Acute Coronary Syndrome

Part 2: Acute Coronary Syndromes Management

In Part 2 of this Episode on Acute Coronary Syndromes Management, the evidence for various medications for ACS, from supplemental oxygen to thrombolytics are debated, and decision making around reperfusion therapy for STEMI as well as NSTEMI are discussed. Finally, there is a discussion on risk stratification of low risk chest pain patients and all it’s attendant challenges as well as disposition and follow-up decisions.

A Closer Look at the HEART Score

Despite popularity, there are challenges with any HEART score approach...

Does Observation for ACS Make Sense? Part 2: Identifying ACS

In conclusion, observation and the interventions and tests that come with it are unlikely to help us identify ACS any better than our initial ED evaluation. Troponin will almost always become positive within 6 hours in patients with NSTEMI, so this can reasonably be identified within an ED visit. For those patients who are high-risk – concerning stories or ECGs or ongoing chest pain – consider the possibility of unstable angina and remember that the treatment for this should be timely and relatively aggressive. I would argue that placing a concerning patient on observation is not appropriate. Cardiology should be consulted early in such patients. For patients with non-concerning stories and ECGs, ACS can be ruled out in an ED visit, regardless of the patient’s age and risk factors.

Sirens to Scrubs: Acute Coronary Syndromes, Part One – Beyond Door-to-Balloon

Behind the curtain of an Acute Coronary Syndrome (ACS) primarily lies the evil wizard, coronary atherosclerosis. Risk factors such as dyslipidemia, diabetes, hypertension, obesity, and smoking result in damage to the endothelium (the inner lining) of coronary arteries, resulting in physiological derangements causing increased clotting and impaired vasodilation.

Typical and Atypical Symptoms of Acute Coronary Syndrome: Time to Retire the Terms?

Studies indicate that symptoms labeled as “atypical” are more common in women evaluated for myocardial infarction (MI) and may contribute to the lower likelihood of a diagnosis and delayed treatment and result in poorer outcomes compared with men with MI. Atypical pain is frequently defined as epigastric or back pain or pain that is described as burning, stabbing, or characteristic of indigestion. Typical symptoms usually include chest, arm, or jaw pain described as dull, heavy, tight, or crushing.

ACS Risk and Treatment

ACS is a spectrum....

Acute Coronary Syndrome (Induction)

Acute Coronary Syndrome (ACS) is a spectrum of symptoms and signs that present due to actue coronary ischaemia: a blockage of a coronary vessel or vessels. This could be anything from a new onset of angina, to an “ST Elevation Myocardial Infarction”.

Acute Coronary Syndromes

An acute coronary syndrome (ACS) is the most ominous manifestation of coronary artery disease (CAD). The burden of ACS and its impact are striking. Cardiovascular disease is now the most common cause of mortality worldwide, and among cardiovascular deaths,

Acute Coronary Syndromes Management

In Part 2 of this Episode on Acute Coronary Syndromes Management, the evidence for various medications for ACS, from supplemental oxygen to thrombolytics are debated, and decision making around reperfusion therapy for STEMI as well as NSTEMI are discussed. Finally, there is a discussion on risk stratification of low risk chest pain patients and all it’s attendant challenges as well as disposition and follow-up decisions.

Can Emergency Physicians Use Clinical Gestalt to Predict Acute Coronary Syndrome?

Authors’ Conclusion: “Clinician gestalt is not sufficiently accurate or safe to either “rule in” or “rule out” ACS as a decision-making strategy.

Does My Patient with Chest Pain Have Acute Coronary Syndrome?

Among patients with suspected ACS presenting to emergency departments, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.”

Ruling Out Acute Coronary Syndrome in Patients With Chest Pain

ACS is a common and potentially lethal problem. However, only about 10% of patients who present to an emergency department with chest pain actually have ACS.

Does Observation for ACS Make Sense? Part 3: Risk Stratifying for Adverse Cardiac Events

Observation units were developed in the 1990s to help hospitals save money. We did not have the sophisticated scoring systems or lab tests that we have today, therefore we needed 12 to 24 hours to rule out MI in patients presenting with chest pain, and we needed somewhere to do this outside of a CCU. This is no longer the case. We can safely rule out MI in 3-4 hours in the ED with contemporary troponin testing.

Does Observation for ACS Makes Sense? Part 1: A History of Observation for Chest Pain

Up until the late 1980s, most patients presenting to the emergency department (ED) with acute chest pain were simply admitted to a coronary care unit (CCU) (3). Some of these patients had acute MI and were treated accordingly. However, the majority were low risk patients admitted simply to monitor for the development of acute MI with serial ECGs and cardiac enzyme measurement (CK-MB at that time). Over half the patients admitted to the CCU with acute chest pain were eventually “ruled out” for myocardial infarction (4). Admission of these “rule out MI” patients to an intensive care unit was costly, leading hospitals to seek ways of distinguishing the low risk patients earlier.

HEART Score

Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.

MACE

Many patients undergoing major noncardiac as well as vascular surgery are at risk for a major adverse cardiac event (MACE).

TIMI Risk Score

Estimates mortality in patients with STEMI.

CDEM

Chest pain is the leading complaint for ED visits in the United States (estimated 5-8 million presentations annually). Acute coronary syndrome (ACS) represents the continuum of disease representing decreased coronary blood flow and acute myocardial ischemia and/or infarction. This decreased flow is abrupt in nature. The ACS continuum consists of unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). ACS is a mix of reversible and irreversible cardiac ischemia. The large majority of patients that come to the ED with chest pain, will not have ACS...

International Emergency Medicine Education Project

Acute coronary syndromes (ACS) include conditions that share the same pathophysiology of myocardial ischaemic states, i.e., unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).

LITFL

Acute coronary syndrome (ACS) is a catch all term that refers to ischemic symptoms resulting from acute coronary occlusion.

Patient

The term 'acute coronary syndrome' (ACS) covers a range of disorders, including a heart attack (myocardial infarction) and unstable angina, that are caused by the same underlying problem. Unstable angina occurs when the blood clot causes a reduced blood flow but not a total blockage. T