Text-to-Speech Revision

So your patient comes in with crushing chest pain — is it a heart attack? This chapter walks you through the entire ACS spectrum, how to read an ECG like a pro, and the reperfusion decisions that save lives. <div class="chapter-summary bg-gradient-to-r from-purple-900/20 to-blue-900/20 border border-purple-500/30 rounded-xl p-4 mb-6" <strong class="text-white text-sm block mb-1"In 30 seconds:</strong <p class="text-zinc-300 text-sm mb-2"Ischemic heart disease is a blockbuster topic — expect 4-5 questions. Master the ACS spectrum, ECG localisation, MONA protocol, and post-MI secondary prevention.</p <strong class="text-white text-sm block mb-1"Key exam topics:</strong <ul class="text-zinc-300 text-sm list-disc pl-4 mb-2" <li<hyMONA management &amp; Killip classification</hy</li <liECG localisation of MI (LAD vs RCA vs LCx)</li <liComplications by timing: arrhythmia → rupture → Dressler</li </ul <strong class="text-white text-sm block mb-1"Most common trap:</strong <p class="text-zinc-300 text-sm"<trapPrinzmetal angina shows ST elevation mimicking STEMI — do NOT thrombolyse. Posterior MI (ST depression V1-V3) is a STEMI equivalent needing urgent reperfusion.</trap</p </div <definitionIschemic heart disease (IHD) is myocardial ischemia due to imbalance between oxygen supply and demand, most commonly from atherosclerotic coronary artery disease (CAD).</definition <hyEpidemiology: Leading cause of death worldwide. Accounts for ~30% of all medicine PG exam questions in cardiology.</hy <pyqNEET PG 2022: "Which coronary artery is most commonly occluded in inferior wall MI?" → RCA (Right Coronary Artery)</pyq <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Pathophysiology — Atherosclerosis Cascade</h3 <flowchart Endothelial dysfunction (shear stress, smoking, HTN, DM, dyslipidemia) ↓ LDL infiltration into intima → oxidation by ROS ↓ Macrophage uptake → foam cell formation → fatty streak ↓ Smooth muscle migration + collagen deposition → fibrous plaque ↓ Plaque progression → vulnerable plaque (thin fibrous cap, large lipid core, inflammation) ↓ Plaque rupture/erosion → platelet activation → thrombus → ACS </flowchart <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"ACS Spectrum</h3 <table <tr<thFeature</th<thUA</th<thNSTEMI</th<thSTEMI</th</tr <tr<tdBiomarkers (Troponin)</td<tdNormal</td<tdElevated</td<tdElevated</td</tr <tr<tdECG</td<tdST depression / T inversion</td<tdST depression / T inversion</td<tdST elevation (≥1mm in limb, ≥2mm in precordial)</td</tr <tr<tdOcclusion</td<tdIncomplete/subtotal</td<tdIncomplete (distal emboli)</td<tdComplete, persistent</td</tr <tr<tdIschemia</td<tdSubendocardial</td<tdSubendocardial</td<tdTransmural</td</tr </table <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Chronic Stable Angina vs ACS</h3 <table <tr<thFeature</th<thStable Angina</th<thACS (UA/NSTEMI/STEMI)</th</tr <tr<tdPattern</td<tdPredictable with exertion/emotion; relieved by rest/NTG</td<tdUnpredictable, progressive, or at rest; may not relieve with NTG</td</tr <tr<tdDuration</td<td<5-10 minutes</td<td20 minutes or persistent</td</tr <tr<tdECG</td<tdST depression during pain, normal between episodes</td<tdST changes ± T inversion or ST elevation; may persist</td</tr <tr<tdBiomarkers</td<tdNormal</td<tdNormal (UA) or elevated (MI)</td</tr <tr<tdManagement</td<tdMedical therapy ± elective revascularization</td<tdUrgent revascularization + DAPT + anticoagulation</td</tr <tr<tdPlaque type</td<tdStable fibrous plaque</td<tdVulnerable/ruptured plaque</td</tr </table <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Vasospastic (Prinzmetal) Angina</h3 <ul <liCoronary artery vasospasm → transient transmural ischemia; typically occurs at rest (often midnight to early morning)</li <liECG: Transient ST elevation during pain that resolves with NTG</li <liDiagnosis: Provocative testing (acetylcholine/ergonovine) during coronary angiography</li <liTreatment: Calcium channel blockers (diltiazem/verapamil) and long-acting nitrates; avoid β-blockers (may worsen spasm via unopposed α-adrenergic activity)</li <li<trapPrinzmetal angina presents with ST elevation (mimicking STEMI) but pain resolves spontaneously and biomarkers are normal. Do NOT thrombolyse — it is vasospasm, not thrombotic occlusion.