Acute coronary syndrome

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Acute coronary syndrome

An acute coronary syndrome (ACS) is a set of signs and symptoms (syndrome

Syndrome

In medicine and psychology, the term syndrome refers to the association of several clinically recognizable features, sign , symptoms , phenomena or characteristics that often occur together, so that the presence of one feature alerts the physician to the presence of the others....
) related to the heart

Heart

The heart is a muscle organ in all vertebrates responsible for pumping blood through the blood vessels by repeated, rhythmic contractions, or a similar structure in annelids, mollusks, and arthropods....
. ACS is compatible with a diagnosis of acute myocardial ischemia, but it is not pathognomonic

Pathognomonic

Pathognomonic is an adjective of Greek origin , often used in medicine, which means diagnosis for a particular disease. A pathognomonic Medical sign is a particular sign whose presence means, beyond any doubt, that a particular disease is present....
.

The subtypes of acute coronary syndrome include unstable angina (UA, not associated with heart muscle damage), and two forms of myocardial infarction

Myocardial infarction

Myocardial infarction , commonly known as a heart attack, occurs when the Blood flow to part of the heart is interrupted. This is most commonly due to occlusion of a coronary artery following the rupture of a Vulnerable plaque, which is an unstable collection of lipids and white blood cells in the wall of an artery....
(MI, heart attack), in which heart muscle is damaged. These types are named according to the appearance of the electrocardiogram

Electrocardiogram

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Encyclopedia

An acute coronary syndrome (ACS) is a set of signs and symptoms (syndrome

Syndrome

Heart

Pathognomonic

Myocardial infarction

Electrocardiogram

An electrocardiogram is a recording of the electricity activity of the heart over time produced by an electrocardiograph, usually in a Non-invasive recording via skin electrodes....
(ECG/EKG) as non-ST segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI). There can be some variation as to which forms of MI are classified under acute coronary syndrome.

ACS should be distinguished from stable angina, which develops during exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual's previous angina ("crescendo angina"). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery.

Though ACS is usually associated with coronary thrombosis

Coronary thrombosis

Coronary thrombosis is a form of thrombosis affecting the coronary circulation. It is associated with stenosis subsequent to clotting. The condition is considered as a type of ischaemic heart disease....
, it can also be associated with cocaine

Cocaine

Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine....
use. Cardiac chest pain can also be precipitated by anemia

Anemia

Anemia or an?mia/anaemia is defined as a qualitative or quantitative deficiency of hemoglobin, a protein found inside red blood cells ....
, bradycardia

Bradycardia

Bradycardia , as applied to adult medicine, is defined as a resting heart rate of under 60 beats per minute, though it is seldom symptomatic until the rate drops below 50 beat/min....
s (excessively slow heart rate) or tachycardia

Tachycardia

The word tachycardia comes from the Greek words tachys and kardia .Tachycardia typically refers to a heartrate that exceeds the range of the normal resting heartrate, based upon age:...
s (excessively fast heart rate).

Signs and symptoms

The cardinal sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. This may be associated with diaphoresis

Diaphoresis

Diaphoresis is excessive Perspiration commonly associated with Shock and other medical emergency conditions.Diaphoretic is the state of perspiring profusely, or something that has the power to cause increased perspiration....
(sweating), nausea

Nausea

Nausea is the sensation of unease and discomfort in the stomach with an urge to vomit....
and vomiting

Vomiting

Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Undesired vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure....
, as well as shortness of breath

Dyspnea

Dyspnea or dyspnoea , from Latin language dyspnoea, from Greek language dyspnoia from dyspnoos, shortness of breath) or shortness of breath is perceived to be difficulty of breathing or painful breathing that a patient is aware of....
. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with diabetes

Diabetes mellitus

Diabetes mellitus , often referred to simply as diabetes , is a syndrome of disordered metabolism, usually due to a combination of genetic disorder and environmental causes, resulting in abnormally high blood sugar levels ....
). Some may report palpitation

Palpitation

A palpitation is an abnormal awareness of the heart rate of the heart, whether it is too slow, too fast, irregular, or at its normal frequency. It should not be confused with ectopic beat....
s, anxiety or a sense of impending doom and a feeling of being acutely ill.

