Diagnosis and management of acute coronary syndrome

Baker Hamilton, Edward Kwakyi, Alex Koyfman, Mark Foran

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min.

Original languageEnglish (US)
Pages (from-to)124-133
Number of pages10
JournalAfrican Journal of Emergency Medicine
Volume3
Issue number3
DOIs
StatePublished - Sep 2013

Fingerprint

Acute Coronary Syndrome
Enoxaparin
clopidogrel
Percutaneous Coronary Intervention
Oxyhemoglobins
Platelets
Coagulation
Developing countries
Nitrates
Morphine
Aspirin
Heparin
vigilance
Oxygen
cardiovascular disease
morbidity
risk factor
coagulation
Process Assessment (Health Care)
drug

Keywords

  • Chest pain
  • Fibrinolysis
  • LAMIC
  • NSTE-ACS
  • PCI
  • STE-ACS

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Diagnosis and management of acute coronary syndrome. / Hamilton, Baker; Kwakyi, Edward; Koyfman, Alex; Foran, Mark.

In: African Journal of Emergency Medicine, Vol. 3, No. 3, 09.2013, p. 124-133.

Research output: Contribution to journalArticle

Hamilton, Baker ; Kwakyi, Edward ; Koyfman, Alex ; Foran, Mark. / Diagnosis and management of acute coronary syndrome. In: African Journal of Emergency Medicine. 2013 ; Vol. 3, No. 3. pp. 124-133.
@article{996efaf9a1024a908de1054490abe636,
title = "Diagnosis and management of acute coronary syndrome",
abstract = "The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94{\%}. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min.",
keywords = "Chest pain, Fibrinolysis, LAMIC, NSTE-ACS, PCI, STE-ACS",
author = "Baker Hamilton and Edward Kwakyi and Alex Koyfman and Mark Foran",
year = "2013",
month = "9",
doi = "10.1016/j.afjem.2012.11.012",
language = "English (US)",
volume = "3",
pages = "124--133",
journal = "African Journal of Emergency Medicine",
issn = "2211-419X",
publisher = "African Federation for Emergency Medicine",
number = "3",

}

TY - JOUR

T1 - Diagnosis and management of acute coronary syndrome

AU - Hamilton, Baker

AU - Kwakyi, Edward

AU - Koyfman, Alex

AU - Foran, Mark

PY - 2013/9

Y1 - 2013/9

N2 - The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min.

AB - The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min.

KW - Chest pain

KW - Fibrinolysis

KW - LAMIC

KW - NSTE-ACS

KW - PCI

KW - STE-ACS

UR - http://www.scopus.com/inward/record.url?scp=84884362330&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84884362330&partnerID=8YFLogxK

U2 - 10.1016/j.afjem.2012.11.012

DO - 10.1016/j.afjem.2012.11.012

M3 - Article

AN - SCOPUS:84884362330

VL - 3

SP - 124

EP - 133

JO - African Journal of Emergency Medicine

JF - African Journal of Emergency Medicine

SN - 2211-419X

IS - 3

ER -