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| ==[[Xyz overview|Overview]]== | | ==[[Xyz overview|Overview]]== |
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| 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.
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| 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.
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| ==[[Xyz historical perspective|Historical Perspective]]== | | ==[[Xyz historical perspective|Historical Perspective]]== |
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| ==[[Xyz classification|Classification]]== | | ==[[Xyz classification|Classification]]== |
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| *Traditionally, [[ACS]] has been classified into:
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| **[[Unstable angina]] ([[UA]])
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| **[[Non-ST-segment elevation myocardial infarction]] ([[NSTEMI]])
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| **[[ST-segment elevation myocardial infarction]] ([[STEMI]]).
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|
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| *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.
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| *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.
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| *In other words, it is very unlikely that patients with clinical and [[ECG]] evidence of [[myocardial ischemia]] have normal [[high-sensitivity troponin]] levels.
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| *Consequently, in recent guidelines, acute coronary syndrome is classified into two broad categories:
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| **[[Non-ST-segment elevation acute coronary syndrome]] ([[NSTE-ACS]]), encompassing :
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| ***[[Non-ST-segment elevation myocardial infarction]] ([[NSTEMI]])
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| ***[[Unstable angina]]
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| **[[ST-segment elevation myocardial infarction]] ([[STEMI]])
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| ==[[Xyz pathophysiology|Pathophysiology]]== | | ==[[Xyz pathophysiology|Pathophysiology]]== |
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| For more information on atherosclerotic plaque, click [[Atherosclerosis |here]].
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| The pathophysiology of acute coronary syndromes depends on [[atherosclerosis|coronary atherosclerotic plaque]] which includes:
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| '''Initiation and Progression of Coronary Atherosclerotic Plaque'''
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| *The [[endothelium]] of [[coronary arteries]] are damaged by the risk factors resulting in [[endothelium|endothelial dysfunction]], leading to the formation of [[Atherosclerosis|atherosclerotic plaque]].
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| *The [[macrophages]] in the atherosclerotic plaque release matrix [[metalloproteinases]], leading to plaque disruption.
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| *The balance between [[smooth muscle cells]] and [[macrophages]] in the plaque plays a major role in plaque vulnerability and the propensity to rupture.
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| '''Plaque Vulnerability'''
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| 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>
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| *[[Inflammation]] (A high density of [[macrophages]] and [[T-lymphocytes]] are marker of unstable [[atherosclerotic plaque]])
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| *Large [[lipid]] core
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| *Locally increased matrix [[metalloproteinases]] that degrade [[collagen]]
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| *Thin [[fibrous cap]]
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| *Relative paucity of [[smooth muscle cells]]
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| *Increase in plaque [[Neovascularization|neovascularity]] and plaque [[hemorrhage]]
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| *Eccentric outward remodeling
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| The pathogenesis of acute coronary syndrome depends on:
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| *[[Endothelium|Endothelial integrity]]
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| *[[Inflammation]]
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| *[[Thrombogenicity]] of the blood
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| 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:
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| *White clots: Platelet-rich [[thrombi|clots]] which partially occludes the artery
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| *Red clots: [[Fibrin]] rich clots superimposed on white clots and cause total occlusion of the artery
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| ==[[Xyz causes|Causes]]== | | ==[[Xyz causes|Causes]]== |
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| ==[[Xyz differential diagnosis|Differentiating Xyz from other Diseases]]== | | ==[[Xyz differential diagnosis|Differentiating Xyz from other Diseases]]== |
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| *Diagnosis of ACS is initiated by a clinical suspicion based on a thorough history of the patient's symptoms.
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| *Subsequently, confirmatory tests should be ordered to confirm the diagnosis, identify the specific cause of ACS, or to rule out other possible differentials.
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| *In some circumstances, utilizing a clinical prediction tool may be beneficial in guiding the clinician's diagnosis.
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| *View the page on [[Clinical prediction rule#Acute MI / Unstable Angina|diagnosis using the clinical prediction rule]] for ACS for more detail.
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| *Acute Coronary Syndrome (ACS) may be differentiated from other diseases as follows:
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| {|
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| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
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| ! rowspan="3" |<small>Organ System</small>
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| ! rowspan="3" |<small>Diseases</small>
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| ! colspan="10" |<small>Presentation</small>
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| ! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
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| ! colspan="6" rowspan="2" |<small>Past Medical History</small>
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| ! rowspan="3" | <SMALL>Other Findings</SMALL>
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| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
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| ! colspan="5" |<SMALL>Chest Pain</SMALL>
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| ! colspan="3" |<SMALL>GI Symptoms</SMALL>
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| !<SMALL>Pulmonary</SMALL>
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| !<SMALL>Neck</SMALL>
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| |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
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| !<SMALL><SMALL>On Palpation</SMALL></SMALL>
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| !<SMALL><SMALL>On inspiration</SMALL></SMALL>
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| !<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
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| !<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
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| !<SMALL><SMALL>With Movement</SMALL></SMALL>
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| !<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
