Materiały źródłowe

• #1 Diagnosis and Management of Acute Coronary Syndrome: An Evidence-Based Update | American Board of Family Medicine

  https://www.jabfm.org/content/28/2/283

  Acute coronary syndrome (ACS) describes the range of myocardial ischemic states that includes unstable angina, non-ST elevated myocardial infarction (MI), or ST-elevated MI. […] The diagnosis of ACS begins with a thorough clinical assessment of a patient’s presenting symptoms, electrocardiogram, and cardiac troponin levels as well as a review of past medical history. […] The diagnosis and classification of ACS is based on a thorough review of clinical features, including electrocardiogram (ECG) findings and biochemical markers of myocardial necrosis. […] A diagnosis of ACS should be considered in all patients presenting with ischemic symptoms. […] Obtaining a thorough past medical history in patients with suspected ACS is essential in assuring appropriate diagnosis and management. […] It is important to remember that MI represents myocardial necrosis due to myocardial ischemia.

• #2 Acute coronary syndrome – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/diagnosis-treatment/drc-20352140

  Acute coronary syndrome is an emergency. It’s usually diagnosed at a hospital. The healthcare team runs tests to check the heart and determine the cause of symptoms. Some tests may be done while the healthcare team asks you questions about your symptoms or medical history. […] Your healthcare team looks at your symptoms and test results to diagnose acute coronary syndrome. This information also can help classify your condition as a heart attack or unstable angina. […] Other tests may be done to rule out other possible causes of symptoms. The tests also may help determine treatment. […] Tests for acute coronary syndrome may include: […] Electrocardiogram. This quick test, also called an ECG or EKG, shows how the heart is beating. […] Blood tests. Some heart proteins slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these proteins.

• #3 Overview of Acute Coronary Syndromes (ACS) – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs

  Acute coronary syndromes result from acute obstruction of a coronary artery. […] Diagnosis is by electrocardiography (ECG) and biomarkers. […] These syndromes all involve acute coronary ischemia and are distinguished based on symptoms, ECG findings, and cardiac biomarker levels. […] ECG changes such as ST-segment depression, ST-segment elevation, or T-wave inversion may occur during unstable angina but they are transient. Of cardiac biomarkers, creatine kinase MB fraction (CK-MB) is not elevated but cardiac troponin, particularly when measured using high-sensitivity troponin tests (hs-cTn), may be slightly increased. […] NonST-segment elevation MI (NSTEMI, subendocardial MI) is myocardial necrosis (evidenced by cardiac biomarkers in blood; troponin I or troponin T and CK-MB will be elevated) without acute ST-segment elevation.

• #4 Diagnosis of Acute Coronary Syndrome | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/0701/p119.html

  Differentiating acute coronary syndrome from noncardiac chest pain is the primary diagnostic challenge. The initial assessment requires a focused history (including risk factor analysis), a physical examination, an electrocardiogram (ECG) and, frequently, serum cardiac marker determinations. […] Symptoms of acute coronary syndrome include chest pain, referred pain, nausea, vomiting, dyspnea, diaphoresis, and light-headedness. Some patients may present without chest pain; in one review, sudden dyspnea was the sole presenting feature in 4 to 14 percent of patients with acute myocardial infarction. Pain may be referred to either arm, the jaw, the neck, the back, or even the abdomen. Pain radiating to the shoulder, left arm, or both arms somewhat increases the likelihood of acute coronary syndrome (likelihood ratio [LR]: 1.6).

• #5 Diagnosis of Acute Coronary Syndrome | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/0701/p119.html

  Typical angina is described as pain that is substernal, occurs on exertion, and is relieved with rest. Patients with all three of these features have a greater likelihood of having acute coronary syndrome than patients with none, one, or even two of these features. Chest pain that occurs suddenly at rest or in a young patient may suggest acute coronary vasospasm, which occurs in Prinzmetals angina or with the use of cocaine or methamphetamine. Only about 2 percent of patients with cocaine-associated chest pain have acute coronary syndrome. […] Atypical symptoms do not necessarily rule out acute coronary syndrome. One study found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. However, a combination of atypical symptoms improves identification of low-risk patients. The same study demonstrated that patients presenting with sharp or stabbing pain, pleuritic pain, and positional chest pain had only a 3 percent likelihood of having acute coronary syndrome.

