Acute coronary syndromes: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
 
(169 intermediate revisions by 3 users not shown)
Line 6: Line 6:
|}
|}
{{Acute coronary syndrome}}
{{Acute coronary syndrome}}
{{CMG}} {{AE}} {{YK}}; {{TarekNafee}}; {{sab}}
{{CMG}} {{AE}} {{Mitra}} {{YK}}; {{TarekNafee}}; {{sab}}


{{SK}} ACS
{{SK}} acute coronary syndrome, acute coronary syndromes, ST-elevation myocardial infarction, Non-ST-segment elevation acute coronary syndrome, unstable angina, STEMI, UA, , NSTEMI, NSTE-ACS  


==Overview==
Acute coronary syndrome (ACS) refers to any group of [[Symptom|symptoms]] attributed to obstruction of the [[coronary artery|coronary arteries]]. The most common [[symptom]] prompting [[diagnosis]] of ACS is [[chest pain]], often radiating to the [[Arm|left arm]] or [[Jaw|angle of the jaw]], pressure-like in character, and associated with [[nausea]] and [[sweating]]. Acute coronary syndrome usually occurs as a result of one of three problems: [[ST-elevation myocardial infarction]] (30%), [[non ST-elevation myocardial infarction]] (25%), or [[unstable angina]] (38%). These types are named according to the appearance of the [[electrocardiogram]]. There can be some variation as to which forms of [[myocardial infarction]] (MI) are classified under acute coronary syndrome.


ACS should be distinguished from [[Chronic stable angina|stable angina]], which is chest pain which develops during [[exertion]] and resolves at rest. New onset [[angina]] however should be considered as a part of acute coronary syndrome, since it suggests a new problem in a [[Coronary arteries|coronary artery]].Though ACS is usually associated with [[coronary thrombosis]], it can also be associated with [[cocaine]] use. Cardiac chest pain can also be precipitated by [[anemia]], [[bradycardia]]s or [[tachycardia]]s.
==[[Acute coronary syndromes overview|Overview]]==


==Classification==
[[Acute coronary syndrome]] ([[ACS]]) refers to a spectrum of conditions resulting from acute myocardial [[ischemia]] and/or [[infarction]] that is most often due to an
Acute coronary syndrome may be classified as follows:
abrupt reduction in [[coronary blood flow]]. The most common [[symptom]] prompting [[diagnosis]] of [[ACS]] is [[chest pain]], often radiating to the [[Arm|left arm]] or [[Jaw|angle of the jaw]], pressure-like in character, and associated with [[nausea]] and [[sweating]]. [[ACS]] should be distinguished from [[Chronic stable angina|stable angina]], which is [[chest pain]] that develops during [[exertion]] and resolves at rest. Traditionally, [[ACS]] has been classified into [[non-ST-elevation myocardial infarction]] ([[NSTEMI]]), [[ST-elevation MI]] ([[STEMI]]), and [[unstable angina]]. [[Unstable angina]] is differentiated from [[NSTEMI]] by the absence of elevated [[cardiac biomarkers]]. The basic pathology in both conditions involves a non-occlusive [[thrombus]] formation from a previously disrupted [[atherosclerotic plaque]] causing an inadequate [[blood supply]] to the heart muscle. Though [[ACS]] is usually associated with [[coronary thrombosis]], it can also be associated with other causes such as [[cocaine]] use. Cardiac [[chest pain]] can also be precipitated by [[anemia]], [[bradycardia]]s or [[tachycardia]]s.


* [[Unstable Angina]]
==[[Acute coronary syndromes classification|Classification]]==
* [[Non ST Elevation Myocardial Infarction]]
* [[ST Elevation Myocardial Infarction]]
==Symptoms==
The signs and symptoms of acute coronary syndrome include:
*[[Chest pain]]
:*[[Chest pain|Substernal chest pain]]
:*Occurs at rest or [[exertion]]
:*Radiation to neck, jaw, left shoulder and left arm
:*Aggravated by physical activity and emotional stress
:*Relieved by rest, [[nitroglycerin]] or both
*Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
*[[Dyspnea]]
*[[Diaphoresis]]
*[[Nausea]] and [[vomiting]]
*[[Fatigue]]
*[[Syncope]]


==Pathophysiology==
For more information on atherosclerotic plaque, click [[Atherosclerosis |here]].


The pathophysiology of acute coronary syndromes depends on [[atherosclerosis|coronary atherosclerotic plaque]] which includes:
*Traditionally, [[ACS]] has been classified into:
**[[Unstable angina]] ([[UA]])
**[[Non-ST-segment elevation myocardial infarction]] ([[NSTEMI]])
**[[ST-segment elevation myocardial infarction]] ([[STEMI]]).


'''Initiation and Progression of Coronary Atherosclerotic Plaque'''
*According to this classification, [[unstable angina]] was defined as clinical and electrocardiographic ([[ECG]]) evidence of [[myocardial ischemia]] in the absence of an elevated [[troponin]] level.
*The [[endothelium]] of [[coronary arteries]] are damaged by the risk factors resulting in [[endothelium|endothelial dysfunction]], leading to the formation of [[Atherosclerosis|atherosclerotic plaque]].
*However, the widespread use of the high-sensitivity [[troponin]] assays made [[UA]] and [[NSTEMI]] indistinguishable since it was shown that almost all patients previously named [[UA]] actually have increased high-sensitivity [[troponin]] levels.  
*The [[macrophages]] in the atherosclerotic plaque release matrix [[metalloproteinases]], leading to plaque disruption.  
*In other words, it is very unlikely that patients with clinical and [[ECG]] evidence of [[myocardial ischemia]] have normal high-sensitivity [[troponin]] levels. <ref name="pmid23775194">{{cite journal| author=Braunwald E, Morrow DA| title=Unstable angina: is it time for a requiem? | journal=Circulation | year= 2013 | volume= 127 | issue= 24 | pages= 2452-7 | pmid=23775194 | doi=10.1161/CIRCULATIONAHA.113.001258 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23775194  }} </ref>
*The balance between [[smooth muscle cells]] and [[macrophages]] in the plaque plays a major role in plaque vulnerability and the propensity to rupture.
*Consequently, in recent guidelines, the [[acute coronary syndromes]] are classified into two broad categories: <ref name="pmid32860058">{{cite journal| author=Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL | display-authors=etal| title=2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. | journal=Eur Heart J | year= 2020 | volume=  | issue=  | pages=  | pmid=32860058 | doi=10.1093/eurheartj/ehaa575 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32860058  }} </ref> <ref name="pmid25249585">{{cite journal| author=Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR | display-authors=etal| title=2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= 130 | issue= 25 | pages= e344-426 | pmid=25249585 | doi=10.1161/CIR.0000000000000134 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25249585  }} </ref>
'''Plaque Vulnerability'''
**[[Non-ST-segment elevation acute coronary syndrome]] ([[NSTE-ACS]]), encompassing :
***[[Non-ST-segment elevation myocardial infarction]] ([[NSTEMI]])
***[[Unstable angina]]  
**[[ST-segment elevation myocardial infarction]] ([[STEMI]])