Diagnosis

Electrocardiogram

In the setting of acute chest pain, the electrocardiogram

Electrocardiogram

An electrocardiogram is a recording of the electricity activity of the heart over time produced by an electrocardiograph, usually in a Non-invasive recording via skin electrodes....
is the investigation that most reliably distinguishes between various causes. If this indicates acute heart damage (elevation in the ST segment, new left bundle branch block

Left bundle branch block

Left bundle branch block is a cardiac conduction abnormality seen on the electrocardiogram . In this condition, activation of the left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle....
), treatment for a heart attack in the form of angioplasty

Angioplasty

Angioplasty is the technique of mechanically widening a narrowed or obstructed blood vessel; typically as a result of atherosclerosis. Tightly folded balloons are passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure ....
or thrombolysis

Thrombolysis

Thrombolysis is the breakdown of thrombosis by pharmacology means. It is colloquially referred to as clot busting for this reason. It works by stimulating fibrinolysis by plasmin through infusion of analogs of tissue plasminogen activator, the protein that normally activates plasmin....
is indicated immediately (see below). In the absence of such changes, it is not possible to immediately distinguish between unstable angina and NSTEMI.

Imaging and blood tests

As it is only one of the many potential causes of chest pain

Chest pain

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the chest pain is non-cardiac in origin this is often a diagnosis of exclusion made after ruling out more serious causes of pain....
, the patient usually has a number of tests in the emergency department

Emergency department

The emergency department , sometimes termed the emergency room , emergency ward , accident & emergency department or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injury, some of which may be Medical emergency and requiri...
, such as a chest X-ray

Chest X-ray

A chest X-ray, commonly Abbreviation CXR, is a projection radiograph , taken by a radiographer, of the thorax which is used to diagnose problems with that area....
, blood test

Blood test

A blood test is a medical laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick....
s (including myocardial markers such as troponin

Troponin

Troponin is a complex of three regulatory proteins that is integral to muscle contraction in skeletal muscle and cardiac muscle, but not smooth muscle....
I or T, and a D-dimer

D-dimer

D-dimer is a fibrin degradation product, a small protein fragment present in the blood after a thrombus is degraded by fibrinolysis.D-dimer concentration may be determined by a blood test to help diagnose thrombosis....
if a pulmonary embolism

Pulmonary embolism

Pulmonary embolism is a blockage of the pulmonary artery or one of its branches, usually occurring when a deep vein thrombosis becomes dislodged from its site of formation and travels, or embolism, to the pulmonary artery blood supply of one of the lungs....
is suspected), and telemetry (monitoring of the heart rhythm).

Prediction scores

The ACI-TIPI score can be used to aid diagnosis; using 7 variables from the admission record, this score predicts crudely which patients are likely to have myocardial ischemia.

Prognosis

TIMI score

The TIMI

TIMI

TIMI stands for 'Thrombolysis In Myocardial Infarction' Trial and is the name of a study group coordinating several trials, particularly focusing on percutaneous coronary intervention, thrombolysis as well as cardiovascular disease in general....
risk score can identify high risk patients and has been independently validated.

Biomarkers for diagnosis

The aim of diagnostic markers is to identify patients with ACS even when there is no evidence of myocyte necrosis.

Ischemia-Modified Albumin (IMA) - In cases of Ischemia - Albumin undergoes a conformational change and loses its ability to bind transitional metals (copper or cobalt). IMA can be used to assess the proportion of modified albumin in ischemia. Its use is limited to ruling out ischemia rather than a diagnostic test for the occurrence of ischemia.
Myeloperoxidase (MPO) - The levels of circulating MPO, a leukocyte enzyme, elevate early after ACS and can be used as an early marker for the condition.

Glycogen Phosphorylase Isoenzyme BB-(GPBB) is an early marker of cardiac ischemia and is one of three isoenzyme of Glycogen Phosphorylase.

Troponin
Troponin

Troponin is a complex of three regulatory proteins that is integral to muscle contraction in skeletal muscle and cardiac muscle, but not smooth muscle....
is a late cardiac marker of ACS

Biomarkers for Risk Stratification

The aim of prognostic markers is to reflect different components of pathophysiology of ACS. For example:

Natriuretic peptide - Both B-type natriuretic peptide (BNP) and N-terminal Pro BNP can be applied to predict the risk of death and heart failure following ACS.
Monocyte chemo attractive protein (MCP)-1 - has been shown in a number of studies to identify patients with a higher risk of adverse outcomes after ACS.