• #6 Acute Coronary Syndromes: NSTE-ACS (Unstable Angina and NSTEMI) | 5-Minute Clinical Consult

  https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/816961/all/

  Associated symptoms of palpitations, dyspnea, nausea/vomiting, diaphoresis, light-headedness, syncope, or dysphoria can occur. […] Atypical symptoms: stabbing or pleuritic pain, epigastric/abdominal pain, indigestion or isolated dyspnea; more common in those aged 75 years, in women, or in those with diabetes, renal insufficiency, and dementia; may present without chest pain and with symptoms of dyspnea, diaphoresis, and extreme fatigue which represent anginal equivalents. […] 12-lead ECG: should be obtained within 10 minutes of presentation; applies to both UA and NSTEMI. […] CBC, BMP (to evaluate for electrolyte abnormalities), and serum troponin biomarkers (negative by definition in UA), which can be elevated within the first 2 to 3 hours since the onset of chest pain. […] Troponin concentration rises within 3 to 6 hours after onset of ischemic symptoms but can be delayed up to 8 to 12 hours (troponin T is not specific in patients with renal dysfunction).

• #7 Diagnosis of Acute Coronary Syndrome | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/0701/p119.html

  The physical examination in patients with acute coronary syndrome frequently is normal. Ominous physical findings include a new mitral regurgitation murmur, hypotension, pulmonary rales, a new third heart sound (S3 gallop), and new jugular venous distention. […] Any patient with a history suggestive of acute coronary syndrome should be evaluated in a facility that has ECG and cardiac monitoring equipment. Patients with suspected acute coronary syndrome who have chest pain at rest for more than 20 minutes, syncope/presyncope, or unstable vital signs should be referred to an emergency department immediately. The diagnosis of acute myocardial infarction, which includes both STEMI and NSTEMI, requires at least two of the following: ischemic symptoms, diagnostic ECG changes, and serum cardiac marker elevation.

• #8 Overview of Acute Coronary Syndromes (ACS) – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs

  ECG is the most important test and should be done as soon as possible (eg, within 10 minutes of presentation). […] Immediate medical treatment depends on the specific syndrome and patient characteristics but typically involves antiplatelet agents, anticoagulants, beta-blockers, and nitrates as needed (eg, for chest pain, hypertension, pulmonary edema), and a statin to improve prognosis. […] For unstable angina and NSTEMI, do angiography within 24 to 48 hours of hospitalization to identify coronary lesions requiring percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); fibrinolysis is not indicated. […] For STEMI, do emergency PCI when door to balloon-inflation time is 90 minutes; do fibrinolysis if such timely PCI is not available.

• #9 Acute Coronary Syndromes: Diagnosis and Management, Part I

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2755812/

  The 2007 guidelines for managing UA/NSTEMI, released by the American College of Cardiology (ACC) and the American Heart Association (AHA), state that patients with symptoms suggestive of ACS should be instructed to call 9-1-1 and should be referred to a facility that has capabilities for 12-lead ECG recording, biomarker determination, and evaluation by a physician (eg, an emergency department [ED]). […] The 2007 ACC/AHA guidelines for managing UA/NSTEMI state that the first step in assessing patients with chest discomfort or other symptoms suggestive of ACS is determining the likelihood that the symptoms and signs represent ACS secondary to obstructive CAD. […] The ACC/AHA guidelines state that risk stratification is an integral prerequisite to decision-making. […] The admission ECG is a strong predictor of both early and long-term prognosis.

• #10 Acute Coronary Syndrome Workup: Approach Considerations, Electrocardiography, Measurement of CK-MB Levels

  https://emedicine.medscape.com/article/1910735-workup

  Recording an ECG during an episode of the presenting symptoms is valuable. Transient ST-segment changes (0.05 mV) that develop during a symptomatic period and that resolve when the symptoms do are strongly predictive of underlying CAD and have prognostic value. Comparison with previous ECGs is often helpful. […] In the emergency setting, ECG is the most important ED diagnostic test for angina. It may show changes during symptoms and in response to treatment, confirm a cardiac basis for symptoms. It also may demonstrate preexisting structural or ischemic heart disease (left ventricular hypertrophy, Q waves). A normal ECG or one that remains unchanged from the baseline does not exclude the possibility that chest pain is ischemic in origin. Changes that may be seen during anginal episodes include the following:

• #11 Acute Coronary Syndrome: Practice Essentials, Background, Etiology

  https://emedicine.medscape.com/article/1910735-overview

  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 scoring.

