eMedicine Specialties > Emergency Medicine > Cardiovascular

Acute Coronary Syndrome: Follow-up

Author: Drew Evan Fenton, MD, Hospitalist, Our Health Care Consultants
Contributor Information and Disclosures

Updated: Aug 6, 2009

Follow-up

Further Inpatient Care

  • Patients with unstable angina, ECG changes, or both should be admitted to a telemetry bed. A certain subset of patients with stable angina may be treated as outpatients with antianginal agents, but close follow-up is necessary.
  • Patients with symptoms refractory to aggressive medical treatment, shock, suspected or known aortic stenosis, or new or worsening mitral regurgitation are at high risk. Management for these patients should include the following:
    • Admission to an intensive care unit setting
    • Cardiology consultation
  • Intra-aortic balloon pump (IABP) and early angiography to delineate anatomy should be considered.
  • Antiplatelet and antianginal medications initiated in the ED should be continued. Subsequent dosing is determined by symptomatic response and tolerance of side effects.
  • The routine use of lidocaine as prophylaxis for ventricular arrhythmias in patients with ACS is not indicated. In MI, it has been shown to increase mortality rates. Lidocaine may be used for patients with complex ventricular ectopy or for patients with hemodynamically significant, nonsustained, or sustained ventricular tachycardia.
  • Mehta et al studied 3031 patients with acute coronary syndromes. Early intervention (coronary angiography £ 24 h after randomization; median time 14 h) in acute coronary syndromes did not differ greatly from delayed intervention (coronary angiography >24 h randomization; median time 50 h) in preventing the primary outcome (ie, composite of death, myocardial infarction, or stroke at 6 mo). Early intervention did reduce the rate of the secondary outcome (ie, death, myocardial infarction, or refractory ischemia at 6 mo) and improved the primary outcome in patients who were at highest risk (ie, Global Registry of Acute Coronary Events [GRACE] risk score >140).10

Further Outpatient Care

  • Patients with chronic stable angina may be considered for discharge after occurrence of the following:
    • Symptom duration is brief and identical to symptoms experienced in the past.
    • ECG is normal or unchanged.
    • Patient has access to timely follow-up with a primary care provider.
  • When in doubt, admit. The usual reason for a patient with chronic stable angina to present to the ED is a change in pattern or severity of symptoms, which makes their angina unstable.
  • A study by Bartholomew et al may be helpful in making the decision to admit or discharge. This prospective thrombolysis in myocardial infarction risk score (TIMI-RS) used 7 variables in patients with suspected ACS: (1) age older than 65 years, (2) 3 or more cardiac risk factors, (3) ST deviation, (4) aspirin use within 7 days, (5) 2 or more anginal events over 24 hours, (6) history of coronary stenosis, and (7) elevated troponin levels. Patients were contacted at 30 days, and data were collected concerning major adverse cardiac events.11
    • In patients presenting with chest pain, a higher TIMI-RS was associated with an increase in major adverse cardiac events within 30 days. The authors concluded that the 30-day event rate was 0% for a score of 1, 20% for a score of 2, 24% for a score of 3, 42% for a score of 4, 52% for a score of 5, and 70% for a score of 6 or 7 (p < 0.0001).
    • The TIMI-RS successfully differentiates early risk for major adverse cardiac events in a general population presenting with symptoms suggestive of ACS. A simple bedside calculation of the TIMI-RS provides rapid risk stratification, allowing facilitation of therapeutic decision-making in patients with symptoms suggestive of ACS and may be helpful with the patient's disposition.

Inpatient & Outpatient Medications

  • Aspirin
  • Use clopidogrel as a substitute for patients unable to take aspirin because of a history of hypersensitivity or bleeding. Use a 300-mg loading dose, then 75 mg qd.
  • Nitrates
    • Use topical or oral nitrates for those who are discharged or for those who are stable inpatients.
    • Intravenous infusion is preferable for those admitted with unstable symptoms.
  • Beta-blockers
    • Metoprolol and propranolol are excellent choices for inpatient and outpatient management.
    • Use esmolol for inpatient treatment, particularly those at risk for adverse effects from beta-blockade.
  • Heparin: Use heparin for inpatient management of unstable angina. Some preliminary data suggest that LMWH is a safe and effective alternative.
  • Significant clustering of recurrent ischemic events occurs within 24 hours after cessation of both short-term UFH and enoxaparin treatment, and patients should be carefully monitored during that period. This early rebound may be prevented by continuation of a fixed dose of enoxaparin.

