Acute coronary syndromes
Resident Survival Guide |
Acute Coronary Syndrome Chapters |
AHA/ACC Guidelines for Acute Coronary Syndrome |
---|
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]; Tarek Nafee, M.D. [3]
Synonyms and keywords: ACS
Overview
Acute coronary syndrome (ACS) refers to any group of symptoms attributed to obstruction of the coronary arteries. The most common symptom prompting diagnosis of ACS is chest pain, often radiating of the left arm or 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%).[1] These types are named according to the appearance of the electrocardiogram.[2] There can be some variation as to which forms of myocardial infarction (MI) are classified under acute coronary syndrome.
ACS should be distinguished from 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 artery.Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use.[3] Cardiac chest pain can also be precipitated by anemia, bradycardias or tachycardias.
Classification
Acute coronary syndrome may be classified as follows:
Symptoms
The signs and symptoms of acute coronary syndrome include:[4]
- 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 here
The pathophysiology of acute coronary syndromes depends on coronary atherosclerotic plaque which includes:[5][6]
Initiation and progression of coronary atherosclerotic plaque
- The endothelium of coronary arteries are damaged by the risk factors resulting in endothelial dysfunction, leading to the formation of atherosclerotic plaque.
- The macrophages in the atherosclerotic plaque release matrix metalloproteinases, leading to plaque disruption. [7]
- The balance between smooth muscle cells and macrophages in the plaque plays a major role in plaque vulnerability and the propensity to rupture.
Plaque vulnerability
The plaque vulnerability depends on the following factors:[8][9][10][10][11]
- 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 neovascularity and plaque hemorrhage
- Eccentric outward remodelling
Pathogenesis
The pathogenesis of acute coronary syndrome depends on:[12][13][14][15]
- Endothelial integrity
- Inflammation
- Thrombogenicity of the blood
Following 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:
- White clots: Platelet-rich clots which partially occludes the artery
- Red clots: Fibrin rich clots superimposed on white clots and cause total occlusion of the artery
Risk Factors
Common risk factors in the development of acute coronary syndrome are:[5]
- 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
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 diagnosis using the clinical prediction rule for ACS for more detail.[16][17] Acute Coronary Syndrome (ACS) may be differentiated from other diseases as follows:[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]
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 etc
•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 causes:Pulmonary embolism, malignancy, automimmune diseases etc | |||||||||||
Pulmonary Embolism | + | •Aggravating factors: Deep breathing, coughing, eating, bending and stooping | + | + | + | •Other causes: immobility, pregnancy, oral contraceptive pills etc | ||||||||||||||||||
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 etc | ||||||||||||||||
Gastritis | + | + | + | + | + | + | + | • Causes: H.pylori infection, bile reflux, alcohol use, alcohol use etc | ||||||||||||||||
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 etc | ||||||||||||||||||
Costochondritis | + | + | + | + | + | + | + | + | + | + | + | • Risk factors: Rheumatoid arthritis, ankylosing spondylitis, reiter's syndrome | ||||||||||||
Rib fracture/Trauma | + | + | + | + | + | + | + | + | + | + | • Complications: Pneumothorax, hemothorax, surgical emphysema etc | |||||||||||||
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:[33][34][35][36][37][38]
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)
|
+ | •Arrhythmias
•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)
|
+ | + | •Arrhythmias
•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
two precordial leads V1-V4
leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)
|
+ | + | •Reinfarction
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 | 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%) |
Prevention
Primary prevention
The primary prevention strategies include:[39]
- Dietary modifications:
- High consumption of fruits, vegetables, whole grains and lean meats
- 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
The secondary prevention strategies include:[40][41][42]
- Dietary modifications
- Regular blood pressure, blood sugar and cholesterol check
- Compliance with therapy for post acute coronary syndrome event
- Cardiac rehabilitation programs
References
- ↑ Torres M, Moayedi S (2007). "Evaluation of the acutely dyspneic elderly patient". Clin. Geriatr. Med. 23 (2): 307–25, vi. doi:10.1016/j.cger.2007.01.007. PMID 17462519. Unknown parameter
|month=
ignored (help) - ↑ Grech ED, Ramsdale DR (2003). "Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction". BMJ. 326 (7401): 1259–61. doi:10.1136/bmj.326.7401.1259. PMC 1126130. PMID 12791748. Unknown parameter
|month=
ignored (help) - ↑ Achar SA, Kundu S, Norcross WA (2005). "Diagnosis of acute coronary syndrome". Am Fam Physician. 72 (1): 119–26. PMID 16035692.