The plaque vulnerability depends on the following factors:<ref name="pmid10330380">{{cite journal| author=Sukhova GK, Schönbeck U, Rabkin E, Schoen FJ, Poole AR, Billinghurst RC et al.| title=Evidence for increased collagenolysis by interstitial collagenases-1 and -3 in vulnerable human atheromatous plaques. | journal=Circulation | year= 1999 | volume= 99 | issue= 19 | pages= 2503-9 | pmid=10330380 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10330380  }} </ref>
*[[Inflammation]] (A high density of [[macrophages]] and [[T-lymphocytes]] are marker of unstable [[atherosclerotic plaque]])
*Large [[lipid]] core
*Locally increased matrix [[metalloproteinases]] that degrade [[collagen]]
*Thin [[fibrous cap]]
*Relative paucity of [[smooth muscle cells]]
*Increase in plaque [[Neovascularization|neovascularity]] and plaque [[hemorrhage]]
*Eccentric outward remodelling


===Pathogenesis===
* Therefore, [[acute coronary syndromes]] can be classified as follows:


The pathogenesis of acute coronary syndrome depends on:
{{familytree/start}}
*[[Endothelium|Endothelial integrity]]
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | |A01= [[Acute coronary syndromes]]}}
*[[Inflammation]]
{{familytree | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| }}
*[[Thrombogenicity]] of the blood
{{familytree | | | | B01 | | | | | | | | | | | | | | | | B02 | B01=Non-ST-elevation acute coronary syndrome (NTE-ACS) | B02 = [[ST elevation myocardial infarction]]}}
{{familytree | | |,|-|^|-|-|.| | | | | | }}
{{familytree | | |!| | | | |!| }}
{{familytree | | C01 | | | C02 | | | | | | | | | C01 = [[Unstable angina]] | C02 = [[Non-ST-segment elevation myocardial infarction]]}}
{{familytree/end}}


Following [[atherosclerosis|plaque]] rupture or endothelial erosion, the subendothelial matrix is exposed to the circulating [[platelets]], which get activated leading to [[thrombus]] formation. Two types of thrombi can form:
== Defining Lesion Severity. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. (Please do not edit). ==
*White clots: Platelet-rich [[thrombi|clots]] which partially occludes the artery
*Red clots: [[Fibrin]] rich clots superimposed on white clots and cause total occlusion of the artery


==Risk Factors==
=== Angiography to Define Anatomy and Assess Lesion Severity ===
Common risk factors in the development of acute coronary syndrome are:<ref name="pmid3286036">{{cite journal| author=Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J| title=Insights into the pathogenesis of acute ischemic syndromes. | journal=Circulation | year= 1988 | volume= 77 | issue= 6 | pages= 1213-20 | pmid=3286036 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3286036  }} </ref>
The standard procedure for defining coronary anatomy and assessing the degree of coronary artery stenosis is still coronary angiography<ref name="pmid: 35286170"><pmid>35286170</pmid></ref>.
*Age (men >45 and women >55)
*[[Diabetes mellitus]]
*[[Hypercholesterolemia]]
*[[Hypertension]]
*[[Smoking]]
*[[Obesity]]
*Lack of physical activity
*Family history of [[heart disease]]
*History of [[HTN]], [[DM]] and [[pre-eclampsia]] during [[pregnancy]]


==Diagnosis==
* Severe Stenosis:  diameter stenosis severity of 70% for non-left main disease and 50% for left main illness <ref name="pmid: 35286170" />.
* A diameter stenosis severity of 40% to 69% is referred to as an angiographically intermediate coronary stenosis, and it usually necessitates further examination to determine its physiological significance <ref name="pmid: 35286170" />.
* Longer  lesions may cause more ischemia than a single severe lesion <ref name="pmid: 35286170" />.


===High-sensitivity Cardiac Troponin (hs-cTn)===
== [[Acute coronary syndromes causes|Causes]] ==
{| class="wikitable"
*[[ACS]] is characterized by a sudden imbalance between myocardial oxygen consumption and demand, which is usually the result of coronary artery obstruction. <ref name="pmid25249585">{{cite journal| author=Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR | display-authors=etal| title=2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= 130 | issue= 25 | pages= e344-426 | pmid=25249585 | doi=10.1161/CIR.0000000000000134 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25249585 }} </ref>
 
*The most common causes of coronary artery obstruction are:
|- caption = "High sensitivity cardiac troponin assays"
**[[Atherosclerotic]] [[plaque rupture]] and subsequent [[coronary thrombus]]
 
*Other conditions may also cause an imbalance, including:
!
**Excessive [[myocardial oxygen demand]] (in the setting of a stable flow-limiting lesion)
! 99th percentile of a healthy reference population<br/>(recommended cut-off)
**[[Coronary artery spasm]] causing vasospastic ([[Prinzmetal]]) angina
! Turnaround time
**Coronary [[embolism]]
! Name and manufacturer
**Coronary [[arteritis]]
! FDA Approval?
**Noncoronary causes of myocardial oxygen supply-demand mismatch :
|-
***[[Hypotension]]
! Troponin T<br />hs-cTnT
***Severe [[anemia]]
| 14 ng/L<ref name="pmid29691270" />
***[[Hypertension]]
| 18 minutes<ref name="pmid25646632" />
***[[Tachycardia]]
| Elecsys<br/>(Roche Diagnostics)
***[[Hypertrophic cardiomyopathy]]
|
***Severe [[aortic stenosis]]
|-
***Nonischemic [[myocardial injury]]:
! Troponin I<br />hs-cTnI
****[[Myocarditis]]
| 26.2 ng/L<ref name="pmid29691270" />
****[[Cardiac contusion]]
|
****[[Cardiotoxic]] drugs
| ARCHITECT''STAT''<br/>(Abbott Laboratories)
**Multifactorial causes:  
|
***[[Stress cardiomyopathy]] ([[Takotsubo cardiomyopathy]])
|}
***[[Pulmonary embolism]]
 
