Part 9: Acute Coronary Syndromes

To facilitate interpretation of this algorithm and a more detailed discussion in the text, each box is assigned a letter code that reflects its level in the algorithm and a number that is allocated from left to right across the diagram on a given level. ACC/AHA American College of Cardiology/American Heart Association; ACS acute coronary syndrome; ECG electrocardiogram; LV left ventricular. Anderson et al ACC/AHA UA/NSTEMI Guideline Revision e159 Downloaded from http://ahajournals.org by on August 29, 2023 a 12-lead ECG and biomarker determination (e.g., an ED or other acute care facility). (Level of Evidence: C) 2. Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s], back, neck, jaw or epigastrium; shortness of breath; weakness; diaphoresis; nausea; lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B) 3. Health care providers should actively address the following issues regarding ACS with patients with or at risk for CHD and their families or other responsible caregivers: a. The patient's heart attack risk; (Level of Evidence: C) b. How to recognize symptoms of ACS; (Level of Evidence: C) c. The advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 min, despite feelings of uncertainty about the symptoms and fear of potential embarrassment; (Level of Evidence: C) d. A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access EMS, generally 9-1-1 (74). (Level of Evidence: C) 4. Prehospital EMS providers should administer 162 to 325 mg of ASA (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non-enteric-coated formulations. (Level of Evidence: C) 5. Health care providers should instruct patients with suspected ACS for whom nitroglycerin [NTG] has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (Level of Evidence: C) 6. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED. Other patients with suspected ACS who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (Level of Evidence: C) CLASS IIa 1. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients without a history of ASA allergy who have symptoms of ACS to chew ASA (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used entericcoated ASA for initial dosing, more rapid buccal absorption occurs with non-enteric-coated formulations. (Level of Evidence: B) 2. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients who tolerate NTG to repeat NTG every 5 min for a maximum of 3 doses while awaiting ambulance arrival. (Level of Evidence: C) 3. It is reasonable that all prehospital EMS providers perform and evaluate 12-lead ECGs in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions. Electrocar-diographs with validated computer-generated interpretation algorithms are recommended for this purpose. (Level of Evidence: B) 4. If the 12-lead ECG shows evidence of acute injury or ischemia, it is reasonable that prehospital ACLS providers relay the ECG to a predetermined medical control facility and/or receiving hospital. (Level of Evidence: B) Downloaded from http://ahajournals.org

Background: There is a great deal of mortality and morbidity associated with various cardiovascular diseases that comprise acute coronary syndrome (ACS). One crucial factor in the development of ACS is inflammation of the coronary plaque. Cell adhesion molecules play a key role in the inflammatory cascade. The vascular endothelium is directly affected by elevated levels of pro-inflammatory cytokines and other systemic inflammatory markers in ACS related to atherogenesis. This causes an increase in the expression of adhesion molecules, such as selectins. Objective: This study aims to document the inflammatory response after acute coronary syndrome by evaluating the association between serum E-selectin levels and the risk and severity of acute coronary syndrome. Materials and Methods: A case-control study involving 120 male subjects aged 41–70 years, who were divided into two groups: 60 ACS patients and 60 healthy individuals as a control. Serum E-selectin levels were measured using an ELISA technique. Results: The study revealed a significant increase in serum E-selectin levels when comparing patients to the healthy control group (216.07±20.26 pg/ml Vs 179.74±53 pg/ml, P ≤ 0.0001) respectively. The analysis of the receiver operating curve (ROC) for E-selectin showed a sensitivity of 85%, a specificity of 70%, a 95% confidence interval (CI) of 0.673-0.863, and the area under the curve (AUC) was 0.768. The cut-off point was set at 197.37 pg/ml or higher. Conclusion: Elevated serum E-selectin levels in ACS patients suggest a potential role for adhesion molecules in the pathogenesis of ACS. Adhesion molecules could be considered as a biochemical marker for assessing ACS.