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| !<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
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| !<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
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| !<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
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| !<SMALL><SMALL>Jugular
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| Distention</SMALL></SMALL>
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| !<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
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| !<SMALL><SMALL>CBC Findings</SMALL></SMALL>
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| !<SMALL><SMALL>ESR</SMALL></SMALL>
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| !<SMALL><SMALL>D-Dimer</SMALL></SMALL>
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| !<SMALL><SMALL>EKG
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| Findings</SMALL></SMALL>
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| !<SMALL><SMALL>CXR Findings</SMALL></SMALL>
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| !<SMALL><SMALL>DM</SMALL></SMALL>
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| !<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
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| !<SMALL><SMALL>Obesity</SMALL></SMALL>
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| !<SMALL><SMALL>Trauma</SMALL></SMALL>
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| !<SMALL><SMALL>Inxn*</SMALL></SMALL>
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| !<SMALL><SMALL>Htn</SMALL></SMALL>
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| |-
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| ! rowspan="5" style="background: #DCDCDC; padding: 5px; text-align: center;" |<small>Cardiovascular</small>
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| | style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>Acute Coronary Syndrome</SMALL>
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |<small>•[[Palpitation|Palpitations]]</small>
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|
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| <small>•[[Perspiration|Sweating]]</small>
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| |-
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| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Aortic dissection|Aortic Dissection]]</SMALL>
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |-
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |-
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |<small>•Pain maximal upon onset</small> <small>•Pain difficult to treat with opiates</small>
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|
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| <small>•'''Weak pulse in one arm compared to other'''</small>
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|
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| <small>•[[Syncope]]</small>
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|
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| <small>•Symptoms similar to [[stroke]]</small>
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|
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| <small>•'''[[Smoking]]'''</small>
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| |-
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| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Brugada syndrome|Brugada Syndrome]]</SMALL>
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| | colspan="5" style="background: #F5F5F5; padding: 5px;" |No chest pain
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |<small>•</small><SMALL>[[Syncope]]</SMALL>
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|
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| <small>•</small><SMALL>[[Cardiac arrest]]</SMALL>
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|
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| <small>•'''ST-segment elevation'''</small>
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|
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| <small>•F/H of sudden cardiac death</small>
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| |-
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| | style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Takotsubo cardiomyopathy|Takotsubo carditis]]</SMALL>
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| | colspan="5" style="background: #F5F5F5; padding: 5px;" |Sudden onset of chest pain mimicking myocardial infarction
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |-
| |
| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |<small>•Extreme emotional or physical stress</small><small>•</small>syncope
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|
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| <small>•Women>men</small>
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|
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| <small>•'''ST segment elevation'''</small>
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|
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| <small>•'''Left ventricular apical ballooning on echo'''</small>
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|
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| <small>•'''Normal coronary arteries'''</small>
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| |-
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| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pericarditis]]</SMALL>
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| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |<small>•Relieving factor: Sitting up and leaning forward</small>
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|
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| <small>•Aggravating factor: Lying down and breathing deep</small>
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |+
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| | style="background: #F5F5F5; padding: 5px;" |
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| | style="background: #F5F5F5; padding: 5px;" |<small>•Other causes:Malignancy, autoimmune disorders, chest trauma</small>
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|
| |
| <small>•'''[[Pericardial friction rub]]'''</small>
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| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
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| ! rowspan="3" |<small>Organ System</small>
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| ! rowspan="3" |<small>Diseases</small>
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| ! colspan="10" |<small>Presentation</small>
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| ! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
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| ! colspan="6" rowspan="2" |<small>Past Medical History</small>
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| ! rowspan="3" | <SMALL>Other Findings</SMALL>
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| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
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| ! colspan="5" |<SMALL>Chest Pain</SMALL>
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| ! colspan="3" |<SMALL>GI Symptoms</SMALL>
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| !<SMALL>Pulmonary</SMALL>
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| !<SMALL>Neck</SMALL>
| |
| |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| !<SMALL><SMALL>On Palpation</SMALL></SMALL>
| |
| !<SMALL><SMALL>On inspiration</SMALL></SMALL>
| |
| !<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
| |
| !<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
| |
| !<SMALL><SMALL>With Movement</SMALL></SMALL>
| |
| !<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
| |
| !<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
| |
| !<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
| |
| !<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
| |
| !<SMALL><SMALL>Jugular
| |
