Risk stratification allows appropriate referral of patients to a chest pain center or emergency department, where cardiac enzyme levels can be assessed. The magnitude of an ECG abnormality affects diagnostic accuracy. This lack of blood supply can be due to an acute absolute or relative deficiency in coronary artery blood flow. Elevated cTn values outside of ACS are not uncommon and reflect cardiomyocyte necrosis from a wide array of cardiac, pulmonary and systemic diseases. ESRD patients who present with volume overload due to missed dialysis also typically have a non-MI troponin elevation. Cardiol J. Cureus. Kott KA, Bishop M, Yang CHJ, Plasto TM, Cheng DC, Kaplan AI, Cullen L, Celermajer DS, Meikle PJ, Vernon ST, Figtree GA. Iser, D.M., et al., Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. FOIA All rights reserved. Although CK commonly was measured serially (along with CK-MB) at the time of hospital admission and six to 12 hours after admission, this marker largely has been replaced by cardiac troponins and CK-MB.9,16, CK-MB is much more cardiac specific than CK alone, and is useful for the early diagnosis of acute myocardial infarction.9 CK-MB typically is detectable in the serum four to six hours after the onset of ischemia, peaks in 12 to 24 hours, and normalizes in two to three days. Advertising revenue supports our not-for-profit mission. Esophageal spasm: Causes, symptoms, and treatments Elevated By definition this will be shown by an elevation of serum troponin levels in the absence of S-T segment elevation; coronary artery spasm, coronary embolism, tachy-/brady-arrhythmias, anemia, respiratory failure, hypotension, and hypertension with or without LVH Elevated serum troponin; High risk co-morbidities: Left ventricular Troponin: What Is it, Tests, and More - Healthline sharing sensitive information, make sure youre on a federal Red wine or extremely hot or cold liquids are more common culprits. WebTroponin is a protein enzyme that leaks from the heart when this muscle is damaged. Linked to ventricular remodeling, elevated cTn in HF should not be discarded as false positive as the prognosis associated with elevated cTn in this setting is poor.7, An important non-ACS diagnosis to consider in a patient presenting with chest pain and elevated cTn is acute aortic dissection (AAD). The troponin I levels peaked at 2.6 (normal <0.04ng/mL) and creatinine kinase levels were within normal limits. Disclaimer. Many people find that there are specific triggers that prompt esophageal spasms. Measurement of cardiac troponin (cTn) has revolutionized the evaluation and management of patients with suspected acute coronary syndrome (ACS). A Case of Elevated Troponin I Level After Packed Red Blood Cell Transfusion With Normal Coronary Angiography. There are no known risk factors for esophageal spasms. Barium esophagram demonstrated a smooth short narrowing in the distal esophagus proximal to the gastroesophageal junction, suggesting a stricture or spasm from yet controlled reflux disease (Figures 2(a) and 2(b)). WebGiven extensive prior cardiac history, anginal equivalent symptoms, ischemic ECG changes, and elevated troponin I levels, non-ST elevation myocardial infarction 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. Symptoms of acute myocardial ischemia such as typical chest pain. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. In general, renal failure in the absence of symptoms/signs of ischemia is best classified as a non-MI troponin elevation. Patients with elevated cTnI levels, compared with those with normal cTnI, were older (63 +/- 13 y vs 56 +/- 14 y, P =.032), had a higher incidence of males (78% vs 52%, P =.049) and positive ergonovine provocation tests (74% vs 30%, P <.0001), and tended to have a lower incidence of hypercholesterolemia (26% vs 48%, P =.088) and normal electrocardiograms (48% vs 70%, P =.078). The term acute coronary syndrome encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and nonST-segment elevation myocardial infarction. 1994 Oct;24(4):888-92. doi: 10.1016/0735-1097(94)90846-x. 261266, 2002. Early markers of acute ischemia include myoglobin and creatine kinaseMB subforms (or isoforms), when available. doi: 10.7759/cureus.26193. The likelihood of acute infarction is 1.1 percent or less with a normal ECG and 2.6 percent or less with nonspecific ECG changes.10, The ECG provides information that assists in stratifying the patients risk of having acute coronary syndrome, establishing the diagnosis, and determining the treatment strategy. Accessed Oct. 6, 2020. Recent consensus statements endorse the use of cTnI or cTnT as the biomarker of choice for such application.1 In order to maximize sensitivity for diagnosis of ACS, as well as for superior prognostication, these same consensus statements endorse the use of the lowest cTn cut-off point, down