Acute Coronary Syndrome

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
Heavy Thrombus Extracted from Infarcted Artery


Updated guidelines for the management of non-ST-segment elevation ACS were released in 2020 by the European Society of Cardiology (ESC). [1The 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


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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