• #12 Acute Coronary Syndrome: Diagnosis and Initial Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2024/0100/acute-coronary-syndrome.html

  Acute coronary syndrome (ACS) is defined as reduced blood flow to the coronary myocardium manifesting as ST-segment elevation myocardial infarction or nonST-segment elevation ACS, which includes unstable angina and nonST-segment elevation myocardial infarction. […] Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw. […] Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves. […] No validated clinical decision tool is available to rule out ACS in the outpatient setting. […] Elevated troponin levels without ST-segment elevation on electrocardiography suggest nonST-segment elevation ACS. […] Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization.

• #13 02. Diagnosis of Suspected ACS | Hospital Handbook

  https://hospitalhandbook.ucsf.edu/02-diagnosis-suspected-acs/02-diagnosis-suspected-acs

  Typical symptoms of acute coronary syndrome (ACS) include chest pressure, heaviness, burning, or dyspnea that is left-sided or retrosternal. […] While these characteristics can be helpful in determining the likelihood of ACS, patients often present with atypical symptoms, and none of these are adequate to rule-in or rule-out ACS. […] Acute coronary syndrome is defined as an atherothrombotic plaque rupture event leading to myocardial infarction. In the evaluation of findings suspicious for ACS, clinicians should consider and exclude other causes of the patients symptoms or troponin elevation that may mimic ACS while initiating management for possible ACS. […] Diagnosis of STE-ACS: New ST-segment elevation at the J-point in 2 contiguous leads meeting the following criteria: In V2-V3: 1.5 mm for women. 2 mm for men 40 years. 2.5 mm for men 40 years.

• #14 Acute coronary syndrome

  https://elsevier.health/en-US/preview/acute-coronary-syndrome

  Normal ECG results do not preclude diagnosis of acute coronary syndromes; normal tracing results are seen in 1% to 6% of cases. […] Always consider cardiac cause of chest pain even if gastrointestinal medications relieve pain. […] In patients aged 75 years or older presenting with chest pain, consider acute coronary syndrome when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present or when an unexplained fall occurs. […] Coronary angiography is recommended for most patients with ST-elevation myocardial infarction or high-risk nonST-elevation myocardial infarction/unstable angina. […] Early coronary angiography (ie, within 24 hours) is recommended in patients with nonST-elevation myocardial infarction/unstable angina who do not have an emergent indication for intervention, but are assessed to be at high clinical risk.

• #15 Acute Coronary Syndrome – Ischemic Heart Disease | Choose the Right Test

  https://arupconsult.com/content/acute-coronary-syndrome

  Acute coronary syndrome (ACS, formerly called ischemic heart disease) refers to a large spectrum of clinical conditions including unstable angina, myocardial injury, and myocardial infarction (MI). […] The recommended evaluation includes a clinical assessment, ECG, and laboratory testing. Laboratory testing for ACS includes diagnostic testing for markers of damage to heart tissue such as cardiac troponins (cTns), as well as prognostic testing (eg, B-type natriuretic peptide). […] Cardiac troponin I and T (cTnI and cTnT, respectively) are the preferred biomarkers for the evaluation of myocardial injury and MI; high-sensitivity cTn (hs-cTn) assays are recommended if available. […] Current guidelines recommend a first cTn test on presentation with chest pain, and a second test 3-6 hours later (or sooner if using hs-cTn).

• #16 Acute Coronary Syndrome Workup: Approach Considerations, Electrocardiography, Measurement of CK-MB Levels

  https://emedicine.medscape.com/article/1910735-workup

  Measure cardiac enzyme levels at regular intervals, starting at admission and continuing until the peak is reached or until 3 sets of results are negative. Biochemical biomarkers are useful for diagnosis and prognostication. […] Of note, cardiac-specific troponins are not detectable in the blood of healthy individuals; therefore, they provide high specificity for detecting injury to cardiac myocytes. These molecules are also more sensitive than CK-MB for myocardial necrosis and therefore improve early detection of small myocardial infarctions. Although blood troponin levels increase simultaneously with CK-MB levels (about 6 h after the onset of infarction), they remain elevated for as long as 2 weeks. As a result, troponin values cannot be used to diagnose reinfarction. New methods of detecting troponins in the blood can measure levels as low as 0.1-0.2 ng/mL.