***Severe [[heart failure]] ([[HF]])
=== Clinical Implications of High-sensitivity Cardiac Troponin Assays ===
***[[Sepsis]]
{| class="wikitable"
|+
!Compared with standard cardiac troponin assays, high-sensitivity assays:
|-
|Have higher negative predictive value for acute MI.
|-
|Reduce the “troponin-blind” interval leading to earlier detection of acute MI.
|-
|Reduce the “troponin-blind” interval leading to earlier detection of acute MI.
|-
|Are associated with a 2-fold increase in the detection of type 2 MI.
|-
!Levels of high-sensitivity cardiac troponin should be interpreted as quantitative markers of cardiomyocyte damage
 
(i.e. the higher the level, the greater the likelihood of MI):
|-
|Elevations beyond 5-fold the upper reference limit have high (>90%) positive predictive value for acute type 1 MI.
|-
|Elevations up to 3-fold the upper reference limit have only limited (50–60%) positive predictive value for acute MI
 
and may be associated with a broad spectrum of conditions.
|-
|It is common to detect circulating levels of cardiac troponin in healthy individuals.
|-
!Rising and/or falling cardiac troponin levels differentiate acute from chronic cardiomyocyte damage
 
(the more pronounced the change, the higher the likelihood of acute MI).  
|-
|<small>Adapted from ''European Heart Journal'' (2016) 37, 267–315</small>
|}
 
 
 
 
Available high sensitivity troponin assays:
 
* Troponin T: Elecsys by Roche Diagnostics
* Troponin  I: ARCHITECT''STAT'' by Abbott Laboratories
 
When both tests have sensitivity of > 99%, cTnT can exclude infarction in more patients with a sensitivity of 90% according to meta-analysis.
 
The agreement between hscTnT and hscTnI measurements is excellent (Cohen's kappa =0.9)<ref name="pmid29691270">{{cite journal| author=van der Linden N, Wildi K, Twerenbold R, Pickering JW, Than M, Cullen L et al.| title=Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction. | journal=Circulation | year= 2018 | volume= 138 | issue= 10 | pages= 989-999 | pmid=29691270 | doi=10.1161/CIRCULATIONAHA.117.032003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29691270 }} </ref>.
 
High sensitivity troponin levels have reduced predictive value when prevalence is low.
 
===Clinical Prediction Rules===
 
[[Clinical prediction rule]]s can help diagnose:
 
* HEART risk score (History, EKG, Age, Risk factors, and troponin) is the only one of these three prediction rules designed for use prior to diagnosis
* [[The GRACE risk score|GRACE risk score]] incorporates 8 findings
* [[TIMI risk score]]
Regarding the comparative performance of the prediction rules:
 
* In the setting of acute chest pain, the HEART score  may best predict complications according to a [[cohort study]].
*In the setting of NSTEMI, the [[The GRACE risk score|GRACE risk score]] may best predict complications according to a [[cohort study]]. However, the HEART risk score was not assessed in this cohort.
 
===Diagnostic Pathways===
 
Clinical diagnostic pathways may help. The European Society of Cardiology recommends two pathways<ref name="pmid26320110">{{cite journal| author=Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F et al.| title=2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2016 | volume= 37 | issue= 3 | pages= 267-315 | pmid=26320110 | doi=10.1093/eurheartj/ehv320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26320110  }} </ref>:


* 0 h/3 h
* 0 h/1 h<ref name="pmid30071991">{{cite journal| author=Twerenbold R, Neumann JT, Sörensen NA, Ojeda F, Karakas M, Boeddinghaus J et al.| title=Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction. | journal=J Am Coll Cardiol | year= 2018 | volume= 72 | issue= 6 | pages= 620-632 | pmid=30071991 | doi=10.1016/j.jacc.2018.05.040 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30071991  }} </ref><ref name="pmid27754881">{{cite journal| author=Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S et al.| title=Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. | journal=Circulation | year= 2016 | volume= 134 | issue= 20 | pages= 1532-1541 | pmid=27754881 | doi=10.1161/CIRCULATIONAHA.116.022677 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27754881  }} </ref>
The last American Health Association guidelines were prepared prior to approval of hs-cTn tests by the FDA.


More recent strategies include:
''For a complete list of causes for [[UA]] click [[Unstable angina pathophysiology|here]], for [[NSTEMI]] click [[Non ST elevation myocardial infarction pathophysiology|here]], and for [[STEMI]] click [[ST elevation myocardial infarction pathophysiology|here]]''.


* Single cTnT measurement, combined with a non-ischemic EKG, that reports troponin is below the limits of detection.
==[[Acute coronary syndromes differential diagnosis|Differentiating Acute coronary syndromes from other Diseases]]==
*View the page on [[Clinical prediction rule#Acute MI / Unstable Angina|diagnosis using the clinical prediction rule]] for ACS for more detail.
*To view the detailed differential diagnosis of [[chest pain]] [[Chest pain differential diagnosis|click here]].


* Single cTnI measurement, combined with low-risk clinical prediction rule<ref name="pmid29622596">{{cite journal| author=Reaney PDW, Elliott HI, Noman A, Cooper JG| title=Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events. | journal=Emerg Med J | year= 2018 | volume= 35 | issue= 7 | pages= 420-427 | pmid=29622596 | doi=10.1136/emermed-2017-207172 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29622596 }} </ref>
*[[Acute Coronary Syndrome]] ([[ACS]]) may be differentiated from other diseases as follows: <ref name="pmid29173670">{{cite journal| author=Chang AM, Fischman DL, Hollander JE| title=Evaluation of Chest Pain and Acute Coronary Syndromes. | journal=Cardiol Clin | year= 2018 | volume= 36 | issue= 1 | pages= 1-12 | pmid=29173670 | doi=10.1016/j.ccl.2017.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29173670  }} </ref> <ref name="pmid29348012">{{cite journal| author=Raphael CE, Heit JA, Reeder GS, Bois MC, Maleszewski JJ, Tilbury RT | display-authors=etal| title=Coronary Embolus: An Underappreciated Cause of Acute Coronary Syndromes. | journal=JACC Cardiovasc Interv | year= 2018 | volume= 11 | issue= 2 | pages= 172-180 | pmid=29348012 | doi=10.1016/j.jcin.2017.08.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29348012  }} </ref> <ref name="pmid25308305">{{cite journal| author=Bastante T, Rivero F, Cuesta J, Benedicto A, Restrepo J, Alfonso F| title=Nonatherosclerotic causes of acute coronary syndrome: recognition and management. | journal=Curr Cardiol Rep | year= 2014 | volume= 16 | issue= 11 | pages= 543 | pmid=25308305 | doi=10.1007/s11886-014-0543-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25308305  }} </ref> <ref name="pmid27528647">Hollander JE, Than M, Mueller C (2016) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=27528647 State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes.] ''Circulation'' 134 (7):547-64. [http://dx.doi.org/10.1161/CIRCULATIONAHA.116.021886 DOI:10.1161/CIRCULATIONAHA.116.021886] PMID: [https://pubmed.gov/27528647 27528647]</ref> <ref name="pmid29173670">{{cite journal| author=Chang AM, Fischman DL, Hollander JE| title=Evaluation of Chest Pain and Acute Coronary Syndromes. | journal=Cardiol Clin | year= 2018 | volume= 36 | issue= 1 | pages= 1-12 | pmid=29173670 | doi=10.1016/j.ccl.2017.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29173670 }} </ref>