Treatment

STEMI

If the ECG confirms changes suggestive of myocardial infarction

Myocardial infarction

Myocardial infarction , commonly known as a heart attack, occurs when the Blood flow to part of the heart is interrupted. This is most commonly due to occlusion of a coronary artery following the rupture of a Vulnerable plaque, which is an unstable collection of lipids and white blood cells in the wall of an artery....
(ST elevations in specific leads, a new left bundle branch block or a true posterior MI pattern), thrombolytics may be administered or primary coronary angioplasty

Angioplasty

Fibrinolysis

Fibrinolysis is the process wherein a fibrin thrombus, the product of coagulation, is broken down. Its main enzyme plasmin cuts the fibrin mesh at various places, leading to the production of circulating fragments that are cleared by other proteases or by the kidney and liver....
, destroying blood clots obstructing the coronary arteries. In the latter, a flexible catheter is passed via the femoral or radial arteries and advanced to the heart to identify blockages in the coronaries. When occlusions are found, they can be intervened upon mechanically with angioplasty

Angioplasty

Stent

In medicine, a stent is a man-made 'tube' inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction....
deployment if a lesion, termed the culprit lesion, is thought to be causing myocardial damage.

NSTEMI and NSTE-ACS

If the ECG does not show typical changes, the term "non-ST segment elevation ACS" is applied. The patient may still have suffered a "non-ST elevation MI" (NSTEMI). The accepted management of unstable angina and acute coronary syndrome is therefore empirical treatment with aspirin

Aspirin

Heparin

Heparin, a highly-sulfated glycosaminoglycan, is widely used as an injectable anticoagulant and has the highest negative charge density of any known biomolecule....
(usually a low-molecular weight heparin such as enoxaparin

Enoxaparin

Enoxaparin is a low molecular weight heparin marketed as Lovenox or Clexane.It is used to prevent and treat deep vein thrombosis or pulmonary embolism, and is given as a subcutaneous injection ....
) and clopidogrel

Clopidogrel

Clopidogrel is an oral Antiplatelet drug to inhibit blood clots in coronary artery disease, peripheral vascular disease, and cerebrovascular disease....
, with intravenous glyceryl trinitrate

Glyceryl trinitrate (pharmacology)

Glyceryl trinitrate is an alternate name for the chemical nitroglycerine, which has been used to treat Angina pectoris and heart failure since at least 1870....
and opioid

Opioid

An opioid is a chemical substance that has a morphine-like action in the body. The main use is for analgesia. These agents work by binding to opioid receptors, which are found principally in the central nervous system and the gastrointestinal tract....
s if the pain persists.

A blood test is generally performed for cardiac troponins twelve hours after onset of the pain. If this is positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-future. If the troponin is negative, a treadmill exercise test or a thallium scintigram may be requested.

Cocaine

Cocaine

Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine....
associated ACS should be managed in a manner similar to other patients with acute coronary syndrome except beta blocker

Beta blocker

Beta blockers are a class of medication used for various indications, but particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction , and hypertension....
s should not be used and benzodiazepines should be administered early.

Prevention

Acute coronary syndrome often reflects a degree of damage to the coronaries by atherosclerosis

Atherosclerosis

Atherosclerosis is a syndrome affecting artery blood vessels. It is a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by low density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoprot...
. Primary prevention of atherosclerosis is controlling the risk factors: healthy eating, exercise, treatment for hypertension

Hypertension

Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated....
and diabetes

Diabetes mellitus

Tobacco smoking

Tobacco smoking is the inhalation of smoke from burned dried or cured leaves of the tobacco plant, most often in the form of a cigarette. People may smoke casually for pleasure, habitually to satisfy an addiction to the nicotine present in tobacco and to the act of smoking, or in response to social pressure....
and controlling cholesterol

Cholesterol

Cholesterol is a lipidic, waxy alcohol found in the cell membranes and transported in the blood plasma of all animals. It is an essential component of mammalian cell membranes where it is required to establish proper membrane permeability and membrane fluidity....
levels); in patients with significant risk factors, aspirin

Aspirin

Aspirin , also known as acetylsalicylic acid , is a salicylate medication, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication....
has been shown to reduce the risk of cardiovascular events. Secondary prevention is discussed in myocardial infarction

Myocardial infarction

Myocardial infarction , commonly known as a heart attack, occurs when the Blood flow to part of the heart is interrupted. This is most commonly due to occlusion of a coronary artery following the rupture of a Vulnerable plaque, which is an unstable collection of lipids and white blood cells in the wall of an artery....
.

After a ban on smoking in all enclosed public places was introduced in Scotland in March 2006, there was a 17 percent reduction in hospital admissions for acute coronary syndrome. 67% of the decrease occurred in non-smokers.