- ↑ Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
- ↑ 5.0 5.1 Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J (1988). "Insights into the pathogenesis of acute ischemic syndromes". Circulation. 77 (6): 1213–20. PMID 3286036.
- ↑ Libby P (2001). "Current concepts of the pathogenesis of the acute coronary syndromes". Circulation. 104 (3): 365–72. PMID 11457759.
- ↑ Fuster V, Badimon L, Badimon JJ, Chesebro JH (1992). "The pathogenesis of coronary artery disease and the acute coronary syndromes (2)". N Engl J Med. 326 (5): 310–8. doi:10.1056/NEJM199201303260506. PMID 1728735.
- ↑ Moreno PR, Falk E, Palacios IF, Newell JB, Fuster V, Fallon JT (1994). "Macrophage infiltration in acute coronary syndromes. Implications for plaque rupture". Circulation. 90 (2): 775–8. PMID 8044947.
- ↑ Davies MJ, Richardson PD, Woolf N, Katz DR, Mann J (1993). "Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content". Br Heart J. 69 (5): 377–81. PMC 1025095. PMID 8518056.
- ↑ 10.0 10.1 Sukhova GK, Schönbeck U, Rabkin E, Schoen FJ, Poole AR, Billinghurst RC; et al. (1999). "Evidence for increased collagenolysis by interstitial collagenases-1 and -3 in vulnerable human atheromatous plaques". Circulation. 99 (19): 2503–9. PMID 10330380.
- ↑ Herman MP, Sukhova GK, Libby P, Gerdes N, Tang N, Horton DB; et al. (2001). "Expression of neutrophil collagenase (matrix metalloproteinase-8) in human atheroma: a novel collagenolytic pathway suggested by transcriptional profiling". Circulation. 104 (16): 1899–904. PMID 11602491.
- ↑ Davies MJ (1990). "A macro and micro view of coronary vascular insult in ischemic heart disease". Circulation. 82 (3 Suppl): II38–46. PMID 2203563.
- ↑ Conti CR, Brawley RK, Griffith LS, Pitt B, Humphries JO, Gott VL; et al. (1973). "Unstable angina pectoris: morbidity and mortality in 57 consecutive patients evaluated angiographically". Am J Cardiol. 32 (6): 745–50. PMID 4542757.
- ↑ Moreno PR, Bernardi VH, López-Cuéllar J, Murcia AM, Palacios IF, Gold HK; et al. (1996). "Macrophages, smooth muscle cells, and tissue factor in unstable angina. Implications for cell-mediated thrombogenicity in acute coronary syndromes". Circulation. 94 (12): 3090–7. PMID 8989114.
- ↑ Weiss EJ, Bray PF, Tayback M, Schulman SP, Kickler TS, Becker LC; et al. (1996). "A polymorphism of a platelet glycoprotein receptor as an inherited risk factor for coronary thrombosis". N Engl J Med. 334 (17): 1090–4. doi:10.1056/NEJM199604253341703. PMID 8598867.
- ↑ Christenson J, Innes G, McKnight D, Thompson CR, Wong H, Yu E; et al. (2006). "A clinical prediction rule for early discharge of patients with chest pain". Ann Emerg Med. 47 (1): 1–10. doi:10.1016/j.annemergmed.2005.08.007. PMID 16387209.
- ↑ Jalili M, Hejripour Z, Honarmand AR, Pourtabatabaei N (2012). "Validation of the vancouver chest pain rule: a prospective cohort study". Acad Emerg Med. 19 (7): 837–42. doi:10.1111/j.1553-2712.2012.01399.x. PMID 22805631.
- ↑ Kumar A, Cannon CP (2009). "Acute coronary syndromes: diagnosis and management, part I." Mayo Clin Proc. 84 (10): 917–38. doi:10.1016/S0025-6196(11)60509-0. PMC 2755812. PMID 19797781.
- ↑ Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A; et al. (2001). "Diagnosis and management of aortic dissection". Eur Heart J. 22 (18): 1642–81. doi:10.1053/euhj.2001.2782. PMID 11511117.
- ↑ Khan IA, Nair CK (2002). "Clinical, diagnostic, and management perspectives of aortic dissection". Chest. 122 (1): 311–28. PMID 12114376.
- ↑ Antzelevitch C (2006). "Brugada syndrome". Pacing Clin Electrophysiol. 29 (10): 1130–59. doi:10.1111/j.1540-8159.2006.00507.x. PMC 1978482. PMID 17038146.
