Acute Coronary Syndrome (ACS) is a set of cardiovascular diagnoses that have similar underlying pathophysiology, involving atherosclerosis and acute thrombosis. In the United States, cardiovascular disease, including ACS, is the single leading cause of death among males and females.1 Over 900,000 patients present with ACS each year, with mortality ranging from 3% to 15% depending on the subtype of ACS.1 The prevalence of ACS makes knowledge of appropriate treatment of great importance to both inpatient and community pharmacists.
Diagnosis as to the subtype of ACS is important to guide early and potentially 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 nonspecific symptoms including diaphoresis, nausea, vomiting, and a sense of illness (Table 7-1). It is important to note that ACS presentation can also be clinically silent, particularly in women.2 Beyond presenting symptoms, diagnosis is confirmed with electrocardiography (ECG), which should be immediately performed by emergency medical services (EMS) or upon arrival to the emergency department (ED). This important step is used to differentiate 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). Because UA is not associated with heart muscle damage, while NSTEMI and STEMI result in cell death, cardiac biomarkers (troponin, creatine kinase-MB) are used to further stratify unstable angina from heart attacks.
TABLE 7-1 Signs and Symptoms of Acute Coronary Syndrome ||Download (.pdf)
TABLE 7-1 Signs and Symptoms of Acute Coronary Syndrome
|Signs of Acute Coronary Syndrome|
|• Elevated cardiac biomarkers|
|• Troponin I or T|
|• Other potentially abnormal laboratory values|
|• Elevated white blood count|
|• Increased aspartate transaminase (AST)|
|• Elevated lactate dehydrogenase (LDH)|
|• ECG findings|
|• ST-segment elevations myocardial infarction (STEMI)|
|• New left bundle branch block|
|• ST-segment depressions|
|• T-wave changes|
|Symptoms of Acute Coronary Syndrome|
|• Chest pain|
|• Chest tightness / pressure|
|• Pain radiation to the left arm and/or jaw|
|• Diaphoresis (sweating)|
|• Shortness of breath|
|• Anxiety or sense of doom|
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), ...