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Source: Spinler SA, De Denus S. Acute Coronary Syndromes. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7972196. Accessed June 30, 2012.

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

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

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  • Partially or completely occlusive clot forms on top of ruptured atherosclerotic plaque within coronary artery.
  • Release of adenosine diphosphate and thromboxane A2 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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  • >1.2 million Americans experience ACS each year; 220,000 die of MI.
  • Up to 6.3 million emergency department visits each year are linked to possible ACS.
  • >17.6 million in U.S. have coronary heart disease (CHD).

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

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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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Means of Confirmation and Diagnosis

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  • Use patient symptoms, past medical history, ECG, and troponin or CK-MB 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.
  • Increased CK-MB may be used if troponin test is not available.
  • 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 STE MI
    • Non–ST-segment elevation (NSTE) ACS, which includes non–ST-segment elevation myocardial infarction (NSTE MI) and unstable angina (UA)

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Differential Diagnosis

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  • Early restoration of blood flow to the infarct-related artery
  • Prevention of complications and death
  • Prevention of coronary artery reocclusion
  • Relief of ischemic chest discomfort
  • Resolution of ST-segment and T-wave changes on ECG

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  • Hospital admission, oxygen if saturation <90%, continuous ST-segment monitoring, glycemic control, frequent vital sign measurement, bedrest, stool softeners, and pain relief
  • For patients with STE MI, attempt to reestablish coronary perfusion immediately (without evaluation of biochemical markers).
  • Obtain serial biochemical markers in patients with NSTE ACS who are low risk.
  • High-risk NSTE ACS patients should undergo early coronary angiography (within 12–24 hours) and revascularization if significant stenosis is ...

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