| Distention</SMALL></SMALL>
| |
| !<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
| |
| !<SMALL><SMALL>CBC Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>ESR</SMALL></SMALL>
| |
| !<SMALL><SMALL>D-Dimer</SMALL></SMALL>
| |
| !<SMALL><SMALL>EKG
| |
| Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>CXR Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>DM</SMALL></SMALL>
| |
| !<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
| |
| !<SMALL><SMALL>Obesity</SMALL></SMALL>
| |
| !<SMALL><SMALL>Trauma</SMALL></SMALL>
| |
| !<SMALL><SMALL>Inxn*</SMALL></SMALL>
| |
| !<SMALL><SMALL>Htn</SMALL></SMALL>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" |<small>Pulmonary</small>
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pleuritis]]<br>(pleurisy)</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•'''Aggravating factor: Deep breathing'''</small>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•Other causes[[:Pulmonary embolism]], [[malignancy]], [[autoimmune diseases]]</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pulmonary embolism|Pulmonary Embolism]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•Aggravating factors: Deep breathing, [[coughing]], eating, bending and stooping</small>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•Other causes: Immobility, [[pregnancy]], oral contraceptive pills</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pneumonia]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•Complications: [[Sepsis]],</small> <small>[[ARDS]]</small><small>,</small> <small>[[Lung abscess]]</small>
| |
|
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="4" |<small>Gastrointestinal</small>
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[GERD]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>•Other symptoms: Hoarseness,</small> <small>Dry cough at night</small><small>,</small> <small>Sensation of lump in throat</small> <small>etc</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Esophageal spasm|Esophageal Spasms]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Risk factors: [[Anxiety]] or [[depression]] and drinking wine, very hot or cold foods</small>
| |
|
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Esophagitis]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Causes: [[Hiatal hernia]], infection, medications, [[radiation therapy]]</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Gastritis]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Causes: [[Helicobacter pylori infection|H.pylori infectio]]<nowiki/>n, bile reflux, alcohol use, alcohol use</small>
| |
| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| ! rowspan="3" |<small>Organ System</small>
| |
| ! rowspan="3" |<small>Diseases</small>
| |
| ! colspan="10" |<small>Presentation</small>
| |
| ! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
| |
| ! colspan="6" rowspan="2" |<small>Past Medical History</small>
| |
| ! rowspan="3" | <SMALL>Other Findings</SMALL>
| |
| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| ! colspan="5" |<SMALL>Chest Pain</SMALL>
| |
| ! colspan="3" |<SMALL>GI Symptoms</SMALL>
| |
| !<SMALL>Pulmonary</SMALL>
| |
| !<SMALL>Neck</SMALL>
| |
| |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| !<SMALL><SMALL>On Palpation</SMALL></SMALL>
| |
| !<SMALL><SMALL>On inspiration</SMALL></SMALL>
| |
| !<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
| |
| !<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
| |
| !<SMALL><SMALL>With Movement</SMALL></SMALL>
| |
| !<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
| |
| !<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
| |
| !<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
| |
| !<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
| |
| !<SMALL><SMALL>Jugular
| |
| Distention</SMALL></SMALL>
| |
| !<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
| |
| !<SMALL><SMALL>CBC Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>ESR</SMALL></SMALL>
| |
| !<SMALL><SMALL>D-Dimer</SMALL></SMALL>
| |
| !<SMALL><SMALL>EKG
| |
| Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>CXR Findings</SMALL></SMALL>
| |
| !<SMALL><SMALL>DM</SMALL></SMALL>
| |
| !<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
| |
| !<SMALL><SMALL>Obesity</SMALL></SMALL>
| |
| !<SMALL><SMALL>Trauma</SMALL></SMALL>
| |
| !<SMALL><SMALL>Inxn*</SMALL></SMALL>
| |
| !<SMALL><SMALL>Htn</SMALL></SMALL>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" |<small>Musculoskeletal<small>
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>Muscle sprain/Spasm</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Causes: Over use, dehydration, electrolyte abnormalities</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Costochondritis]]</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Risk factors: [[Rheumatoid arthritis]], [[ankylosing spondylitis]], [[Reiter's syndrome]]</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Rib fracture]]/Trauma</SMALL>
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Complications: [[Pneumothorax]], [[hemothorax]], surgical [[emphysema]]</small>
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |<small>Psychiatry</small>
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Anxiety]] ([[Panic attack|Panic Attack]])</SMALL>
| |
| | colspan="5" style="background: #F5F5F5; padding: 5px;" |Chest tightness
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| | style="background: #F5F5F5; padding: 5px;" |<small>• Other symptoms: [[Palpitations]], trembling, [[Perspiration|sweating]], choking, light headed, hot or cold flashes.</small>
| |
| |-
| |
| |}
| |
|
| |
|
| |
|
| |
| 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:
| |
|
| |
| {|
| |
| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| ! rowspan="3" colspan="1" |Acute Coronary Syndromes
| |
| ! rowspan="1" colspan="3" |History and Symptoms
| |
| ! rowspan="1" colspan="2" |Pathology
| |
| ! colspan="2" rowspan="1" |Diagnostic tests
| |
| ! rowspan="1" colspan="2" |Treatment
| |
| ! rowspan="3" colspan="1" |Complications
| |
| ! rowspan="3" colspan="1" |Prognosis
| |
| |-style="background: #4479BA; color: #FFFFFF; text-align: center;"
| |
| ! rowspan="1" colspan="2" |Chest pain
| |
| ! rowspan="2" colspan="1" style="vertical-align:top;" |Duration of Chest pain
| |
| ! rowspan="2" colspan="1" style="vertical-align:top;" |<SMALL>Coronary Artery</SMALL>
| |
| ! rowspan="2" colspan="1" style="vertical-align:top;" |<SMALL>Plaque</SMALL>
| |
| ! rowspan="2" colspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Cardiac Biomarkers <br> <SMALL>(e.g.CK-MB, Troponins)</SMALL>
| |
| ! rowspan="2" style="vertical-align:top;" |EKG Findings
| |
| ! rowspan="2" colspan="1" style="width: 50x; vertical-align:top;" |Medical Therapy
| |
| ! rowspan="2" colspan="1" style="width: 50x; vertical-align:top;"|Reperfusion<br><SMALL>(e.g. PCI, CABG, or Medical)</SMALL>
| |
| |-
| |
| ! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" | <SMALL>At Rest </SMALL>
| |
| ! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" | <SMALL>Exertion </SMALL>
| |
| |-
| |
| |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Unstable Angina]]
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |<30 minutes
| |
| |style="background: #F5F5F5; padding: 5px;" |Partial occlusion
| |
| |style="background: #F5F5F5; padding: 5px;" |Erosion
| |
| or
| |
|
| |
| [[Plaque rupture|Rupture]]
| |
|
| |
| (39%)
| |
| |style="background: #F5F5F5; padding: 5px; text-align:center;" |Normal
| |
| |style="background: #F5F5F5; padding: 5px;" | •Normal EKG findings (some cases)
| |
| <br>•Flipped or inverted T waves
| |
|
| |
| <br>•ST segment depression
| |
|
| |
| <br>•Non-specific ST-T changes
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| | style="background: #F5F5F5; padding: 5px;" |
| |
| |style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
| |
|
| |
| •[[Congestive heart failure]]
| |
|
| |
| •[[Hypotension]]
| |
|
| |
| •[[Mitral regurgitation|New mitral regurgitation]]
| |
|
| |
| •[[MI]]
| |
|
| |
| •Sudden death
| |
| |style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 1.7%
| |
| |-
| |
| |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[NSTEMI]]
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |>30 minutes
| |