Transfer

  • Consider transfer only for patients at particularly high risk and for those who are being evaluated in a center without access to timely cardiac catheterization, PTCA, or bypass.
  • High-risk criteria include the following:
    • Symptoms refractory to medical management
    • Hemodynamic instability, cardiogenic shock
    • New or worsening mitral regurgitant murmur
    • Known or suspected severe aortic stenosis
  • The risks of transferring these unstable patients must be carefully weighed against the benefits of transfer.

Deterrence/Prevention

  • Cessation of smoking
  • Assessment of lipid profile and dietary changes, where appropriate (Among patients who have recently had an ACS, an intensive lipid-lowering statin regimen provides greater protection against death or major cardiovascular events than a standard regimen.12 )
  • Blood pressure control
  • Compliance with medications, particularly aspirin
  • Comprehensive risk assessment by primary care provider, including exercise tolerance test (ETT) for individuals at high risk and identification of structural heart disease (eg, left ventricular hypertrophy [LVH], aortic stenosis)

Complications

  • Acute myocardial infarction
  • Cardiogenic shock
  • Ischemic mitral regurgitation
  • Arrhythmias
    • Supraventricular arrhythmias (rare complication of ischemia, may actually precipitate ischemic events)
    • Ventricular arrhythmias; simple and complex premature ventricular contractions (PVCs), and nonsustained ventricular tachycardia (NSVT)
  • Atrioventricular nodal blockade
    • Usually transient in setting of reversible ischemia
    • Treatment guided by location of block and hemodynamic stability
  • Ventricular rupture occurs in the interventricular septum or the LV free wall. This represents a catastrophic event with mortality rates greater than 90%. Prompt recognition, stabilization, and surgical repair are crucial to any hope of survival. An echocardiogram will usually define the abnormality, and a right heart catheterization may show an oxygenation increase with septal rupture.

Prognosis

  • Patients with angina either proceed to infarct or have their disease stabilized by medical and/or interventional therapies. Patients with angina are a heterogeneous group; therefore, prognosis varies with respect to stability of disease, demographics, comorbidity, and current intervention.
  • Patients with ACS with atrial fibrillation (AF) are associated with increased morbidity and mortality.13
  • Patients with ACS and diabetes mellitus, especially those with ST elevation, had increased in-hospital mortality rates. Among patients with ACS and diabetes mellitus, those receiving insulin had worse outcomes. Outcomes were similar for those on hypoglycemic medication or on diet alone.14
  • In chronic stable angina, prognosis is generally excellent. Factors that have been shown to impact prognosis include the following:
    • Aspirin reduces progression to both nonfatal MI and cardiac death.
    • Beta-blockers control anginal symptoms and reduce cardiac complications in patients with hypertension.
    • PTCA and revascularization improve the prognosis in high-risk patients.
    • Poor prognostic factors include male sex, diabetes, and hypertension.
  • In unstable angina, prognosis is determined by the ability to control symptoms acutely, preventing progression to AMI. Factors associated with a poorer prognosis include the following:
    • Evidence of myocardial necrosis, as determined by elevated troponin T level
    • Delays in angiography in patients at high risk (Early angiography allows for triage to medical therapy, PTCA, or revascularization.)

Patient Education

  • For patients being discharged home, emphasize the following:
    • Timely follow-up with primary care provider
    • Compliance with discharge medications, specifically aspirin and other medications used to control symptoms
    • Need to return to ED for any change in frequency or severity of symptoms

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis - Groups at risk include the following:
    • Women, particularly premenopausal
    • Patients with diabetes
    • Elderly patients
    • Patients with cocaine-related ischemia
  • Inadequate risk stratification in ED
  • Failure to administer aspirin as first-line therapy
  • Overcautious use of beta-blockers in ED
 


More on Acute Coronary Syndrome

Overview: Acute Coronary Syndrome
Differential Diagnoses & Workup: Acute Coronary Syndrome
Treatment & Medication: Acute Coronary Syndrome
Follow-up: Acute Coronary Syndrome
Multimedia: Acute Coronary Syndrome
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Zellweger MJ, Schaer BA, Cron TA, Pfisterer ME, Osswald S. Elevated troponin levels in absence of coronary artery disease after supraventricular tachycardia. Swiss Med Wkly. Aug 9 2003;133(31-32):439-41. [Medline].

  2. Koller A. Exercise-induced increases in cardiac troponins and prothrombotic markers. Med Sci Sports Exerc. Mar 2003;35(3):444-8. [Medline].

  3. [Best Evidence] Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ. May 19 2009;338:b1807. [Medline].

