Acute coronary syndrome

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In medicine and cardiology, acute coronary syndrome (ACS) is a collection of signs and symptoms due to inadequate oxygenation of the heart muscle, the myocardium.[1] In common usage, ACS includes myocardial infarction ("heart attack") and angina.

Pain relief and proper oxygenation is the core of ACS treatment. When the root causie is angina, the temporary cause of ischemia should be reversed. For myocardial infarction, more vigorous interventions are appropriate if they can prevent damage to myocardium.

Etiology/causes

Atheroclerotic obstruction

ACS is usually caused by obstruction in an epicardial coronary artery.[2] The obstruction may be due to a thrombus at the site of a ruptured atherosclerotic plaque.[3]

Rupture seems more likely to occur during the morning hours.[4] Rupture may be precipited by inflammation from non-cardiac infections.[5] Rupture may be triggered by vigorous exercise among individuals who do not ordinarily do vigorous exercise.[6]

Coronary vasospasm

Approximately 15% of NSTEMI and 2% of STEMI patients have no obstruction of coronary vessels and in about half of these patients, spasm can be induced of a coronary artery.[2]

Emotional stress

The role of emotional stress was supported in a study of the incidence of coronary events in the Munich area during the 2006 FIFA World Cup Football (soccer) championship.[7] The incidence of coronary events was higher during the match, especially for people who had pre-existing coronary disease. Similar findings have been reported in Los Angeles, California during the American Super Bowl.[8] Stress, via increases in unhealthy behaviors, was also identified as more important than hypertension or C-reactive protein level in predicting coronary events.[9]

Stress-induced (takotsubo) cardiomyopathy

Stress-induced (takotsubo) cardiomyopathy may occur during acute medical illness or after intense emotional or physical stress.[10] It may be caused by catecholamines.

Classification

Classification of acute coronary syndrome[11]
  Electrocardiogram Serum biomarkers Typical appearance of culprit vessel at angioscopy[3]
Unstable angina "ST-segment depression or prominent T-wave inversion"[11] Normal Nonocclusive grayish-white thrombus
(platelet-rich)
Non-ST segment elevation myocardial infarction
(NSTEMI) 		"ST-segment depression or prominent T-wave inversion"[11] Elevated Primary NSTEMI: Nonocclusive grayish-white thrombus
(platelet-rich)

Secondary NSTEMI: no thrombus

ST segment elevation myocardial infarction
(STEMI) 		ST-segment elevation Elevated Occlusive reddish thrombus
(fibrin-rich)
Q-wave myocardial infarction Q-waves Elevated Occlusive reddish thrombus
(fibrin-rich)

Unstable angina

Unstable angina is defined as "precordial pain at rest, which may precede a myocardial infarction".[12]

Myocardial infarction

For more information, see: Myocardial infarction.

A myocardial infarction is defined as "gross necrosis of the myocardium, as a result of interruption of the blood supply to the area".[13] It is usually caused by occlusion of an epicardial coronary artery.[14]

Non-ST segment elevation myocardial infarction (NSTEMI)

NSTEMI is usually caused by a grayish-white thrombus that is platelet-rich.[3]

ST segment elevation myocardial infarction (STEMI)

STEMI is usually caused by a reddish thrombus that is fibrin-rich.[3]

Diagnosis

History and physical examination

A helpful finding is exact reproduction of chest pain upon palpating the chest.[15] In a patient whose other findings also suggest a non-cardiac course of their chest pain, this finding can help rule out coronary disease.[16]

Electrocardiogram

The electrocardiogram is a key part of decision making. For example, the presence of ST changes and Q-waves determines therapy.

A normal electrocardiogram has been reported not to exclude acute coronary syndrome, even when the electrocardiogram is taken during pain.[17] Although this study used defined unstable angina as either a coronary stenosis or positive stress test and so likely includes patients without true acute coronary syndrome as defined by the American Heart Association[11], the study was still not able to show that a normal electrocardiogram helped exclude a NSTEMI.

Isolated abnormalities of T-waves also confers worse prognosis.[18]

Laboratory tests

Clinical practice guidelines jointly written by multiple expert groups anchor the diagnosis on troponin blood assays obtained within 6 hours and again within 8-12 hours of a patient arriving for medical care.[11][19]

In NSTEMI, typical troponin I levels are less than 9 ng/ml with the median values 1.0 to 2.0 nl/ml.[20]

Clinical prediction rules

The Thrombolysis in Myocardial Infarction risk score for unstable angina or non-ST elevation myocardial infarction is a clinical prediction rule that may detect patients with chest pain who are at increased risk of acute coronary syndrome[21][22]

A second clinical prediction rule, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) can help diagnose patients with chest pain and has been shown to improve medical care in a randomized controlled trial.[23][24] The ACI-TIPI was studied up through 1993 before troponin assays were widely available and thus does not incorporate the troponin. However, the ACI-TIPI should retain its ability to use the medical history and the EKG to decide who should be observed for serial troponin levels. It is unclear why this role is not recognized by the ACC/AHA guidelines. One reason may be that the ACI-TIPI is patented.[25][26]

A third clinical prediction rule, also prior to availability of troponin tests, was created by Pozen.[27] The rule is available online through the New England Journal of Medicine website.