==Differential Diagnosis==
Diagnosis of ACS is initiated by a clinical suspicion based on a thorough history of the patient's symptoms. Subsequently, confirmatory tests should be ordered to confirm the diagnosis, identify the specific cause of ACS, or to rule out other possible differentials. In some circumstances, utilizing a clinical prediction tool may be beneficial in guiding the clinician's diagnosis. View the page on [[Clinical prediction rule#Acute MI / Unstable Angina|diagnosis using the clinical prediction rule]] for ACS for more detail.
Acute Coronary Syndrome (ACS) may be differentiated from other diseases as follows:
{|
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
Line 811: Line 721:
•Sudden death
•Sudden death
|style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 24.4%
|style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 24.4%
•30 day mortality rate is about 2%
• 30-day mortality rate is about 2%
|-
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[STEMI]]
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[STEMI]]
Line 872: Line 782:
•Down sloping, up sloping or  
•Down sloping, up sloping or  


horizontal ST segment depression
horizontal ST-segment depression


•T wave inversion
•T wave inversion
Line 882: Line 792:
•Annual incidence of non-fatal MI between 0.5%-2.6%
•Annual incidence of non-fatal MI between 0.5%-2.6%


•1 year mortality rate is 1.3%
•1-year mortality rate is 1.3%
|-
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Prinzmetal's angina]]
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Prinzmetal's angina]]
Line 902: Line 812:


|-
|-
|}<br />
|}
 
== SYNTAX Score to Calculate the Complexity of Coronary Artery Lesions. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. (Please do not edit.) ==
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization (Level of Evidence B-R)".
|}
<ref name="pmid: 35286170" />


=== Differential Diagnoses of Acute Coronary Syndromes in the Setting of Chest Pain ===
=== Differential Diagnoses of Acute Coronary Syndromes in the Setting of Chest Pain ===
<br />
{| class="wikitable"
{| class="wikitable"
|+
|+
Line 915: Line 833:
!Other
!Other
|-
|-
!'''Myopericarditis'''
!'''[[Myopericarditis]]'''
'''Cardiomyopathies'''<sup>a</sup>
'''[[Cardiomyopathies]]'''<sup>a</sup>
!Pulmonary embolism
![[Pulmonary embolism]]
!Aortic dissection
![[Aortic dissection]]
!Esophagitis, reflex or spasm
![[Esophagitis]]
[[Esophageal spasm]]
!Musculoskeletal disorders
!Musculoskeletal disorders
!Anxiety disorders
!Anxiety disorders
Line 977: Line 896:


==Treatment==
==Treatment==
* To view the detailed treatment of [[Unstable angina]]/[[NSTEMI]] [[Unstable angina/ NSTEMI resident survival guide|click here]].
* To view the detailed treatment of [[STEMI ]] [[STEMI resident survival guide|click here]].


===Coronary Angiography===
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Recommendations  to prefer PCI or CABG (Please do not edit) ==


[[Coronary angiography]] within 12 hours likely benefits high risk (elevated [[cardiac biomarkers]] at baseline or [[diabetes]] or a [[GRACE score]] more than 140) [[Patient|patients]].
=== Patients With Complex Disease ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1'''.''' In patients who require revascularization for significant left main CAD with high complexity CAD, it is recommended to choose CABG over PCI to improve survival ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients who require revascularization for multivessel CAD with complex or diffuse CAD (eg, SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage (Level of Evidence B-R)".
|}
<ref name="pmid: 35286170" />


=== Recommendations for Anti-ischemic Drugs in the Acute Phase of Non-ST-elevation Acute Coronary Syndromes===
=== Patients with Diabetes ===
{| class="wikitable"
{| class="wikitable" style="width:80%"
|+
|-
!style="background:yellow"|Recommendations
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
!style="background:yellow"|Class
|-
of Recommendations
| bgcolor="LightGreen" |"1'''.''' In patients with diabetes and multivessel CAD with the involvement of the LAD, who are appropriate candidates for CABG, CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
!style="background:yellow"|Level
|}
of Evidence
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with diabetes who have multivessel CAD amenable to PCI and an indication for revascularization and are poor candidates for surgery, PCI can be useful to reduce long-term ischemic outcomes (Level of Evidence B-NR)".
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' In patients with diabetes who have left main stenosis and low- or intermediate-complexity CAD in the rest of the coronary anatomy, PCI may be considered an alternative to CABG to reduce major adverse cardiovascular out-comes. (Level of Evidence B-R)".
|}
<ref name="pmid: 35286170" />
 
=== Patients With Previous CABG ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with previous CABG with a patent LIMA to the LAD who need repeat revascularization, if PCI is feasible, it is reasonable to choose PCI over CABG (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients with previous CABG and refractory angina on GDMT that is attributable to LAD disease, it is reasonable to choose CABG over PCI when an internal mammary artery (IMA) can be used as a conduit to the LAD (Level of Evidence C-LD)
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|Early initiation of beta-blocker treatment is recommended
| bgcolor="LemonChiffon" |" 3'''.''' In patients with previous CABG and complex CAD, it may be reasonable to choose CABG over PCI when an IMA can be used as a conduit to the LAD (Level of Evidence B-NR)".
|}
<ref name="pmid: 35286170" />


in patients with ongoing ischemic symptoms and without contraindications.
=== Dual antiplatelet therapy (DAPT) ===
!style="background:green; color:white"|I
{| class="wikitable" style="width:80%"
!style="background:blue; color:white"|B
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|It is recommended to continue chronic beta-blocker therapy,
| bgcolor="LemonChiffon" |" 1'''.''' In patients with multivessel CAD amenable to treatment with either PCI or CABG who are unable to access, tolerate, or adhere to DAPT for the appropriate duration of treatment, CABG is reasonable in preference to PCI(Level of evidence B-NR)".
|}
<ref name="pmid: 35286170" />


