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Acute coronary syndrome Last updated: January 20, 2021

Summary

Acute coronary syndrome (ACS) is the clinical manifestation of myocardial infarct and
commonly the default working diagnosis in patients with new-onset chest pain suspected to be
of cardiac ischemic origin. Clinical ndings (e.g., onset and characteristics of pain, patient
history) in combination with ECG and troponin are the mainstays of diagnosis. Based on ECG
ndings, patients are categorized into those with ST-elevation (STE-ACS) or non-ST-elevation
ACS (NSTE-ACS). Depending on serum levels of cardiac troponin (cTn), NSTE-ACS can be
categorized as NSTEMI or unstable angina (UA). STE-ACS patients require immediate
revascularization therapy. The timing and necessity of revascularization therapy in NSTE-ACS
is determined based on multiple risk factors. All ACS patients receive dual antiplatelet therapy
and initially anticoagulation. Adjunctive therapy (e.g., beta blockers, oxygen) helps reduce
symptoms and can have a positive impact on mortality.
This article concerns the initial management of ACS patients. See “Myocardial infarction” for
more details regarding, e.g., histopathology and long-term management.
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De nition

Acute coronary syndrome (ACS): the suspicion or con rmed presence of acute myocardial
ischemia [1][2]
Acute coronary syndrome may be further classi ed into the following categories:
NSTE-ACS: acute coronary syndrome manifesting without ST-elevations on ECG
NSTEMI: positive myocardial injury biomarkers
Unstable angina: absence of detectable myocardial injury biomarkers
STE-ACS: acute coronary syndrome manifesting with ST-elevations on ECG
See “Myocardial infarction” for more de nitions.

Übersicht

Overview of acute coronary syndrome (ACS) [1][2]

NSTE-ACS STE-ACS

Unstable angina (UA) Non-ST-segment ST-segment

elevation myocardial elevation myocardial
infarction (NSTEMI) infarction (STEMI)

Description Acute myocardial Acute myocardial Acute myocardial

ischemia that is not ischemia that is severe ischemia that is
severe enough to enough to cause severe enough to
cause detectable detectable quantities cause ST-segment
quantities of of myocardial injury elevations on ECG
myocardial injury biomarkers but without
biomarkers or ST- ST-segment elevations
segment elevations on on ECG
ECG
Overview of acute coronary syndrome (ACS) [1][2] REGISTER / LOG IN

NSTE-ACS STE-ACS

Unstable angina (UA) Non-ST-segment ST-segment

elevation myocardial elevation myocardial
infarction (NSTEMI) infarction (STEMI)

Clinical Symptoms are not reproducible/predictable.

presentation Angina at rest/with minimal exertion and is usually not relieved by rest or
nitroglycerin [3]
New-onset angina
Severe, persistent, and/or worsening angina (crescendo angina)
Autonomic symptoms may be present: diaphoresis, syncope, palpitations, nausea,
and/or vomiting

Pathophysiology Partial occlusion of Classically due to Classically due to

coronary vessel → partial occlusion of a complete
decreased blood coronary artery occlusion of a
supply → ischemic coronary artery
Affects the inner layer
symptoms (also at
of the heart Affects the full
rest)
(subendocardial thickness of the
infarction) myocardium (
transmural
infarction)

Cardiac Not elevated Elevated Usually elevated

troponin

ECG ndings No ST elevations No ST elevations ST elevations (in

two contiguous
Normal or nonspeci c
leads) or new
(e.g., ST depression,
left bundle branch
loss of R wave, or
block
T-wave inversion)
with strong clinical
suspicion of
myocardial
ischemia [1]
 Overview of acute coronary syndrome (ACS) [1][2] REGISTER / LOG IN

NSTE-ACS STE-ACS

Unstable angina (UA) Non-ST-segment ST-segment

elevation myocardial elevation myocardial
infarction (NSTEMI) infarction (STEMI)

Treatment Invasive management depends on risk strati cation Immediate

(e.g., TIMI score) revascularization
Anticoagulants, antiplatelet therapy (e.g., aspirin, ADP Adjunctive medical
receptor inhibitors) therapy similar to
Statins NSTE-ACS
See “Acute
Antihypertensive therapy (beta blockers, ACEIs)
management
Pain management (opioids, nitrates) checklist for
See “Acute management checklist for NSTE-ACS.” STEMI.”