• #17 Acute Coronary Syndrome Workup: Approach Considerations, Electrocardiography, Measurement of CK-MB Levels

  https://emedicine.medscape.com/article/1910735-workup

  Keller et al suggest that among patients with suspected acute coronary syndrome, highly sensitive troponin I assay (hsTnI) or contemporary troponin I assay (cTnI) determination 3 hours after admission for chest pain may facilitate early rule-out of acute myocardial infarction. A serial change in hsTnI or cTnI levels from admission (using the 99th percentile diagnostic cutoff value) to 3 hours postadmission may aid in early diagnosis of acute myocardial infarction. […] Minor elevations in these molecules can be detected in the blood of patients without ACS in the setting of myocarditis (pericarditis), sepsis, renal failure, acute congestive heart failure (CHF), acute pulmonary embolism, or prolonged tachyarrhythmias. […] ECGs should be reviewed promptly. Involve a cardiologist when in doubt.

• #18 Acute coronary syndrome – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/diagnosis-treatment/drc-20352140

  Coronary angiogram. This test looks for blockages in the heart arteries. […] Echocardiogram. Sound waves create pictures of the beating heart. This test shows how blood flows through the heart and heart valves. […] Myocardial perfusion imaging. This test shows how well blood flows through the heart muscle. […] CT angiogram. This test looks at the arteries that supply blood to the heart. […] Exercise stress test. A stress test shows how well the heart works when you exercise.

• #19 Acute Coronary Syndrome: Diagnostic Evaluation – PubMed

  https://pubmed.ncbi.nlm.nih.gov/28145667/

  Myocardial infarction (MI), a subset of acute coronary syndrome, is damage to the cardiac muscle as evidenced by elevated cardiac troponin levels in the setting of acute ischemia. […] The assessment of a possible MI includes evaluation of risk factors and presenting signs and symptoms, rapid electrocardiography, and serum cardiac troponin measurements. […] Electrocardiography should be performed within 10 minutes of presentation. ST elevation MI is diagnosed with ST segment elevation in two contiguous leads on electrocardiography. In the absence of ST segment elevation, non-ST elevation ACS can be diagnosed. An elevated cardiac troponin level is required for diagnosis, and an increase or decrease of at least 20% is consistent with MI. […] Cardiac catheterization is the standard method for diagnosing coronary artery disease, but exercise treadmill testing, a stress myocardial perfusion study, stress echocardiography, and computed tomography are noninvasive alternatives.

• #20 Acute Coronary Syndrome (ACS): Causes and Treatment | Doctor

  https://patient.info/doctor/acute-coronary-syndrome-pro

  Acute coronary syndrome (ACS) is a medical emergency and requires immediate hospital admission. ACS is now classified on the findings on the admission ECG and the results of serial cardiac troponin levels. […] […] Diagnosing acute coronary syndrome (investigations) It is essential to exclude a myocardial infarction with ST elevation for which immediate thrombolysis is indicated. […] […] High-sensitivity cardiac troponin (hs-cTn) measurement is recommended in all patients with suspected ACS. If the clinical presentation is compatible with myocardial ischaemia, then a rise and/or fall above the 99th percentile of healthy individuals points to a diagnosis of MI. […] […] As soon as the diagnosis of unstable angina or NSTEMI is made and aspirin and antithrombin therapy have been offered, individual risk of future adverse cardiovascular events should be assessed using an established risk scoring system that predicts six-month mortality. […]

• #21 Acute Coronary Syndrome (ACS): Causes and Treatment | Doctor

  https://patient.info/doctor/acute-coronary-syndrome-pro

  The National Institute for Health and Care Excellence (NICE) recommends the Global Registry of Acute Cardiac Events (GRACE) risk score. […] The Thrombolysis in Myocardial Infarction (TIMI) risk score is another method used to assess risk in patients with ACS. […] […] Treatment includes antithrombotic treatment, as well as coronary angiography followed by revascularisation if appropriate. The treatment of patients with NSTE-ACS is directed to alleviate pain and anxiety, prevent recurrences of ischaemia and prevent or limit progression to acute myocardial infarction. […]