| |style="background: #F5F5F5; padding: 5px;" |Partial or complete occlusion
| |
| |style="background: #F5F5F5; padding: 5px;" |[[Plaque rupture|Rupture]]
| |
| (56%)
| |
|
| |
| or
| |
|
| |
| Erosion
| |
| |style="background: #F5F5F5; padding: 5px; text-align:center;" |Elevated
| |
| |style="background: #F5F5F5; padding: 5px;" |•No EKG findings (some cases)
| |
| <br>•Flipped or inverted T waves
| |
|
| |
| <br>•ST segment depression
| |
|
| |
| <br>•Non-specific ST-T changes
| |
|
| |
| •[[Left bundle branch block|New left bundle branch block]]
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
| |
|
| |
| •[[Congestive heart failure]]
| |
|
| |
| •[[Hypotension]]
| |
|
| |
| •[[Mitral regurgitation|New mitral regurgitation]]
| |
|
| |
| •[[Left ventricular aneurysm|Ventricular aneurysms]]
| |
|
| |
| •Sudden death
| |
| |style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 24.4%
| |
| •30 day mortality rate is about 2%
| |
| |-
| |
| |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[STEMI]]
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |>30 minutes
| |
| |style="background: #F5F5F5; padding: 5px;" |Complete occlusion
| |
| |style="background: #F5F5F5; padding: 5px;" |[[Plaque rupture|Rupture]]
| |
| (50%-75%) or
| |
|
| |
| Erosion
| |
| |style="background: #F5F5F5; padding: 5px; text-align:center;" |Elevated
| |
| |style="background: #F5F5F5; padding: 5px;" |•ST elevation in at least 2
| |
| contiguous leads in V2-V3
| |
|
| |
| <br>•ST depression in at least
| |
|
| |
| two precordial leads V1-V4
| |
|
| |
| <br>•ST depression in several
| |
|
| |
| leads plus ST elevation in
| |
|
| |
| lead aVR (suggestive of occlusion of the [[Coronary ateries|left main
| |
|
| |
| or proximal LAD artery]])
| |
|
| |
| <br>
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |•[[Reinfarction]]
| |
|
| |
| •[[Arrhythmias]]
| |
|
| |
| •[[Left ventricular aneurysm]]
| |
|
| |
| •[[Pseudoaneurysm]]
| |
|
| |
| •[[papillary muscle rupture|rupture of papillary muscle]],
| |
|
| |
| [[interventricular septum]] and LV free wall
| |
|
| |
| •Sudden death
| |
| |style="background: #F5F5F5; padding: 5px;" |•30 day mortality rate is
| |
|
| |
| 1.1% in <45 yrs and 20.4% in >75 yrs patients
| |
| |-
| |
| ! colspan="12" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: left;" |'''Other Coronary Artery Diseases'''
| |
| |-
| |
| |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic stable angina]]
| |
| | style="background: #F5F5F5; padding: 5px;" |-
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |≤ 5 minutes
| |
| |style="background: #F5F5F5; padding: 5px;" |Severely narrowed
| |
| [[coronary vessels]]
| |
| |style="background: #F5F5F5; padding: 5px;" |Stable plaque
| |
| |style="background: #F5F5F5; padding: 5px;" |Normal
| |
| |style="background: #F5F5F5; padding: 5px;" |•Normal EKG in 50% of cases
| |
|
| |
| •Down sloping, up sloping or
| |
|
| |
| horizontal ST segment depression
| |
|
| |
| •T wave inversion
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |
| |
| |style="background: #F5F5F5; padding: 5px;" |•[[Heart failure]]
| |
| |style="background: #F5F5F5; padding: 5px;" |•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%
| |
| |-
| |
| |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Prinzmetal's angina]]
| |
| |style="background: #F5F5F5; padding: 5px;" colspan="2" |•Occur at rest
| |
| (Mid night to early morning)
| |
|
| |
| •Not associated with exertion
| |
| |style="background: #F5F5F5; padding: 5px;" |5-30 minutes
| |
| |style="background: #F5F5F5; padding: 5px;" |Coronary artery [[vasospasm]]
| |
| | style="background: #F5F5F5; padding: 5px;" |-
| |
| |style="background: #F5F5F5; padding: 5px;" |Normal
| |
| |style="background: #F5F5F5; padding: 5px;" |•Transient ST segment elevation
| |
| |style="background: #F5F5F5; padding: 5px;" |+
| |
| |style="background: #F5F5F5; padding: 5px;" |
| |
| |style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
| |
|
| |
| •[[MI]]
| |
| |style="background: #F5F5F5; padding: 5px;" |•5 year survival is excellent (90%-95%)
| |
|
| |
| |-
| |
| |}<br />
| |
|
| |
| === Differential Diagnoses of Acute Coronary Syndromes in the Setting of Chest Pain ===
| |
| <br />
| |
| {| class="wikitable"
| |
| |+
| |
| !Cardiac
| |
| !Pulmonary
| |
| !Vascular
| |
| !Gastrointestinal
| |
| !Orthopedic
| |
| !Other
| |
| |-
| |
| !'''Myopericarditis'''
| |
| '''Cardiomyopathies'''<sup>a</sup>
| |
| !Pulmonary embolism
| |
| !Aortic dissection
| |
| !Esophagitis, reflex or spasm
| |
| !Musculoskeletal disorders
| |
| !Anxiety disorders
| |
| |-
| |
| |[[Tachyarrhythmias]]
| |
| |([[Tension Pneumothorax|Tension]])-[[Pneumothorax]]
| |
| |[[Symptomatic]] [[aortic aneurysm]]
| |
| |[[Peptic ulcer]], [[gastritis]]
| |
| |[[Chest trauma]]
| |
| |[[Herpes zoster]]
| |
| |-
| |
| |[[Acute heart failure]]
| |
| |[[Bronchitis]], [[pneumonia]]
| |
| |[[Stroke]]
| |
| |[[Pancreatitis]]
| |
| |[[Muscle]] [[injury]]/[[inflammation]]
| |
| |[[Anemia]]
| |
| |-
| |
| |[[Hypertensive emergency|Hypertensive emergencies]]
| |
| |[[Pleuritis]]
| |
| |
| |
| |[[Cholecystitis]]
| |
| |[[Costochondritis]]
| |
| |
| |
| |-
| |
| |[[Aortic stenosis|Aortic valve stenosis]]
| |
| |
| |
| |
| |
| |
| |
| |[[Cervical spine]] [[Pathology|pathologies]]
| |
| |
| |
| |-
| |
| |[[Takosubo cardiomyopathy|Tako-Tsubo cardiomyopathy]]
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |-
| |
| |[[Coronary spasm]]
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |-
| |
| |[[Heart|Cardiac]] [[trauma]]
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |-
| |
| | colspan="6" |Bold = Common and/or important [[Differential diagnosis|differential diagnoses]]
| |
| <sup>a</sup>[[Dilated cardiomyopathy|Dilated]], [[Hypertrophic cardiomyopathy|hypertrophic]] and [[Restrictive cardiomyopathy|restrictive cardiomyopathies]] may cause [[angina]] or [[chest discomfort]]
| |
| |}
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| ==[[Xyz epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Xyz epidemiology and demographics|Epidemiology and Demographics]]== |
|
| |
|
| ==[[Xyz risk factors|Risk Factors]]== | | ==[[Xyz risk factors|Risk Factors]]== |
|
| |
| 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>
| |
| *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]]
| |
|
| |
|
| ==[[xyz screening|Screening]]== | | ==[[xyz screening|Screening]]== |
| Line 898: |
Line 35: |
| ==Treatment== | | ==Treatment== |
| [[Xyz medical therapy|Medical Therapy]] | [[Xyz interventions|Interventions]] | [[Xyz surgery|Surgery]] | [[Xyz primary prevention|Primary Prevention]] | [[Xyz secondary prevention|Secondary Prevention]] | [[Xyz cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Xyz future or investigational therapies|Future or Investigational Therapies]] | | [[Xyz medical therapy|Medical Therapy]] | [[Xyz interventions|Interventions]] | [[Xyz surgery|Surgery]] | [[Xyz primary prevention|Primary Prevention]] | [[Xyz secondary prevention|Secondary Prevention]] | [[Xyz cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Xyz future or investigational therapies|Future or Investigational Therapies]] |
|
| |
|
| |
|
| |
| =
| |
|
| |
|
| |
| ==Diagnosis==
| |
| Diagnostic Study of Choice
| |
| History and Symptoms
| |
| Physical Examination
| |
| Laboratory Findings
| |
| Electrocardiogram
| |
| X-ray
| |
| Echocardiography or Ultrasound
| |
| CT scan
| |
| MRI
| |
| Other Imaging Findings
| |
| Other Diagnostic Studies
| |
|
| |
| *Diagnosis of acute coronary syndrome needs a combination of:
| |
| ** careful history
| |
| ** physical examination
| |
| ** Electrocardiography (ECG)
| |
| ** serum markers of myocardial injury
| |
|
| |
| *According to the 2014 ACC/AHA guidelines for managing Non-ST-elevation ACS, clinical assessment and initial evaluation of patients with suspected ACS should include risk stratification based on the likelihood of ACS as well as adverse clinical outcomes. These assessments would help for the decision on the need for hospitalization and guide in choosing appropriate treatment strategies.
| |
|
| |
| *In all patients with suspected ACS these two questions should be answered:
| |
| ** 1) What is the likelihood that this patient is having ACS?
| |
| *** The likelihood that symptoms and signs represent an ACS can be assessed according to the table below.
