffuse ST elevation may point to the diagnosis of pericarditis. A serial ECG should be obtained to evaluate for continued or progression of myocardial injury over time.

Electrocardiogram

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/ SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[1]

Class I
"1 In patients presented with chest pain and non diagnostic ECG, performing serial ECG is recommended, especially in patients with high clinical suspicion of ACS, persistent symptoms, or clinical condition deterioration, . (Level of Evidence C-EO)"
Class I
"2 In patients with chest pain and evidence of ischemia on ECG, treatment should be done based on the guideline of STEMI, NSTE-ACS (Level of Evidence C-EO)"
Class IIa
"3 In patients with chest pain and nondiagnostic ECG and evidence of intermediate to high clinical suspicion of ACS, leads V7-V9 should be taken for evaluation of posterior STEMI (Level of Evidence B-NR)"

An electrocardiogram is usually required for the initial evaluation of chest pain. It is very useful for the diagnosis of several etiologies of chest pain such as:

Acute coronary syndrome

  • A standard 12 lead ECG is recommended in all patients with chest pain within 10 minutes of presentation if acute coronary syndrome is suspected. [2][3]
  • Findings on an ECG suggestive of ACS include [4][5], ST elevation, ST depression and a new left bundle branch block (LBBB)
  • It is important to note that a normal ECG does not rule out the presence of an acute myocardial infarction as an ECG can show a hyper-acute T wave [6][7] [8] as an early presentation.
  • If an initial ECG is non-diagnostic and there is still a high clinical suspicion of an MI, a repeat ECG should be conducted.
  • It is helpful to have precious ECGs of a patient to determine if observed findings are new.

Shown below is an ECG demonstrating clear ST elevation in the right precordial leads depicting STEMI. A coronary angiography revealed a proximal right coronary artery occlusion. [9]

[10]
[10]


For more ECG examples of ST elevation myocardial infarction click here

Pericarditis

  • ECG findings in patients with pericarditis may mirror that seen in acute myocardial infarction and carrying changes may be seen as the disease progresses.
  • Findings on an ECG suggestive of pericarditis at different levels include: [11]
  • Stage I: ST elevation in all leads; PTa depression (depression between the end of the P wave and the beginning of the QRS complex)
  • Stage II: Pseudonormalization (transition)
  • Stage III: Inverted T waves
  • Stage IV: Normalization
[12]
[12]

Acute aortic dissection

Exercise ECG

Contraindications

There are conditions that may render the exercise ECG useless for assessing acute coronary syndromes such as:

  • Abnormal ST changes on resting ECG;
  • Digoxin;
  • Left bundle branch block;
  • Wolff-Parkinson-White pattern;
  • Ventricular paced rhythm (not useful for establishing ischemia);
  • Unable to achieve ≥5 METs or unsafe to exercise;
  • High-risk unstable angina or acute myocardial ischemia;
  • Uncontrolled heart failure;
  • Significant cardiac arrhythmias or high risk for arrhythmias caused by QT prolongation;
  • Severe aortic stenosis;
  • Severe hypertension (eg, ≥200/110mmHg);
  • Acute illness.[15]

References

  1. ↑ Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).
  2. ↑ Slater DK, Hlatky MA, Mark DB, Harrell FE, Pryor DB, Califf RM (October 1987). "Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings". Am. J. Cardiol. 60 (10): 766–70. doi:10.1016/0002-9149(87)91020-4. PMID 3661390.
  3. ↑ Brush JE, Brand DA, Acampora D, Chalmer B, Wackers FJ (May 1985). "Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction". N. Engl. J. Med. 312 (18): 1137–41. doi:10.1056/NEJM198505023121801. PMID 3920520.
  4. ↑ Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (January 1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients". Arch. Intern. Med. 145 (1): 65–9. PMID 3970650.
  5. ↑ O'Gara, Patrick T.; Kushner, Frederick G.; Ascheim, Deborah D.; Casey, Donald E.; Chung, Mina K.; de Lemos, James A.; Ettinger, Steven M.; Fang, James C.; Fesmire, Francis M.; Franklin, Barry A.; Granger, Christopher B.; Krumholz, Harlan M.; Linderbaum, Jane A.; Morrow, David A.; Newby, L. Kristin; Ornato, Joseph P.; Ou, Narith; Radford, Martha J.; Tamis-Holland, Jacqueline E.; Tommaso, Carl L.; Tracy, Cynthia M.; Woo, Y. Joseph; Zhao, David X. (2013). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction". Journal of the American College of Cardiology. 61 (4): e78–e140. doi:10.1016/j.jacc.2012.11.019. ISSN 0735-1097.
  6. ↑ Somers MP, Brady WJ, Perron AD, Mattu A (2002). "The prominant T wave: electrocardiographic differential diagnosis". Am J Emerg Med. 20 (3): 243–51. PMID 11992348. Unknown parameter |month= ignored (help)
  7. ↑ Smith SW, Whitwam W. "Acute Coronary Syndromes." Emerg Med Clin N Am 2006; 24(1): 53-89. PMID 16308113
  8. ↑ "The clinical value of the ECG in noncardiac conditions." Chest 2004; 125(4): 1561-76. PMID 15078775
  9. ↑ "ST elevation myocardial infarction electrocardiogram - wikidoc".
  10. ↑ http://en.ecgpedia.org/wiki/Main_Page
  11. ↑ "Pericarditis electrocardiogram - wikidoc".
  12. ↑ http://en.ecgpedia.org/wiki/Main_Page
  13. ↑ Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
  14. ↑ Hirata, Kazuhito; Wake, Minoru; Kyushima, Masahiro; Takahashi, Takanori; Nakazato, Jun; Mototake, Hidemitsu; Tengan, Toshiho; Yasumoto, Hiroshi; Henzan, Eisei; Maeshiro, Masao; Asato, Hiroaki (2010). "Electrocardiographic changes in patients with type A acute aortic dissection". Journal of Cardiology. 56 (2): 147–153. doi:10.1016/j.jjcc.2010.03.007. ISSN 0914-5087.
  15. ↑ Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK; et al. (2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001030. PMID 34709928 Check |pmid= value (help).
Retrieved from "https://www.wikidoc.org/index.php?title=Chest_pain_electrocardiogram&oldid=1731363"