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.
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.
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”.
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,
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.
Authors’ Conclusion: “Clinician gestalt is not sufficiently accurate or safe to either “rule in” or “rule out” ACS as a decision-making strategy.
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.”
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.
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.
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.
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.
Many patients undergoing major noncardiac as well as vascular surgery are at risk for a major adverse cardiac event (MACE).
Estimates mortality in patients with STEMI.
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...
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).
Acute coronary syndrome (ACS) is a catch all term that refers to ischemic symptoms resulting from acute coronary occlusion.
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