| |
|
| |
| ==="The likelihood that Signs and symptoms reflect an underlying ACS"===
| |
| {| class="wikitable"
| |
|
| |
| |- caption = "The likelihood that Signs and symptoms reflect an underlying ACS"
| |
| ! Feature
| |
| ! High
| |
| (Any of the Following)
| |
| !Intermediate
| |
| (Absence of High-Likelihood Features and Presence of Any of the Following)
| |
| ! Low
| |
| (Absence of High- or Intermediate-Likelihood Features but May Have the Following)
| |
| |-
| |
| ! History
| |
| |
| |
| * Chest or left arm pain or discomfort as chief symptom
| |
| * Known history of CAD, including MI
| |
| |
| |
| * Chest or left arm pain or discomfort as chief symptoms
| |
| * Age older than 70 yr, male gender
| |
| |
| |
| * Probable ischemic symptoms in absence of any of the intermediate likelihood characteristics
| |
| *Recent cocaine use
| |
| |-
| |
| ! Physical examination
| |
| |
| |
| *Transient MR murmur
| |
| *Hypotension
| |
| *Diaphoresis
| |
| *Pulmonary edema or rales
| |
| |
| |
| *Extracardiac vascular disease
| |
| |
| |
| *Chest discomfort reproduced by palpation
| |
| |-
| |
| ! ECG
| |
| |
| |
| *New, or presumably new, transient ST-segment deviation (1 mm or more)
| |
| or
| |
| *T-wave inversion in multiple precordial leads
| |
| |
| |
| *Fixed Q waves
| |
| *ST depression 0.5 to 1 mm
| |
| or
| |
| *T-wave inversion more than 1 mm
| |
| |
| |
| *T-wave flattening or inversion less than 1 mm in leads with dominant R waves
| |
| *Normal ECG
| |
| |-
| |
| ! Cardiac markers
| |
| |
| |
| *Elevated cardiac TnI, TnT, or CK-MB levels
| |
| |
| |
| *Normal
| |
| |
| |
| *Normal
| |
| |}
| |
|
| |
| ** 2) What is the likelihood of adverse clinical outcome(s) in this patient?
| |
| ***Several risk assessment scores and clinical prediction algorithms have been used to identify patients who are at high risk of developing adverse outcomes.
| |
| ***These risk scores and algorithms use an integration of clinical history, physical examination findings, ECG, and cardiac troponins.
| |
| ***The most common risk assessment tools include:
| |
| ****[[TIMI]] (Thrombolysis In Myocardial Infarction) risk score
| |
| ****PURSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy) risk score
| |
| ****[[GRACE]] (Global Registry of Acute Coronary Events) risk score
| |
| ****NCDR-ACTION (National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network) registry (https://www.ncdr.com/webncdr/action/).
| |
|
| |
| ***The following risk scores have been designed to specifically assess patients presenting to the ED with chest pain:
| |
| ****Sanchis score
| |
| ****Vancouver rule
| |
| ****Heart (History, ECG, Age, Risk Factors, and Troponin) score
| |
| ****HEARTS3 score
| |
| ****Hess prediction rule
| |
|
| |
|
| |
|
| |
| ==Symptoms==
| |
| The symptoms of [[acute coronary syndrome]] include:
| |
| * Chest discomfort described as:
| |
| ** pain
| |
| ** pressure
| |
| ** tightness
| |
| ** burning.
| |
| *In contrast to the pain described in [[stable angina]] as deep, poorly localized [[retrosternal]] chest discomfort that is reproducible with activity or emotional stress and relieved promptly (within less than 5 minutes) by rest and/or short-acting [[nitroglycerin]], [[ACS]] patients tend to experience the episodes that are more severe and prolonged, may occur at rest, or may be precipitated by less exertion than the patient's previous experiences.
| |
| *Pain frequently radiates to the left arm, left shoulder, back, jaw, neck, or epigastric region
| |
| *Some patients may not have [[chest pain]] and present with other symptoms, known as "[[anginal equivalents]]", including:
| |
| **[[Dyspnea]] (most common)
| |
| **[[Nausea]] and [[vomiting]]
| |
| **[[Diaphoresis]]
| |
| **Unexplained [[fatigue]]
| |
| *[[Syncope]] may be a rare presentation of ACS.
| |
|
| |
| The following features are usually in favor of the non-ischemic nature of pain:
| |
| *[[Pleuritic pain]]: sharp or stabbing pain increased in intensity by respiration or cough
| |
| *Pain reproduced with movement or palpation
| |
| *Pain which can be localized by the tip of 1 finger
| |
| *Brief episodes of pain (lasting a few seconds)
| |
| *Pain with maximal intensity at onset
| |
| *Primary or the only location of pain in the middle or lower [[abdomen]]
| |
| *Pain radiating to lower extremities
| |
|
| |
|
| |
| ==Treatment==
| |
| ===Medical Therapy===
| |
| *The management of non-ST-elevation (NSTE) acute coronary syndrome (ACS) is presented here.
| |
| *For more information on the management of [[ST-elevation myocardial infarction]], click [[ST elevation myocardial infarction|here]].
| |
| *Standard Medical Therapies in NSTE-ACS include the following:
| |
|
| |
| ====Oxygen====
| |
| *No benefit has been shown for routine [[supplemental oxygen]] administration in [[NSTE-ACS]] patients with normal [[arterial oxygen saturation]].
| |
| *[[Supplemental oxygen]] should be administered to with [[NSTE-ACS]] patients who have:
| |
| **[[Arterial oxygen saturation]] less than 90%
| |
| **[[Respiratory distress]]
| |
| **Other high-risk features of [[hypoxemia]]
| |
| (Class I, Level of Evidence: C)
| |
|
| |
| ====Anti-Ischemic and [[Analgesic]] Medications====
| |
| =====1) [[Nitrates]]=====
| |
| * Sublingual [[nitroglycerin]] (every 5 minutes for up to 3 doses) should be administered to patients with [[NSTE-ACS]] with continuing ischemic pain (Class I, Level of Evidence: C).
| |
| * After 3 doses of sublingual [[nitroglycerin]], patients should be assessed for the need for intravenous [[nitroglycerin]].
| |
| * Intravenous [[nitroglycerin]] is indicated for [[NSTE-ACS]] patients with persistent [[ischemia]], [[HF]], and [[hypertension]]. (Class I, Level of Evidence: B)
| |
| * [[Nitrates]] are contraindicated in [[NSTE-ACS]] patients who recently received a [[phosphodiesterase inhibitor]], especially within 24 hours of [[sildenafil]] or [[vardenafil]], or within 48 hours of [[tadalafil]] (Class III, Level of Evidence: B).