Subtypes of ACS cannot be differentiated based on clinical presentation alone.

Clinical features

[4][5]
Classic presentation

Acute retrosternal chest pain

Typical: dull, squeezing pressure and/or tightness

Commonly radiates to left chest, arm, shoulder, neck, jaw, and/or epigastrium
Precipitated by exertion or stress

Symptom relief after administration of nitrates is not a diagnostic criterion for cardiac
[2]
ischemia.
The peak time of occurrence is usually in the morning.

See also “Angina.”

Dyspnea (especially with exertion)

 Pallor
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Nausea, vomiting

Diaphoresis, anxiety

Dizziness, lightheadedness, syncope

Other ndings

Tachycardia, arrhythmias
Symptoms of CHF (e.g., orthopnea, pulmonary edema) or cardiogenic shock (e.g.,
hypotension, tachycardia, cold extremities)

New heart murmur on auscultation (e.g., new S4)

[2][6]
Atypical presentations: more likely in elderly, diabetic individuals, and women

Stabbing, sharp chest pain

No or minimal chest pain

”Silent MI” without chest pain is more common in patients with diabetes, as a result of
polyneuropathy.

Autonomic symptoms (e.g., nausea, diaphoresis)

More common in inferior wall infarction

Epigastric pain
Bradycardia

Clinical triad in right ventricular infarction: hypotension, elevated jugular venous pressure,
clear lung elds [1]

Classically, it has been taught that STEMI manifests with more severe symptoms
than NSTEMI, but this is not always the case.

Diagnostics

Approach [1][2][6][7]
 ECG: should be performed immediately once ACS is suspected or considered as differential
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diagnosis.

ST-elevations present: immediate revascularization therapy, preferably PCI (see

“Management of STEMI”)

No ST-elevations present (i.e., NSTE-ACS): management strategy is guided by ECG

ndings, troponin levels, clinical features, and risk factors.

Cardiac troponin levels: Measure as soon as possible and repeat after 1–6 hours.

Consider bedside TTE if the diagnosis is unclear.

Patients suspected of having STE-ACS should be evaluated immediately for

revascularization therapy.

12-lead ECG [1][2]

Indicated for every patient with suspected ACS (best initial test) within 10 minutes of
presentation [2]

Findings: should always be interpreted in the context of clinical ndings and patient history

ECG changes in STEMI

ECG changes in NSTEMI/unstable angina

Repeat every 15–30 minutes in the rst hour (especially if the rst ECG is inconclusive or
symptoms recur or change in quality)
Compare with previous ECGs (if available).

ECG ndings can change within minutes and ST elevations can appear or
disappear.

Cardiac troponin [2][7]

[2][8]
Indication: obtain troponin T/I in every patient with suspected ACS
Timing

At arrival and after 1–6 hours

Repeat if symptoms or ECG changes occur.
 Consider repeat after 72 hours as a marker of infarct size.
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Findings: should always be interpreted in combination with clinical ndings.

STEMI: usually elevated

NSTEMI: elevation above the 99thpercentile

Unstable angina: usually normal

See “Cardiac biomarkers” for more information.

Transthoracic echocardiography (TTE) [1][2][7][8]

TTE is generally not necessary and should not delay reperfusion therapy. However, it may be a
helpful study in patients with atypical symptoms or if the diagnosis is unclear.
Indications include:

Cardiogenic shock
Infarct-like symptoms but inconclusive ECG ndings

Evaluation for complications of myocardial infarction

Findings
Wall motion abnormalities
[1]
Decreased LV function
Signs of different conditions that cause chest pain (see “Differential diagnoses of chest
pain”)

Imaging should not delay treatment of ACS.