The inflammatory etiology of atherosclerosis has prompted a search for biomarkers of inflammation that predict risk for coronary artery disease and its sequelae. Within the acute coronary syndromes (ACS), inflammatory biomarkers may provide independent information regarding pathophysiology, prognosis, and optimal therapeutic strategies. On the basis of the hypothesis that different pathophysiological processes provide nonoverlapping information regarding risk stratification and disease management, this review series addresses biomarkers for each step in the inflammatory process that leads to ACS. Part I reviewed cytokines; this part reviews acute-phase reactants and biomarkers of endothelial cell activation; subsequent parts will address biomarkers of oxidative stress, angiogenesis, extracellular matrix degradation, and platelet activation. In the acute-phase response, cytokines drive production of acute-phase reactants, defined by >25% change in circulating concentration during an inflammatory response. These markers may also remain elevated chronically because of continuing inflammatory stimuli (Table). View this table: Inflammatory Biomarkers in ACS ### C-Reactive Protein C-reactive protein (CRP) is a pentraxin acute-phase protein, members of which are evolutionarily conserved in most vertebrates.1 Hepatocytes and possibly smooth muscle cells and macrophages transcriptionally activate production of CRP in response to inflammatory cytokines, including interleukin-1 and interleukin-6.2 CRP is a robust clinical marker because of its stability, reproducible results, and ease of assay. Although it was originally proposed as a nonspecific marker of inflammation, several reports suggest that CRP may play a direct pathophysiological role in the development and progression of atherosclerosis. Proposed mechanisms include induction of endothelial dysfunction,3 promotion of foam cell formation,4 inhibition of endothelial progenitor cell survival and differentiation,5 and activation of complement in atherosclerotic plaque intima6 and ischemic myocardium.7 Patients with ACS have elevations in CRP in association with their presenting symptoms. There appears to be a bimodal CRP response among patients with ACS. In some patients, CRP may remain elevated for …

Treatment and Outcomes of Patients With Suspected Acute Coronary Syndromes in Relation to Initial Diagnostic Impressions (Insights from the Canadian Global Registry of Acute Coronary Events [GRACE] and Canadian Registry of Acute Coronary Events [CANRACE

Emergency physician threshold to test for acute coronary syndrome (ACS) is directly related to ACS diagnosis rate and inversely related to ACS missed diagnosis rate. Feedback to emergency physicians of information on their prior patients whose ACS diagnosis was not identified may improve physician diagnostic performance. A critical pathway for evaluation of patients for ACS was modified to include feedback to physicians on their cases who had a return visit and did not have their ACS diagnosis identified at their prior emergency department visit. Feedback included case-specific details, discussion of the case at the monthly Morbidity and Mortality conference, and a yearly a report to each physician comparing their performance to their peers (ACS evaluation rate, ACS diagnosis rate, and ACS missed diagnosis rate). Cases were identified, and physician-specific performance was calculated from a computerized encounter database at 2 community teaching hospitals. During the study period, 29 emergency physicians evaluated 295,758 patients and identified 6472 ACS cases. During the study, the yearly ACS evaluation rate for individual physician ranged from 19% to 70% (average 40.3%; 95% confidence interval [CI], 39.5%-41.1%), the yearly ACS diagnosis rate for individual physician ranged from 1.1% to 4.2% (average 1.7%; 95% CI, 1.65%-1.75%), and the yearly missed ACS diagnosis rate for individual physician ranged from 0% to 17% (average 2.8%; 95% CI, 2.3%-3.3%). Individual physician ACS evaluation rate was directly related to physician ACS diagnosis rate (r 0.76, P = 0.00012) and was inversely related to that physician missed ACS rate (r 0.45, P = 0.001). During the study, implementation of the critical pathway increased the ACS evaluation rate from 30% to 48% and decreased the ACS missed diagnosis rate from 1.5% to 0.3%. Emergency physicians with lower threshold for ACS evaluation more frequently diagnose patients with ACS and less frequently miss the diagnosis of ACS. Feedback to emergency physicians of information on their patient's return visits and their own diagnostic performance may improve outcome for patients with ACS.

