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SOURCE

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Source: Rogers KC, De Denus S, Finks SW, Spinler SA. Acute coronary syndromes. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146056870. Accessed April 8, 2017.

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DEFINITION

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  • Acute coronary syndromes (ACS) include all clinical syndromes of acute myocardial ischemia resulting from an imbalance between myocardial oxygen demand and supply.

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ETIOLOGY

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  • Diminished myocardial blood flow secondary to occlusive or partially occlusive coronary artery thrombus.

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PATHOPHYSIOLOGY

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  • Partially or completely occlusive clot forms on top of ruptured atherosclerotic plaque within coronary artery.

  • Release of adenosine diphosphate (ADP) and thromboxane A2 (TXA2) from platelets produces vasoconstriction and platelet activation.

  • Activation of extrinsic coagulation cascade leads to formation of fibrin clot.

  • Ventricular remodeling after myocardial infarction (MI) may lead to heart failure (HF).

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EPIDEMIOLOGY

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  • >1.1 million Americans experience ACS each year; 116,800 die of MI.

  • Approximately 660,000 Americans will have a new coronary event, while 305,000 will have a recurrent event.

  • The rate of death from coronary heart disease (CHD) has declined 38% from 2003 to 2013, but the estimated annual mortality in first year after a new coronary event and MI remains high (34% and 15% respectively).

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PREVENTION AND SCREENING

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  • Risk factor modification (smoking cessation; control of blood pressure, diabetes, dyslipidemia)

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RISK FACTORS

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  • Increasing age.

  • Hypertension.

  • Male sex.

  • Smoking.

  • Diabetes mellitus.

  • Dyslipidemia.

  • Obesity.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Symptoms: Chest discomfort (usually at rest), severe new-onset or increasing angina. Discomfort may radiate to shoulder, down left arm, or to back or jaw. Nausea, vomiting, diaphoresis, and shortness of breath may also occur.

  • Signs: Patients with ACS may present with signs of acute HF or dysrhythmias.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Use patient symptoms, past medical history, ECG, and troponin to stratify patients into low, medium, or high risk.

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LABORATORY TESTS
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  • Increased troponin I or T with a typical rise and fall indicates MI.

  • Serum potassium and magnesium, glucose, serum creatinine, complete blood cell count (CBC), coagulation tests, and fasting lipid panel.

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DIAGNOSTIC PROCEDURES
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  • 12-lead ECG findings indicating myocardial ischemia or MI include ST-segment elevation, ST-segment depression, and T-wave inversion.

  • Classification of ACS

    • ST-segment elevation (STE) ACS or STEMI

    • non-ST elevation acute coronary syndrome (NSTE-ACS), which includes non–ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA).

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DIFFERENTIAL DIAGNOSIS
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  • Aortic dissection.

  • Pulmonary embolism.

  • Tension pneumothorax.

  • Pericarditis.

  • Esophageal rupture.

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DESIRED OUTCOMES

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  • Early restoration of ...

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