</trap</li </ul <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Microvascular Angina (Cardiac Syndrome X)</h3 <ul <liAngina-like chest pain with normal epicardial coronaries on angiography; due to microvascular endothelial dysfunction and impaired coronary flow reserve</li <liMore common in women; associated with DM, HTN, and chronic inflammation</li <liDiagnosis: Invasive coronary function testing (CFR <2.0, IMR ≥25)</li <liTreatment: Statins, ACEi, CCBs, β-blockers, nitrates; consider ivabradine, ranolazine, or tricyclic antidepressants for refractory symptoms</li </ul <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Clinical Presentation</h3 <ul <li<hyClassic: Severe crushing retrosternal chest pain (heaviness/pressure), radiating to left arm/neck/jaw/epigastrium</hy</li <liAssociated symptoms: Dyspnea, diaphoresis, Nausea, Anxiety, Fatigue</li <li<trapAtypical presentations (women, elderly, diabetics): Epigastric discomfort, dyspepsia, isolated dyspnea, syncope, confusion — do NOT rule out MI without ECG + troponin</trap</li <liSigns: Pallor, hypotension, S3 gallop, MR murmur (papillary muscle dysfunction), crackles, JVD</li <liKillip classification for hemodynamic severity in MI: <ul <liClass I: No signs of HF</li <liClass II: S3 gallop / crackles <50% lung fields</li <liClass III: Acute pulmonary edema</li <liClass IV: Cardiogenic shock</li </ul </li </ul <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Emergency Management</h3 <hyMONA: Morphine (pain + anxiety), Oxygen (SaO2 90%), Nitrates (sublingual/IV), Aspirin (325 mg chewed — mortality benefit 23%)</hy <mnemonicMONA: Morphine, Oxygen, Nitrates, Aspirin — "MONA should be given to every MI patient"</mnemonic <clinicalA 55-year-old male with crushing chest pain for 2 hours, ECG shows STEMI. Door-to-balloon time must be <90 min for primary PCI. If transfer to PCI-capable center will take 120 min, give fibrinolytic therapy (tenecteplase) within 30 min of arrival.</clinical <ul <li<hyReperfusion: Primary PCI within 90 min (gold standard) OR Fibrinolysis within 30 min (if PCI unavailable within 120 min)</hy</li <liAbsolute contraindications to fibrinolysis: Prior ICH, known structural cerebrovascular lesion, ischemic stroke within 3 months, active bleeding, recent major trauma/surgery</li <li<pyqNEET PG 2021: "Absolute contraindication to thrombolysis in STEMI?" → Prior stroke within 3 months</pyq</li <liDAPT: Aspirin + Ticagrelor/Prasugrel (loading dose followed by maintenance)</li <liAnticoagulation: Unfractionated heparin / Enoxaparin / Bivalirudin</li <li<hyTime is muscle: Total ischemic time = patient delay + door-to-balloon time. Every 30-minute delay increases 1-year mortality by ~7.5%.</hy</li </ul <pyqNEET PG 2021: "Which of the following is NOT a component of the TIMI risk score for UA/NSTEMI?" → Prior coronary stenosis ≥50% (Components: Age ≥65, ≥3 CAD risk factors, known CAD ≥50%, aspirin use past 7 days, ≥2 anginal events in 24h, ST deviation, elevated cardiac biomarkers)</pyq <pyqNEET PG 2023: "In a patient with inferior wall STEMI and right ventricular involvement, which additional ECG leads must be obtained?" → Right precordial leads V3R and V4R — ST elevation ≥1mm in V4R is most sensitive and specific for RV infarction</pyq <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Lipid-Lowering