Treatment

Clinical practice guidelines address the treatment of unstable angina and non-ST-elevation myocardial infarction.[11][19]

In the absence of specific contraindications, aspirin may be of benefit, both in the prehospital and emergency department settings, for all forms of ACS. [28]

Patients without contraindication should receive anticoagulation with unfractionated heparin.[29] The risk of bleeding can be estimated with a clinical prediction rule (http://www.crusadebleedingscore.org/).

Unstable angina or NSTEMI

Adrenergic beta-antagonists

Adrenergic beta-antagonists (beta-blockers) are effective according to a systematic review[30]

Platelet ADP receptor blockers

Thienopyridine ADP blockers such as clopidogrel, ticlopidine, and the prodrug prasugrel may help especially for patients undergoing percutaneous coronary intervention (PCI). Ticagrelor may be better than clopidogrel for some patients.[31][32]

Glycoprotein IIb/IIIa inhibitors

Glycoprotein IIb/IIIa inhibitors such as eptifibatide should not be given until after percutaneous transluminal coronary angioplasty.[33]

Percutaneous transluminal coronary angioplasty

Among patients with unstable angina or NSTEMI and without ST-segment elevation (but may have other EKG evidence of ischemia such as ST-segment depression of ≥1 mm or transient ST-segment elevation or T-wave inversion of >3 mm) may benefit from early invasive management (percutaneous transluminal coronary angioplasty) if:

In patients without ST-segment elevation on the electrocardiogram, urgent angioplasty may occur anytime within the first 24 hours according to a randomized controlled trial.[37]

Myocardial infarction

For more information, see: Myocardial infarction.


Prognosis

Three clinical prediction rules can help prognosticate with similar ability:[38]

These rules can help estimate prognosis and guide decisions.