Risk strati cation

Several scoring systems are available to help identify low-risk patients, facilitate disposition
(e.g., necessity of ICU admission), and guide timing of PCI in patients with chest pain.

Risk strati cation tools are not a substitute for clinical judgment.
Should not be used for patients suspected of having STEMI
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Risk strati cation tools are not appropriate in the setting of STEMI; patients
suspected of having STEMI should be evaluated immediately for
revascularization.

GRACE score for risk of mortality in ACS [2][9][10]

Based on the Global Registry of Acute Coronary Events (GRACE)

May be used to inform management and disposition (e.g., ICU admission, timing of
intervention in NSTE-ACS).
Incorporates different criteria to estimate risk of mortality in patients with ACS, including:

Patient age

Vital signs
Cardiac and renal function
Cardiac arrest on presentation

ECG ndings
Troponin levels

HEART score [11]

The HEART score is an acronym of its components: history, ECG, age, risk factors, and
troponin values.
Risk assessment for major adverse cardiovascular events (MACE) in patients with chest pain
presenting to the emergency department
Can be integrated into decision pathways for early discharge
Potentially reduces hospital admissions of low-risk patients

Should not be used in patients with STEMI or those who are hemodynamically unstable

HEART score for the risk of MACE [11]

Component Characteristic Points

 HEART score for the risk of MACE [11] REGISTER / LOG IN

Component Characteristic Points

History Slightly suspicious 0

Moderately suspicious 1

Highly suspicious 2

ECG Normal 0

Nonspeci c repolarization changes 1

Signi cant ST depression 2

Age < 45 years 0

45–65 years 1

≥ 65 years 2

Risk factors None 0

1–2 1

≥ 3 or history of atherosclerotic disease 2

Troponin (initial) [12][13] normal 0

1–2 x upper limit 1

> 2 x upper limit 2

Interpretation

Score ≤ 3 (low risk): consider early discharge

Score 4–6 (intermediate risk): hospital admission

Score ≥ 7 (high risk): consider early invasive strategy

Any positive troponin level: usually considered non-low risk and requires further evaluation [14]

TIMI score for NSTE-ACS [2][15][16]

 Estimates the risk of mortality, new or recurrent myocardial infarction, or the need for/ LOG IN
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urgent revascularization in patients with NSTE-ACS
Can help determine the therapeutic regimen and timing for revascularization.

TIMI score for NSTE-ACS [16]

Characteristics Points

Age ≥ 65 years 1

1
≥ 3 CAD risk factors (e.g., family history of CAD, DM, smoking, HTN, hypercholesterolemia)

Known CAD (stenosis > 50%) 1

≥ 2 episodes of severe angina in the last 24 hours 1

ASA use in the past 7 days 1

ST deviation (≥ 0.5 mm) 1

Elevated cardiac biomarkers 1

Interpretation

Score of 0–1 (low-risk): favors an ischemia-guided strategy [15]

Score ≥ 2 (non-low-risk): favors an invasive strategy

STEMI

Patients with STEMI require immediate revascularization and should be identi ed as soon as
possible.; ECG ndings can change over time and with uctuations in symptoms, which is why
the diagnosis of STEMI should not be excluded based on a single ECG.
Percutaneous coronary intervention (PCI) within 90 minutes of rst medical contact (FMC) is
the treatment of choice. Intravenous brinolytics are an alternative if PCI can not be performed
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within 120 minutes and no contraindications are present.