unless the patient is in Killip class III or higher.
=== Revascularization in Pregnant Patients ===
!style="background:green; color:white"|I
{| class="wikitable" style="width:80%"
!style="background:blue; color:white"|B
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In pregnant patients with STEMI not caused by spontaneous coronary artery dissection (SCAD), it is reasonable to perform primary PCI as the preferred revascularization strategy. (Level of Evidence C-LD)".
|-
|-
|Sublingual or i.v. nitrates are recommended to relieve angina;<sup>a</sup> intravenous treatment is recommended
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In pregnant patients with NSTE-ACS, an invasive strategy is reasonable if medical therapy is ineffective for the management of life-threatening complications (Level of Evidence C-LD)
|}
<ref name="pmid: 35286170" />


in patients with recurrent angina, uncontrolled hypertension or signs of heart failure.
=== Revascularization in Older Patients ===
!style="background:green; color:white"|I
{| class="wikitable" style="width:80%"
!style="background:indigo; color:white"|C
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
|In patients with suspected/confirmed vasospastic angina, calcium channel blockers and  
| bgcolor="LightGreen" |"1'''.''' In older adults, as in all patients, the treatment strategy for CAD should be based on an individual patient’s preferences, cognitive function, and life expectancy''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid: 35286170" />


nitrates should be considered and beta-blockers avoided.
=== Revascularization in Patients With Chronic Kidney Disease ===
!style="background:orange; color:white"|IIa
{| class="wikitable" style="width:80%"
!style="background:blue; color:white"|B
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| colspan="3" |<small><sup>a</sup>Should not be administered in patients with recent intake of sildenafil or vardenafil (< 24 h) or tadalafil (< 48 h).</small>
| bgcolor="LightGreen" |"1'''.''' In patients with CKD undergoing contrast media injection for coronary angiography, measures should be taken to minimize the risk of contrast-induced acute kidney injury''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>''</nowiki>2. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to reduce the risk of AKI.(Level of evidence C-EO )<nowiki>''</nowiki>
|}
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with adequate measures to reduce the risk of AKI (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |" 4. In low-risk patients with NSTE-ACS and CKD, it is reasonable to weigh the risk of coronary angiography and revascularization against the potential benefit(Level of Evidence C-EO)<nowiki>''</nowiki>
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"5'''.''' In asymptomatic patients with stable CAD and CKD, routine angiography and revascularization are not recommended if there is no compelling indication. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
|}
=== <ref name="pmid: 35286170" /> ===
=== Revascularization in Patients Before Noncardiac Surgery ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"1'''.''' In patients with non–left main or noncomplex CAD who is undergoing noncardiac surgery, routine coronary revascularization is not recommended solely to reduce perioperative cardiovascular events. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
|}<ref name="pmid: 35286170" />


==Prevention==
=== Revascularization in Patients to Reduce Ventricular Arrhythmias ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1'''.''' In patients with ventricular fibrillation, polymorphic ventricular tachycardia (VT), or cardiac arrest, revascularization of significant CAD is recommended to improve survival. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"2'''.''' In patients with CAD and suspected scar-mediated sustained monomorphic VT, revascularization is not recommended for the sole purpose of preventing recurrent VT. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD]])'' <nowiki>"</nowiki>
|}<ref name="pmid: 35286170" />


'''Primary Prevention'''
=== Revascularization in Patients With Spontaneous coronary artery dissection (SCAD) ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with SCAD who have hemody-namic instability or ongoing ischemia despite conservative therapy, revascularization may be considered if feasible (Level of Evidence C-LD)".
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"2'''.''' Routine revascularization for SCAD should not be performed ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD]])'' <nowiki>"</nowiki>
|}<ref name="pmid: 35286170" />


The [[Prevention (medical)|primary prevention]] strategies include:
=== Revascularization in Patients With Cardiac Allografts ===
*Dietary modifications:  
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients with cardiac allograft vasculopathy and severe, proximal, discrete coronary lesions, revascularization with PCI is reasonable (Level of Evidence C-LD)".
|}<ref name="pmid: 35286170" />


:*Regular consumption of [[Fruit|fruits]], [[Vegetable|vegetables]], [[whole grains]] and lean meats
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). RECOMMENDATIONS FOR ADDRESSING PSYCHOSOCIAL FACTORS AND LIFESTYLE CHANGES AFTER REVASCULARIZATION ==
:*Limit foods high in [[cholesterol]] and [[saturated fats]]
*Physical exercise
:*30 minutes of moderate exercise
*[[Weight loss]]
*[[Smoking cessation]]
*Regular [[blood pressure]], [[blood sugar]] and [[cholesterol]] check


'''Secondary Prevention'''
=== Cardiac Rehabilitation and Education ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1'''.''' In patients who have undergone revascularization, a comprehensive cardiac rehabilitation program (home-based or center-based) should be prescribed either before hospital discharge or during the first outpatient visit to reduce deaths and hospital readmissions and improve quality of life ''[[ACC AHA guidelines classification scheme#Level of Evidence|(Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>''</nowiki>2. Patients who have undergone revascularization should be educated about CVD risk factors and their modification to reduce cardiovascular events. (Level of evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid: 35286170" />


The [[Prevention (medical)|secondary prevention]] strategies include:
=== Smoking Cessation in Patients After Revascularization ===
*Dietary modifications
{| class="wikitable" style="width:80%"
*Regular [[blood pressure]], [[blood sugar]] and [[cholesterol]] check
|-
*Compliance with [[therapy]] for post acute coronary syndrome event
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
*[[Cardiac rehabilitation]] programs
|-
| bgcolor="LightGreen" |"1'''.''' In patients who use tobacco and have undergone coronary revascularization, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize cessation and reduce adverse cardiac events ''[[ACC AHA guidelines classification scheme#Level of Evidence|(Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>''</nowiki>2. In patients who use tobacco and have under-gone coronary revascularization, smoking cessation interventions are recommended during hospitalization and should include supportive follow-up for at least 1 month after discharge to facilitate tobacco cessation and reduce morbidity and mortality (Level of evidence A)<nowiki>''</nowiki>
|}
<ref name="pmid: 35286170" />


==References==
=== Psychological Interventions in Patients After Revascularization ===
{{Reflist|2}}
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1'''.''' In patients who have undergone coronary revascularization who have symptoms of depression, anxiety, or stress, treatment with cognitive behavioral therapy, psychological counseling, and/or pharmacological interventions is beneficial to improve quality of life and cardiac outcomes ''[[ACC AHA guidelines classification scheme#Level of Evidence|(Level of Evidence: B-R)]]'' <nowiki>"</nowiki>
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients who have undergone coronary revascularization, it may be reasonable to screen for depression and refer or treat when it is indicated to improve quality of life and recovery. (Level of Evidence C-LD)".
|}
<ref name="pmid: 35286170" />