to the 99th percentile of a normal population as long as the assay used delivers imprecision < 10% at this cut-off point.1 While the most widely-used conventional cTn methods cannot deliver this combination of sensitivity and precision, novel very high sensitivity cTn (hsTn) assays have now been developed; these assays have a greatly improved detection limit (10- to 100-times lower than that of currently available commercial assays) with improved precision.2 hsTn assays are soon to be more widely used. Patients with NSTE-ACS who have had previous PCI or WebEsophagitis oresophagealspasm Pleurisy Costochondritis Chest wall / musculoskeletal pain Gastritis Hiatal hernia Anxiety Hyperventilation syndrome Biliary colic Peptic Ulcer Other cause(please specify) None of the above/ not applicable This is an open access article distributed under the, http://www.worldgastroenterology.org/assets/downloads/pdf/wdhd/2008/events/map_of_digestive_disorders_2008.pdf, http://www.niddk.nih.gov/health-information/health-statistics/Pages/digestive-diseases-statistics-for-the-united-states.aspx. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). eCollection 2022 Aug. Life (Basel). eCollection 2022 Jun. Melanson, S.E., D.A. Accessed Oct. 6, 2020. Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes. J. P. Liuzzo and J. Clipboard, Search History, and several other advanced features are temporarily unavailable. Esophageal spasm Wang CH, Cherng WJ, Meng HC, Hong MJ, Kuo LT. Echocardiography. Medication adjustment resulted in resolution of nocturnal symptoms, which were likely a manifestation of GERD and angina. Some patients may present without chest pain; in one review,2 sudden dyspnea was the sole presenting feature in 4 to 14 percent of patients with acute myocardial infarction. The authors declare that there is no conflict of interests regarding the publication of this paper. WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. How to Interpret Elevated Cardiac Troponin Levels | Circulation Furthermore, the prevalence of GERD in patients with CAD is higher, with some studies reporting prevalence ranging from 40% to 78% [4]. Occasionally, reciprocal ST-segment depression occurs in leads that are electrically opposite to the area of injury. S20S32, 2003. Liu et al. WebEsophageal spasms are problems with muscles in your esophagus, the tube that takes food and drink to your stomach after you swallow. Accessed Oct. 6, 2020. The cTn complex is found both in the sarcomere (accounting for ~95% of cTn in the heart) as well as to a lesser extent in the cytosol of cardiomyocytes. Coronary vasospasm, documented by an ergonovine provocation test, was found in 38 patients (41%). Pruszczyk, P., et al., Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism. When is a troponin elevation an acute myocardial infarction? Careers. A. Valiati, Extraesophageal manifestations of gastroesophageal reflux disease, Jornal Brasileiro de Pneumologia, vol. Pericarditis and myocarditis: Due to direct injury from myocardial inflammation. Serum markers such as aspartate transaminase, lactate dehydrogenase, and lactate dehydrogenase subforms no longer are used because they lack cardiac specificity and their delayed elevation precludes early diagnosis.9 Characteristics of the most important serum cardiac markers are summarized in Table 3.1619. WebIn patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI Your email address will not be published. However, in a patient presenting with other or vague complaints where an elevated troponin was found amongst a battery of tests, a type 2 MI may be favored, particularly if there is evidence of an underlying trigger for a supply-demand mismatch. Subsequently, patient underwent an early invasive strategy of cardiac catheterization and angiography that revealed chronic, severe, native 3-vessel CAD (Figures 1(a) and 1(b)). In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Cardiac markers (troponin T, troponin I, and/or creatine kinaseMB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome. However, many non-ACS diagnoses should be kept in mind as potential cause for cTn elevation, Both acutely decompensated and chronic HF are associated with elevated cTn values, which may frequently be substantial. The CK-MB mass assay is more sensitive than the CK-MB activity assay.20, Like the CK level, the peak CK-MB level does not predict infarct size; however, it can be used to detect early reinfarction.16 Serial CK-MB levels commonly are obtained at admission to the emergency department and are repeated in six to 12 hours, depending on the assay that is used.20. Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Based on the coronary anatomy the patient was managed conservatively with optimal medical therapy with no plan for percutaneous intervention or revascularization. A spasm can reduce or block blood flow to part of the heart. Keywords: Acute Coronary Syndrome, Troponin, Biomarkers, Coronary Artery Disease, Coronary Thrombosis, Coronary Disease, Heart Failure, Hypertension, Hypertension, Pulmonary, Hypertrophy, Left Ventricular, Hypotension, Myocardial Infarction, Myocardial Ischemia, Myocarditis, Myocytes, Cardiac, Pericarditis, Pulmonary Embolism, Systemic Inflammatory Response Syndrome, Risk Factors, Chronic Disease, Tachycardia, Limit of Detection. Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). In general, the prevalence of cTn elevation in the general population is low when currently available assays are used. Diagnosing Type 2 Myocardial Infarction - American College of 2022 Jun 22;14(6):e26193. This widely available marker has low sensitivity and specificity for cardiac damage. The most common signs and symptoms include: Skin changes. Elsevier; 2021. https://www.clinicalkey.com. It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. Becattini, C., M.C. 70, no. A patient whose presenting symptoms include acute chest discomfort, acute ST-T wave changes, and a rise in troponin would be suspected of having a type 1 NSTEMI. Acute Coronary Syndromes Stress-induced (takotsubo) cardiomyopathy: Stress-induced release of neurohormonal factors and catecholamines that cause direct myocyte injury and transient dilatation of the ventricle. This content does not have an English version. These small Q waves are known as septal Q waves because of the origin of the initial vector in ventricular depolarization. A normal electrocardiogram does not rule out acute coronary syndrome. 2018 Jan;33(1):17-24. doi: 10.1007/s00380-017-1029-9. and transmitted securely. 8600 Rockville Pike doi: 10.1371/journal.pone.0271189. There are two types of esophageal spasms distal esophageal spasm and hypercontractile esophagus, also referred to as jackhammer esophagus. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for Serial cardiac marker determinations confirm myocardial injury or infarction in more than 90 percent of patients with J-point elevation in the limb leads.9. Non-ST-elevation myocardial infarction De Borba, and A. Esophageal spasms typically occur only occasionally and might not need treatment. Cardiac Tn elevations have been reported in patients with snake or scorpion bites, and thought to be in part due to myocardial injury by biologic toxins, vasospasm and coagulation abnormalities.28 Elevated cTn levels have been reported to be frequently elevated in asymptomatic athletes who complete endurance exercise. If you experience squeezing chest pain, seek immediate medical care. Brandt, R.R., K. Filzmaier, and P. Hanrath, Circulating cardiac troponin I in acute pericarditis. R. Salvador, T. J. Watson, F. Herbella et al., Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse oximetry, Journal of Gastrointestinal Surgery, vol. We would further classify the NSTEMI into type 1 or type 2, depending on the mechanism of injury. High troponin levels can be a sign of a heart attack or other heart damage. Epub 2015 Oct 27. 2022 Feb 8;11(3):588. doi: 10.3390/cells11030588. Patients with all three of these features have a greater likelihood of having acute coronary syndrome than patients with none, one, or even two of these features. Esophageal spasms - Diagnosis and treatment - Mayo Clinic Misdiagnosis can have downstream repercussions. Your provider might recommend 2023 American College of Cardiology Foundation. The symptoms lasted for an hour and he was taken to the hospital due to persistent discomfort. The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. Waxman, D.A., et al., A model for troponin I as a quantitative predictor of in-hospital mortality. Distinguishing the diagnose of type 2 MI vs. non-MI troponin elevation depends on documenting whether there are ancillary ischemic symptoms, ECG findings, imaging, and/or cath findings of acute myocardial ischemia. A. Ambrose, Chest pain from gastroesophageal reflux disease in patients with coronary artery disease, Cardiology in Review, vol. 2022 Jul 8;17(7):e0271189. Measurement of troponins I and T and/or CK-MB at admission and six to eight hours after admission; 3. Identifying the cause and effect relationship between respiratory symptoms and GERD has been a clinical challenge. In a recent study examining 69,299 patients admitted through the emergency department(ED), 48% had their cTn measured. See permissionsforcopyrightquestions and/or permission requests. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Januzzi, Jr., Clinical applications of highly sensitive troponin assays. Based on Marriotts criteria,15 epicardial injury is diagnosed when the J point (origin of the ST segment at its junction with the QRS complex) is (1) elevated by 1 mm or more in two or more limb leads or precordial leads V4 to V6 or by 2 mm or more in two or more precordial leads V1 to V3; or is (2) depressed by 1 mm or more in two or more precordial leads V1 to V3. Type 2 MI is defined as "myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. The https:// ensures that you are connecting to the Squeezing pain in your chest. He had patent sequential saphenous venous graft to right posterolateral and posterior descending artery and a patent left internal mammary artery to left anterior descending artery (Figures 1(c) and 1(d)). A 12-lead ECG should be obtained within 10 minutes of presentation.7. Eur J Intern Med. The cardiac troponins typically are measured at emergency department admission and repeated in six to 12 hours. Wallace, T.W., et al., Prevalence and determinants of troponin T elevation in the general population. (a) Right coronary artery 100% occluded in the proximal segment. Esophageal spasms are divided into two categories: Diffuse esophageal spasms : These usually make a person regurgitate food or drink. Very high levels of troponin typically indicate that a person has had a heart attack, which can occur if the blood supply to some of the heart muscle suddenly Can Troponin Be Elevated Without Heart Attack One group of investigators13 found that the diagnosis of NSTEMI is greater than three times more likely in patients with chest pain whose ECG showed ST-segment depression in three or more leads or ST-segment depressions that were greater than or equal to 0.2 mV. Elevation of cTn in the context of HF often occurs in the absence of coronary ischemia, and frequently occurs even in the absence of coronary artery disease. Cardiac troponin (cTn) is the standard blood-based test to confirm the diagnosis of acute myocardial infarction. 13, no. The troponins also can help identify low-risk patients who may be sent home with close follow-up.17 In a study17 of 773 patients presenting to an emergency department with acute chest pain, those with a normal or nearly normal ECG and a normal troponin I test six hours after admission had a very low risk of major cardiac events (0.3 percent) during the next 30 days. An exercise treadmill test for patients without abnormal findings on the initial tests, or a nuclear stress test or echocardiographic stress test; 6. Park JY, Kang EJ, Kim MH, Yong HS, Rha SW. PLoS One. The silent myocardial infarction hypothesis is based on the relatively high incidence of ischemic changes noted on screening ECGs in patients with diabetes. Combining a doubling of the baseline myoglobin level at two hours after symptom onset with an abnormal myoglobin test at six hours after symptom onset increases the sensitivity to 95 percent at six hours.25. WebTroponin levels may remain high for 1 to 2 weeks after a heart attack. When is a troponin elevation an acute myocardial infarction? He was diagnosed with non-ST elevation myocardial infarction based on the electrocardiographic changes and cardiac biomarker elevation. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. 2010 December 15, 2009 [cited 2010 August 3]; Available from: Kelley, W.E., J.L. Background: Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Is there a clinical way to differentiate between esophageal spasm The site is secure. All too often, esophageal spasm is diagnosed on the basis of minor Short course of PPI not only resulted in fewer ischemic events, but also significantly improved the general health-related quality of life of patients [12]. The lab has to be taken in the context of the patients presentation and other supporting findings. Feldman, A.M. and D. McNamara, Myocarditis. Damage to the heart causes troponin to be released into the bloodstream. Chest pain that occurs suddenly at rest or in a young patient may suggest acute coronary vasospasm, which occurs in Prinzmetals angina or with the use of cocaine or methamphetamine. Esophagus. Vital signs on admission revealed blood pressure of 146/95mmHg, pulse of 90bpm, respiratory rate of 18 per minute with 100% O2 saturation on 2L of oxygen via nasal cannula. Esophageal Spasms: Causes, Symptoms, Diagnosis & Treatment Elsevier; 2020. https://www.clinicalkey.com. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. COPD exacerbation), shock states (cardiogenic, hypovolemic, hemorrhagic, or septic), coronary vasospasm (e.g. While cTn elevation in CKD necessarily leads to a higher risk for false positive ACS diagnosis, cTn values in this setting are to be taken seriously; a true positive cTn related to ACS in patients with CKD is associated with a heightened risk for mortality29 compared to non CKD patients, while an asymptomatic elevation in cTn in severe CKD is associated with an increased incidence of ACS30 and a 2- to 5-fold increase in mortality.31 Serial measurement, observing for a rise and/or fall of an elevated cTn value in a patient with CKD is recommended to differentiate ACS