Giới thiệu
Patients with suspected acute coronary syndrome (ACS) must be evaluated quickly
- Early, focused management of ACS reduces adverse events and improves outcomes
- Pre-hospital department management includes:
- Early activation of emergency medical service system (EMS)
- Administration of Aspirin, oxygen, Nitroglycerin and Morphine (if needed)
- If available, obtain 12-lead electrocardiogram (ECG)
- Emergency department management includes:
- Checking of vital signs, evaluating oxygen (O2) saturation (sat) and establishing intravenous (IV) access
- Obtaining initial cardiac biomarker levels, chest X-ray and 12-lead ECG (if not yet done)
Definition
Acute Coronary Syndrome (ACS)
- Any constellation of symptoms compatible with acute myocardial ischemia usually caused by sudden reduction in coronary blood flow
ACS with Persistent ST-Segment Elevation
- ST-segment elevation myocardial infarction (STEMI)
- Presents with elevated levels of cardiac biomarkers
- Please see Myocardial Infarction w/ ST-Segment Elevation disease management chart for further information
ACS without Persistent ST-Segment Elevation (Non-ST Elevation ACS [NSTE-ACS])
- Unstable angina (UA)
- Ischemic discomfort that presents with normal cardiac biomarkers in the blood
- Non-ST-segment elevation myocardial infarction (NSTEMI)
- Presents with elevated levels of cardiac biomarkers
Signs and Symptoms
- Patients present with a broad range of signs and symptoms, from asymptomatic at presentation to patients with ongoing chest discomfort (eg pain, pressure, tightness, heaviness, burning); may also present with cardiac arrest, electrical or hemodynamic instability or cardiogenic shock
- Patient typically presents with ischemic-type chest pain except that the episodes may be more severe and prolonged, may occur at rest or may be caused by less exertion than previous episodes
- Chest pain-equivalent symptoms are often observed in younger (25 to 40 years old) and older (>75 years old) patients, in women, and in patients with diabetes mellitus (DM), chronic renal failure or dementia
- Eg pain that occurs predominantly at rest, epigastric pain, recent onset of unexplainable indigestion, belching, stabbing chest pain, chest pain with some pleuritic features or increasing dyspnea
- Common features of UA:
- Rest angina: Angina occurring at rest and prolonged, usually >20 minutes
- New-onset severe angina: Patient usually has marked limitation on ordinary physical activity (angina occurs on walking 1 to 2 blocks on level or climbing one flight of stairs under normal conditions and at a normal pace)
- Increasing or crescendo angina: Previously diagnosed effort-related angina that has become distinctly more frequent, longer in duration or more easily provoked (by less effort than before)
- Post-myocardial infarction (MI) angina
Ischemic-type Chest Discomfort or Anginal Equivalent
- Retrosternal chest pain
- Pain is usually described as heaviness, pressure, tightness, cramping or burning in nature
- Pain may occur at rest or during activity that may be associated with physical exertion or emotional stress
- The pain which is usually central or in the left chest may radiate to the jaw, neck, left or both arms, back or shoulder
- Accompanying symptoms may include: Nausea and vomiting, dyspnea, diaphoresis, lightheadedness, abdominal (epigastric) pain, dizziness, fatigue, weakness and loss of consciousness
- Chest pain-equivalent symptoms: Pain develops in the arm, shoulder, wrist, jaw or back without occurrence in the chest
- Discomfort that presents solely as jaw, neck, ear, arm or epigastric pain and is associated with exertion or stressor is relieved promptly with Glyceryl trinitrate (GTN) should be considered equivalent to angina
- Pain is usually not relieved by rest or GTN
Yếu tố nguy cơ
- Smoking
- Dyslipidemia
- Hypertension
- Diabetes
- History of coronary artery disease (CAD)