- ↑ Troughton RW, Asher CR, Klein AL (2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
- ↑ Kass SM, Williams PM, Reamy BV (2007). "Pleurisy". Am Fam Physician. 75 (9): 1357–64. PMID 17508531.
- ↑ Goldhaber SZ, Bounameaux H (2012). "Pulmonary embolism and deep vein thrombosis". Lancet. 379 (9828): 1835–46. doi:10.1016/S0140-6736(11)61904-1. PMID 22494827.
- ↑ Pachon J, Prados MD, Capote F, Cuello JA, Garnacho J, Verano A (1990). "Severe community-acquired pneumonia. Etiology, prognosis, and treatment". Am Rev Respir Dis. 142 (2): 369–73. doi:10.1164/ajrccm/142.2.369. PMID 2382902.
- ↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
- ↑ Roman S, Kahrilas PJ (2012). "Distal esophageal spasm". Dysphagia. 27 (1): 115–23. doi:10.1007/s00455-011-9388-3. PMID 22215281.
- ↑ Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA; et al. (2013). "ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)". Am J Gastroenterol. 108 (5): 679–92, quiz 693. doi:10.1038/ajg.2013.71. PMID 23567357.
- ↑ Sipponen P, Kekki M, Seppälä K, Siurala M (1996). "The relationships between chronic gastritis and gastric acid secretion". Aliment Pharmacol Ther. 10 Suppl 1: 103–18. PMID 8730265.
- ↑ Proulx AM, Zryd TW (2009). "Costochondritis: diagnosis and treatment". Am Fam Physician. 80 (6): 617–20. PMID 19817327.
- ↑ Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S; et al. (2003). "A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management". Eur J Cardiothorac Surg. 24 (1): 133–8. PMID 12853057.
- ↑ Craske MG, Rauch SL, Ursano R, Prenoveau J, Pine DS, Zinbarg RE (2009). "What is an anxiety disorder?". Depress Anxiety. 26 (12): 1066–85. doi:10.1002/da.20633. PMID 19957279.
- ↑ Iannaccone M, Quadri G, Taha S, D'Ascenzo F, Montefusco A, Omede' P; et al. (2016). "Prevalence and predictors of culprit plaque rupture at OCT in patients with coronary artery disease: a meta-analysis". Eur Heart J Cardiovasc Imaging. 17 (10): 1128–37. doi:10.1093/ehjci/jev283. PMID 26508517.
- ↑ Dong L, Mintz GS, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL; et al. (2015). "Comparison of plaque characteristics in narrowings with ST-elevation myocardial infarction (STEMI), non-STEMI/unstable angina pectoris and stable coronary artery disease (from the ADAPT-DES IVUS Substudy)". Am J Cardiol. 115 (7): 860–6. doi:10.1016/j.amjcard.2015.01.008. PMID 25661569.
- ↑ Bassand JP (2003). "[Classification of acute coronary syndromes]". Rev Prat. 53 (6): 597–601. PMID 12749143.
- ↑ Roe MT, Chen AY, Thomas L, Wang TY, Alexander KP, Hammill BG; et al. (2011). "Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score". Am Heart J. 162 (5): 875–883.e1. doi:10.1016/j.ahj.2011.08.010. PMID 22093204.
- ↑ Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A; et al. (2007). "STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry)". Eur Heart J. 28 (12): 1409–17. doi:10.1093/eurheartj/ehm031. PMID 17412730.
- ↑ Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N; et al. (2001). "Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban". N Engl J Med. 344 (25): 1879–87. doi:10.1056/NEJM200106213442501. PMID 11419424. Review in: ACP J Club. 2002 Jan-Feb;136(1):4
- ↑ Acute Coronary Syndrome https://medlineplus.gov/ency/article/007639.htm (2016) Accessed on November 17, 2016
- ↑ Lee HY, Cooke CE, Robertson TA (2008). "Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge". J Manag Care Pharm. 14 (3): 271–80. doi:10.18553/jmcp.2008.14.3.271. PMID 18439049.
- ↑ Diamantis E, Troupis T, Mazarakis A, Kyriakos G, Diamanti S, Troupis G; et al. (2014). "Primary and Secondary Prevention of Acute Coronary Syndromes: The Role of the Statins". Recent Adv Cardiovasc Drug Discov. 9 (2): 97–105. PMID 26152179.
- ↑ Islam AM, Patel PM (2010). "Preventing serious sequelae after an acute coronary syndrome: the consequences of thrombosis versus bleeding with antiplatelet therapy". J Cardiovasc Pharmacol. 55 (6): 585–94. doi:10.1097/FJC.0b013e3181d9f81f. PMID 20224426.