| |
|
| |
| =====2) [[Analgesic]] therapy=====
| |
| * In patients with continued ischemic chest pain despite receiving maximally tolerated anti-ischemic medications, intravenous [[morphine sulfate]] can be administered (Class IIb, Level of Evidence: B).
| |
| * Due to the increased risk of [[major adverse cardiovascular events]] ([[MACE]]s), [[nonsteroidal anti-inflammatory drugs]] ([[NSAIDs]]) (except [[aspirin]]) should not be initiated and should be discontinued during hospitalization for [[NSTE-ACS]] (Class III, Level of Evidence: B).
| |
|
| |
| =====3) [[Beta Blockers]]=====
| |
| * Oral [[beta-blocker]]s should be initiated within the first 24 hours in [[NSTE-ACS]] patients, in the absence of any of the following: (Class I, Level of Evidence: A)
| |
| ** 1) Signs of [[heart failure]]
| |
| ** 2) Evidence of [[low-output state]],
| |
| ** 3) Increased risk for [[cardiogenic shock]], including:
| |
| *** Patients >70 years of age
| |
| *** Heart rate >110 beats per minute
| |
| *** Systolic BP <120 mm Hg
| |
| *** Late presentation
| |
| ** 4) Other contraindications to [[beta-blockers]], such as:
| |
| *** [[PR interval]] >0.24 second
| |
| *** Second- or third-degree [[heart block]] without a [[cardiac pacemaker]]
| |
| *** Active [[asthma]] or reactive airway disease
| |
| **** In the absence of active [[bronchospasm]], chronic obstructive lung disease or asthma are not considered contraindications of beta-blocker therapy.
| |
| **** In these patients, beta-1 selective beta-blockers are preferred and should be initiated at a low dosage.
| |
| * In patients with concomitant [[NSTE-ACS]], stabilized [[HF]], and reduced [[systolic function]], beta-blocker therapy should be continued with any of: (Class I, Level of Evidence: C)
| |
| ** [[sustained-release]] [[metoprolol succinate]]
| |
| ** [[carvedilol]]
| |
| ** [[bisoprolol]]
| |
| ** These [[beta-blockers]] have been shown to reduce [[mortality]] in patients with [[heart failure]].
| |
| * In [[NSTE-ACS]] patients with normal [[LV function]], [[beta-blocker]] therapy can also be continued (Class IIa, Level of Evidence: C).
| |
|
| |
| =====4) [[Calcium Channel Blockers]]=====
| |
|
| |
| {| class="wikitable"
| |
| |+
| |
| ! colspan="3"; style="background:maroon; color:white"|Recommendations for Calcium Channel Blockers in Non-ST-elevation Acute Coronary Syndromes
| |
| |-
| |
| |+
| |
| !style="background:LightGray"|Recommendations
| |
| !style="background:LightGray"|Class
| |
| of Recommendations
| |
| !style="background:LightGray"|Level
| |
| of Evidence
| |
| |-
| |
| |In patients with NSTE-ACS, continuing or frequently recurring ischemia, and a contraindication to beta-blockers, a nondihydropyridine calcium channel blocker (CCB) (eg, verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant LV dysfunction, increased risk for cardiogenic shock, PR interval greater than 0.24 second, or second- or third-degree atrioventricular block without a cardiac pacemaker.
| |
| !style="background:green; color:white"|I
| |
| !style="background:RoyalBlue; color:white"|B
| |
| |-
| |
| |Oral nondihydropyridine calcium antagonists are recommended in patients with NSTE-ACS who have recurrent ischemia in the absence of contraindications, after appropriate use of beta blockers and nitrates.
| |
| !style="background:green; color:white"|I
| |
| !style="background:SkyBlue; color:white"|C
| |
| |-
| |
| |CCBs† are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects.
| |
| !style="background:green; color:white"|I
| |
| !style="background:SkyBlue; color:white"|C
| |
| |-
| |
| |Long-acting CCBs and nitrates are recommended in patients with coronary artery spasm.
| |
| !style="background:green; color:white"|I
| |
| !style="background:SkyBlue; color:white"|C
| |
| |-
| |
| |Immediate-release nifedipine should not be administered to patients with NSTE-ACS in the absence of beta-blocker therapy.
| |
| !style="background:red; color:white"|III: Harm
| |
| !style="background:RoyalBlue; color:white"|B
| |
| |-
| |
| | colspan="3" |<small><sup></sup> † Short-acting dihydropyridine calcium channel blockers should be avoided.</small>
| |
| |}
| |
|
| |
| =====5) Other Anti-Ischemic Interventions=====
| |
|
| |
| *[[Ranolazine]]
| |
| *[[Intra-Aortic Balloon Pump]] ([[IABP]]) Counterpulsation: In [[NSTE-ACS]] patients with severe persistent or recurrent [[ischemia]] despite receiving intensive medical therapy [[IABP]] counterpulsation may be used, in particular in patients awaiting [[invasive angiography]] and [[revascularization]].
| |
|
| |
| ====Lipid-lowering therapy====
| |
| In the absence of contraindications, high-intensity [[statin]] therapy should be initiated or continued in all patients with [[NSTE-ACS]], I, regardless of baseline LDL cholesterol levels. (Class I, Level of Evidence: A).
| |
|
| |
| ====Inhibitors of the Renin-Angiotensin-Aldosterone System====
| |
|
| |
|
| |
| {| class="wikitable"
| |
| |+
| |
| ! colspan="3"; style="background:maroon; color:white"|Recommendations for Inhibitors of the Renin-Angiotensin-Aldosterone System in Non-ST-elevation Acute Coronary Syndromes in Non-ST-elevation Acute Coronary Syndromes
| |
| |-
| |
| |+
| |
| !style="background:Lavender"|Recommendations
| |
| !style="background:Lavender"|Class of Recommendation
| |
| !style="background:Lavender"|Level of Evidence
| |
| |-
| |
| |ACE inhibitors should be started and continued indefinitely in:
| |
| * all patients with LVEF less than 0.40
| |
| * those with hypertension, diabetes mellitus, or stable CKD
| |
| , unless contraindicated.
| |
| !style="background:green; color:white"|I
| |
| !style="background:Blue; color:white"|A
| |
| |-
| |
| |ARBs are recommended in patients with HF or MI with LVEF less than 0.40 who are ACE inhibitor intolerant.
| |
| !style="background:green; color:white"|I
| |
| !style="background:Blue; color:white"|A
| |
| |-
| |
| |Aldosterone blockade is recommended in:
| |
| * patients post–MI without significant renal dysfunction (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) or hyperkalemia (K+ >5.0 mEq/L) who are receiving therapeutic doses of ACE inhibitor and beta blocker and have a LVEF 0.40 or less, diabetes mellitus, or HF.