ECG changes in STEMI

ECG changes in STEMI [1][6][8][17]

De nition: signi cant ST elevation in two contiguous leads

Speci c criteria: elevation measured at the J point in reference to the onset of the Q wave

In all leads except V2 and V3: ≥ 1 mm (≥ 0.1 mV)

In V2 and V3: depends on patient's sex and age

Men < 40 years: ≥ 2.5 mm (≥ 0.25 mV)

Men ≥ 40 years: ≥ 2.0 mm (≥ 0.2 mV)
Women of any age: ≥ 1.5 mm (≥ 0.15 mV)

The criteria are valid only in the absence of left ventricular hypertrophy and LBBB.
Additional considerations

ECG ndings may change over time (see “Timeline of ECG changes in STEMI”)
Hyperacute T waves can be present without ST elevations in the very early stages of
ischemia.

If inferior myocardial infarction is suspected, investigate for signs of right ventricular

involvement (see “Localization of myocardial infarct on ECG”)

Any patient with ST elevations on ECG requires immediate evaluation for urgent
revascularization. The administration of other therapies should not delay care.
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Acute stage: myocardial damage ongoing

Hyperacute T waves (peaked T wave)

ST elevations in two contiguous leads with reciprocal ST depressions

Intermediate stage: myocardial necrosis present

Absence of R wave
T-wave inversions
Pathological Q waves
Duration ≥ 0.04 seconds
Amplitude ≥ ¼ of the R wave or ≥ 0.1 mV

Any Q wave in leads V1–3

Chronic stage: permanent scarring
Persistent, broad, and deep Q waves
Often incomplete recovery of R waves
Permanent T-wave inversion is possible.

The sequence of ECG changes over several hours to days: hyperacute T wave →
ST elevation → pathological Q wave → T-wave inversion → ST normalization →
T-wave normalization

STEMI-equivalent ECG ndings [1][6][17]

Presence of any of the following ndings requires immediate evaluation for

revascularization therapy (i.e., management is the same as that for STEMI).

Posterior myocardial infarction

ST depression ≥ 0.5 mm in leads V1–V 4

ST elevations ≥ 0.5 mm in leads V7–V 9

 Left main-vessel occlusion or three-vessel disease
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[6][17]
ST depression ≥ 1 mm in ≥ 6 leads
Combined with ST elevation in leads aVR and/or V1

[6]
New or presumably new LBBB or RBBB with strong suspicion for myocardial ischemia
[18][19][20]

[6][21][22]
Modi ed Sgarbossa criteria for suspected STEMI in patients with LBBB

Can help assess the need for emergency revascularization in patients with ACS and LBBB.
The criteria can also be used in right-ventricular pacing with LBBB con guration but are less
speci c in this scenario.
Presence of any of the following indicate a high risk for acute myocardial ischemia requiring
immediate revascularization:
Concordant ST elevation of ≥ 1 mm in any lead
Concordant ST depression of ≥ 1 mm in any of leads V1–V 3

Discordant ST elevation ≥ 1 mm and ≥ 25% of preceding S wave

Assessment of ST elevations in the presence of left bundle branch block (LBBB)

can be dif cult. If clinical suspicion for myocardial ischemia is high, patients with
this constellation should be managed like patients with STEMI.

Management
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The following recommendations are generally consistent with the 2013 AHA/ACC guidelines
for the management of STE-ACS. [1]

"Time is muscle": Revascularization should occur as soon as possible in patients

with STEMI! All other interventions can wait!

Approach [1]

For patients < 120 minutes away from a PCI-capable facility

Immediate cardiology consult and evaluation for emergency revascularization (code
STEMI)
Start medical therapy (see “Antiplatelet therapy and anticoagulation in STEMI”)

For patients > 120 minutes away from a PCI-capable facility and symptom onset < 12 hours
Immediate cardiology consult (code STEMI), even if no PCI is available
Check for absolute and relative contraindications to brinolysis (see “Contraindications
for brinolysis in STEMI and STEMI-equivalents”).
If no absolute contraindications present: Administer brinolysis (see “Fibrinolytic therapy
in STEMI”).

Start medical therapy (see “Antiplatelet therapy and anticoagulation in STEMI”).

