Acute Coronary Syndrome - AMBOSS
Acute Coronary Syndrome - AMBOSS
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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
NSTE-ACS STE-ACS
NSTE-ACS STE-ACS
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
troponin
NSTE-ACS STE-ACS
Clinical features
[4][5]
Classic presentation
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.
Diaphoresis, anxiety
Other ndings
Tachycardia, arrhythmias
Symptoms of CHF (e.g., orthopnea, pulmonary edema) or cardiogenic shock (e.g.,
hypotension, tachycardia, cold extremities)
”Silent MI” without chest pain is more common in patients with diabetes, as a result of
polyneuropathy.
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.
Cardiac troponin levels: Measure as soon as possible and repeat after 1–6 hours.
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 ndings can change within minutes and ST elevations can appear or
disappear.
Cardiogenic shock
Infarct-like symptoms but inconclusive ECG ndings
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.
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
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
Moderately suspicious 1
Highly suspicious 2
ECG Normal 0
45–65 years 1
≥ 65 years 2
1–2 1
Interpretation
Any positive troponin level: usually considered non-low risk and requires further evaluation [14]
Characteristics Points
Age ≥ 65 years 1
1
≥ 3 CAD risk factors (e.g., family history of CAD, DM, smoking, HTN, hypercholesterolemia)
Interpretation
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.
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.
Any patient with ST elevations on ECG requires immediate evaluation for urgent
revascularization. The administration of other therapies should not delay care.
Classical timeline of ECG changes in STEMI REGISTER / LOG IN
Absence of R wave
T-wave inversions
Pathological Q waves
Duration ≥ 0.04 seconds
Amplitude ≥ ¼ of the R wave or ≥ 0.1 mV
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
[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
Management
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The following recommendations are generally consistent with the 2013 AHA/ACC guidelines
for the management of STE-ACS. [1]
Approach [1]
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”).
[1]
Emergency coronary angiography with PCI
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
Streptokinase
Post brinolysis: Check TIMI coronary grade ow and transfer to a facility with PCI
capabilities.
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
Immediate cardiology consult and evaluation for emergency revascularization (code STEMI)
Transfer to cath lab for angiography.
For patients > 120 min away from a PCI-capable facility and symptom onset <
12 hours
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.
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
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.
Class Regimen
Dual antiplatelet therapy (DAPT) and anticoagulation in NSTEMI [2] REGISTER / LOG IN
Class Regimen
Ticagrelor
Clopidogrel
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.
Evaluate for very-high risk factors requiring urgent coronary angiography : If present,
follow STEMI checklist. [2]
Start antiplatelet therapy and anticoagulation.
Aspirin
Monitoring
Lethargy
Hypotension
Bradycardia
Known hypersensitivity
LVEF ≤ 40%
Heart failure
Diabetes mellitus
Supportive measures
Subsequent measures
See “Prevention of myocardial infarction.”
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See “Coronary artery surgery.”
Differential diagnoses
Cardiovascular causes
Myocarditis
Decompensated congestive heart failure
Pulmonary embolism
Hypothyroidism or hyperthyroidism
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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