Strategies</h3 <table <tr<thAgent</th<thMechanism</th<thLDL Reduction</th<thKey Trials</th</tr <tr<tdHigh-intensity statin (Atorvastatin 80 / Rosuvastatin 40)</td<tdHMG-CoA reductase inhibition</td<td≥50%</td<tdPROVE-IT, TNT, IMPROVE-IT</td</tr <tr<tdEzetimibe</td<tdNPC1L1 inhibitor (intestinal absorption)</td<tdAdditional 15-20%</td<tdIMPROVE-IT (add-on to statin → ↓CV events)</td</tr <tr<tdPCSK9i (Evolocumab, Alirocumab)</td<td↑ LDL receptor recycling</td<tdAdditional 50-60%</td<tdFOURIER, ODYSSEY — ↓MACE even at very low LDL</td</tr <tr<tdBempedoic acid</td<tdACL inhibitor (liver-specific ATP citrate lyase)</td<tdAdditional 15-20%</td<tdCLEAR Outcomes — ↓MACE in statin-intolerant</td</tr </table <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Secondary Prevention</h3 <hyPost-MI pharmacotherapy reduces mortality and recurrent events: DAPT (aspirin + ticagrelor for 12 months), high-intensity statin (atorvastatin 80 mg), beta-blocker (metoprolol/bisoprolol), ACEi/ARB (ramipril), and eplerenone (if LVEF ≤40% or HF).</hy <table <tr<thDrug</th<thMortality Reduction</th<thDuration</th</tr <tr<tdAspirin</td<td23%</td<tdLifelong</td</tr <tr<tdP2Y12 inhibitor (ticagrelor/prasugrel)</td<tdAdditional 15-20% vs aspirin alone</td<td12 months (may extend in high-risk)</td</tr <tr<tdHigh-intensity statin</td<td22% (LDL <55 mg/dL target)</td<tdLifelong</td</tr <tr<tdBeta-blocker</td<td23% (within first year)</td<td≥3 years; lifelong if LV dysfunction</td</tr <tr<tdACEi/ARB</td<td26% in high-risk patients</td<tdLifelong (especially if LVEF ≤40%)</td</tr </table <mnemonicPost-MI Secondary Prevention: "ABCDE" — A: Aspirin + ACEi; B: Beta-blocker + BP control; C: Cholesterol management (statin) + Cigarette cessation; D: Diet + Diabetes management; E: Exercise + Education</mnemonic <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Complications of MI</h3 <table <tr<thComplication</th<thTiming</th<thKey Features</th</tr <tr<tdVentricular arrhythmia (VT/VF)</td<tdFirst few hours</td<tdMost common cause of early death; defibrillate immediately</td</tr <tr<tdCardiogenic shock</td<tdFirst 24-48h</td<tdSBP <90, end-organ hypoperfusion; intra-aortic balloon pump + revascularization</td</tr <tr<tdFree wall rupture</td<td1-7 days</td<tdSudden death, tamponade; surgical emergency — more common in anterior STEMI, elderly, and first MI</td</tr <tr<tdVentricular septal rupture</td<td3-7 days</td<tdNew holosystolic murmur, thrill, acute RHF; surgical repair (note: VSR murmur is at LLSB, MR murmur at apex)</td</tr <tr<tdPapillary muscle rupture</td<td2-7 days</td<tdAcute MR, pulmonary edema; emergency valve surgery — posteromedial papillary muscle more commonly affected (single blood supply from PDA)</td</tr <tr<tdLV aneurysm</td<tdWeeks-months</td<tdPersistent ST elevation, dyskinesis, thrombus → anticoagulate; commonest in LAD territory (apical/anterior)</td</tr <tr<tdRV infarction</td<tdWith inferior MI</td<tdHypotension + clear lung fields + JVD (Kussmaul sign); treat with volume expansion, avoid nitrates</td</tr <tr<tdDressler syndrome</td<td2-6 weeks</td<tdAutoimmune pericarditis; NSAIDs/colchicine/steroids — now less common with early reperfusion era</td</tr </table <clinicalA 60-year-old male with inferoposterior STEMI develops sudden hypotension 6 hours post-PCI. JVP is 14 cm H2O, lungs are clear. BP 80/50. ECG shows ST elevation in II, III, aVF and V4R. Diagnosis: RV infarction complicating inferior STEMI. Management: IV fluids (aggressive volume resuscitation) and inotropic support; avoid nitrates and diuretics.</clinical <trap"Persistent ST elevation post-MI" → think LV aneurysm, NOT recurrent ischemia. Confirm with echocardiography showing dyskinetic segment.