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Acute Coronary Syndrome

ACS


Presentation

  • […] mainly on presence of chest pain to define atypical presentation and used medical record reviews to characterise clinical presentation.[bmjopen.bmj.com]
  • […] samples at a single timepoint – on presentation to the ED.[h-fabp.com]
  • Infarction mimics involving Q waves were presented in Vol 18, No. 4 (Oct-Dec 2007); infarction mimics that involve the ST segment or T wave will be presented in a subsequent issue.[nursingcenter.com]
  • The S4 had been present since her previous event.[ahajournals.org]
Pain
  • Pain, referred pain and symptoms other than pain were measured dichotomously (yes/no). For the location of pain (direct and referred), patients were asked to point out where pain was occurring.[bmjopen.bmj.com]
  • They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw Nausea or vomiting Indigestion Shortness of breath (dyspnea[mayoclinic.org]
  • Chest pain caused by acute coronary syndromes can come on suddenly, as is the case with a heart attack. Other times, the pain can be unpredictable or get worse even with rest, both hallmark symptoms of unstable angina.[heart.org]
  • Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE, 2010.[bpac.org.nz]
Chest Discomfort
  • She presented to her primary cardiologist the following morning with ongoing chest discomfort.[ahajournals.org]
  • The description of the chest discomfort as a pressure has little utility in aiding a diagnosis as it is not specific for ACS. [7] Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use. [8] Chest pain with[en.wikipedia.org]
Congestive Heart Failure
  • Congestive heart failure: Killip class 6. Cardiac arrest on admission 7. ST-segment deviation 8.[pharmaceutical-journal.com]
  • Lung exam is normal, although at times crackles may be heard pointing toward associated congestive heart failure (CHF). Bilateral leg edema may be present indicating CHF.[ncbi.nlm.nih.gov]
  • heart failure 176 (1.9) 179 (1.9) 0.98 (0.79–1.20) Table 3.[nejm.org]
  • A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New Eng J Med 1995;333:1190-1195. rich-mw-beckham-v-wittenberg-c-et-al-1995 Westert GP, Lagoe RJ, Keskimaki I, et al.[heartonline.org.au]
  • Long-term management includes use of medications shown to be beneficial in the secondary prevention of atherosclerotic disease and congestive heart failure.[thecardiologyadvisor.com]
Coronary Atherosclerosis
  • Cerebral atherosclerosis may thus facilitate depressive symptoms and anxiety even before coronary atherosclerosis generates cardiac ischaemia 9.[scielo.isciii.es]
  • In older adults, there are more extensive calcifications of coronary atherosclerosis with more multi-vessel and left main disease. [20] These adverse changes increase the risk for myocardial injury without new thrombosis. 3. [ncbi.nlm.nih.gov]
  • A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011 Jan 20. 364(3):226-35. [Medline]. Rosner GF, Kirtane AJ, Genereux P, Lansky AJ, Cristea E, Gersh BJ, et al.[emedicine.medscape.com]
Dyspnea
  • They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw Nausea or vomiting Indigestion Shortness of breath (dyspnea[mayoclinic.org]
  • Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.[litfl.com]
  • There may be associated dyspnea, diaphoresis, and nausea. If significant myocardial pump dysfunction is present, the patient may report orthopnea or paroxysmal nocturnal dyspnea.[thecardiologyadvisor.com]
  • During hospitalization, heart failure was defined as significant dyspnea with oxygen desaturation requiring diuretics, characteristic chest x-ray, and presence of lung rales or medical notes indicating Killip class 3 or 4.[cjasn.asnjournals.org]
  • Symptoms are similar in each of these syndromes (except sudden death) and include chest discomfort with or without dyspnea, nausea, and diaphoresis. Diagnosis is by ECG and the presence or absence of serologic markers.[msdmanuals.com]
Exertional Dyspnea
  • 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[emedicine.medscape.com]
Hypoventilation
  • Obesity hypoventilation syndrome. Eur Respir Rev 2019; 28: 180097. No. 2: Bruyneel M. Telemedicine in the diagnosis and treatment of sleep apnoea. Eur Respir Rev 2019; 28: 180093. No. 3: Ryan S, Arnaud C, Fitzpatrick SF, et al.[err.ersjournals.com]
Nausea
  • They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw Nausea or vomiting Indigestion Shortness of breath (dyspnea[mayoclinic.org]
  • […] of these common signs of an acute coronary syndrome: Chest pain or discomfort, which may involve pressure, tightness or fullness Pain or discomfort in one or both arms, the jaw, neck, back or stomach Shortness of breath Feeling dizzy or lightheaded Nausea[heart.org]
  • Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or haemodynamic instability.[patient.info]
  • Our dyspnoea and sweating cluster has two common symptoms similar to the Riegel et al 26 stress symptoms cluster, which includes shortness of breath, sweating, nausea, indigestion, dread and anxiety.[bmjopen.bmj.com]
  • This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath.[en.wikipedia.org]
Vomiting
  • They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw Nausea or vomiting Indigestion Shortness of breath (dyspnea[mayoclinic.org]
  • Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or haemodynamic instability.[patient.info]
  • Generally, discomfort associated with an acute MI lasts at least 20 minutes and it may be associated with breathlessness, syncope, diaphoresis, nausea and/or vomiting.[heartonline.org.au]
