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  Acute coronary syndrome

Acute coronary syndrome includes a range of conditions involving chest pain or other related symptoms caused by insufficient oxygen supply to the heart muscle or the myocardium. It is the most common presentation of a heart attack, also known as myocardial infarction. Acute coronary syndrome is most often but not always exclusively associated with an abnormal electrocardiogram (ECG/EKG). The syndrome is a combination of coronary artery disease clinical manifestations that falls under a single term because of the similarity of its pathophysiology. This condition is one of the most common causes of emergency consult.

Acute coronary syndrome
Acute coronary syndrome

The clinical spectrum of Acute Coronary Syndrome ranges from varying degrees of obstruction of the coronary arteries, the blood vessels supplying the cardiac muscles. Previous studies have shown that nearly everyone has some evidence of atherosclerotic plaque formation which accumulates with advancing age. This atherosclerotic plaque formation is more pronounced in some individuals as a result of life style, environment and/or genetics. An atherosclerotic plaque is defined as a lipid or fat-rich deposits embedded within the coronary intima, the innermost lining of blood vessels. The other side of the plaque surface, along the lumen of the blood vessel is covered by a fibrous cap. Dense extracellular matrix of collagen, elastin and proteoglycans makes up a fibrous cap. The fibrous cap provides integrity and is of prime importance for the maintenance of plaque stability. However, in time, these susceptible plaques may thicken and eventually may erode, fissures may form that may subsequently rupture, exposing a thrombogenic surface upon which platelets aggregate resulting to thrombus (clot) formation. Thrombus formation will continue and this will eventually lead to symptomatic coronary vessel occlusion or partial narrowing of the arterial lumen decreasing oxygen perfusion to the cardiac muscles known as myocardial ischemia. This cardiac condition is now referred to as angina pectoris.

Angina pectoris is further categorized most commonly as stable or unstable angina based on the change in the severity or of duration of symptoms. Stable angina, in contrast to unstable angina, develops chest pain only during exertion and resolves at rest. Unstable angina occurs suddenly, most often at rest, and its progressively worsening as to severity of chest pain which is either partially responsive or unresponsive to nitrate (coronary vasodilators) drugs. There are secondary causes of unstable angina namely: fever, tachycardia, thyrotoxicosis, hypotension, anemia or hypoxemia. Secondary unstable angina is due to causes or conditions which are extrinsic to the coronary arteries. The end result of persistent ischemia is myocardial infarction (MI) or known in the layman’s term as “heart attack”. Acute coronary syndrome ranges from the clinical spectrum of unstable angina to non-Q-wave and Q-wave myocardial infarction. These are all considered as life-threatening disorders and major causes of emergency medical care. In fact, coronary artery disease or also known as ischemic heart disease is the leading cause of death in the United States.

Diagnosis of acute coronary syndrome is based on the medical history especially the risk factors, physical examination and to a lesser degree, by electrocardiogram findings. For those with severe chest pain, close monitoring and symptomatic treatment may given right away even before all laboratory results are complete. Two common mnemonics to serve as a guide during these emergency situations are: MOVE (monitor, oxygen, venous access, ECG) and MONA (morphine, oxygen, nitrate, aspirin).

In the emergency room, laboratory work-ups such as ECG, chest X-ray, blood tests (such as cardiac enzyme markers: troponin I or T and a D-dimer if a pulmonary embolism is suspected), and telemetry (heart rhythm monitoring) are requested in order to confirm the cardiac involvement. The treatment is mainly dependent on the ECG findings. If the ECG confirms myocardial infarction, a clot busting drug (thrombolytics) may be administered or a coronary angioplasty may be performed. In thrombolysis, a drug is injected at least within 3 hours of onset of symptoms to destroy the blood clots and relieve the obstruction in the coronary arteries. In percutaneous transluminal angioplasty (PTCA), a flexible catheter is inserted into the femoral or radial arteries until it reaches the heart unblocking the coronaries. If the ECG finding does not reveal typical changes, then the term "non-ST segment elevation ACS" is used because the patient may still have suffered a "non-ST elevation MI" (NSTEMI). Management of unstable angina and acute coronary syndrome is empirical using the following drugs: aspirin, low-molecular weight heparin such as enoxaparin , clopidogrel, with IV glyceryl trinitrate and opioids for persistent chest pain.

The major predisposing factor for acute coronary syndrome is often the degree of coronary arterial damage by atherosclerosis. Therefore, the main prevention of atherosclerosis is controlling the risk factors by healthy eating, regular exercise, treatment for hypertension and diabetes, avoiding smoking and maintaining normal cholesterol levels. In patients with highly significant risk factors, daily aspirin use is advised to reduce the risk of another heart attack. Maintaining wellness that focuses on healthy lifestyles and prevention remains the most effective way to prevent morbidity and mortality associated with acute coronary syndrome.

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