1. Subjective Patient’s chief complaint: A man aged 69 comes to the emergency room with a sharp pain to his chest’s left side, lasting between 30 and 40 mins and then subsiding.

History of present illness: The pain has woken him up thrice in the last 7 days. He claims the pain first started roughly six months ago. Initially, however, the pain used to surface only occasionally, commonly while he was doing gardening. The patient’s past medical history reveals a diagnosis of hypertension twenty-five years back.

Precipitating/alleviating factors: The patient has been smoking a half-cigarette pack daily for the last forty-five years.

Family History: The patient has lost two brothers and his dad to heart disease. The patient does not report any other significant illness history in the family.

Social History: His typical pastimes include sharing a drink with pals and gardening.

Review of Systems: From a physical examination of the patient, no heaves, acute distress, hepatojugular, carotid bruits appreciated, abnormal pulsations, thrills or tenderness to palpation have been observed. All lung fields reveal clear breathing sounds.

2. Objective

Diagnostic Study: Acute Coronary Syndrome (ACS)

ACS constitutes a continuum of states of myocardial ischemia including unstable angina, ST-elevated and non-ST elevated MI (myocardial infarction). ACS has been linked to significant mortality and morbidity, significantly burdening the US healthcare system financially. Its diagnosis commences with an in-depth clinical evaluation of presenting patient symptoms, cardiac troponin level, electrocardiogram, and prior medical history examination. Early stratification of risk may help providers ascertain which approach ought to be adopted: initial conservative or early invasive, besides facilitating ascertainment of appropriate pharmacologic treatments (Smith JN, 2015).

ACS’s characteristic symptom include substernal chest pain, described typically as a pressing or crushing feeling, that radiates to the left arm and jaw. This doesn’t, however, manifest in all cases. Presenting symptoms may be highly subtle and vague with the main complaints commonly being breathing difficulties, isolated pain in the left arm or jaw, light-headedness, nausea, diaphoresis, weakness, and epigastric pain (Singh & Grossman, 2017).

3. Assessment

Pathophysiology: ACS’s underlying pathophysiology is partial reduction in heart musculature blood flow, normally secondary to thrombus formation and plaque...

This leads to reduced flow of blood to heart musculature (partially), subsequently leading to ischemia and infarction of the area (Singh & Grossman, 2017).
Such syndromes’ underlying pathophysiological mechanisms commence with atherosclerosis, developing and progressing for several decades before acute event occurrence. Atherosclerosis is a low-grade inflammation of mid-sized arteries’ inner lining (intima), speeded up by widely-recognized risk factors like elevated cholesterol levels, elevated blood pressure, diabetes, genetics and smoking. This gradual development in coronary atherosclerosis results in slow thickening of coronary arteries’ inner layer that can, with time, narrow the arterial lumen to various extents. Atherosclerosis resulting in the grave SCD (sudden cardiac death) and AMI (acute myocardial infarction) syndromes has a preference for major coronary arteries’ proximal segments, typically arterial bifurcation sites altering arterial flow (Wang et al, 2004). Such gradual atherosclerotic progression can be disrupted by at least one swift progression cycle linked to either plaque haemorrhage or asymptomatic disruption of plaque with intraluminal non-occlusive thrombus formation (Ambrose & Singh, 2015). 

Differential Diagnosis

Pulmonary Embolism: Electrocardiograms are a swift, inexpensive diagnostic test to detect pulmonary embolism (PE), but they have certain limitations when it comes to differentially diagnosing acute PE and ACS (Gul, Nikus, Erdogan, & Ozdemir, 2016). The clinical symptoms of APE and ACS patients can be similar, with myocardial necrosis biochemical markers potentially elevated in case of both ailments. Besides lab and clinical findings and medical history, 12-lead electrocardiogram is vital though it has been linked to certain limitations when it comes to PE and ACS’s differential diagnosis. ECG changes suggesting myocardial ischemia have been noted among 7 out of 10 APE patients, with aggravated progression and one-month mortality predicted (Gul, Nikus, Erdogan, & Ozdemir, 2016).

Myeloperoxidase (MPO): This recognized activated neutrophil-released enzyme has strong pro-inflammatory and pro-oxidative properties. Of late, it has been recommended as a valuable ACS diagnostic tool and risk marker for patients brought to the emergency department with chest pain. Inflammation and oxidative stress contribute significantly to pathogenesis of CAD (coronary artery disease) destabilization causing ACS.…