| |
| !style="background:green; color:white"|I
| |
| !style="background:Blue; color:white"|A
| |
| |-
| |
| |ARBs are reasonable in other patients with cardiac or other vascular disease who are ACE inhibitor intolerant.
| |
| !style="background:gold; color:white"|IIa
| |
| !style="background:RoyalBlue; color:white"|B
| |
| |-
| |
| |ACE inhibitors may be reasonable in all other patients with cardiac or other vascular disease.
| |
| !style="background:Orange; color:white"|IIb
| |
| !style="background:RoyalBlue; color:white"|B
| |
| |}
| |
|
| |
| ====Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS====
| |
| *Initial oral and intravenous antiplatelet therapy in patients with definite or likely NSTE-ACS (treated with an initial invasive or ischemia-guided strategy) can be done with:
| |
| ** [[Aspirin]]
| |
| ** [[P2Y12 Receptor Inhibitors]]
| |
| *Initial parenteral anticoagulant therapy in patients with definite NSTE-ACS can be done with:
| |
| **[[Low-Molecular-Weight Heparin]]
| |
| **[[Bivalirudin]]
| |
| **[[Fondaparinux]]
| |
| **[[Unfractionated Heparin]]
| |
| **[[Argatroban]]
| |
|
| |
| {| class="wikitable"
| |
| |+
| |
| ! colspan="4"; style="background:maroon; color:white"|Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI
| |
| |-
| |
| |+
| |
| !style="background:Lavender"|Recommendations
| |
| !style="background:Lavender"|Special considerations
| |
| !style="background:Lavender"|Class of Recommendations
| |
| !style="background:Lavender"|Level of Evidence
| |
| |-
| |
| | colspan="4"|'''[[Aspirin]]'''
| |
| |-
| |
| | Non–enteric-coated [[aspirin]] to all patients promptly after presentation
| |
| ! 162 mg-325 mg
| |
| !style="background:green; color:white"|I
| |
| !style="background:Royalblue; color:white"|A
| |
| |-
| |
| | [[Aspirin]] maintenance dose continued indefinitely
| |
| ! 81 mg/d-325 mg/d
| |
| !style="background:green; color:white"|I
| |
| !style="background:royalblue; color:white"|A
| |
| |-
| |
| |colspan="4"|'''[[P2Y12 inhibitors]]'''
| |
| |-
| |
| |[[Clopidogrel]] [[loading dose]] followed by daily [[maintenance dose]] in patients unable to take [[aspirin]]
| |
| ! 75 mg
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyblue; color:white"|B
| |
| |-
| |
| | [[P2Y12 inhibitor]], in addition to [[aspirin]], for up to 12 mo for patients treated initially with either an early invasive or initial ischemia-guided strategy:
| |
| *[[Clopidogrel]]
| |
| *[[Ticagrelor]]
| |
| !
| |
| * 300-mg or 600-mg [[loading dose]], then 75 mg/d
| |
| * 180-mg [[loading dose]], then 90 mg BID
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyblue; color:white"|B
| |
| |-
| |
| | [[P2Y12 inhibitor]] therapy ([[clopidogrel]], [[prasugrel]], or [[ticagrelor]]) continued for at least 12 mo in post–PCI patients treated with [[coronary stents]]
| |
| ! N/A
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyblue; color:white"|B
| |
| |-
| |
| | [[Ticagrelor]] in preference to [[clopidogrel]] for patients treated with an early invasive or ischemia-guided strategy
| |
| ! N/A
| |
| !style="background:gold; color:white"|IIa
| |
| !style="background:skyblue; color:white"|B
| |
| |-
| |
| |colspan="4"|'''GP IIb/IIIa inhibitors'''
| |
| |-
| |
| |[[GP IIb/IIIa inhibitor]] in patients treated with an early invasive strategy and [[DAPT]] with intermediate/high-risk features (eg, positive [[troponin]])
| |
| ! Preferred options are [[eptifibatide]] or [[tirofiban]]
| |
| !style="background:orange; color:white"|IIb
| |
| !style="background:skyBlue; color:white"|B
| |
| |-
| |
| |colspan="4"|'''Parenteral [[anticoagulant]] and [[fibrinolytic]] therapy'''
| |
| |-
| |
| | SC [[enoxaparin]] for duration of hospitalization or until [[PCI]] is performed
| |
| !
| |
| * 1 mg/kg SC every 12 h (reduce dose to 1 mg/kg/d SC in patients with CrCl<30 mL/min)
| |
| * Initial 30 mg IV [[loading dose]] in selected patients
| |
| !style="background:green; color:white"|I
| |
| !style="background:royalBlue; color:white"|A
| |
| |-
| |
| | [[Bivalirudin]] until diagnostic [[angiography]] or [[PCI]] is performed in patients with early invasive strategy only
| |
| !
| |
| *Loading dose 0.10 mg/kg [[loading dose]] followed by 0.25 mg/kg/h
| |
| * Only provisional use of [[GP IIb/IIIa inhibitor]] in patients also treated with [[DAPT]]
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyBlue; color:white"|B
| |
| |-
| |
| | SC [[fondaparinux]] for the duration of hospitalization or until [[PCI]] is performed
| |
| ! 2.5 mg SC daily
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyBlue; color:white"|B
| |
| |-
| |
| | Administer additional [[anticoagulant]] with anti-IIa activity if [[PCI]] is performed while patient is on [[fondaparinux]]
| |
| ! N/A
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyBlue; color:white"|B
| |
| |-
| |
| | IV [[UFH]] for 48 h or until [[PCI]] is performed
| |
| !
