As the temperature gradually drops, the number of patients with coronary heart disease increases day by day, and every time we go to the clinic, we always have the feeling of being on tenterhooks for fear of stepping on a “hidden mine” accidentally. No doctor would be afraid of the typical symptoms of coronary heart disease, but are there so many typical patients? The other day, I met a former colleague from the emergency department and told him that he had recently encountered a series of “dark mines”, but fortunately they were all successfully detected. The other day, I was reminded of @EmergencyNightHawk’s tweet, “The biggest medical risk doctors face: seemingly minor problems, sudden death”, and was deeply moved. I would like to share with you my past experience in emergency medicine for many years. 1, the symptoms of typical coronary heart disease symptoms for the activity of chest pain, mostly located in the precordial region or behind the sternum, a squeeze-like, can be accompanied by sweating, shoulder and back discomfort, each lasting a few minutes to tens of minutes, rest or nitroglycerin can be relieved. I think if you encounter a patient with such typical symptoms and you have not been able to diagnose them, I think you should retake the medical exam :), but. In clinical work, there are really not many patients with such typical symptoms, especially among women, diabetics, and the elderly. For patients with coronary heart disease that I have encountered, their symptoms include toothache, sore throat, back pain, chest pain (left, right, or middle), upper abdominal pain, and even no chest pain directly manifested as hypotensive symptoms, such as syncope and impaired mobility. Many people may lament that there are so many symptoms, how can doctors screen them? Yes, the diagnosis and treatment of chest pain or coronary artery disease is a huge challenge for doctors all over the world. In the United States, about 8 million patients go to the emergency room each year with chest pain, 5 million are admitted with suspected acute coronary syndrome, about half of them are eventually ruled out, and about 1.3% (40,000) of patients who are sent home with acute coronary syndrome ruled out in the emergency room have a myocardial infarction, which is a real figure, although this is an earlier figure. For the present, the improvement of this situation is not promising. I remember when I was in school, an old director gave us a lesson on coronary heart disease, he once said something like this: “Below the chin, above the belly button, all symptoms related to activity or that you cannot explain, please never consider the possibility of coronary heart disease”. 2, ECG ECG is an inexpensive and easy to perform test. Many people will say, if the symptoms are not typical, won’t everything be understood by doing an ECG? If that were true, then things would be much simpler, but the reality is not like that at all. The data show that only about 50% of patients with coronary artery disease will have a typical ECG (this is the result of my postgraduate project), and the 50% mentioned here is still the result in a rather experienced tertiary hospital. So why is it so? On the one hand, many patients with coronary artery disease often have a “normal” ECG when they have an asymptomatic attack. On the other hand, in the early stage of acute infarction, the ECG is often atypical, and if there is no experience in this area, it is very easy to miss the diagnosis. Therefore, regarding ECG, this is something that makes doctors feel helpless, because often patients will ask “Doctor, my ECG is normal, why do you say I may have a heart attack?” . I would say, yes, in many cases, even if your ECG is normal, the doctor cannot completely rule out the possibility of heart disease. 3. Myocardial markers Myocardial injury markers are the gold standard for diagnosing acute myocardial infarction, but again, they have significant drawbacks. Typically, the currently used myocardial markers do not show an abnormal increase until 1-4 hours after a myocardial infarction occurs, and then they gradually return to normal over a period of hours to days. This poses a problem if there is a potential for “false normal” in the early and late stages of the attack. Moreover, these markers are usually not useful in patients with ischemia without necrosis, that is, if the patient only has angina but the vessel is not completely blocked and myocardial necrosis is not occurring, but as we all know, most patients with angina are at the same risk as myocardial infarction, so if we identify high-risk patients by myocardial markers, we may miss many patients with potential cardiovascular risk. patients with potential cardiovascular risk. Since symptoms, ECG and myocardial markers have one or another drawbacks, what can be done to avoid missing the diagnosis? Currently, most chest pain centers use the screening method of categorical observation. Although this method cannot prevent 100% of high-risk patients from being missed, it is a practical solution that may be widely adopted by medical units that are less than those that have the conditions for observation, or if they do not have the conditions for observation, they can admit patients for evaluation.