Acute coronary syndromes. Jason Smith Consultant in Emergency Medicine Derriford Hospital, Plymouth. The problem. Objectives . To define ACS we all know this bit, but do we apply it in practice? Therapeutic dilemmas Diagnostic dilemmas How do I rule it in? How do I rule it out?
Consultant in Emergency Medicine
Derriford Hospital, Plymouth
College of Emergency Medicine CPD Event, 29 March 2011
ACS represent a life-threatening manifestation of atherosclerosis usually precipitated by acute thrombosis, induced by a ruptured or eroded atherosclerotic plaque, with or without concomitant vasoconstriction, causing a sudden and critical reduction in blood flow.
European Society of Cardiology definition 2007
Little WC et al.
Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease?
Savonitto S, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999;281: 707– 713.
Volmink JA, et al. Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidence study. Heart 1998;80:40– 44.
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988;2(8607):349-60.
Eikelboom JW, et al. Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis. Lancet 2000; 355:1936– 1942.
Yusuf S, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.
N Engl J Med 2001;345:494–502.
Goodacre S, et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care.
BMJ doi:10.1136/bmj.37956.664236.EE (published 14 January 2004)
McCord J, Nowak RM, McCullough PA, et al. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. Circulation 2001;104:1483-8
Apple FS, Christensen RH, Valdes R, et al. Simultaneous rapid measurement of whole blood myoglobin, creatininekinase MB and cardiac troponin I by the triage cardiac panel for detection of myocardial infarction. ClinChem 1999;45:199-205
Newby LK, Storrow AB, Gibler WB, et al. Bedside multimarker testing for risk stratification in chest pain units: the CHECKMATE Study. Circulation 2001;103:1832-7
Caragher TE, Fernandez BB, Jacobs FL, et al. Evaluation of quantitative cardiac biomarker point of care testing in the emergency department. J Emerg Med 2002;22:1-7
Ng SM, Krishnaswamy P, Morissey R, et al. Ninety-minute accelerated critical pathway for chest pain evaluation. Am J Cardiol 2001;88:611-17
Hamilton AJ, Swales LA, Neill J, et al. Risk stratification of chest pain patients in the emergency department by a nurse utilizing a point of care protocol. Eur J Emerg Med 2008;15:9-15
Rathore S, Knowles P, Mann APS, et al. Is it safe to discharge patients from accident and emergency using a rapid point of care triple cardiac marker test to rule out acute coronary syndrome in low to intermediate risk patients presenting with chest pain? Eur J Int Med 2008;19:537-40
Straface AL, Myers JH, Kirchick HJ, et al. A rapid point-of-care cardiac marker testing strategy facilitates the rapid diagnosis and management of chest pain patients in the emergency department. Am J ClinPathol 2008;129:788-95
CG95. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE 2010.
Hess EP. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ 2010. DOI:10.1503/cmaj.092119 (July 2010)