For all patients with STEMI
Adjunctive medical therapy for ACS
Continuous telemetry, serial ECG, and serum troponins every 4–6 hours
ICU level of care

Immediate revascularization [1]

[1]
Emergency coronary angiography with PCI

Indication: preferred method of revascularization in patients suspected of having STEMI

STEMI and STEMI equivalents

LBBB with positive modi ed Sgarbossa criteria

LBBB or RBBB with strong clinical suspicion of myocardial ischemia
Procedure: balloon dilatation with stent implantation (see “Cardiac catheterization”)
 First medical contact (FMC) to PCI time
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Ideally ≤ 90 minutes.
Should not exceed 120 minutes

Fibrinolytic therapy in STEMI [1]

Indications (in STEMI and STEMI equivalents, if all of the following apply):
PCI cannot be performed ≤ 120 minutes after FMC.
Symptom onset
≤ 12 hours

OR 12–24 hours with clinical signs of ongoing ischemia (PCI is even more preferable in
this context)
No contraindications to brinolysis present
Timing: within < 30 minutes of patient arrival at the hospital
Contraindications
If > 24 hours after symptom onset

See “Contraindications for brinolysis in STEMI and STEMI-equivalents.”

Regimens (one of the following)
Tenecteplase
Alteplase
Reteplase

Streptokinase
Post brinolysis: Check TIMI coronary grade ow and transfer to a facility with PCI
capabilities.

PCI should be performed even if lysis is successful.

Common contraindications for brinolysis in STEMI and STEMI-equivalents [1][6][23]

Common contraindications for brinolysis in STEMI and STEMI-equivalents [1][6][23]
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Absolute Active bleeding (not including menses)

contraindications Bleeding diathesis/known coagulopathy

Any prior intracranial bleeding
Intracranial or intraspinal surgery within the past 2 months
Serious head trauma within the past 3 months
Ischemic stroke within the past 3 months
Severe hypertension unresponsive to emergency therapy
Presence of intracranial conditions that increase the risk of bleeding (e.g.
arteriovenous malformation)
Suspected aortic dissection
Intracranial malignancy
Additionally for streptokinase: previous exposure within 6 months (highly
antigenic) [23][24]

Relative Major surgery within past 21 days

contraindications Current SBP > 180 mm Hg or DBP > 110 mm Hg

Ischemic stroke > 3 months ago
Solid malignancies
Internal bleeding (e.g., GI bleed) in the past 2–4 weeks
Oral anticoagulant therapy
Prolonged or traumatic CPR (> 10 min)
Puncture at a noncompressible vascular site
Severe, poorly controlled chronic hypertension
Intracranial structural abnormality that is not an absolute contraindication
Infective endocarditis
Active peptic ulcer disease
Signi cant liver dysfunction
Pregnancy or within 7 days after delivery
Dementia

Streptokinase is non brin-speci c and highly antigenic. It is contraindicated

within 6 months of previous exposure to streptokinase.
Other REGISTER / LOG IN

Coronary artery bypass grafting: Not routinely recommended for acute STEMI [1]
Consider in the following cases:
Coronary anatomy poorly suited to PCI
After unsuccessful PCI

STEMI occurring at the time of surgical repair of a mechanical defect

Antiplatelet therapy and anticoagulation in STEMI [1]

Timing: Therapy should be initiated without delaying revascularization.

Dual antiplatelet therapy (DAPT) and anticoagulation in STEMI [1]

Class Regimen if undergoing PCI Regimen if undergoing

brinolysis

Dual antiplatelet therapy ( Aspirin Aspirin

DAPT) [1] AND one of the following ADP AND

receptor inhibitors ADP receptor inhibitor:
Prasugrel clopidogrel
Ticagrelor
Clopidogrel

Anticoagulation [1] Unfractionated heparin One of the following

If GPIIa/IIIa receptor antagonist is Unfractionated
planned heparin
If GPIIa/IIIa receptor antagonist is
not planned or uncertain Enoxaparin
OR Bivalirudin Fondaparinux

Consider one of the following at time Not routinely

Glycoprotein IIb/IIIa of primary PCI. recommended
inhibitor Abciximab
(GPI) [1] Epti batide
Tiro ban

Acute management checklist

For patients < 120 min away from a PCI-capable facility
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Immediate cardiology consult and evaluation for emergency revascularization (code STEMI)
Transfer to cath lab for angiography.

