A 59-year-old woman presents to your office with chest discomfort, jaw pain, and nausea. The symptoms occurred suddenly 2 hours ago and are getting worse. She has a history of poorly controlled hypertension, and she has a 30 pack-year smoking history. You decide to send her to the Emergency Department and order some initial tests, which are shown below.
An ECG shows multiple T wave inversions and ST depressions in contiguous leads.
Which of the following is the most likely diagnosis?
A. Stable anginaNon-ST elevation myocardial infarction. It is important to know how to differentiate the types of ACS, since this guides the course of action as well as the prognosis. ACS is made up of unstable angina, non-ST elevation myocardial infarction (NSTEMI), and STEMI. (A, B) Stable angina is not an ACS, and typically occurs with a consistent level of exertion that is relieved with rest and/or nitroglycerin; however, it can progress to unstable angina which typically lasts less than 30 minutes and manifests as angina without exertion, angina with a crescendo pattern, or angina that is severe and of new onset. Any new presentation of typical angina is unstable angina, even if the description sounds like stable angina. (C, D) NSTEMI is differentiated from unstable angina by positive troponins, and STEMI is differentiated from NSTEMI by ST elevations seen on ECG. In unstable angina and NSTEMI, there may or may not be ST depression and T wave inversions (signs of myocardial ischemia), but there will not be ST elevations.