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FOUNDATION OVERVIEW

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Acute Coronary Syndrome (ACS) is a set of cardiovascular diagnoses that have similar pathophysiology, involving atherosclerosis and acute thrombosis. Diagnosis of the ACS subtype is important to guide life-saving interventions such as percutaneous transluminal coronary angioplasty (PTCA) and other percutaneous coronary interventions (PCI). The first step in the recognition of ACS is to understand the classic clinical presentation. As the word “acute” implies, all subtypes of ACS have a sudden onset, differentiating them from stable angina. A patient presenting with ACS typically describes crushing chest pressure with radiation to the jaw, arm, and shoulder. They may also have a combination of non-specific symptoms including diaphoresis, nausea, vomiting, and a sense of illness (Table 8-1). The diagnosis is confirmed with electrocardiography (ECG), which differentiates T-wave changes and/or ST-segment depressions seen with unstable angina (UA) and non-ST segment elevation myocardial infarctions (NSTEMI) from the ST-segment elevation observed with ST-segment elevation myocardial infarctions (STEMI). Additionally, cardiac biomarkers (troponin, creatine kinase-MB) are used to further differentiate unstable angina from myocardial infarctions.

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TABLE 8-1Signs and Symptomsa of Acute Coronary Syndrome
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PRIMARY PREVENTION

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Due to the vast number of people afflicted with ACS each year, there is great interest in prevention of ACS. Large cohort studies have been performed to identify characteristics that put individuals at increased risk of developing coronary artery disease. About 90% of patients presenting with ACS have at least one of the following risk factors for atherosclerosis: high total cholesterol measurement (or treatment with cholesterol-lowering medications), hypertension (or current treatment), current cigarette smoking, or history of diabetes. Other modifiable risk factors include abdominal obesity, low fruit and vegetable consumption and lack of physical activity. If these risk factors are prevented or aggressively treated, the prevalence of ACS would likely decrease. Once ACS events occur, initial treatments, medical management, and secondary prevention become vitally important.

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TREATMENT

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Overview and Treatment Goals

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In the treatment of ACS, a clear delineation must be made between the emergency of STEMI and the urgency of NSTEMI and UA. In patients experiencing STEMI, complete occlusion of a coronary artery results in elimination of blood flow to the distal heart muscle. It is vital that this ...

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