{{WH}}{{WS}}
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Revascularization Outcomes ==


[[CME Category::Cardiology]]
=== Assessment of Outcomes in Patients After Revascularization ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |"1'''.''' With the goal of improving patient outcomes, it is recommended that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted out-comes as a quality assessment and improvement strategy ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' With the goal of improving patient outcomes, it is reasonable for cardiac surgery and PCI programs to have a quality improvement program that routinely 1) reviews institutional quality programs and outcomes
2) reviews individual operator outcomes
3) provides peer review of difficult or complicated cases
4) performs random case reviews
(Level of Evidence C-LD)".
|}
<ref name="pmid: 35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' Smaller volume cardiac surgery and PCI programs may consider affiliating with a high-volume center to improve patient care. (Level of Evidence C-EO)".
|}
<ref name="pmid: 35286170" />


[[Category:Cardiology]]
== References ==
<references />
{{Reflist|2}}
[[Category:Resident survival guide]]
[[Category:Primary care]]

Latest revision as of 16:46, 6 December 2022
Resident
Survival
Guide

Acute Coronary Syndrome Chapters

Heart Attack Patient Information

Unstable Angina Patient Information

Overview

Classification

Unstable Angina
Non-ST Elevation Myocardial Infarction
ST Elevation Myocardial Infarction

Causes

Differential Diagnosis

Treatment

AHA/ACC Guidelines for Acute Coronary Syndrome

Guideline for Risk Stratification in ACS
Guideline for Pre-Hospital Evaluation and Care
Guidelines for Initial Management of ACS
Guidelines for Patients with Atrial Fibrillation Complicating ACS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Yamuna Kondapally, M.B.B.S[3]; Tarek Nafee, M.D. [4]; Sabawoon Mirwais, M.B.B.S, M.D.[5]

Synonyms and keywords: acute coronary syndrome, acute coronary syndromes, ST-elevation myocardial infarction, Non-ST-segment elevation acute coronary syndrome, unstable angina, STEMI, UA, , NSTEMI, NSTE-ACS


Overview

Acute coronary syndrome (ACS) refers to a spectrum of conditions resulting from acute myocardial ischemia and/or infarction that is most often due to an abrupt reduction in coronary blood flow. The most common symptom prompting diagnosis of ACS is chest pain, often radiating to the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. ACS should be distinguished from stable angina, which is chest pain that develops during exertion and resolves at rest. Traditionally, ACS has been classified into non-ST-elevation myocardial infarction (NSTEMI), ST-elevation MI (STEMI), and unstable angina. Unstable angina is differentiated from NSTEMI by the absence of elevated cardiac biomarkers. The basic pathology in both conditions involves a non-occlusive thrombus formation from a previously disrupted atherosclerotic plaque causing an inadequate blood supply to the heart muscle. Though ACS is usually associated with coronary thrombosis, it can also be associated with other causes such as cocaine use. Cardiac chest pain can also be precipitated by anemia, bradycardias or tachycardias.

Classification


 
 
 
 
 
 
 
 
 
 
 
 
Acute coronary syndromes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-ST-elevation acute coronary syndrome (NTE-ACS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ST elevation myocardial infarction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable angina
 
 
Non-ST-segment elevation myocardial infarction
 
 
 
 
 
 
 
 

Defining Lesion Severity. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. (Please do not edit).

Angiography to Define Anatomy and Assess Lesion Severity

The standard procedure for defining coronary anatomy and assessing the degree of coronary artery stenosis is still coronary angiography[4].

  • Severe Stenosis: diameter stenosis severity of 70% for non-left main disease and 50% for left main illness [4].
  • A diameter stenosis severity of 40% to 69% is referred to as an angiographically intermediate coronary stenosis, and it usually necessitates further examination to determine its physiological significance [4].
  • Longer lesions may cause more ischemia than a single severe lesion [4].

Causes


For a complete list of causes for UA click here, for NSTEMI click here, and for STEMI click here.

Differentiating Acute coronary syndromes from other Diseases

Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Cardiovascular Acute Coronary Syndrome + + + + + + + + + + + •Palpitations

•Sweating

Aortic Dissection + + + - + + - + •Pain maximal upon onset •Pain difficult to treat with opiates

•Weak pulse in one arm compared to other

•Syncope

•Symptoms similar to stroke

•Smoking

Brugada Syndrome No chest pain + •Syncope

•Cardiac arrest

•ST-segment elevation

•F/H of sudden cardiac death

Takotsubo carditis Sudden onset of chest pain mimicking myocardial infarction + + + + + - •Extreme emotional or physical stress•syncope

•Women>men

•ST segment elevation

•Left ventricular apical ballooning on echo

•Normal coronary arteries

Pericarditis + + + •Relieving factor: Sitting up and leaning forward

•Aggravating factor: Lying down and breathing deep

+ + + + + + + •Other causes:Malignancy, autoimmune disorders, chest trauma

•Pericardial friction rub

Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Pulmonary Pleuritis
(pleurisy) 		+ + + + •Aggravating factor: Deep breathing + + + + + + •Other causesPulmonary embolism, malignancy, autoimmune diseases
Pulmonary Embolism + •Aggravating factors: Deep breathing, coughing, eating, bending and stooping + + + •Other causes: Immobility, pregnancy, oral contraceptive pills
Pneumonia + + + + + + •Complications: Sepsis, ARDS, Lung abscess
Gastrointestinal GERD + + + •Other symptoms: Hoarseness, Dry cough at night, Sensation of lump in throat etc
Esophageal Spasms + + + + + + + • Risk factors: Anxiety or depression and drinking wine, very hot or cold foods
Esophagitis + + + + + + + • Causes: Hiatal hernia, infection, medications, radiation therapy
Gastritis + + + + + + + • Causes: H.pylori infection, bile reflux, alcohol use, alcohol use
Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Musculoskeletal Muscle sprain/Spasm + + + + • Causes: Over use, dehydration, electrolyte abnormalities
Costochondritis + + + + + + + + + + + • Risk factors: Rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome
Rib fracture/Trauma + + + + + + + + + + • Complications: Pneumothorax, hemothorax, surgical emphysema
Psychiatry Anxiety (Panic Attack) Chest tightness + + • Other symptoms: Palpitations, trembling, sweating, choking, light headed, hot or cold flashes.