Start antiplatelets and anticoagulation (see “Antiplatelet therapy and anticoagulation in

STEMI”).
Aspirin
ADP receptor inhibitor (can also be given at time of PCI)
Start anticoagulation with UFH, bivalirudin, or fondaparinux.

Consider glycoprotein (GP) IIb/IIIa receptor antagonist.

For patients > 120 min away from a PCI-capable facility and symptom onset <
12 hours

Immediate cardiology consult (code STEMI), even if no PCI is available

Check for contraindications to brinolysis (see “Contraindications for brinolysis in STEMI
and STEMI-equivalents”).

If no absolute contraindications present: Administer brinolytic (see “Fibrinolytic therapy in

STEMI”).
Start antiplatelets and anticoagulation (see “Antiplatelet therapy and anticoagulation in
STEMI”).
Aspirin (as soon as possible)
ADP receptor inhibitor: clopidogrel

Start anticoagulation with UFH, enoxaparin, or fondaparinux.

Post brinolysis: Check TIMI coronary grade ow.
Transfer to a PCI-capable facility.

For all patients with STEMI

Adjunctive medical therapy for ACS

Supplemental oxygen as needed: target SpO2 > 90%

Nitroglycerin for patients with ongoing chest pain or hypertension
Analgesia with morphine only for patients with very strong pain.
High-intensity statin
Consider a beta blocker if there are no contraindications.

Consider an ACE inhibitor if there are no contraindications.

 Order continuous telemetry, serial ECG, and serum troponins every 4–6 hours.
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Consider ICU level of care

NSTEMI/UA

Patients with NSTE-ACS are classi ed based on the presence (NSTEMI) or absence (UA) of
signi cantly elevated cardiac troponin (cTn) levels. A key element of management is to assess
the necessity for and timing of PCI ( brinolytics are not indicated in NSTE-ACS).
Hemodynamically unstable patients and those with intractable angina require immediate PCI
(i.e., the are managed like STEMI patients). Multiple risk scores (e.g., HEART, TIMI, GRACE) can
help to determine an adequate strategy but are no substitute for individual clinical judgment.
Dual antiplatelet therapy and anticoagulation is indicated initially and the preferred regimens
vary based on patient risk factors and timing of revascularization. Some low-risk NSTE-ACS
patients can be managed conservatively.

ECG changes in NSTEMI/UA

Findings [2]

No ST elevations present
Nonspeci c signs of ischemia may be present, including:
ST depression, especially if horizontal or downsloping
Transient ST deviations ≥ 0.5 mm (≥ 0.05 mV) in symptomatic patients at rest
T-wave inversions of ≥ 2 mm (≥ 0.2 mV) in V1–V 6

Additional considerations

Normal ECG may be seen in up to 15% of patients with NSTEMI. [2][25]

Be wary of STEMI-equivalent ECG ndings (e.g., signs of posterior myocardial infarction)
and repeat ECGs if inconclusive.

To identify STEMI or STEMI-equivalent ECG ndings, repeat ECGs if the initial

one is inconclusive or any changes in symptoms occur.
Management REGISTER / LOG IN

The following recommendations are generally consistent with the 2014 AHA/ACC guidelines
for the management of NSTE-ACS. [2]
Risk-dependent timing of revascularization [2][7]

Management of NSTE-ACS depends on a patient's mortality risk (e.g., TIMI score), clinical
ndings, and the availability of resources.
Invasive strategy for NSTE-ACS (very high- to intermediate-risk patients):
coronary angiography within 2–72 hours
Ischemia-guided strategy for NSTE-ACS (in stable, low-risk patients): Further testing (e.g.,
exercise ECG, stress echocardiography) is used to evaluate the need for
coronary angiography.