It is necessary to search for new risk factors that contribute to atherogenesis in presence of an unfavorable trend of increasing primary morbidity of ischemic heart disease (IHD). Objective. To study the features of cytokine status and its relationship with the severity of atherosclerotic coronary bed lesion in middle-aged men with chronic coronary syndrome and acute coronary syndrome without ST-segment elevation. Material and methods. A number of men equal 192 were examined (mean age 55.1±3.4 years), who were divided into 3 groups: the 1st group — patients with acute coronary syndrome without ST-segment elevation (n=93; mean age 55.37±3.14 years); the 2nd group — patients with chronic coronary syndrome (n=63; mean age 55.12±3.50 years) and the 3rd group — control, which consisted of conditionally healthy subjects without cardiac pathology (n=36; mean age 52.8±4.2 years). Levels of proinflammatory cytokines (interleukin (IL) IL-8, tumor necrosis factor-α — TNF-α), anti-inflammatory cytokine (IL-4) in the blood serum were determined in all participants of the study. Instrumental examination of patients with IHD included electrocardiography, echocardiography and selective coronary angiography. Results. The highest levels of IL-8 (93.62±13.04; 7.34±2.26; 5.86±1.13 pg/ml; F=38.12; p<0.001), TNF-α (12.44±2.04; 4.34±1.21; 3.53±0.96 pg/ml; F=77.73; p<0.001) and IL-4 (289.83±30.61; 3.70±0.16; 1.87±0.11 pg/ml; F=75.12; p<0.001) have been determined in patients with acute coronary syndrome without ST-segment elevation compared to patients with chronic coronary syndrome and subjects of control group. Correlations between the levels of all studied cytokines and the number of hemodynamically significant stenoses (p<0.05), the total number of the coronary bed sections affected by atherosclerosis, degree of stenosing of different sections of the coronary bed according to coronary angiography results (p<0.05) have been established. The most significant positive correlation was between TNF-α and the number of coronary bed lesions detected by coronary angiography (R=0.54; p<0.05). The cytokine TNF-α level >4.41 pg/ml was related to the probability of acute coronary syndrome without ST-segment elevation in middle-aged men with IHD. The value of the IL-4/IL-8 coefficient >3.4 was associated with the probability of IHD exacerbation in middle-aged males. Conclusions. The development of acute coronary syndrome without ST-segment elevation is associated with increase of both proinflammatory (IL-8, TNF-α) and anti-inflammatory cytokines (IL-4) levels. The imbalance between levels of proinflammatory and anti-inflammatory cytokines contributes to the progression of coronary atherosclerosis in patients with ischemic heart disease.

Aim: to investigate the prevalence of diabetes mellitus type 2 (T2DM) and association of HbA1c with the severity of coronary artery disease (CAD) in patients presenting at tertiary care center as acute coronary syndrome and non-diabetic. Study Design: Prospective observational study Duration and Place Study was conducted at department of general medicine Nishter Hospital, Multan from January 2021 to January 2022 in 1 year duration. Methodology: A total of 200 patients were enrolled in study. Main variables of study were BMI, smoking status, dyslipidemia, hypertension, STEMI, angina, HbA1c and treatment strategy. SPSS version 23 was used for data analysis. P value below or equal to 0.05 was taken as significant. Results: Among total 83.5% patients intervened by therapeutic, whereas 48.0% used thrombolytic drug in STEMI. 70.7% patients were thrombolysis in therapeutic intervention and 44.8% were streptokinase in thrombolytic drug. In fasting blood sugar, 53.0% patients were diabetic, whereas in HbA1c levels, 52.3% patients were diabetic. Conclusion: This study highlights the significance of testing for diabetes in individuals in poor nations who report with non-diabetic acute coronary syndrome. One of manifestations of diabetes mellitus may be the acute coronary syndrome. Keywords: Acute coronary syndrome, Coronary angiography, Diabetes, HbA1c.

De-escalation in intensity or duration of dual antiplatelet therapy in patients with coronary artery disease: More than alternative treatment options

Comparison of effectiveness of excimer laser angioplasty in patients with acute coronary syndromes in those with versus those without normal left ventricular function

Outcomes and Radiation Exposure of Emergency Department Patients With Chest Pain and Shortness of Breath and Ultralow Pretest Probability: A Multicenter Study

Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine

Incidence, predictors, and sex differences in acute coronary syndrome overdiagnosis among patients presenting to the emergency department with acute chest pain.

Aim. To evaluate patients with acute coronary syndrome (ACS) in combination with atrial fibrillation (AF) according to the total register of ACS in the Krasnodar region of echocardiographic (EchoCG) parameters (left atrial dimension (LAD), left ventricular wall thickness (LVWT), left ventricle end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), pulmonary artery systolic pressure (PASP), as well as coronary substrate assessment according to coronary angiography (CAG) and determination of the relationship between the value of LVEF and the coronary substrate.Material and methods. From the register of the ACS in the Krasnodar region, patients were successively taken to the cardiology departments of Krasnodar regional clinical hospital № 1 for the period from November 20, 2015 to November 20, 2017 with a diagnosis of ACS, accompanied by one of the types of atrial fibrillation. This group of patients was designated as a group of ACS + AF and amounted to 119 patients. The comparison group was selected with the help of a random number generator from patients admitted to the hospital with ACS and intact sinus rhythm (SR) for the period of time from November 20, 2015 to November 20, 2017 (120). We analyzed the ECHO-CG parameters, the coronary substrate — according to the CAG.Results. When comparing the cohort of patients with ACS + AF with the cohort of patients with ACS + SR, we determined a significant (p<0,05) difference of LA size, LVEF and values of PASP. During comparing the presence of hemodynamically significant stenosis in the coronary arteries we noticed that in ACS + AF patients with LVEF <40% in significantly higher percentage of cases (p=0,0007) occurs significant hemodynamic stenosis of coronary arteries, in contrast to the group of patients with ACS + SR with LVEF <40%. In patients with EF >40% and ACS + SR we determined a significantly more frequent (p<0,001) stenosis.Conclusion. The results of the analysis are important for understanding the distinguishing characteristics of patients with ACS that occur on the background of AF, which is important for correct prediction of the course of the disease. The maintenance of the ACS register will provide information on the real clinical course of the disease, as well as improve the effectiveness of treatment in real clinical practice.

