Acute coronary syndrome: diagnosis and treatment update

2021-06-18 04:09 PM

Checking immediately when the pain currently exists or prolong, especially within the last 12 hours. Checking if chest pain could be caused by the acute coronary syndrome.

Clinical Notes

Time of symptom onset and duration.

Electrocardiograms, past and present.

Current blood pressure, heart rate, and oxygen saturation level.

List of medications taken, including timing and dosage.


All medications are currently prescribed as well as any over-the-counter products.


Any details about the person involved, such as an enhanced care plan.

Any relevant family history.

Check immediately to see when the pain is current or last, especially within the last 12 hours. Check to see if the chest pain could be caused by the heart. Consider:

History of pain.

Any cardiovascular risk factors.

History of ischemic heart disease.

Any previous treatment for chest pain.

Initial evaluation for any of the following symptoms, which may be signs of acute coronary syndromes:

Pain in the chest and/or other areas (eg, arms, back, or jaw) that lasts more than 15 minutes with nausea and vomiting, pronounced sweating or shortness of breath (or a combination of the two), or new-onset hemodynamic instability, or abrupt relief unstable angina, with recurrent attacks frequently occurring with little or no exertion and usually lasting more than 15 minutes. Chest pain may not be the main symptom.

The response to glyceryl trinitrate (GTN) should not be used to diagnose acute coronary syndromes.

Do not assess whether symptoms of acute coronary syndromes differ in men and women or between different ethnic groups. There were no major differences in symptoms of acute coronary syndromes between different ethnic groups.

Diagnosis is based on clinical judgment

Angina is:

An uncomfortable spasm in the front of the chest, or the neck, shoulder, jaw, or arm.

Pain increases with exertion.

Pain relieved at rest.

Use the clinical judgment and typical nature of the angina features listed below to estimate the likelihood of an acute coronary syndrome:

Three of the above features are identified as typical angina.

Two of these three features are defined as atypical angina.

One or none of the above is defined as the absence of chest pain.

According to typical proportions of symptoms, age, sex, and risk factors, a percentage of people are estimated to have coronary heart disease.

For men over 70 years of age with atypical or typical symptoms, assume an estimate of >90%.

For women older than 70 years, the presumptive estimate is 61–90% except for women at high risk and with typical symptoms where a risk >90% should be assumed.

Value as a percentage of people at each mid-decade with significant coronary heart disease (CAD)

Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre).

Lo = Low risk = none of these three.

Electrocardiogram results

These results have the potential to evaluate acute coronary syndromes in primary care.

If there are resting ST-T ECG changes or Q waves, the likelihood of acute coronary syndrome is higher.

Unless clinical suspicion is raised based on other aspects of history and risk factors, the diagnosis of stable angina should not be ruled out if the pain is not angina. Other features that help diagnose stable angina that is unlikely when the chest pain is present are:

Continuous or very prolonged and/or.

Not related to the activity and/or.

Relieve pain by inhalation and/or.

Combined with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing.

Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).

Relieve pain as soon as possible. This can be achieved with GTN (sublingual), but give intravenous opioids such as morphine, especially if acute myocardial infarction is suspected.

Give a single loading dose of 324 mg of aspirin as soon as possible unless there is clear evidence that they are allergic to it.

If aspirin is used before going to the hospital, tell your doctor.

Do not use regular oxygen, but monitor oxygen saturation with pulse oximetry as soon as possible, ideally before admission. Provide supplemental oxygen only for:

People with oxygen saturation (SpO2) less than 94% have no risk of respiratory failure due to hypercapnia, the SpO2 target is 94–98% of people with chronic obstructive pulmonary disease at risk of hypercapnia. to achieve SpO2 target of 88–92% until blood gas analysis is available.

Perform a resting 12-lead ECG as soon as possible. Send the results to the hospital before they arrive if possible. Recording and sending of the ECG should not delay referral to the hospital.

Some changes on the 12-lead ECG at rest are consistent with acute coronary syndromes and may indicate prior ischemia or infarction. Including:

Pathological Q waves.

Left bundle branch block.

ST-segment and T wave abnormalities (eg, flattening or inversion).

Note that results may not be conclusive.

If ST-segment elevation is detected, the patient must be referred immediately to the hospital.

Monitor people with acute chest pain, using clinical judgment to decide how often this should be done until a definite diagnosis is made. This should include:

Paroxysmal pain and/or other symptoms

Pulse and blood pressure


Oxygen saturation by pulse oximetry

Repeated 12-lead resting electrocardiogram

Check if the pain relief is working.

Initial treatment

Patient care.

Aspirin 324 mg. Check for allergies. Check for contraindications.

Nitro-glycerine. Give glyceryl trinitrate 0.4 mg sublingually or equivalent every 5 minutes, up to 3 doses when blood pressure allows. Initiate intravenous dosing at 10 micrograms/min for persistent pain or pulmonary oedema; titrate to the desired blood pressure effect. An intravenous line must be established before nitro-glycerine administration.

Blood pressure should be > 100 mmHg.

Oxygen therapy should not be performed routinely. Do not give oxygen to patients with ST-elevation acute coronary syndromes unless:

Shortness of breath.

Hypoxia, i.e. oxygen saturation < 93%.

Having heart failure.

In a state of cardiogenic shock.

Note: A second intravenous line may be indicated for high-risk patients.

Risk-based therapeutic interventions for acute coronary syndromes, clinical presentation, and/or diagnostic ECG changes.

Follow-up indicated treatment 

Additional doses of the above drugs.

Intravenous (IV) morphine is effective for severe pain in patients with acute coronary syndromes. For example, give morphine 5 -10 mg IV at 1–2 mg/min, repeat as needed: morphine 2.5 - 5 mg for frail elderly patients.

Intravenous antiemetics, eg metoclopramide 10 mg or cyclizine 25 mg, are usually given at the same time or immediately before intravenous morphine.

Aspirin 324 mg, should be given to all patients with acute coronary syndromes, including those already taking aspirin; If enteric-coated aspirin is available, the patient should chew the tablet. Treat with aspirin in all patients unless contraindicated.

Clopidogrel 300 mg (75 mg for patients older than 75 years) given immediately in addition to aspirin, is recommended for patients with acute coronary syndromes who also have evidence of ischemia on the electrocardiogram.


Avoid nitro-glycerine in all patients who have taken a phosphodiesterase inhibitor such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) within the past 48 hours. These drugs are commonly used for erectile dysfunction and pulmonary hypertension. Also, avoid use in patients receiving intravenous epoprostenol (Flolan) also used for pulmonary hypertension.

Use nitrates with extreme caution, if available, to patients with inferior myocardial infarction or suspected right ventricular (RV) involvement.