Diagnosis and Treatment of Acute Coronary Syndromes

Abstract

cute coronary syndromes (ACS) are defined by a sudden reduction in blood supply to the heart and include ST-segmentelevationmyocardialinfarction(STEMI)andnon-ST-segment elevation ACS (NSTE-ACS). NSTE-ACS consists of non-STsegment elevation myocardial infarction (NSTEMI) and unstable angina. [1][2][3][4] Each year, an estimated more than 7 million people are diagnosed with ACS worldwide, including more than 1 million patients hospitalized in the US for ACS. 5,6 Approximately 5% of patients with ACS die before hospital discharge. 2,[5][6][7] Coronary atherosclerotic plaque rupture with thrombus formation accounts for approximately 70% of fatal acute MIs and sudden coronary deaths. 8 This review summa-rizes current evidence regarding epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and prognosis of ACS (Box). MethodsWe searched PubMed for English-language studies of the epidemiology, pathophysiology, diagnosis, treatment, and prognosis of ACS that were published from January 1, 2000, to January 1, 2022. A total of 1094 articles were retrieved with the search. We manually inspected the reference lists of selected articles for other relevant IMPORTANCE Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.OBSERVATIONS Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by tran...

Unstable Angina as a Component of Primary Composite Endpoints in Clinical Cardiovascular Trials: Pros and Cons

“…The major international cardiovascular societies categorize UA and NSTEMI together using the term NSTE-ACS [3,5]. ACS is mainly attributed to plaque rupture, resulting in thrombosis and complete or incomplete occlusion of a coronary artery [6]. An additional cause of ACS includes plaque erosion.…”

Nitroglycerin Use in the Emergency Department: Current Perspectives

“…Although recent chest pain guidelines suggest that the relief of chest pain by NTG should not be used as a diagnostic factor (as other etiologies of chest pain such as esophageal spasm may be relieved by NTG), 10 the current treatment guidelines for ACS include percutaneous coronary intervention (PCI), thrombolytics, oxygen, aspirin, P2Y12 inhibitors, anticoagulation, and NTG. 11 As per the recent guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC), NTG is a first-line treatment for ACS. 12 , 13 Similarly, the 2020 European Society of Cardiology recommends (Class I, Level C) the use of sublingual or IV nitrates in patients with ongoing ischemic symptoms and IV nitrates in patients with uncontrolled hypertension or signs of heart failure.…”

Promise of a Novel Bedside-to-Bench Paradigm: Can Percutaneous Coronary Intervention Proteomics Balloon Into Clinical Practice?

“…Hence, rapid reperfusion PCI is the standard of care that reduces mortality when performed within 2 hours of symptoms. 6 In this issue of ATVB, Lorentzen et al 7 demonstrate that angioplasty balloons, inflated during PCIs, retain sufficient protein from the lesions for mass spectrometry-enabled proteomics. Patients diagnosed with STEMI or SAP underwent a PCI procedure.…”