• #22 Acute coronary syndrome – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/acute-coronary-syndrome/

  Unstable angina is a clinical diagnosis associated with normal troponin levels. Suggestive ECG changes can support the diagnosis but are not required to establish it. […] The HEART score is an acronym of its components: history, ECG, age, risk factors, and troponin values. […] The TIMI score for NSTE-ACS estimates the risk of mortality, new or recurrent myocardial infarction, or the need for urgent revascularization in patients with NSTE-ACS. […] Dual antiplatelet therapy and anticoagulation is indicated initially and the preferred regimens vary based on patient risk factors and timing of revascularization. […] Patients with NSTE-ACS are classified based on the presence (NSTEMI) or absence (UA) of significantly elevated cardiac troponin (cTn) levels.

• #23 Diagnosis of Acute Coronary Syndrome | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/0701/p119.html

  Patients who are at high risk for acute coronary syndrome should be admitted to a coronary care unit. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. A chest pain unit is a specialized unit within an emergency department or a medical center; the unit is dedicated to careful monitoring and aggressive implementation of diagnostic protocols for the evaluation of acute coronary syndrome. Most low-risk patients may undergo early exercise testing or can be discharged with careful outpatient follow-up. […] Use of this type of systematic approach has the potential to improve the ability of physicians to care for patients with possible acute coronary syndrome, as well as reduce the likelihood of medical error. In the future, advanced diagnostic modalities, such as myocardial perfusion imaging, may have a role in reducing unnecessary hospitalizations.

• #24 Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines

  https://www.mdpi.com/2077-0383/9/11/3474

  The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. […] The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients presenting without persistent ST-segment elevation myocardial infarction have incorporated the most recent breakthroughs and updates from large randomized controlled trials (RCT) on the diagnosis and management of this disease. […] Measurement of cardiac troponin (cTn) T or I is mandatory for the diagnosis and risk stratification of an ACS. […] Over the last decade, use of high-sensitivity (Hs) assays has considerably grown in clinical practice, allowing for more rapid detection of troponin elevation, within one hour of symptom onset, and with improved sensibility and specificity.

• #25 Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines

  https://www.mdpi.com/2077-0383/9/11/3474

  The 2020 ESC Non-ST-segment elevation Myocardial infarction (NSTEMI) guidelines have extended these recommendations to include validated 0 h/2 h algorithms, following recent publications. […] In case of ruled-out-patients, or patients for whom electrocardiogram or hs-cTn dosage may be inconclusive, coronary computed tomography angiogram (CCTA) may be readily performed as an alternative to invasive coronary angiography to exclude ACS. […] B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) may be useful for the diagnosis and evaluation of the severity of heart failure in the setting of ACS. […] The rationale behind pretreatment is ensuring an adequate platelet inhibition as fast as possible once the diagnosis of ACS is suspected. […] Following the ACCOAST trial, the ESC guidelines have recommended against pretreatment, but only with prasugrel, and without specific recommendations for pretreatment with ticagrelor.

• #26 Acute coronary syndrome | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/acute-coronary-syndrome?lang=us

  Acute coronary syndrome (ACS) is a group of cardiac diagnoses along a spectrum of severity due to the interruption of coronary blood flow to the myocardium, which in decreasing severity are: ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), unstable angina. […] Of all patients who present to emergency departments with symptoms of ACS, only 20-25% will have ACS confirmed as their discharge diagnosis. […] Several other pathological entities may mimic an acute coronary syndrome in both electrocardiographic appearance and clinical presentation; the differential diagnosis for ST segment elevation on the ECG includes myocarditis and/or pericarditis, left ventricular hypertrophy, left ventricular aneurysm, takotsubo cardiomyopathy, electrolyte abnormalities, acute pulmonary embolism, coronary artery vasospasm, acute CNS pathology, benign early repolarization, elevated intraabdominal/intrathoracic pressure.

• #27 Overview of Acute Coronary Syndromes (ACS) – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs

  ST-segment elevation MI (STEMI, transmural MI) is myocardial necrosis with ECG changes showing ST-segment elevation that is not quickly reversed by nitroglycerin or showing new left bundle branch block. […] Diagnosis is more challenging when test results are discordant with pre-test probability, in which case serial hs-cTn assays often help. […] The ECG must be read carefully because ST-segment elevation may be subtle, particularly in the inferior leads (II, III, aVF); sometimes the readers attention is mistakenly focused on leads with ST-segment depression. […] Cardiac biomarkers (serum biomarkers of myocardial cell injury) are released into the bloodstream after myocardial cell necrosis. […] Patients suspected of having an ACS should have an hs-cTn assay done on presentation and again 2 to 3 hours later.

