Signs and symptoms
Atherosclerosis is the primary cause of ACS, with most cases occurring from the disruption of a previously nonsevere lesion. Complaints reported by patients with ACS include the following:
- Palpitations
- Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm
- Exertional dyspnea that resolves with pain or rest
- Diaphoresis from sympathetic discharge
- Nausea from vagal stimulation
- Decreased exercise tolerance
Physical findings can range from normal to any of the following:
- Hypotension: Indicates ventricular dysfunction due to myocardial ischemia, myocardial infarction (MI), or acute valvular dysfunction
- Hypertension: May precipitate angina or reflect elevated catecholamine levels due to anxiety or to exogenous sympathomimetic stimulation
- Diaphoresis
- Pulmonary edema and other signs of left heart failure
- Extracardiac vascular disease
- Jugular venous distention
- Cool, clammy skin and diaphoresis in patients with cardiogenic shock
- A third heart sound (S3) and, frequently, a fourth heart sound (S4)
- A systolic murmur related to dynamic obstruction of the left ventricular outflow tract
- Rales on pulmonary examination (suggestive of left ventricular dysfunction or mitral regurgitation)
Potential complications include the following:
- Ischemia: Pulmonary edema
- Myocardial infarction: Rupture of the papillary muscle, left ventricular free wall, and ventricular septum
Diagnosis
Updated guidelines for the management of non-ST-segment elevation ACS were released in 2020 by the European Society of Cardiology (ESC). [1] The updates place increased reliance on high-sensitivity cardiac troponin testing (hs-cTn) for diagnosis. The guidelines include the use of the CRUSADE risk score (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation) of the ACC/AHA guidelines.
In the emergency setting, electrocardiography (ECG) is the most important diagnostic test for angina. ECG changes that may be seen during anginal episodes include the following:
- Transient ST-segment elevations
- Dynamic T-wave changes: Inversions, normalizations, or hyperacute changes
- ST depressions: These may be junctional, downsloping, or horizontal
Laboratory studies that may be helpful include the following:
- Creatine kinase isoenzyme MB (CK-MB) levels
- Cardiac troponin levels
- Myoglobin levels
- Complete blood count
- Basic metabolic panel
Diagnostic imaging modalities that may be useful include the following:
- Chest radiography
- Echocardiography
- Myocardial perfusion imaging
- Cardiac angiography
- Computed tomography, including CT coronary angiography and CT coronary artery calcium score
Management
Initial therapy focuses on the following:
- Stabilizing the patient’s condition
- Relieving ischemic pain
- Providing antithrombotic therapy
Pharmacologic anti-ischemic therapy includes the following:
- Nitrates (for symptomatic relief)
- Beta blockers (eg, metoprolol): These are indicated in all patients unless contraindicated
Pharmacologic antithrombotic therapy includes the following:
- Aspirin
- Clopidogrel
- Prasugrel
- Ticagrelor
- Glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, tirofiban)
Pharmacologic anticoagulant therapy includes the following:
- Unfractionated heparin (UFH)
- Low-molecular-weight heparin (LMWH; dalteparin, nadroparin, enoxaparin)
- Factor Xa inhibitors (rivaroxaban, fondaparinux)
Additional therapeutic measures that may be indicated include the following:
- Thrombolysis
- Percutaneous coronary intervention (preferred treatment for ST-elevation MI)
Current guidelines for patients with moderate- or high-risk ACS include the following:
- Early invasive approach
- Concomitant antithrombotic therapy, including aspirin and clopidogrel, as well as UFH or LMWH
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