  • Symptoms suggestive of an acute coronary syndrome include: 1 Chest pain and/or pain in areas such as the upper arms, back or jaw, that lasts longer than 15 minutes Chest pain in combination with nausea and vomiting, sweating, breathlessness, and particularly[bpac.org.nz]
  • This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath.[en.wikipedia.org]
Increased Appetite
  • appetite, sleep quality, enhancement of physical activity).[emro.who.int]
Heart Failure
  • Many heart failure medications modify neurohormonal responses to break the vicious cycle of heart failure. See Combating the neurohormonal cycle in heart failure.[heartonline.org.au]
  • Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293-302. 14.[uspharmacist.com]
  • Some degree of heart failure occurs in about two thirds of hospitalized patients with acute myocardial infarction. It is termed ischemic cardiomyopathy if low cardiac output and heart failure persist.[msdmanuals.com]
  • Heart failure, low blood pressure (hypotension), and/or shock develop. If more than half of the heart tissue is damaged or dies, the heart generally cannot function, and severe disability or death is likely.[merckmanuals.com]
  • These drugs help prevent death and the development of heart failure, particularly in people who have had a massive heart attack or who develop heart failure. People should also make changes in their lifestyle.[msdmanuals.com]
Chest Pain
  • ) Sudden, heavy sweating (diaphoresis) Lightheadedness, dizziness or fainting Unusual or unexplained fatigue Feeling restless or apprehensive Chest pain or discomfort is the most common symptom.[mayoclinic.org]
  • Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE, 2010.[bpac.org.nz]
  • Chest pain or discomfort may immediately signal to you that something’s wrong with your heart. Other symptoms, however, may leave you unsure of what’s wrong.[heart.org]
  • […] evaluated 664 chest pain patients presenting to two coronary units in the UK.[h-fabp.com]
  • Approximately 80% of patients felt chest pain (typical pain). Older women presented less frequently with chest pain and had chest pain and pain in other locations (mixture group) more often than did younger women (P 0.014).[bmjopen.bmj.com]
Hypertension
  • In general, PAP improves arterial hypertension only mildly. However, several studies have included non-hypertensive or pharmaceutically well-treated patients.[err.ersjournals.com]
  • Presence of hypertension is very common and can exacerbate the progress of HF. About 5-10% of HF is from non-ischaemic dilated cardiomyopathies.[heartonline.org.au]
  • Narrative: This rational clinical examination confirms the findings of previous studies indicating that traditional coronary artery risk factors (e.g. diabetes, hypertension, etc.) are not useful predictors of acute coronary syndrome.[thennt.com]
  • Intravenous beta-blockers given during the first 24 hours of ACS may be associated with adverse outcomes and should be reserved for those who are hypertensive and with ongoing symptoms.[thecardiologyadvisor.com]
  • Relative contraindication – discuss with senior staff before withholding: Transient ischaemic attack in preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 month post partum Non-compressible punctures Traumatic resuscitation Refractory hypertension[handbook.ggcmedicines.org.uk]
Hypotension
  • Patients present with hypotension and distended neck veins, but without signs of pulmonary odema.[rcemlearning.co.uk]
  • S3/S4, APO, edema, distended tender liver) Look for any evidence of cardiogenic shock (altered mental state, poor skin perfusion /- hypotension) Clinical Risk Stratification for ACS in Patients Presenting with Chest Pain (i.e. possible not confirmed NSTEACS[litfl.com]
  • ., tachycardia, hypotension or anemia).[ncbi.nlm.nih.gov]
  • Prolonged bed rest results in rapid physical deconditioning, with development of orthostatic hypotension, decreased work capacity, increased heart rate during exertion, and increased risk of deep venous thrombosis.[msdmanuals.com]
  • Heart failure, low blood pressure (hypotension), and/or shock develop. If more than half of the heart tissue is damaged or dies, the heart generally cannot function, and severe disability or death is likely.[merckmanuals.com]
Palpitations
  • Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.[litfl.com]
  • Ordinary physical activity results in fatigue, palpitation, dyspnoea (shortness of breath). III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnoea.[heartonline.org.au]
  • Symptoms other than pain included dyspnoea at rest, exertional dyspnoea, sweating, nausea, vomiting, dizziness, blurry vision, presyncope, syncope, palpitation, weakness and an open-ended question of ’other' (12 items).[bmjopen.bmj.com]
  • Chest pain may be associated with sweating, nausea, vomiting, fatigue, shortness of breath and palpitations. Some patients, particularly the elderly and patients with diabetes, may not have chest pain.[patient.info]
  • Other symptoms include a feeling of faintness or actually fainting, sudden heavy sweating, nausea, shortness of breath, and a heavy pounding of the heart (palpitations).[msdmanuals.com]
Blurred Vision
  • Other risks related to tricyclic antidepressants include altered cardiac conduction (prolonged QTc), orthostatic hypotension, anticholinergic effects (including but not limited to constipation, urinary retention and blurred vision) and CNS depression[effectivehealthcare.ahrq.gov]
Burning Sensation
  • 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[emedicine.medscape.com]