from non-ACS causes of cTn elevations. Unauthorized use of these marks is strictly prohibited. Morrow, and P. Jarolim, Earlier detection of myocardial injury in a preliminary evaluation using a new troponin I assay with improved sensitivity. In conclusion, there is a high prevalence of GERD in patients with CAD. Chest-wall tenderness reduces the likelihood of acute coronary syndrome (-LR: 0.2).3. Esophageal spasms make it difficult for the muscles in the walls of your lower esophagus to coordinate in order to move food to your stomach. WebCauses of elevated troponin STEMI: ST elevation myocardial infarction; NSTEMI: non-ST elevation myocardial infarction; PCI: percutaneous coronary intervention; SLE: systemic lupus erythematosus; BSA: body surface area. K. R. DeVault, Extraesophageal symptoms of GERD, Cleveland Clinic Journal of Medicine, vol. Please enable it to take advantage of the complete set of features! Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. A. Chauhan, P. A. Mullins, G. Taylor, M. C. Petch, and P. M. Schofield, Cardioesophageal reflex: a mechanism for linked angina in patients with angiographically proven coronary artery disease, Journal of the American College of Cardiology, vol. Esophageal Rupture Presenting with ST He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. High Troponin Levels An elevated troponin T or I level is helpful in identifying patients at increased risk for death or the development of acute myocardial infarction.16 Increased risk is related quantitatively to the serum troponin level. Though a rise in troponin levels is often an indication of a heart attack, there are a number of other reasons why your troponin levels could be elevated. Troponin levels can be acutely elevated or chronically elevated. Thompson PD, Klocke FJ, Levine BD, Van Camp SP. Recurrent Transient Apical Cardiomyopathy (Tako Your provider might recommend a proton pump inhibitor to treat GERD. The patient was stabilized with resolution of nocturnal symptoms and he was discharged home with plan to perform an outpatient upper EGD to evaluate for reflux and esophagitis. M. Swiatowski, B. Jacek, M. Klopocka et al., Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease, Medical Science Monitor, vol. However, in a prospective observational study6 of 528 patients with symptoms suggestive of coronary artery disease on presentation to the emergency department of a cardiac referral center, symptoms did not differ significantly in patients with and without diabetes. Upon presentation to the Emergency Department, he denied any chest discomfort, palpitations, dizziness, orthopnea, or lower extremity swelling. Horwich, T.B., et al., Cardiac Troponin I Is Associated With Impaired Hemodynamics, Progressive Left Ventricular Dysfunction, and Increased Mortality Rates in Advanced Heart Failure. Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. Some people may mistake it for heart pain, also called angina. 52, no. Despite multiple mechanisms suggested to explain its pathophysiology, there is increasing evidence that supports direct neuroadrenergic myocardial stimulation with concomitant transient, reversible, coronary vasospasm as the inciting event, either at the epicardial or arteriolar level. The predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. In a study12 of 775 consecutive patients with chest pain who were admitted to a cardiac care unit, acute myocardial infarction was diagnosed in 10 percent of patients with normal ECG findings (11 of 107 patients) in the emergency department, 8 percent of patients with minimal changes (six of 73 patients), and 41 percent of patients with frankly abnormal ECG findings (245 of 595 patients). Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. Esophageal 6772, 2005. University of Florida, Gastroesophageal Reflux Disease, Office of Medical Informatics. Copyright 2023 American Academy of Family Physicians. Esophageal spasms - Symptoms and causes - Mayo Clinic Subendocardial ischemia classically results in ST-segment depression and T-wave inversion.14 Approximately 25 percent of patients with ST-segment depression and elevated creatine kinaseMB isoenzyme (CK-MB) levels eventually develop STEMI, and 75 percent have NSTEMI. Reproduction of previous documented angina, Known history of coronary artery disease, including myocardial infarction, New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales, New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms, Elevated cardiac troponin T or I, or elevated CK-MB, ST-segment elevation greater in lead III than in lead II, ST-segment elevation of > 2.5 mm in lead V, ST-segment depression of > 1 mm in leads II, III, and aVF, ST-segment depression of 1 mm or ST-segment elevation in leads II, III, and aVF, Measured 4 hours after onset of chest pain, Measured 10 hours after onset of chest pain.