Acute Coronary Syndromes w/out Persistent ST-Segment Elevation Disease Summary

Overview

Acute coronary syndrome refers to any constellation of clinical symptoms compatible with acute myocardial ischemia usually caused by sudden reduction in coronary blood flow from atherosclerotic plaque rupture or erosion and subsequent thrombosis. It is further defined in the Introduction section.

Acute coronary syndrome causes an estimate of 32% of all deaths worldwide. The incidence of acute coronary syndrome locally and regionally is featured in the Epidemiology section.  

As explained in the Pathophysiology section, the mismatch between myocardial oxygen demand and myocardial oxygen consumption resulting in myocardial injury is the hallmark of acute coronary syndrome. Further details are contained in this section.

The Risk Factor section enumerates the same factors that are seen as manifestations of ischemic heart disease.

History and Physical Examination

Patients with acute coronary syndrome usually present with retrosternal chest pain. The Clinical Presentation section gives a complete description of the ischemic-type chest discomfort that can be experienced by patients. Patients with acute coronary syndrome may also present with a broad range of signs and symptoms, from asymptomatic at presentation to patients with ongoing chest discomfort. The section enumerates other clinical presentations of the disease as well.

In the Physical Examination section, the importance of identifying precipitating causes, very high risk and high risk acute coronary syndrome features and assessing the hemodynamic impact of the ischemic event and non-ischemic cardiac disorders are discussed. Physical examination should include vital sign measurements and cardiovascular and chest examination.

Diagnosis

Laboratory Tests and Ancillaries and Imaging studies that are vital to the diagnosis of acute coronary syndrome which include ECG, chest X-ray and biochemical indicators (eg cardiac troponin T or I, myoglobin and/or creatinine kinase) are discussed in this section. Other diagnostic tests that may be useful in the diagnosis of acute coronary syndrome are also included.

Diagnosis is based on clinical history, symptoms, vital signs, and other physical findings, ECG results and laboratory results as discussed in the Diagnosis or Diagnostic Criteria section.

Diseases that present as chest pain should be ruled out and these are enumerated in the Differential Diagnosis section.

Management

The Evaluation section contains tests that are essential to the management of acute coronary syndrome. Repeating laboratory tests such as ECG and cardiac troponin T or I are recommended. Additional tests may also be performed prior to discharge or on an outpatient basis. The Evaluation section also discusses the risk stratification of acute coronary syndrome.

Drug options recommended for treating patients with acute coronary syndrome such as antiplatelet agents (eg Aspirin, Cangrelor, Clopidogrel, Prasugrel, Ticagrelor, Glycoprotein IIb/IIIa inhibitors, Vorapaxar), anticoagulants (eg low-molecular-weight Heparin, unfractionated Heparin), factor Xa inhibitors (eg Apixaban, Fondaparinux, Rivaroxaban), direct thrombin inhibitors (eg Argatroban, Bivalirudin), antianginal agents (eg beta-blockers, nitrates, calcium antagonists, opioids), high-intensity statins, ACE inhibitors, angiotensin II antagonists and aldosterone antagonists are discussed in detail in the Pharmacological Therapy section. Other agents that may be used for the treatment of acute coronary syndrome are also included.

Several non-drug options to consider that may aid in the management of acute coronary syndrome which include patient and caregiver education, invasive strategies such as coronary angiography and revascularization, supportive treatments such as bed rest and supplemental oxygen, and exercise are featured in the Nonpharmacological section. Risk factor management which includes smoking cessation, control of blood pressure, lifestyle and diet modification strategies, and adequate management of comorbidities such as diabetes, hyperlipidemia and obesity/overweight are also discussed in this section.