Workup

  • Computerized tomography angiography might also be utilized for further workup depending on availability and cardiologist preference.[ncbi.nlm.nih.gov]
  • (See Workup.) Attention to the underlying mechanisms of ischemia is important when managing ACS.[emedicine.medscape.com]
  • Further evaluation to delineate these possibilities included a broad laboratory workup.[ahajournals.org]
Sinus Arrhythmia
  • Relationship of sinus arrhythmia to age and its prognostic significance in ischemic heart disease [abstract]. Clin Res. 1965;13:219. 35. Wolf MM, Varigos GA, Hunt D, Sloman JG. Sinus arrhythmia in acute myocardial infarction.[dovepress.com]
Ventricular Hypertrophy
  • Parameters of left ventricular hypertrophy, including left ventricular mass/height relationship, wall thickness criteria and concentric left ventricular hypertrophy, were all higher in OSA.[err.ersjournals.com]
  • Out of these 5 variables, the 3 with the most significance were any type of bundle branch block [adjusted odds ratio (aOR) 5.66], left ventricular hypertrophy (aOR 4.63), and nonwhite race (aOR 3.53).[journals.lww.com]
Liver Biopsy
  • Previous haemorrhagic stroke or stroke of unknown origin Ischaemic stroke within one year Gastrointestinal bleeding with one year Other internal bleeding within six weeks Non-compressible vascular punctures within 24 hours, e.g. central venous lines, liver[bpac.org.nz]

Treatment

  • […] while referencing recent treatment guidelines.[hospitalmedicine.org]
  • Note that causal effect analysis is useful to find out unexpected changes in treatment interventions and explain why scheduled treatment plans are changed to obtain the optimal treatment effects.[bmcmedinformdecismak.biomedcentral.com]
  • Oxygen treatment should not be routinely administered.[bpac.org.nz]
  • Table II Acute coronary syndrome (ACS) diagnosis, presentation and acute treatment according to age group. Table III Treatment administered according to age group.[smj.org.sg]
  • For the 3-way interaction among treatment, age group, and TRS 2 P, P  .09. Safety Outcomes According to Age and Treatment Safety events during treatment stratified by age and randomized treatment assignment are shown in Table 2.[jamanetwork.com]

