Acute%20coronary%20syndromes%20w_out%20persistent%20st-segment%20elevation Signs and Symptoms

Patients with suspected acute coronary syndrome (ACS) must be evaluated quickly

• Early, focused management of ACS reduces adverse events and improves outcomes
• Pre-hospital department management includes:
  • Early activation of emergency medical service system (EMS)
  • Administration of Aspirin, oxygen, Nitroglycerin and Morphine (if needed)
  • If available, obtain 12-lead electrocardiogram (ECG)
• Emergency department management includes:
  • Checking of vital signs, evaluating oxygen (O₂) saturation (sat) and establishing intravenous (IV) access
  • Obtaining initial cardiac biomarker levels, chest X-ray and 12-lead ECG (if not yet done)

Acute Coronary Syndrome (ACS)

• Constellation of conditions which include patients with recent changes in clinical signs or symptoms with or without 12-lead ECG changes and with or without acute elevations in cardiac troponin (cTn) concentrations   
• First clinical manifestation of cardiovascular disease (CVD) in most cases

ACS encompasses the following:

• Unstable Angina (UA)
  • Ischemic discomfort that presents without persistent ST-segment elevation on the ECG and without the presence of cardiac markers in the blood
  • Myocardial ischemia at rest or on minimal exertion without acute cardiomyocyte injury or necrosis

• Non-ST-Segment Elevation Myocardial Infarction (NSTEMI)
  • Diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs

• ST-Segment Elevation Myocardial Infarction (STEMI)
  • Please see Myocardial Infarction w/ ST-Segment Elevation disease management chart for further information

• Patients present with a broad range of signs and symptoms, from asymptomatic at presentation to patients with ongoing chest discomfort (eg pain, pressure, tightness, heaviness, burning); may also present with cardiac arrest, electrical or hemodynamic instability or cardiogenic shock 
• Patient typically presents with ischemic-type chest pain except that the episodes may be more severe and prolonged, may occur at rest or may be caused by less exertion than previous episodes
• Chest pain-equivalent symptoms are often observed in younger (25 to 40 years old) and older (>75 years old) patients, in women, and in patients with diabetes mellitus (DM), chronic renal failure or dementia
  • Eg pain that occurs predominantly at rest, epigastric pain, recent onset of unexplainable indigestion, belching, stabbing chest pain, chest pain with some pleuritic features or increasing dyspnea
• Common features of UA:
  • Rest angina: Angina occurring at rest and prolonged, usually >20 minutes
  • New-onset severe angina: Patient usually has marked limitation on ordinary physical activity (angina occurs on walking 1 to 2 blocks on level or climbing one flight of stairs under normal conditions and at a normal pace)
  • Increasing or crescendo angina: Previously diagnosed effort-related angina that has become distinctly more frequent, longer in duration or more easily provoked (by less effort than before)
  • Post-myocardial infarction (MI) angina

Ischemic-type Chest Discomfort or Anginal Equivalent

• Retrosternal chest pain
  • Pain is usually described as heaviness, pressure, tightness, cramping or burning in nature
  • Pain may occur at rest or during activity that may be associated with physical exertion or emotional stress
  • The pain which is usually central or in the left chest may radiate to the jaw, neck, left or both arms, back or shoulder
• Accompanying symptoms may include: Nausea and vomiting, dyspnea, diaphoresis, lightheadedness, abdominal (epigastric) pain, dizziness, fatigue, weakness and loss of consciousness
• Chest pain-equivalent symptoms: Pain develops in the arm, shoulder, wrist, jaw or back without occurrence in the chest
  • Discomfort that presents solely as jaw, neck, ear, arm or epigastric pain and is associated with exertion or stressor is relieved promptly with Glyceryl trinitrate (GTN) should be considered equivalent to angina
• Pain is usually not relieved by rest or GTN

• Smoking
• Dyslipidemia
• Hypertension
• Diabetes
• History of coronary artery disease (CAD)