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Last Updated: 11/12/2014  

Acute Coronary Syndromes

Diagnosis
  • Ask patients about symptoms suggesting ACS, typically described as chest pressure, tightness, or heaviness radiating to the jaw, back, or arm.

  • Obtain ECG immediately in all patients with suspected ACS.

  • Measure troponin T or I upon initial evaluation of patients with presumed ACS.

  • Consider using a diagnostic tool that combines history, physical exam, and laboratory data to aid in early risk stratification.

  • Use stress testing or consider coronary CT angiography in patients stratified as low-risk.

Therapy
  • Give full-dose aspirin therapy promptly and continue low-dose aspirin in all patients with suspected ACS.

  • Proceed directly to coronary angiography in patients with STEMI who present to experienced centers or can be transferred to a referral center in order to perform primary percutaneous intervention.

  • Administer a thrombolytic agent as an alternative to primary PCI in suitable candidates with STEMI.

  • Give anticoagulant therapy with unfractionated heparin, LMWH, or bivalirudin to moderate- and high-risk patients with ACS.

  • Administer clopidogrel or a newer P2Y12 receptor inhibitor in selected patients with ACS.

  • Consider administering glycoprotein IIb/IIIa antagonists in addition to aspirin and an anticoagulant as adjunctive therapy in patients undergoing primary percutaneous intervention, or as an alternative to P2Y12 receptor inhibitors.

  • Administer β-blockers early to patients with suspected ACS unless there are significant contraindications; give a nonselective β-blocker to patients with LV dysfunction after an MI.

  • Administer nitroglycerin to patients with ACS with ongoing chest discomfort.

  • Administer an ACE inhibitor early in the course of ACS.

  • Prescribe high-potency HMG-CoA reductase inhibitors (statins) in patients with ACS and continue after hospitalization.

  • Aim for glycemic control (glucose <180 mg/dL) in patients with diabetes.

  • Strongly advise all tobacco users who have had an acute coronary event to quit smoking.

  • Begin counseling efforts to maximize adherence to post-ACS therapies and lifestyle changes early in the hospitalization.

  • Consider referral for all patients post-ACS to appropriate cardiac rehabilitation programs.

DOI: 10.7326/d361
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Helene Glassberg, MD is a speaker for pharmaceutical companies. Rozy Desai, MD has nothing to disclose. Sanjum S. Sethi, MD has nothing to disclose. Michael E. Farkouh, MD, MSc, FRCPC, FACC consults for Eli Lilly and AstraZeneca.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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