Prognosis

  • It is helpful to distinguish the syndromes because prognosis and treatment vary.[msdmanuals.com]
  • The prognosis for smaller people is worse than that for larger people. This finding may help explain why the prognosis for women who have had a heart attack is, on average, worse than that for men.[msdmanuals.com]
  • A 35-year perspective (1975 to 2009) into the long-term prognosis and hospital management of patients discharged from the hospital after a first acute myocardial infarction. Am J Cardiol., 116 (2015), pp. 24-29 [4] K.A. Fox, K.F. Carruthers, D.R.[revespcardiol.org]
  • Key words: Acute coronary syndrome; Anxiety; Prognosis.[scielo.isciii.es]
  • Factors associated with a poorer prognosis include: [ 6 ] Advancing age. Presence and severity of ECG changes of ischaemia. Magnitude of rise in biomarkers of myocardial injury (eg, serum troponin). Left ventricular dysfunction, cardiogenic shock.[patient.info]

Etiology

  • This systematic review also shows that isolated signs and symptoms are not helpful in identifying the underlying ischemic etiology for chest pain.[thennt.com]
  • Some forms of CHD can be asymptomatic, but ACS is always symptomatic. [1] [2] [3] Etiology ACS is a manifestation of CHD (coronary heart disease) and usually a result of plaque disruption in coronary arteries (atherosclerosis).[ncbi.nlm.nih.gov]
  • […] disorders can elevate cTn levels (see table Causes of Elevated Troponin Levels ); not all elevated levels detected with hs-cTn represent myocardial infarction, and not all myocardial necrosis results from an acute coronary syndrome event even when the etiology[msdmanuals.com]
  • Post ACS, elderly patients have a high risk of re-hospitalization and death both from cardiovascular and non-cardiovascular etiologies. There is a 50% increased mortality risk per 10-year increase in age starting from 65 years of age. [46] 6.1.[ncbi.nlm.nih.gov]

Epidemiology

  • Research and Markets; EpiCast Report: Acute Coronary Syndrome ACS - Epidemiology Forecast to 2022", 2014, Cardiovascular Week,, pp. 17. Davies, M.J. et al., 1993.[physio-pedia.com]
  • Singapore and coronary heart disease: a population laboratory to explore ethnic variations in the epidemiologic transition. Eur Heart J. 2003 ; 24 : 127 - 9. 13. Zuhdi AS, Mariapun J, Mohd Hairi NN, et al.[smj.org.sg]
  • Epidemiology See also separate Epidemiology of Coronary Heart Disease article.[patient.info]
  • Epidemiological studies suggest age and sex differences in the association between OSA and cardiovascular outcome.[err.ersjournals.com]
  • Journal of Clinical Epidemiology. 2003 56:124-30.[nzma.org.nz]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Acute Coronary Syndrome (ACS) refers to any condition attributed to obstruction of the coronary arteries which reduces blood flow to the heart, and includes unstable angina and myocardial infarction (MI).[heartonline.org.au]
  • Classification by pathophysiology By our definitions, both patients have had a ‘myocardial infarction’. However, there is clearly different pathophysiology at work. The ESC has again come to the rescue with a helpful classification system.[geekymedics.com]
  • Pathophysiology The underlying pathophysiology in ACS is decreased blood flow to part of heart musculature which is usually secondary to plaque rupture and formation of thrombus.[ncbi.nlm.nih.gov]
  • However, they may guide directions for further research, especially focussing on the differentiation of pathophysiological, clinical and prognostic phenotypes.[err.ersjournals.com]
  • Troponin is a late cardiac marker of ACS Biomarkers for risk determination [ edit ] The aim of prognostic markers is to reflect different components of pathophysiology of ACS.[en.wikipedia.org]

Prevention

  • These advances undoubtedly offer new opportunities to improve long-term secondary prevention.[revespcardiol.org]
  • Secondary prevention of coronary artery disease with omega-3 fatty acids. Am J Cardiol. 2006;98:61i-70i. 36.[uspharmacist.com]
  • Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med 2005;353:2373–2383. 11.[romanianjournalcardiology.ro]
  • NICE lipid modificati on guidance (clinical guidance 181) [11] suggests high intensity statins should be used for secondary prevention.[pharmaceutical-journal.com]
  • In May 2013, European Union drug regulators approved an ACS indication for rivaroxaban, to prevent atherothrombotic events (cardiovascular death, myocardial infarction, or stroke) after an ACS in adults with elevated cardiac biomarkers, at a dose of 2.5[mdedge.com]

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