  4. [Best Evidence] Ryan RJ, Lindsell CJ, Hollander JE, O'Neil B, Jackson R, Schreiber D, et al. A multicenter randomized controlled trial comparing central laboratory and point-of-care cardiac marker testing strategies: the Disposition Impacted by Serial Point of Care Markers in Acute Coronary Syndromes (DISPO-ACS) trial. Ann Emerg Med. Mar 2009;53(3):321-8. [Medline].

  5. [Guideline] Fesmire FM, Decker WW, Diercks DB, Ghaemmaghami CA, Nazarian D, Brady WJ, et al. Clinical policy: critical issues in the evaluation and management of adult patients with non-ST-segment elevation acute coronary syndromes. Ann Emerg Med. Sep 2006;48(3):270-301. [Medline].

  6. [Guideline] Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ, et al. Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):670S-707S. [Medline].

  7. [Guideline] Storrow AB, Apple FS, Wu AH, Jesse R, Francis G, Christenson RH. Use of cardiac biomarkers for acute coronary syndromes. In: Laboratory medicine practice guidelines: evidence-based practice for point-of-care testing. Washington (DC): National Academy of Clinical Biochemistry (NACB). 2006;13-20.

  8. [Best Evidence] Lopes RD, Alexander KP, Manoukian SV, Bertrand ME, Feit F, White HD, et al. Advanced age, antithrombotic strategy, and bleeding in non-ST-segment elevation acute coronary syndromes: results from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. J Am Coll Cardiol. Mar 24 2009;53(12):1021-30. [Medline].

  9. Lev EI, Hasdai D, Scapa E, Tobar A, Assali A, Lahav J, et al. Administration of eptifibatide to acute coronary syndrome patients receiving enoxaparin or unfractionated heparin: effect on platelet function and thrombus formation. J Am Coll Cardiol. Mar 17 2004;43(6):966-71. [Medline].

  10. Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. May 21 2009;360(21):2165-75. [Medline].

  11. Bartholomew BA, Sheps DS, Monroe S, McGorray S, Smith K, Pepine CJ. A population-based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non-ST elevation myocardial infarction. Clin Cardiol. Feb 2004;27(2):74-8. [Medline].

  12. Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. Apr 8 2004;350(15):1495-504. [Medline].

  13. Mehta RH, Dabbous OH, Granger CB, Kuznetsova P, Kline-Rogers EM, Anderson FA Jr, et al. Comparison of outcomes of patients with acute coronary syndromes with and without atrial fibrillation. Am J Cardiol. Nov 1 2003;92(9):1031-6. [Medline].

  14. Hasdai D, Behar S, Boyko V, Battler A. Treatment modalities of diabetes mellitus and outcomes of acute coronary syndromes. Coron Artery Dis. May 2004;15(3):129-135. [Medline].

  15. Abbott BG, Wackers FJ. Use of radionuclide imaging in acute coronary syndromes. Curr Cardiol Rep. Jan 2003;5(1):25-31. [Medline].

  16. Alam SE, Nasser SS, Fernainy KE, Habib AA, Badr KF. Cytokine imbalance in acute coronary syndrome. Curr Opin Pharmacol. Apr 2004;4(2):166-70. [Medline].

  17. Antman EM, Cohen M, Radley D, McCabe C, Rush J, Premmereur J, et al. Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction. TIMI 11B-ESSENCE meta-analysis. Circulation. Oct 12 1999;100(15):1602-8. [Medline].

  18. Antman EM, Kereiakes DJ. Antithrombotic therapy in unstable angina/non-ST elevation myocardial infarction: the evolving role of low-molecular-weight heparin. J Invasive Cardiol. Dec 2000;12 Suppl E:E1-4;discussion E25-8. [Medline].

  19. Antman EM, McCabe CH, Gurfinkel EP, Turpie AG, Bernink PJ, Salein D, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. Oct 12 1999;100(15):1593-601. [Medline].

  20. Bhatt DL, Topol EJ. Current role of platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. JAMA. Sep 27 2000;284(12):1549-58. [Medline].

  21. Bijsterveld NR, Peters RJ, Murphy SA, Bernink PJ, Tijssen JG, Cohen M. Recurrent cardiac ischemic events early after discontinuation of short-term heparin treatment in acute coronary syndromes: results from the Thrombolysis in Myocardial Infarction (TIMI) 11B and Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) studies. J Am Coll Cardiol. Dec 17 2003;42(12):2083-9. [Medline].

  22. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. Sep 2000;36(3):970-1062. [Medline].