The following table summarizes the significant history, and diagnostic test findings that will help differentiate the acute coronary syndromes from one another, as well as from other coronary artery diseases:

Acute Coronary Syndromes History and Symptoms Pathology Diagnostic tests Treatment Complications Prognosis
Chest pain Duration of Chest pain Coronary Artery Plaque Cardiac Biomarkers
(e.g.CK-MB, Troponins) 		EKG Findings Medical Therapy Reperfusion
(e.g. PCI, CABG, or Medical)
At Rest Exertion
Unstable Angina + + <30 minutes Partial occlusion Erosion

or

Rupture

(39%)

Normal •Normal EKG findings (some cases)


•Flipped or inverted T waves


•ST segment depression


•Non-specific ST-T changes

+ •Arrhythmias

•Congestive heart failure

•Hypotension

•New mitral regurgitation

•MI

•Sudden death

•1 year mortality rate is 1.7%
NSTEMI + + >30 minutes Partial or complete occlusion Rupture

(56%)

or

Erosion

Elevated •No EKG findings (some cases)


•Flipped or inverted T waves


•ST segment depression


•Non-specific ST-T changes

•New left bundle branch block

+ + •Arrhythmias

•Congestive heart failure

•Hypotension

•New mitral regurgitation

•Ventricular aneurysms

•Sudden death

•1 year mortality rate is 24.4%

• 30-day mortality rate is about 2%

STEMI + + >30 minutes Complete occlusion Rupture

(50%-75%) or

Erosion

Elevated •ST elevation in at least 2

contiguous leads in V2-V3


•ST depression in at least

two precordial leads V1-V4


•ST depression in several

leads plus ST elevation in

lead aVR (suggestive of occlusion of the left main or proximal LAD artery)


+ + •Reinfarction

•Arrhythmias

•Left ventricular aneurysm

•Pseudoaneurysm

•rupture of papillary muscle,

interventricular septum and LV free wall

•Sudden death

•30 day mortality rate is

1.1% in <45 yrs and 20.4% in >75 yrs patients

Other Coronary Artery Diseases
Chronic stable angina - + ≤ 5 minutes Severely narrowed

coronary vessels

Stable plaque Normal •Normal EKG in 50% of cases

•Down sloping, up sloping or

horizontal ST-segment depression

•T wave inversion

+ •Heart failure •Estimated annual mortality rate is 0.9%-1.4%

•Annual incidence of non-fatal MI between 0.5%-2.6%

•1-year mortality rate is 1.3%

Prinzmetal's angina •Occur at rest

(Mid night to early morning)

•Not associated with exertion

5-30 minutes Coronary artery vasospasm - Normal •Transient ST segment elevation + •Arrhythmias

•MI

•5 year survival is excellent (90%-95%)

SYNTAX Score to Calculate the Complexity of Coronary Artery Lesions. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. (Please do not edit.)

Class IIb
" 1. In patients with multivessel CAD, an assessment of CAD complexity, such as the SYNTAX score, may be useful to guide revascularization (Level of Evidence B-R)".

[4]

Differential Diagnoses of Acute Coronary Syndromes in the Setting of Chest Pain

Cardiac Pulmonary Vascular Gastrointestinal Orthopedic Other
Myopericarditis

Cardiomyopathiesa

Pulmonary embolism Aortic dissection Esophagitis

Esophageal spasm

Musculoskeletal disorders Anxiety disorders
Tachyarrhythmias (Tension)-Pneumothorax Symptomatic aortic aneurysm Peptic ulcer, gastritis Chest trauma Herpes zoster
Acute heart failure Bronchitis, pneumonia Stroke Pancreatitis Muscle injury/inflammation Anemia
Hypertensive emergencies Pleuritis Cholecystitis Costochondritis
Aortic valve stenosis Cervical spine pathologies
Tako-Tsubo cardiomyopathy
Coronary spasm
Cardiac trauma
Bold = Common and/or important differential diagnoses

aDilated, hypertrophic and restrictive cardiomyopathies may cause angina or chest discomfort

Treatment

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Recommendations to prefer PCI or CABG (Please do not edit)

Patients With Complex Disease

Class I
"1. In patients who require revascularization for significant left main CAD with high complexity CAD, it is recommended to choose CABG over PCI to improve survival (Level of Evidence: A) "

[4]

Class IIa
" 2. In patients who require revascularization for multivessel CAD with complex or diffuse CAD (eg, SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage (Level of Evidence B-R)".

[4]

Patients with Diabetes

Class I
"1. In patients with diabetes and multivessel CAD with the involvement of the LAD, who are appropriate candidates for CABG, CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations(Level of Evidence: A) "

[4]

Class IIa
" 2. In patients with diabetes who have multivessel CAD amenable to PCI and an indication for revascularization and are poor candidates for surgery, PCI can be useful to reduce long-term ischemic outcomes (Level of Evidence B-NR)".

[4]

Class IIb
" 3. In patients with diabetes who have left main stenosis and low- or intermediate-complexity CAD in the rest of the coronary anatomy, PCI may be considered an alternative to CABG to reduce major adverse cardiovascular out-comes. (Level of Evidence B-R)".

[4]

Patients With Previous CABG

Class IIa
" 1. In patients with previous CABG with a patent LIMA to the LAD who need repeat revascularization, if PCI is feasible, it is reasonable to choose PCI over CABG (Level of Evidence B-NR)".
'' 2. In patients with previous CABG and refractory angina on GDMT that is attributable to LAD disease, it is reasonable to choose CABG over PCI when an internal mammary artery (IMA) can be used as a conduit to the LAD (Level of Evidence C-LD)

[4]

Class IIb
" 3. In patients with previous CABG and complex CAD, it may be reasonable to choose CABG over PCI when an IMA can be used as a conduit to the LAD (Level of Evidence B-NR)".

[4]

Dual antiplatelet therapy (DAPT)

Class IIa
" 1. In patients with multivessel CAD amenable to treatment with either PCI or CABG who are unable to access, tolerate, or adhere to DAPT for the appropriate duration of treatment, CABG is reasonable in preference to PCI(Level of evidence B-NR)".