</trap <trapWellens syndrome (critical LAD stenosis): Deeply inverted or biphasic T waves (≥2 mm) in V2-V3 with isoelectric/minimally elevated ST, normal/mildly elevated troponin, and chest pain-free interval. This is a HIGH-RISK pattern for impending anterior STEMI — do NOT perform stress testing; send for urgent coronary angiography.</trap <clinicalA 50-year-old male with chest pain that resolved spontaneously. ECG shows deep symmetrical T-wave inversions in V2-V4 with isoelectric ST segments. Troponin is mildly elevated at 0.5 ng/mL. He is pain-free at presentation. This is Wellens syndrome type B (critical LAD stenosis, 95% occlusion). Urgent coronary angiography confirmed the diagnosis; successful PCI was performed.</clinical <mnemonicECG localization of MI: "LAD = Septal (V1-V2) + Anterior (V3-V4); LCx = Lateral (I, aVL, V5-V6); RCA = Inferior (II, III, aVF)." Posterior MI (dominant R wave, ST depression in V1-V2) → suspect LCx or RCA occlusion. RV MI → add right precordial leads V3R, V4R.</mnemonic <trap"New holosystolic murmur post-MI" → Differential: Papillary muscle rupture (MR, apex radiation) vs Ventricular septal rupture (VSR, LLSB, thrill + step-up in O2 from RA to RV). Echo is diagnostic — do NOT wait for hemodynamic collapse before imaging.</trap <mnemonicComplications by timing: "First hours = arrhythmia, First days = rupture, Weeks = Dressler" - 0-24h: VT/VF - 24-48h: Cardiogenic shock - 2-7 days: Mechanical (rupture, MR, VSD) - 2-6 weeks: Dressler syndrome</mnemonic <mnemonic"Pseudo vs True aneurysm": Pseudoaneurysm (contained rupture) — narrow neck; True aneurysm — wide neck. Pseudoaneurysm is a surgical emergency, true aneurysm is managed medically unless complications arise.</mnemonic <quick-revise 1. MONA is initial management — Aspirin 325 mg chewed within 10 min 2. Reperfusion: Primary PCI (door-to-balloon <90 min) vs Fibrinolysis (door-to-needle <30 min) 3. DAPT = Aspirin + Ticagrelor/Prasugrel; Anticoagulation = Heparin 4. Most common early death = VT/VF; Most common mechanical complication = Papillary muscle rupture (2-7 days) 5. Troponin I/T: Rise 3-6h, peak 12-24h, remain elevated 7-14 days — most sensitive and specific 6. Secondary prevention: DAPT, statin, beta-blocker, ACEi — all reduce mortality 7. Prinzmetal angina: ST elevation, responds to CCBs, avoid β-blockers 8. Killip class: I=no HF, II=crackles <50%, III=pulmonary edema, IV=cardiogenic shock 9. Lipid targets: LDL <55 mg/dL post-MI; consider PCSK9i and ezetimibe if not at target on maximal statin 10. RV infarction: hypotension + clear CXR + JVD; treat with fluids, avoid nitrates 11. Wellens syndrome: biphasic/deep T in V2-V3, pain-free - critical LAD stenosis - urgent angiography, NO stress test 12. CK-MB for reinfarction detection; troponin stays elevated for 7-14 days 13. TIMI score = 3 = high risk - early invasive strategy within 24h 14. DAPT score = 2 - benefit from prolonged DAPT 12 months 15. Posterior MI: tall R wave V1-V3 + ST depression - treat as STEMI equivalent 16. Cocaine chest pain: benzodiazepines first, AVOID beta-blockers acutely </quick-revise <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Thrombolysis vs Primary PCI -- Decision Matrix</h3 <table class="w-full text-sm border-collapse border border-gray-300 mb-4" <thead<tr class="bg-blue-50"<th class="border border-gray-300 p-2"Scenario</th<th class="border border-gray-300 p-2"Preferred Strategy</th<th class="border border-gray-300 p-2"Rationale</th</tr</thead <tbody <tr<td class="border border-gray-300 p-2"PCI-capable center, door-to-balloon <90 min</td<td class="border border-gray-300 p-2"Primary PCI</td<td class="border border-gray-300 p-2"Gold standard; superior outcomes vs lytics (mortality, reinfarction, ICH)</td</tr <tr<td class="border border-gray-300 p-2"Non-PCI center, transfer time <120 min</td<td class="border