• #28 Acute Coronary Syndromes: NSTE-ACS (Unstable Angina and NSTEMI) | 5-Minute Clinical Consult

  https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/816961/all/

  NSTEMI can be diagnosed by initial concentration of 52 ng/L or a change in level from initial reading after 2 hours 10 ng/L. […] In patients with symptoms suggestive of ACS, negative troponin at 6 hours can almost effectively rule out infarct in most patients. […] Repeat biomarkers 8 to 12 hours from onset of symptoms to check if troponin levels have peaked. The expected rise and fall of troponin level in the setting of MI is an important diagnostic factor that can distinguish an MI from alternative causes of elevated troponin. […] NSTEMI is diagnosed in patients who present with symptoms consistent with ACS and elevated troponin levels but without EKG changes suggestive of STEMI. […] UA can present similarly to NSTEMI but without evidence of myocardial necrosis in the form of elevated troponin levels, and initial management for both is the same.

• #29 Diagnosis, management and nursing care in acute coronary syndrome | Nursing Times

  https://www.nursingtimes.net/cardiovascular/diagnosis-management-and-nursing-care-in-acute-coronary-syndrome-13-02-2017/

  If the ECG does not reveal an MI but cardiac ischaemia is suspected, patients should be admitted and have serial 12-lead ECGs to assess any dynamic changes. […] NICE advises that troponin be included in the initial assessment on admission and a second sample be taken 10-12 hours after symptoms began. […] Adults with NSTEMI or unstable angina should be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts six-month mortality. […] Patients with NSTEMI or unstable angina who are clinically unstable should have angiography (followed by PCI if indicated) within 24 hours of becoming clinically unstable. […] The NICE pathway on MI secondary prevention recommends that ACE inhibitors are also started as early as possible normally within 24 hours. […] Patients who present with STEMI within 12 hours of symptom onset should receive emergency reperfusion within two hours to restore the coronary arterial flow and salvage the myocardium. […] All patients with NSTEMI should receive antiplatelet and anticoagulation therapy.

• #30 Acute Coronary Syndrome (ACS) – International Emergency Medicine Education Project

  https://iem-student.org/acute-coronary-syndome-acs/

  Clinical features of unstable angina include the following: Unstable angina differs from stable angina in that the chest pain is usually more intense, easily provoked, more prolonged, more frequent and more severe. All first presentation of angina should be regarded as unstable. In unstable angina typically there is either no ECG changes or non-specific ECG changes, the patient is usually chest pain-free on presentation to the emergency department, and the cardiac enzymes will be normal. […] NSTEMI should be diagnosed in any patient whose cardiac enzymes are raised without evidence of ST elevation MI. An NSTEMI does not need to have ECG changes at the time of presentation. […] STEMI (ST-segment elevation MI) is a true cardiac emergency. The criteria of diagnosing ST-segment elevation MI on ECG are: New ST elevation at the J point in at least two contiguous leads of 2 mm in leads V2V3 and/or of 1 mm in other contiguous chest leads or the limb leads.

• #31 02. Diagnosis of Suspected ACS | Hospital Handbook

  https://hospitalhandbook.ucsf.edu/02-diagnosis-suspected-acs/02-diagnosis-suspected-acs

  New or presumably new left bundle-branch block (LBBB) has been considered an STE-ACS equivalent, but is not diagnostic of MI in isolation. […] Diagnosis of MI in the presence of known LBBB: Modified Sgarbossa criteria (any of the following): ST-segment elevation 1 mm in the same direction as the QRS complex (concordant) in any lead. […] The modified Sgarbossa criteria has a sensitivity of 91% and specificity of 90% for the diagnosis of acute MI. […] Diagnosis of NSTE-ACS: Ischemic symptoms that are due to atherothrombotic plaque rupture coronary artery disease associated with elevated cardiac troponin in the absence of ST-segment elevation on ECG.

