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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.
Authors and 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.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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