We evaluated data on blacks and whites with acute ST-segment-elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention from the National Registry of Myocardial Infarction (NRMI)-4 and -5 participating centers between July 2000 and December 2006 to determine race-related differences in bleeding and outcomes. We found that among patients with ST-segment-elevation myocardial infarction receiving fibrinolysis, the bleeding rates were higher for blacks (n2283) than whites (n42 243; 10.9% versus 10.3%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43). Similarly, in patients receiving primary percutaneous coronary intervention, the bleeding rates were higher in blacks (n2826) than whites (n46 332; 10.3% versus 7.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.13-1.56). Bleeding was associated with a higher risk of death in both ethnic groups. However, there was no overall racial difference in in-hospital mortality among those with bleeding or without bleeding treated with either fibrinolysis or primary percutaneous coronary intervention. We concluded that race-related differences existed in bleeding risk among patients with ST-segmentelevation myocardial infarction receiving reperfusion therapy that portend poor prognosis. Thus, the efficacy and safety of many new drugs or treatment strategies for any disease observed in clinical trials that enroll predominantly white patients may not be similar in other ethnic groups that are underrepresented in these trials.

Background A substantial proportion of patients with acute coronary syndrome (ACS) may have intermediate lesion that are non-ischemic during emergency coronary angiography. The prognosis of such patients, compared to those with stable ischemic heart disease (SIHD) without ischemic lesion is however uncertain. Recently, a novel index, computational pressure-flow dynamics derived fractional flow reserve (caFFR), has been developed to assess myocardial ischemia, without the need of invasive pressure wire and hyperaemic stimulus as required in conventional fractional flow reserve (FFR). By utilizing caFFR to assess for ischaemic status during coronary angiography, the aim of our study is first to assess the prognostic difference between ACS and SIHD with non-ischaemia intermediate lesions. Second, we ascertain whether PCI in patients with ACS with non-ischaemia intermediate lesions provides survival benefit in addition to medical therapy. Methods We retrospectively recruited 551 patients (mean age 64.4 years; male 59.9%) with absence of myocardial ischaemia, defined as caFFR ≥0.80 in all vessels, from our Hospital. Patients were stratified into those with index presentation of ACS (n=132) and those with SIHD (n=491). Among the ACS cohort, patients were further divided into those with PCI (n=83) and with medical therapy alone (n=49). The SIHD cohort (n=491), all of whom were treated with medical therapy alone, was considered as referent group. The primary end point was major adverse cardiovascular events (MACE) at 3 years, which was defined as a composite of all-cause mortality, non-fatal myocardial infarction (MI), and any unplanned revascularization. Results During a median follow-up of 36 months, 54 composite events occurred, including 38 all-cause mortality, 5 MI, and 14 unplanned revascularization. Compared to those with SIHD, patients with ACS was independently associated with MACE even in the absence of myocardial ischaemia (adjusted Hazard Ratios=2.531; 95% confidence interval=1.397–4.586; P=0.002). The 3-year incidence rate of MACE was the highest in ACS patients with medical therapy alone, followed by ACS patients with immediate PCI; the SIHD cohort had the lowest incidence rates (30.6% vs 12.0% vs 5.9%, P<0.001). This was mainly driven by the rate of all-cause death (26.5% vs 12.0% vs 3.1%; P<0.001). Similar findings were observed for hospitalisation due to heart failure (14.3% vs 6.0% vs 3.1%, P=0.031) and cardiac death (8.2% vs 4.8% vs 0.4%, P<0.001) at 3 years. Conclusion In patients with intermediate lesion without myocardial ischaemia (defined as caFFR ≥0.8), those presented with ACS had a higher risk of MACE at 3 years compared to SIHD. Among ACS patients with intermediate lesion without myocardial ischaemia, PCI significantly reduces the rate of MACE. In patients with ACS, our finding suggests that PCI should be advocated to intermediate lesion even without myocardial ischaemia. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier curve for MACECumulative Events at 3 Years