Acute coronary syndrome (main): Difference between revisions
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==Background== | ==Background== | ||
ACS is three diseases involving the coronary arteries: | ACS is three diseases involving the coronary arteries: | ||
*[[ST-Elevation Myocardial Infarction (STEMI)]] (30%) | |||
*[[Non ST-Elevation Myocardial Infarction (NSTEMI)]] (25%) | |||
*[[Unstable Angina]] (38%) | |||
[[File:MI types.png|thumbnail|Myocardial Infarction types]] | [[File:MI types.png|thumbnail|Myocardial Infarction types]] | ||
==Types of MI<ref>Third Universal Definition of Myocardial Infarction http://circ.ahajournals.org/content/126/16/2020.full.pdf</ref>== | ==Types of MI<ref>Third Universal Definition of Myocardial Infarction http://circ.ahajournals.org/content/126/16/2020.full.pdf</ref>== | ||
*Type 1 - Spontaneous Myocardial Infarction | |||
**atherosclerotic plaque rupture or intraluminal thrombus in one or more of the coronary arteries | |||
*Type 2 - Myocardial Infarction Secondary to an Ischaemic Imbalance | |||
**condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand | |||
*Type 3 - Cardiac Death Due to Myocardial Infarction (MI Type 3) | |||
**suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers | |||
*Type 4 -Myocardial Infarction Associated With Revascularization Procedures (MI Types 4 and 5) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Chest Pain DDX}} | {{Template:Chest Pain DDX}} | ||
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== Diagnosis== | == Diagnosis== | ||
Clinical factors that '''increase''' likelihood of ACS/AMI:<ref>Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454</ref><ref>Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377</ref> | Clinical factors that '''increase''' likelihood of ACS/AMI:<ref>Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454</ref><ref>Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377</ref> | ||
*Chest pain radiating both arms >R arm >L arm | |||
*Chest pain associated with diaphoresis | |||
*Chest pain associated with N/V | |||
*Chest pain with exertion | |||
Clinical factors that '''decrease''' likelihood of ACS/AMI:<ref>Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077</ref> | Clinical factors that '''decrease''' likelihood of ACS/AMI:<ref>Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077</ref> | ||
*Pleuritic chest pain | |||
*Positional chest pain | |||
*Sharp, stabbing chest pain | |||
*Chest pain reproducible with palpation | |||
Male and female patients typical present with similar symptoms<ref>Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.</ref> | Male and female patients typical present with similar symptoms<ref>Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.</ref> | ||
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Intensity of Rx should be based on likelihood that sx are due to acute coronary thombosis | Intensity of Rx should be based on likelihood that sx are due to acute coronary thombosis | ||
*[[ST-Elevation Myocardial Infarction (STEMI)]] | |||
*[[Non ST-Elevation Myocardial Infarction (NSTEMI)]] | |||
*[[Unstable Angina]] | |||
==Disposition== | ==Disposition== | ||
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* [[Cocaine Chest Pain]] | * [[Cocaine Chest Pain]] | ||
*[[STEMI equivalents]] | *[[STEMI equivalents]] | ||
==Sources== | ==Sources== | ||
<references/> | <references/> | ||
[[Category:Cards]] | |||
Revision as of 21:19, 18 June 2015
For risk stratification see ACS - Risk Stratification
Background
ACS is three diseases involving the coronary arteries:
- ST-Elevation Myocardial Infarction (STEMI) (30%)
- Non ST-Elevation Myocardial Infarction (NSTEMI) (25%)
- Unstable Angina (38%)
Types of MI[1]
- Type 1 - Spontaneous Myocardial Infarction
- atherosclerotic plaque rupture or intraluminal thrombus in one or more of the coronary arteries
- Type 2 - Myocardial Infarction Secondary to an Ischaemic Imbalance
- condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand
- Type 3 - Cardiac Death Due to Myocardial Infarction (MI Type 3)
- suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers
- Type 4 -Myocardial Infarction Associated With Revascularization Procedures (MI Types 4 and 5)
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Elevated Troponin
Diagnosis
Clinical factors that increase likelihood of ACS/AMI:[2][3]
- Chest pain radiating both arms >R arm >L arm
- Chest pain associated with diaphoresis
- Chest pain associated with N/V
- Chest pain with exertion
Clinical factors that decrease likelihood of ACS/AMI:[4]
- Pleuritic chest pain
- Positional chest pain
- Sharp, stabbing chest pain
- Chest pain reproducible with palpation
Male and female patients typical present with similar symptoms[5]
- ECG (Diagnosis)
- ECG is normal in 8% of all confirmed MI's
- In LBBB see Sgarbossa's Criteria
- Cardiac Enzymes
- ACS - Risk Stratification
- ACS - Anatomical Correlation
Treatment
Intensity of Rx should be based on likelihood that sx are due to acute coronary thombosis
- ST-Elevation Myocardial Infarction (STEMI)
- Non ST-Elevation Myocardial Infarction (NSTEMI)
- Unstable Angina
Disposition
- Admit all ACS pts
Prognosis
External Links
- MDCalc - Framingham Coronary Heart Disease Risk Score
- MDCalc - Sgarbossa’s Criteria for MI in Left Bundle Branch Block
- MDCalc - TIMI Risk Score for UA/NSTEMI
See Also
- ACS - Anatomical Correlation
- ACS - Risk Stratification
- ST-Elevation Myocardial Infarction (STEMI)
- ACS - Stress Testing
- NSTEMI
- Unstable Angina
- Unstable Angina - NSTEMI Guidelines
- Cocaine Chest Pain
- STEMI equivalents
Sources
- ↑ Third Universal Definition of Myocardial Infarction http://circ.ahajournals.org/content/126/16/2020.full.pdf
- ↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
- ↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
- ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
- ↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.