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Last Updated: 1/25/2013  

Acute Coronary Syndromes

Diagnosis
  • Ask patients about symptoms suggesting ACS, “typically” described as pressure, tightness or heaviness and radiates to the jaw, back or arm.

  • Obtain electrocardiogram immediately in all patients with suspected ACS.

  • Measure CK-MB and 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 aspirin therapy promptly and continue 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 a primary percutaneous intervention.

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

  • Give anticoagulant therapy with unfractionated heparin, low-molecular-weight heparin 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 in patients with high-risk NSTEMI, as adjunctive therapy in patients with STEMI 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 left ventricular dysfunction after an MI.

  • Administer nitroglycerin to 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, with goal LDL<100 mg/dL.

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

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

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.
Disclosures:
Helene Glassberg, MD is a speaker for pharmaceutical companies. Rozy Desai, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Sanjum S. Sethi, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Michael E. Farkouh, MD, MSc, FRCPC, FACC consults for Eli Lilly and AstraZeneca.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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