[4]

Revascularization in Pregnant Patients

Class IIa
" 1. In pregnant patients with STEMI not caused by spontaneous coronary artery dissection (SCAD), it is reasonable to perform primary PCI as the preferred revascularization strategy. (Level of Evidence C-LD)".
'' 2. In pregnant patients with NSTE-ACS, an invasive strategy is reasonable if medical therapy is ineffective for the management of life-threatening complications (Level of Evidence C-LD)

[4]

Revascularization in Older Patients

Class I
"1. In older adults, as in all patients, the treatment strategy for CAD should be based on an individual patient’s preferences, cognitive function, and life expectancy(Level of Evidence: B-NR) "

[4]

Revascularization in Patients With Chronic Kidney Disease

Class I
"1. In patients with CKD undergoing contrast media injection for coronary angiography, measures should be taken to minimize the risk of contrast-induced acute kidney injury(Level of Evidence: C-LD) "
''2. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to reduce the risk of AKI.(Level of evidence C-EO )''

[4]

Class IIa
" 3. In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with adequate measures to reduce the risk of AKI (Level of Evidence B-NR)".
" 4. In low-risk patients with NSTE-ACS and CKD, it is reasonable to weigh the risk of coronary angiography and revascularization against the potential benefit(Level of Evidence C-EO)''

[4]

Class III (No Benefit)
"5. In asymptomatic patients with stable CAD and CKD, routine angiography and revascularization are not recommended if there is no compelling indication. (Level of Evidence:B-R) "

[4]

Revascularization in Patients Before Noncardiac Surgery

Class III (No Benefit)
"1. In patients with non–left main or noncomplex CAD who is undergoing noncardiac surgery, routine coronary revascularization is not recommended solely to reduce perioperative cardiovascular events. (Level of Evidence:B-R) "

[4]

Revascularization in Patients to Reduce Ventricular Arrhythmias

Class I
"1. In patients with ventricular fibrillation, polymorphic ventricular tachycardia (VT), or cardiac arrest, revascularization of significant CAD is recommended to improve survival. (Level of Evidence: B-NR) "

[4]

Class III (No Benefit)
"2. In patients with CAD and suspected scar-mediated sustained monomorphic VT, revascularization is not recommended for the sole purpose of preventing recurrent VT. (Level of Evidence:C-LD) "

[4]

Revascularization in Patients With Spontaneous coronary artery dissection (SCAD)

Class IIb
" 1. In patients with SCAD who have hemody-namic instability or ongoing ischemia despite conservative therapy, revascularization may be considered if feasible (Level of Evidence C-LD)".

[4]

Class III (Harm)
"2. Routine revascularization for SCAD should not be performed (Level of Evidence:C-LD) "

[4]

Revascularization in Patients With Cardiac Allografts

Class IIa
" 1. In patients with cardiac allograft vasculopathy and severe, proximal, discrete coronary lesions, revascularization with PCI is reasonable (Level of Evidence C-LD)".

[4]

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). RECOMMENDATIONS FOR ADDRESSING PSYCHOSOCIAL FACTORS AND LIFESTYLE CHANGES AFTER REVASCULARIZATION

Cardiac Rehabilitation and Education

Class I
"1. In patients who have undergone revascularization, a comprehensive cardiac rehabilitation program (home-based or center-based) should be prescribed either before hospital discharge or during the first outpatient visit to reduce deaths and hospital readmissions and improve quality of life (Level of Evidence: A) "
''2. Patients who have undergone revascularization should be educated about CVD risk factors and their modification to reduce cardiovascular events. (Level of evidence C-LD)''

[4]

Smoking Cessation in Patients After Revascularization

Class I
"1. In patients who use tobacco and have undergone coronary revascularization, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize cessation and reduce adverse cardiac events (Level of Evidence: A) "
''2. In patients who use tobacco and have under-gone coronary revascularization, smoking cessation interventions are recommended during hospitalization and should include supportive follow-up for at least 1 month after discharge to facilitate tobacco cessation and reduce morbidity and mortality (Level of evidence A)''

[4]

Psychological Interventions in Patients After Revascularization

Class I
"1. In patients who have undergone coronary revascularization who have symptoms of depression, anxiety, or stress, treatment with cognitive behavioral therapy, psychological counseling, and/or pharmacological interventions is beneficial to improve quality of life and cardiac outcomes (Level of Evidence: B-R) "

[4]

Class IIb
" 2. In patients who have undergone coronary revascularization, it may be reasonable to screen for depression and refer or treat when it is indicated to improve quality of life and recovery. (Level of Evidence C-LD)".

[4]

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Revascularization Outcomes

Assessment of Outcomes in Patients After Revascularization

Class I
"1. With the goal of improving patient outcomes, it is recommended that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted out-comes as a quality assessment and improvement strategy (Level of Evidence: B-NR) "

[4]

Class IIa
" 1. With the goal of improving patient outcomes, it is reasonable for cardiac surgery and PCI programs to have a quality improvement program that routinely 1) reviews institutional quality programs and outcomes

2) reviews individual operator outcomes 3) provides peer review of difficult or complicated cases 4) performs random case reviews (Level of Evidence C-LD)".

[4]

Class IIb
" 3. Smaller volume cardiac surgery and PCI programs may consider affiliating with a high-volume center to improve patient care. (Level of Evidence C-EO)".

[4]

References

  1. ↑ Braunwald E, Morrow DA (2013). "Unstable angina: is it time for a requiem?". Circulation. 127 (24): 2452–7. doi:10.1161/CIRCULATIONAHA.113.001258. PMID 23775194.
  2. ↑ Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL; et al. (2020). "2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation". Eur Heart J. doi:10.1093/eurheartj/ehaa575. PMID 32860058 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR; et al. (2014). "2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. 130 (25): e344–426. doi:10.1161/CIR.0000000000000134. PMID 25249585.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 <pmid>35286170</pmid>
  5. ↑ 5.0 5.1 Chang AM, Fischman DL, Hollander JE (2018). "Evaluation of Chest Pain and Acute Coronary Syndromes". Cardiol Clin. 36 (1): 1–12. doi:10.1016/j.ccl.2017.08.001. PMID 29173670.
  6. ↑ Raphael CE, Heit JA, Reeder GS, Bois MC, Maleszewski JJ, Tilbury RT; et al. (2018). "Coronary Embolus: An Underappreciated Cause of Acute Coronary Syndromes". JACC Cardiovasc Interv. 11 (2): 172–180. doi:10.1016/j.jcin.2017.08.057. PMID 29348012.
  7. ↑ Bastante T, Rivero F, Cuesta J, Benedicto A, Restrepo J, Alfonso F (2014). "Nonatherosclerotic causes of acute coronary syndrome: recognition and management". Curr Cardiol Rep. 16 (11): 543. doi:10.1007/s11886-014-0543-y. PMID 25308305.
  8. ↑ Hollander JE, Than M, Mueller C (2016) State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes. Circulation 134 (7):547-64. DOI:10.1161/CIRCULATIONAHA.116.021886 PMID: 27528647
Retrieved from "https://www.wikidoc.org/index.php?title=Acute_coronary_syndromes&oldid=1731832"