Risk-dependent timing of revascularization in NSTE-ACS [2][7]

Revascularization Risk group Criteria

strategy

Urgent Very high Hemodynamic instability

revascularization (< 2 Life-threatening arrhythmias (e.g.,

hours) ventricular brillation or
sustained ventricular tachycardia)
Refractory ischemic pain despite adequate medical
treatment
Acute heart failure
Mechanical complications (e.g., new/aggravated
mitral regurgitation)

STEMI-equivalent ECG ndings [1]

Early invasive strategy High None of the criteria above

(< 24 hours) GRACE score > 140

Dynamic ST or T-wave changes [7]

Dynamic troponin changes (e.g., ≥ 20% or ≥ 3 standard
deviations)
 Risk-dependent timing of revascularization in NSTE-ACS [2][7] REGISTER / LOG IN

Revascularization Risk group Criteria

strategy

Delayed invasive (24– Intermediate None of the criteria above

72 hours) GRACE score 109–140

TIMI score ≥ 2
Diabetes mellitus

GFR < 60 mL/min/1.73m2

LVEF < 0.40
Prior PCI ≤ 6 months
Prior CABG
Postinfarction angina

Ischemia-guided Low None of the criteria above

GRACE score < 109
TIMI score 0 or 1
Individual decision based on patient and physician
preferences

Patients with NSTEMI who have unstable hemodynamics, intractable angina,

suspected posterior infarction, and/or left main-vessel occlusion require urgent
PCI (< 2 hours), even if no ST elevations are present. [1][2][6]

Fibrinolytic therapy is not indicated in patients with unstable angina or NSTEMI.

Antiplatelet therapy and anticoagulation in NSTE-ACS [2]

Dual antiplatelet therapy (DAPT) and anticoagulation in NSTEMI [2]

Class Regimen
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Class Regimen

Dual antiplatelet therapy (DAPT) [2] Aspirin

AND one of the following ADP receptor inhibitors [2]

Ticagrelor
Clopidogrel

One of the following:

Anticoagulation [2] Enoxaparin
Unfractionated heparin
Fondaparinux
Only in early invasive strategy: bivalirudin

Consider in intermediate/high-risk patients with early-

Glycoprotein IIb/IIIa inhibitor invasive strategy.
(GPI) [2] Epti batide
Tiro ban

Timing [2]
Start DAPT as soon as possible; duration depends on whether PCI is performed or not.
Start anticoagulation as soon as possible; continue for the duration of hospitalization or
until PCI is performed.
GPI should only be started in high-risk patients undergoing PCI and in consultation with a
cardiologist.

Acute management checklist for NSTE-ACS

Evaluate for very-high risk factors requiring urgent coronary angiography : If present,
follow STEMI checklist. [2]
Start antiplatelet therapy and anticoagulation.
Aspirin

ADP receptor inhibitor: ticagrelor or clopidogrel

Anticoagulation with UFH, enoxaparin, bivalirudin, or fondaparinux
 Calculate TIMI score and GRACE score.
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Cardiology consult for discussion of strategy (see “Risk-dependent timing of
revascularization in NSTE-ACS”)
Adjunctive medical therapy for ACS

Supplemental oxygen as needed: target SpO2 > 90%

Nitroglycerin for patients with ongoing chest pain or hypertension
Analgesia with morphine only for patients with very strong pain
High-intensity statin
Consider beta blocker if no contraindications.

Consider ACE inhibitor if no contraindications.

Order continuous telemetry, serial ECG, and serum troponins every 3–6 hours.
Transfer to cardiac telemetry oor or (cardiac) ICU.