| |
| * Initial [[loading dose]] 60 IU/kg (max 4000 IU) with initial infusion 12 IU/kg/h (max 1000 IU/ h)
| |
| * Adjusted to therapeutic [[aPTT]] range
| |
| !style="background:green; color:white"|I
| |
| !style="background:skyBlue; color:white"|B
| |
| |-
| |
| | IV [[fibrinolytic]] treatment not recommended in patients with [[NSTE-ACS]]
| |
| ! N/A
| |
| !style="background:red; color:white"|III: Harm
| |
| !style="background:royalBlue; color:white"|A
| |
| |-
| |
| |}
| |
|
| |
| ====Ischemia-Guided Strategy Versus Early Invasive Strategies====
| |
|
| |
|
| |
| {{Family tree/start}}
| |
| {{familytree | | | | | A01 | | | | | A01= NSTE-ACS
| |
| (Definite or Likely)}}
| |
| {{familytree | | | |,|-|^|-|.| | | | | }}
| |
| {{familytree | | | B01 | | B02 | | | | B01=Ischemia-guided strategy | B02=Early invasive strategy}}
| |
| {{familytree | | | |!| | | |!| | | | | }}
| |
| {{familytree | | | C01 | | C02 | | | | C01=<div style="float: left; text-align: left; width: 17em; padding:1em;"> Initiate DAPT and Anticoagilant Therapy:
| |
| 1. ASA
| |
| 2. P2Y12 inhibitor (in addition to ASA):
| |
| * Clopidogrel
| |
| * Ticagrelor
| |
| 3. Anticoagulant
| |
| * UFH
| |
| * Enoxaparin
| |
| *Fondaparinux| C02=<div style="float: left; text-align: left; width: 17em; padding:1em;"> Initiate DAPT and Anticoagilant Therapy:
| |
| 1. ASA
| |
| 2. P2Y12 inhibitor (in addition to ASA):
| |
| * Clopidogrel
| |
| * Ticagrelor
| |
| 3. Anticoagulant
| |
| * UFH
| |
| * Enoxaparin
| |
| *Fondaparinux
| |
| *Bivalirudin
| |
| 4. Can consider GPI in addition to ASA and P2Y12 inhibitor in high-risk (e.g., troponin positive) patients
| |
| *Eptifibatide
| |
| *Tirofiban}}
| |
| {{familytree | | |,|-|^|-|.| | | | | | | | | | }}
| |
| {{familytree | | |!| | | |!| | | | | | }}
| |
| {{familytree | | D01 | | D02 | | | | | | | | | D01= Therapy effective | D02= Therapy Ineffective: If the patient has ANY of the following findings, pharmacologic therapy is considered ineffective:<br>
| |
| ❑ Refractory angina, OR<br>
| |
| ❑ Angina at rest or with minimal activity, OR <br>
| |
| ❑ Objective evidence of ischemia (dynamic ECG changes or myocardial perfusion defect) by non-invasive testing, OR <br>
| |
| ❑ Presence of high prognostic risk (either high TIMI risk score > 1 or high GRACE score > 109) }}
| |
| {{familytree | | |!| |,|-|^|-|.| | | | | | | }}
| |
| {{familytree | | |!| |!| | | |!| | | | }}
| |
| {{familytree | | |!| E01 | | E02 | | | | | | | E01= PCI with stenting: Initiate/continue antiplatelet and anticoagulant therapy
| |
| 1. ASA
| |
| 2. P2Y12 inhibitor (in addition to ASA):
| |
| *Clopidogrel
| |
| * Prasugrel
| |
| * Ticagrelor
| |
| 3. GPI (if not treated with bivalirudin at the time of PCI):
| |
| * High-risk features, not adequately pretreated with clopidogrel
| |
| High-risk features, adequately treated with clopidogrel
| |
| 4. Anticoagulant:
| |
| Enoxaparin
| |
| bivalirudin
| |
| Fondaparinux as the sole anticoagulant
| |
| UFH| E02= CABG: Initiate/continue ASA therapy and discontinue P2Y12 and/or GPI therapy
| |
| 1. ASA
| |
| 2. Discontinue clopidogrel/ticagrelor 5d before, and prasugrel at least 7d before elective CABG
| |
| 3. Dicontinue clpidogrel/ticagrelor up to 24h before urgent CABG
| |
| May perform CABG<5d after clopidogrel/ticagrelor and <7d after prasugrel discontinued
| |
| 4. Discontinue eptifbatide/tifofiban at least 2-4 h before and abciximab >=12h before CABG}}
| |
| {{familytree | | |!| | |!| | | |!| }}
| |
| {{familytree | | |!| | |!| | | |!| }}
| |
| {{familytree | | |!| | |!| | | |!| | }}
| |
| {{familytree | | |`|-| F01 |-|-|'| | | F01= Late hospitalization/post-hospital care:
| |
| 1. ASA indefinitely
| |
| 2. P2Y12 inhibitor (clopidogrel or ticagrelor), in addition to ASA, up to 12 mo if medically created
| |
| 3. P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor), in addition to ASA, up to 12 mo if treated with coronary stenting}}
| |
| {{familytree/end}}
| |
|
| |
| ===Surgery===
| |
| ===Primary Prevention===
| |
| ===Secondary Prevention===
| |
|
| |
|
| |
| ===Coronary Angiography===
| |
|
| |
| [[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]].
| |
|
| |
| === Recommendations for Anti-ischemic Drugs in the Acute Phase of Non-ST-elevation Acute Coronary Syndromes===
| |
| {| class="wikitable"
| |
| |+
| |
| !style="background:yellow"|Recommendations
| |
| !style="background:yellow"|Class
| |
| of Recommendations
| |
| !style="background:yellow"|Level
| |
| of Evidence
| |
| |-
| |
| |Early initiation of beta-blocker treatment is recommended
| |
|
| |
| in patients with ongoing ischemic symptoms and without contraindications.
| |
| !style="background:green; color:white"|I
| |
| !style="background:blue; color:white"|B
| |
| |-
| |
| |It is recommended to continue chronic beta-blocker therapy,
| |
|
| |
| unless the patient is in Killip class III or higher.
| |
| !style="background:green; color:white"|I
| |
| !style="background:blue; color:white"|B
| |
| |-
| |
| |Sublingual or i.v. nitrates are recommended to relieve angina;<sup>a</sup> intravenous treatment is recommended
| |
|
| |
| in patients with recurrent angina, uncontrolled hypertension or signs of heart failure.
| |
| !style="background:green; color:white"|I
| |
| !style="background:indigo; color:white"|C
| |
| |-
| |
| |In patients with suspected/confirmed vasospastic angina, calcium channel blockers and
| |
|
| |
| nitrates should be considered and beta-blockers avoided.
| |
| !style="background:orange; color:white"|IIa
| |
| !style="background:blue; color:white"|B
| |
| |-
| |
| | 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>
| |
| |}
| |
|
| |
| ==Prevention==
| |
|
| |
| '''Primary Prevention'''
| |
|
| |
| The [[Prevention (medical)|primary prevention]] strategies include:
| |
| *Dietary modifications:
| |
|
| |
| :*Regular consumption of [[Fruit|fruits]], [[Vegetable|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 [[Prevention (medical)|secondary prevention]] strategies include:
| |
| *Dietary modifications
| |
| *Regular [[blood pressure]], [[blood sugar]] and [[cholesterol]] check
| |
| *Compliance with [[therapy]] for post acute coronary syndrome event
| |
| *[[Cardiac rehabilitation]] programs
| |
|
| |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
| {{WH}}{{WS}}
| |
|
| |
| [[CME Category::Cardiology]]
| |
|
| |
| [[Category:Cardiology]]
| |
| <references />
| |