• #32 Acute coronary syndrome – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/acute-coronary-syndrome/

  Recommendations in this article are consistent with the 2021 American Heart Association (AHA) guidelines on chest pain, and 2013 AHA guidelines on STEMI and NSTE-ACS. […] The following applies to patients with acute chest pain and suspected ACS. See Management of chest pain for an approach to patients with undifferentiated chest pain. […] Perform a focused clinical evaluation and ABCDE survey. […] Obtain 12-lead ECG within 10 minutes of patient arrival. […] Start continuous telemetry and pulse oximetry. […] Obtain a V7V9 lead tracing if ST depressions are present in V1V4, as this may be a sign of a posterior wall STEMI. […] Troponin: all patients at arrival (see also Cardiac biomarkers) […] In patients with a normal ECG, a single result below the limit of detection using a high-sensitivity troponin assay 3 hours after symptom onset is considered sufficient to rule out myocardial infarction.

• #33 Contemporary Risk Stratification of Acute Coronary Syndrome

  https://www.uscjournal.com/articles/contemporary-risk-stratification-acute-coronary-syndrome?language_content_entity=en

  Cardiac biomarkers are valuable tools for the diagnosis of and risk stratification for ACS. […] In fact, the 2021 AHA/ACC chest pain guidelines provide a class I recommendation for the use of hs-cTn and a class III recommendation against the use of CK-MB for the diagnosis of acute myocardial injury due to a lack of specificity. […] According to the 2021 AHA/ACC chest pain guidelines, it is a class I recommendation that patients presenting with acute chest pain who have a 1% probability of MACE within the next 30 days can be designated as low risk. These patients do not require admission for further cardiac testing. […] The 2021 AHA/ACC chest pain guidelines favor CCTA over stress testing in intermediate-risk patients who are younger and have a lower pretest probability of obstructive CAD, whereas in patients with a higher pre-test likelihood of CAD, such as older (65 years) patients, functional testing is favored. […] Patients presenting with chest pain and classified as high risk for ACS need urgent ICA because a delay in intervention can cause irreversible myocardial loss (class I recommendation).

• #34 Novel Biomarkers and Their Role in the Diagnosis and Prognosis of Acute Coronary Syndrome

  https://www.mdpi.com/2075-1729/13/10/1992

  Troponin I and T has been a criterion ‘sine qua non’ for myocardial infarction (MI) diagnosis along with clinical and electrocardiography (ECG) conditions. […] High-sensitivity troponin (hs-cTn) has revolutionized ACS diagnosis due to its superior sensitivity and negative predictive value. […] The ESC 2020 guidelines recommend the rapid ‘rule-out’ and ‘rule-in’ algorithms, especially the 0h/1h (alternatively 0 h/2 h) of serial drawing samples with a minimal sensitivity of 99% and a minimal PPV of 70%. […] hs-cTn is also a quantitative biomarker in the diagnosis of MI as 5x Upper Reference Limit (URL) increases have a high PPV (>90%) for type 1 MI and this limit can differentiate from type 2 MI. […] In conclusion, biomarkers play a pivotal role in diagnosing, stratifying risk, and assessing the prognosis of ACS. In this review article, we systematically discuss the role of several biomarkers, categorizing them based on their mechanisms of action and involved pathways, such as myocardial injury, neurohormonal activation, inflammation, and thrombosis. While this approach provides valuable pathophysiological insights, it’s important to note that the diagnostic and prognostic significance, as well as the clinical utility of most of the investigated biomarkers, is not well established. Accordingly, hs-cTn stands out, revolutionizing ACS diagnosis due to its exceptional sensitivity and negative predictive value underscoring the importance of ongoing research for the establishment and development of biomarkers with added prognostic or diagnostic value in ACS settings.

• #35 Machine learning-based prediction of acute coronary syndrome using only the pre-hospital 12-lead electrocardiogram | Nature Communications

  https://www.nature.com/articles/s41467-020-17804-2

  Prompt identification of acute coronary syndrome is a challenge in clinical practice. The 12-lead electrocardiogram (ECG) is readily available during initial patient evaluation, but current rule-based interpretation approaches lack sufficient accuracy. Here we report machine learning-based methods for the prediction of underlying acute myocardial ischemia in patients with chest pain. Using 554 temporal-spatial features of the 12-lead ECG, we train and test multiple classifiers on two independent prospective patient cohorts (n=1244). While maintaining higher negative predictive value, our final fusion model achieves 52% gain in sensitivity compared to commercial interpretation software and 37% gain in sensitivity compared to experienced clinicians. Such an ultra-early, ECG-based clinical decision support tool, when combined with the judgment of trained emergency personnel, would help to improve clinical outcomes and reduce unnecessary costs in patients with chest pain.