Monitoring and adjunctive medical therapy

Monitoring

Continuous cardiac monitoring

Serial 12-lead ECG every 15–30 minutes for the rst hour
Serial serum troponin measurement (every 1–6 hours)

Adjunct medical therapy in ACS [1][2]

Adjunct medical therapy in ACS [1][2][6][7]

Class Drug Indications Contraindications and

additional considerations

Nitroglycerin Continued chest Systolic blood pressure < 90

Nitrates Sublingual pain mm Hg
[1][2]
Hypertension Use of PDE 5 inhibitor (e.g.,
Intravenous Heart failure sildena l) in the previous 24
[1][2] hours (48 hours for tadala l)

Suspected RV infarction [1][2]

Adjunct medical therapy in ACS [1][2][6][7] REGISTER / LOG IN

Class Drug Indications Contraindications and

additional considerations

Metoprolol Oral: any patient Signs of heart failure (e.g.,

Beta [1] without pulmonary edema)
blockers contraindications
Carvedilol (Risk of) cardiogenic shock
[1] Intravenous: Hypotension
continuing
hypertension, Bradycardia
refractory ischemic Second- or
pain third-degree AV block
(without pacemaker)
PR interval > 0.24 seconds
See “
Contraindications for beta
blockers
.”
If contraindications are
present, reevaluate after 24
hours

Morphine Severe pain despite Administer with caution due

Opioids [2] maximal to increased risk of
antianginal complications (e.g.,
medication hypotension, respiratory
depression) and
adverse events [1][2][6]

Lethargy
Hypotension
Bradycardia
Known hypersensitivity

Lisinopril Consider within 24 See “Contraindications for

ACE [1] hours in stable ACE inhibitors and ARBs.”
inhibitors patients with: [1][2]
Captopril
/ARB [1]
STEMI
LVEF ≤ 40%
Ramipril [1]
Heart failure
If
Hypertension
ACE-inhibitor
intolerant: Diabetes mellitus
valsartan
[1]
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Class Drug Indications Contraindications and

additional considerations

E.g., Consider in patients Renal failure (serum creatinine

Aldosterone eplerenone already receiving an > 2.0 mg/dl in women, > 2.5
antagonists [26] ACE inhibitor and mg/dL in men) [2]
[1][2][6] beta blocker with
Hyperkalemia
any of the following:
[2]

LVEF ≤ 40%
Heart failure
Diabetes mellitus

Atorvastatin All STEMI/NSTEMI See “Contraindications for

High- [1] patients, regardless statins.”
intensity of baseline
statin cholesterol

Acute medical treatment in ACS includes “MONA”: Morphine, Oxygen,

Nitroglycerin, and Aspirin. But remember: Morphine, oxygen, and nitroglycerine
are not necessarily indicated for every patient (see “Indications”).

Supportive measures

Oxygen therapy for patients with:

Cyanosis
Severe dyspnea

SpO2 < 90%

Fluid management: see “Management of acute heart failure.”
Intravenous uids (e.g., normal saline): consider for inferior myocardial infarction causing
RV dysfunction
Loop diuretic (e.g., furosemide ): consider for patients with pulmonary edema,
acute heart failure

Subsequent measures
 See “Prevention of myocardial infarction.”
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See “Coronary artery surgery.”

Differential diagnoses

See “Differential diagnoses of chest pain.”

Differential diagnoses of increased troponin [7]

Cardiovascular causes
Myocarditis
Decompensated congestive heart failure
Pulmonary embolism

Cardiac arrhythmia, tachycardia

Aortic dissection
Hypertensive emergencies
Structural heart disease
Myocardial drug toxicity (e.g., doxorubicin)
Cardiac trauma (including iatrogenic/periprocedural)
Takotsubo cardiomyopathy
Stroke
Noncardiovascular causes
Renal failure
Critical illness (e.g., sepsis)

Hypothyroidism or hyperthyroidism

Differential diagnoses of ST elevations on ECG [1]

Early repolarization
LBBB
Brugada syndrome
Myocarditis
Pericarditis
Pulmonary embolism
 Hyperkalemia
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Tricyclic antidepressant use
Poor ECG lead placement
The differential diagnoses listed here are not exhaustive.

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