border-gray-300 p-2"Transfer for primary PCI</td<td class="border border-gray-300 p-2"Pharmacoinvasive strategy inferior to timely primary PCI (DANAMI-2, PRAGUE-2)</td</tr <tr<td class="border border-gray-300 p-2"Non-PCI center, transfer time 120 min</td<td class="border border-gray-300 p-2"Fibrinolysis (door-to-needle <30 min) - transfer</td<td class="border border-gray-300 p-2"Timely lysis better than delayed PCI (every 30 min delay = 7.5% increase in 1yr mortality)</td</tr <tr<td class="border border-gray-300 p-2"Failed fibrinolysis (ST resolution <50% at 90 min)</td<td class="border border-gray-300 p-2"Rescue PCI</td<td class="border border-gray-300 p-2"Reduced rate of death, reinfarction, and HF vs repeat lysis or conservative (REACT trial)</td</tr <tr<td class="border border-gray-300 p-2"Successful fibrinolysis</td<td class="border border-gray-300 p-2"Routine early angiography (3-24h post-lysis)</td<td class="border border-gray-300 p-2"Pharmacoinvasive approach = transfer all post-lytic patients for angiography within 24h (TRANSFER-AMI, CARESS-in-AMI)</td</tr </tbody </table <mnemonicFibrinolysis CI: "ABC-I" -- Aortic dissection, Bleeding (active), CVA/ICH (recent <3mo), Injury (major trauma/surgery <3wk). Also: BP 185/110, INR 1.7, Plt <100K.</mnemonic <clinicalA 42-year-old male with anterior STEMI, BP 140/90, HR 100, at a PCI-capable center at 10:00 AM (onset 9:00 AM). Door-to-balloon target <90 minutes → taken for primary PCI — successful DES to proximal LAD. DAPT started (aspirin + ticagrelor). LVEF 45% post-PCI. Started on atorvastatin 80 mg, bisoprolol 5 mg, ramipril 2.5 mg. Discharged day 3. Plan: DAPT × 12 months, lifelong statin + ACEi + BB.</clinical <pyqNEET PG 2023: "Pharmacoinvasive strategy for STEMI?" -- Fibrinolysis at non-PCI center followed by routine early coronary angiography within 3-24 hours, with PCI if indicated (TRANSFER-AMI trial).</pyq <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"ECG Localization of MI -- Expanded</h3 <table class="w-full text-sm border-collapse border border-gray-300 mb-4" <thead<tr class="bg-blue-50"<th class="border border-gray-300 p-2"Territory</th<th class="border border-gray-300 p-2"Artery</th<th class="border border-gray-300 p-2"ECG Leads</th<th class="border border-gray-300 p-2"Reciprocal</th</tr</thead <tbody <tr<td class="border border-gray-300 p-2"Septal</td<td class="border border-gray-300 p-2"LAD (septal)</td<td class="border border-gray-300 p-2"V1-V2</td<td class="border border-gray-300 p-2"None</td</tr <tr<td class="border border-gray-300 p-2"Anterior</td<td class="border border-gray-300 p-2"LAD</td<td class="border border-gray-300 p-2"V3-V4</td<td class="border border-gray-300 p-2"Inf leads</td</tr <tr<td class="border border-gray-300 p-2"Anteroseptal</td<td class="border border-gray-300 p-2"LAD</td<td class="border border-gray-300 p-2"V1-V4</td<td class="border border-gray-300 p-2"Inf leads</td</tr <tr<td class="border border-gray-300 p-2"Anterolateral</td<td class="border border-gray-300 p-2"LAD/LCx</td<td class="border border-gray-300 p-2"V3-V6, I, aVL</td<td class="border border-gray-300 p-2"II, III, aVF</td</tr <tr<td class="border border-gray-300 p-2"Inferior</td<td class="border border-gray-300 p-2"RCA (80%)/LCx</td<td class="border border-gray-300 p-2"II, III, aVF</td<td class="border border-gray-300 p-2"I, aVL</td</tr <tr<td class="border border-gray-300 p-2"Posterior</td<td class="border border-gray-300 p-2"RCA/LCx</td<td class="border border-gray-300 p-2"Tall R V1-V3, ST↓ V1-V3</td<td class="border border-gray-300 p-2"Ant ST↓</td</tr <tr<td class="border border-gray-300 p-2"RV Infarction</td<td class="border border-gray-300 p-2"Prox RCA</td<td class="border border-gray-300 p-2"V3R, V4R (ST↑ =1mm)</td<td class="border border-gray-300 