• #36 Novel Biomarkers and Their Role in the Diagnosis and Prognosis of Acute Coronary Syndrome

  https://www.mdpi.com/2075-1729/13/10/1992

  Novel Biomarkers and Their Role in the Diagnosis and Prognosis of Acute Coronary Syndrome […] The burden of cardiovascular diseases and the critical role of acute coronary syndrome (ACS) in their progression underscore the need for effective diagnostic and prognostic tools. Biomarkers have emerged as crucial instruments for ACS diagnosis, risk stratification, and prognosis assessment. Among these, high-sensitivity troponin (hs-cTn) has revolutionized ACS diagnosis due to its superior sensitivity and negative predictive value. However, challenges regarding specificity, standardization, and interpretation persist. […] Early diagnosis and risk stratification are therefore critical for guiding timely interventions and improving patient outcomes. […] Biomarkers have emerged as essential endpoints for the diagnosis, risk stratification, and prognosis assessment of ACS. Among these biomarkers, troponin, particularly high-sensitivity troponin (hs-cTn), has revolutionized ACS diagnosis with its superior sensitivity and negative predictive value.

• #37 2023 ESC Guidelines for the management of acute coronary syndromes

  https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Coronary-Syndromes-ACS-Guidelines

  The present guideline has been developed to support healthcare professionals in the diagnosis and management of patients presenting with acute coronary syndrome (ACS). […] The current guideline provides a comprehensive overview of the management of patients presenting with ACS, from the point of diagnosis and risk stratification at initial presentation, through to longterm management after the initial hospitalisation period. […] Particular focus is given to the importance of anti-thrombotic therapy, invasive assessment and revascularisation. […] This guideline also highlights the importance of providing patient-centred care throughout the patient’s ACS journey.

• #38 Acute coronary syndrome – UF Health

  https://ufhealth.org/conditions-and-treatments/acute-coronary-syndrome

  Your provider may use medicines, surgery, or other procedures to treat your symptoms and restore blood flow to your heart. Your treatment depends on your condition and the amount of blockage in your arteries. […] How well you do after an ACS depends on: How quickly you get treated. The number of arteries that are blocked and how bad the blockage is. Whether or not your heart has been damaged, as well as the extent and location of the damage, and where the damage is. […] An ACS is a medical emergency. If you have symptoms, call 911 or the local emergency number quickly.

• #39 Acute Coronary Syndrome: Heart Symptoms in the 3 Types

  https://www.verywellhealth.com/acute-coronary-syndrome-8346870

  Symptoms associated with acute coronary syndrome can include: Chest pain that feels like squeezing, burning, or crushing. […] Any ACS symptoms should be treated as a „call 911” emergency. […] Ideally, someone with ACS receives emergency medical treatment within 60 minutes of symptom onset. […] Troponin blood tests are the golden standard for testing to confirm acute coronary syndrome. […] Long-term treatment and lifestyle changes are essential for preventing another cardiac event after experiencing an acute coronary syndrome event and being treated at the hospital. […] Unstable angina, NSTEMI, and STEMI are the 3 types of acute coronary syndrome (ACS). […] If you or someone you know is having ACS symptoms, call 911 immediately and get to a hospital via ambulance.

• #40 Diagnosis and management of acute coronary syndromes – Australian Prescriber

  https://australianprescriber.tg.org.au/articles/diagnosis-and-management-of-acute-coronary-syndromes.html

  Antiplatelet therapy is a cornerstone of acute coronary syndrome management. […] The goal of anticoagulation in acute coronary syndrome is to prevent clot propagation or reformation, in combination with antiplatelet therapy. […] Following acute management of myocardial infarction, secondary prevention strategies should start before the patient leaves hospital. […] The guidelines for the management of acute coronary syndromes have evolved beyond providing a static framework to ensure timely coronary intervention to decrease morbidity and mortality. They now compel greater clinical judgement in redefining myocardial injury and myocardial infarction.

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