References

  1. ↑ Anonymous (2024), Acute coronary syndrome (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ 2.0 2.1 Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U (August 2008). "Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study". J. Am. Coll. Cardiol. 52 (7): 523–7. DOI:10.1016/j.jacc.2008.04.050. PMID 18687244. Research Blogging.
  3. ↑ 3.0 3.1 3.2 3.3 Mizuno K, Satomura K, Miyamoto A, et al (January 1992). "Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes". N. Engl. J. Med. 326 (5): 287–91. PMID 1728732. [e]
  4. ↑ Muller JE, Stone PH, Turi ZG, et al (November 1985). "Circadian variation in the frequency of onset of acute myocardial infarction". N. Engl. J. Med. 313 (21): 1315–22. PMID 2865677. [e]
  5. ↑ Harskamp RE, van Ginkel MW (2008). "Acute respiratory tract infections: a potential trigger for the acute coronary syndrome". Ann. Med. 40 (2): 121–8. DOI:10.1080/07853890701753672. PMID 18293142. Research Blogging.
  6. ↑ Siscovick DS, Weiss NS, Fletcher RH, Lasky T (October 1984). "The incidence of primary cardiac arrest during vigorous exercise". N. Engl. J. Med. 311 (14): 874–7. PMID 6472399. [e]
  7. ↑ Wilbert-Lampen U, Leistner D, Greven S, et al (2008). "Cardiovascular events during World Cup soccer". N. Engl. J. Med. 358 (5): 475–83. DOI:10.1056/NEJMoa0707427. PMID 18234752. Research Blogging.
  8. ↑ Kloner RA, McDonald S, Leeka J, Poole WK (2009). "Comparison of total and cardiovascular death rates in the same city during a losing versus winning super bowl championship.". Am J Cardiol 103 (12): 1647-50. DOI:10.1016/j.amjcard.2009.02.012. PMID 19539070. Research Blogging.
  9. ↑ Hamer M, Molloy GJ, Stamatakis E (December 2008). "Psychological distress as a risk factor for cardiovascular events pathophysiological and behavioral mechanisms". J. Am. Coll. Cardiol. 52 (25): 2156–62. DOI:10.1016/j.jacc.2008.08.057. PMID 19095133. Research Blogging.
  10. ↑ Kurowski V, Kaiser A, von Hof K, et al (September 2007). "Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis". Chest 132 (3): 809–16. DOI:10.1378/chest.07-0608. PMID 17573507. Research Blogging.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Anderson JL, Adams CD, Antman EM, et al (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". J. Am. Coll. Cardiol. 50 (7): e1–e157. DOI:10.1016/j.jacc.2007.02.013. PMID 17692738. Research Blogging. Executive summary Summary at National Guidelines Clearinghouse Cite error: Invalid <ref> tag; name "pmid17692738" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid17692738" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid17692738" defined multiple times with different content
  12. ↑ National Library of Medicine. Unstable angina. Retrieved on 2007-10-28.
  13. ↑ National Library of Medicine. Myocardial infarction. Retrieved on 2007-10-28.
  14. ↑ DeWood MA, Spores J, Notske R, et al (October 1980). "Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction". N. Engl. J. Med. 303 (16): 897–902. PMID 7412821. [e]
  15. ↑ Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med. 1985 Jan;145(1):65-9. PMID 3970650
  16. ↑ Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F (February 2008). "Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis". Br J Gen Pract 58 (547): 105–11. DOI:10.3399/bjgp08X277014. PMID 18307844. Research Blogging.
  17. ↑ Turnipseed, Samuel D.; William S. Trythall, Deborah B. Diercks, Erik G. Laurin, J. Douglas Kirk, David S. Smith, David N. Main, Ezra A. Amsterdam (2009). "Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain". Academic Emergency Medicine 16 (6): 495-499. DOI:10.1111/j.1553-2712.2009.00420.x. Retrieved on 2009-06-13. Research Blogging.
  18. ↑ Lin KB, Shofer FS, McCusker C, Meshberg E, Hollander JE (June 2008). "Predictive value of T-wave abnormalities at the time of emergency department presentation in patients with potential acute coronary syndromes". Acad Emerg Med 15 (6): 537–43. DOI:10.1111/j.1553-2712.2008.00135.x. PMID 18616439. Research Blogging.
  19. ↑ 19.0 19.1 Braunwald E, Antman EM, Beasley JW, et al (2002). "ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)". J. Am. Coll. Cardiol. 40 (7): 1366–74. PMID 12383588. [e]
  20. ↑ http://content.nejm.org/cgi/content/full/335/18/1342
  21. ↑ Campbell CF, Chang AM, Sease KL, Follansbee C, McCusker CM, Shofer FS et al. (2009). "Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification.". Am J Emerg Med 27 (1): 37-42. DOI:10.1016/j.ajem.2008.01.028. PMID 19041531. Research Blogging.
  22. ↑ Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE (2006). "Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.". Acad Emerg Med 13 (1): 13-8. DOI:10.1197/j.aem.2005.06.031. PMID 16365321. Research Blogging.
  23. ↑ Selker HP, Beshansky JR, Griffith JL, et al (1998). "Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial". Ann. Intern. Med. 129 (11): 845–55. PMID 9867725. [e] Online calculator at InfoRetriever
  24. ↑ Selker HP, Griffith JL, D'Agostino RB (1991). "A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study". Med Care 29 (7): 610–27. PMID 2072767. [e]
  25. ↑ Selker HP et al.. Continuous monitoring using a predictive instrument. Retrieved on 2007-11-29.
  26. ↑ Selker HP et al.. Continuous monitoring using a predictive instrument. Retrieved on 2007-11-29.
  27. ↑ Pozen MW, D'Agostino RB, Selker HP, Sytkowski PA, Hood WB (1984). "A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial.". N Engl J Med 310 (20): 1273-8. DOI:10.1056/NEJM198405173102001. PMID 6371525. Research Blogging.
  28. ↑ M Woollard, A Smith, and P Elwood (2001 November), Pre-hospital aspirin for suspected myocardial infarction and acute coronary syndromes: A headache for paramedics?, vol. 18, DOI:10.1136/emj.18.6.478., at 478–481
  29. ↑ Hillis LD, Lange RA (May 2009). "Optimal management of acute coronary syndromes". N. Engl. J. Med. 360 (21): 2237–40. DOI:10.1056/NEJMe0902632. PMID 19458369. Research Blogging.
  30. ↑ Freemantle N, Cleland J, Young P, Mason J, Harrison J (June 1999). "beta Blockade after myocardial infarction: systematic review and meta regression analysis". BMJ 318 (7200): 1730–7. PMID 10381708. PMC 31101. [e]
  31. ↑ Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C et al. (2009). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes.". N Engl J Med 361 (11): 1045-57. DOI:10.1056/NEJMoa0904327. PMID 19717846. Research Blogging. Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4
  32. ↑ (2010) Lancet. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study
  33. ↑ Giugliano RP, White JA, Bode C, et al. (May 2009). "Early versus delayed, provisional eptifibatide in acute coronary syndromes". N. Engl. J. Med. 360 (21): 2176–90. DOI:10.1056/NEJMoa0901316. Research Blogging.
  34. ↑ Cannon CP, Weintraub WS, Demopoulos LA, et al (2001). "Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban". N. Engl. J. Med. 344 (25): 1879-87. PMID 11419424. [e]
  35. ↑ Bach RG, Cannon CP, Weintraub WS, et al (2004). "The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes". Ann. Intern. Med. 141 (3): 186-95. PMID 15289215. [e]
  36. ↑ Mehta SR, Granger CB, Boden WE, et al. (May 2009). "Early versus delayed invasive intervention in acute coronary syndromes". N. Engl. J. Med. 360 (21): 2165–75. DOI:10.1056/NEJMoa0807986. PMID 19458363. Research Blogging.
  37. ↑ Montalescot G, Cayla G, Collet JP, Elhadad S, Beygui F, Le Breton H et al. (2009). "Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial.". JAMA 302 (9): 947-54. DOI:10.1001/jama.2009.1267. PMID 19724041. Research Blogging.
  38. ↑ de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R (May 2005). "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS". Eur. Heart J. 26 (9): 865–72. DOI:10.1093/eurheartj/ehi187. PMID 15764619. Research Blogging.
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