p-2"--</td</tr </tbody </table <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Antiplatelet Therapy Comparison</h3 <table class="w-full text-sm border-collapse border border-gray-300 mb-4" <thead<tr class="bg-blue-50"<th class="border border-gray-300 p-2"Feature</th<th class="border border-gray-300 p-2"Ticagrelor</th<th class="border border-gray-300 p-2"Prasugrel</th<th class="border border-gray-300 p-2"Clopidogrel</th</tr</thead <tbody <tr<td class="border border-gray-300 p-2"Class</td<td class="border border-gray-300 p-2"Reversible P2Y12 antag</td<td class="border border-gray-300 p-2"Irreversible P2Y12 antag</td<td class="border border-gray-300 p-2"Irreversible P2Y12 antag</td</tr <tr<td class="border border-gray-300 p-2"Onset</td<td class="border border-gray-300 p-2"Rapid (30 min)</td<td class="border border-gray-300 p-2"Rapid (30 min)</td<td class="border border-gray-300 p-2"Slow (2-6h, prodrug)</td</tr <tr<td class="border border-gray-300 p-2"Dyspnea</td<td class="border border-gray-300 p-2"Yes (~14%)</td<td class="border border-gray-300 p-2"No</td<td class="border border-gray-300 p-2"No</td</tr <tr<td class="border border-gray-300 p-2"Contraindication</td<td class="border border-gray-300 p-2"Severe hepatic impair</td<td class="border border-gray-300 p-2"75yr, <60kg, prior stroke/TIA</td<td class="border border-gray-300 p-2"CYP2C19 poor metabolizer</td</tr </tbody </table <h3 class="font-bold text-[071E3D] mt-5 mb-2 text-base"Cardiac Biomarkers Timeline</h3 <table class="w-full text-sm border-collapse border border-gray-300 mb-4" <thead<tr class="bg-blue-50"<th class="border border-gray-300 p-2"Biomarker</th<th class="border border-gray-300 p-2"Rise</th<th class="border border-gray-300 p-2"Peak</th<th class="border border-gray-300 p-2"Normalizes</th<th class="border border-gray-300 p-2"Use</th</tr</thead <tbody <tr<td class="border border-gray-300 p-2"Troponin (hs-cTn)</td<td class="border border-gray-300 p-2"1-3h</td<td class="border border-gray-300 p-2"12-24h</td<td class="border border-gray-300 p-2"7-14 days</td<td class="border border-gray-300 p-2"Most sensitive & specific</td</tr <tr<td class="border border-gray-300 p-2"CK-MB</td<td class="border border-gray-300 p-2"3-6h</td<td class="border border-gray-300 p-2"12-24h</td<td class="border border-gray-300 p-2"48-72h</td<td class="border border-gray-300 p-2"Reinfarction detection</td</tr <tr<td class="border border-gray-300 p-2"Myoglobin</td<td class="border border-gray-300 p-2"0.5-2h</td<td class="border border-gray-300 p-2"6-9h</td<td class="border border-gray-300 p-2"12-24h</td<td class="border border-gray-300 p-2"Earliest, low specificity</td</tr </tbody </table <mnemonicTIMI risk score: "ABCD-STE" -- Age =65 (1), =3 CAD risk factors (1), CAD =50% prior (1), Aspirin use 7d (1), =2 angina events 24h (1), ST deviation =0.5mm (1), Elevated biomarkers (1). Score =3 = high risk.</mnemonic <mnemonicDAPT score for prolonged DAPT: Age =75 (-2), 65-74 (-1), <65 (0); Smoking (1); DM (1); Prior PCI/MI (1); Index PCI of MI (1); Paclitaxel-eluting stent (1); Stent diameter <3mm (1); CHF/LVEF <30% (2); SVG PCI (2). Score =2 = benefit 12 months DAPT.</mnemonic <pyqNEET PG 2023: "Which biomarker detects reinfarction?" -- CK-MB (shorter half-life 48-72h; troponin stays elevated 7-14 days).</pyq <clinicalA 62F diabetic with indigestion x 6h. No chest pain. ECG: ST depression V4-V6. Troponin 1.8. Dx: NSTEMI with atypical presentation. Treat: DAPT + enoxaparin + statin + early invasive strategy within 24h.</clinical <trapPosterior MI (ST depression V1-V3 + tall R) is STEMI EQUIVALENT -- needs emergent reperfusion. Obtain V7-V9. Do NOT misclassify as NSTEMI.</trap <trapCocaine chest pain: AVOID beta-blockers (unopposed alpha - vasospasm). Use benzodiazepines first-line, nitrates, CCBs.</trap