  23. Buseyne F, Le Chenadec J, Corre B, Porrot F, Burgard M, Rouzioux C, et al. Inverse correlation between memory Gag-specific cytotoxic T lymphocytes and viral replication in human immunodeficiency virus-infected children. J Infect Dis. Dec 1 2002;186(11):1589-96. [Medline].

  24. Cohen M. Initial experience with the low-molecular-weight heparin, enoxaparin, in combination with the platelet glycoprotein IIb/IIIa blocker, tirofiban, in patients with non-ST segment elevation acute coronary syndromes. J Invasive Cardiol. Dec 2000;12 Suppl E:E5-9;discussion E25-8. [Medline].

  25. Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. Aug 14 1997;337(7):447-52. [Medline].

  26. Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, et al. Low-molecular-weight heparins in non-ST-segment elevation ischemia: the ESSENCE trial. Efficacy and Safety of Subcutaneous Enoxaparin versus intravenous unfractionated heparin, in non-Q-wave Coronary Events. Am J Cardiol. Sep 10 1998;82(5B):19L-24L. [Medline].

  27. Fesmire FM, Hughes AD, Fody EP, Jackson AP, Fesmire CE, Gilbert MA, et al. The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes. Ann Emerg Med. Dec 2002;40(6):584-94. [Medline].

  28. Gandhi MM, Lampe FC, Wood DA. Incidence, clinical characteristics, and short-term prognosis of angina pectoris. Br Heart J. Feb 1995;73(2):193-8. [Medline].

  29. Gibler WB, Wilcox RG, Bode C, Castaigne AD, Delooz H, Elich D, et al. Prospective use of glycoprotein IIb/IIIa receptor blockers in the emergency department setting. Ann Emerg Med. Dec 1998;32(6):712-22. [Medline].

  30. Goodman SG, Cohen M, Bigonzi F, Gurfinkel EP, Radley DR, Le Iouer V, et al. Randomized trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one-year results of the ESSENCE Study. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events. J Am Coll Cardiol. Sep 2000;36(3):693-8. [Medline].

  31. Hamm CW, Heeschen C, Goldmann B, Vahanian A, Adgey J, Miguel CM, et al. Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin T levels. c7E3 Fab Antiplatelet Therapy in Unstable Refractory Angina (CAPTURE) Study Investigators. N Engl J Med. May 27 1999;340(21):1623-9. [Medline].

  32. Hamm CW, Ravkilde J, Gerhardt W, Jørgensen P, Peheim E, Ljungdahl L, et al. The prognostic value of serum troponin T in unstable angina. N Engl J Med. Jul 16 1992;327(3):146-50. [Medline].

  33. Hasdai D, Haim M, Behar S, Boyko V, Battler A. Acute coronary syndromes in patients with prior cerebrovascular events: lessons from the Euro-Heart Survey of Acute Coronary Syndromes. Am Heart J. Nov 2003;146(5):832-8. [Medline].

  34. Hillis GS, Terregino CA, Taggart P, Killian AJ, Mangione A. Inflammatory cytokines provide limited early prognostic information in emergency department patients with suspected myocardial ischemia. Ann Emerg Med. Sep 2003;42(3):337-42. [Medline].

  35. Hjemdahl P, Eriksson SV, Held C, Rehnqvist N. Prognosis of patients with stable angina pectoris on antianginal drug therapy. Am J Cardiol. Jun 20 1996;77(16):6D-15D. [Medline].

  36. Juul-Moller S, Edvardsson N, Jahnmatz B, Rosén A, Sorensen S, Omblus R. Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet. Dec 12 1992;340(8833):1421-5. [Medline].

  37. Kawahito M, Kondo M, Abe Y, et al. [Usefulness of technetium-99m tetrofosmin single-photon emission computed tomography for short-term risk stratification in patients with acute chest pain in the emergency room]. J Cardiol. Oct 2003;42(4):147-54. [Medline].

  38. Kim C, Schaaf CH, Maynard C, Every NR. Unstable angina in the myocardial infarction triage and intervention registry (MITI): short- and long-term outcomes in men and women. Am Heart J. Jan 2001;141(1):73-7. [Medline].

  39. Kwong RY, Schussheim AE, Rekhraj S, Aletras AH, Geller N, Davis J, et al. Detecting acute coronary syndrome in the emergency department with cardiac magnetic resonance imaging. Circulation. Feb 4 2003;107(4):531-7. [Medline].

  40. Lindahl B, Venge P, Wallentin L. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. The FRISC study group. Circulation. May 1 1996;93(9):1651-7. [Medline].

  41. Panagiotakos DB, Chrysohoou Ch, Pitsavos Ch, Antoniou S, Vavouranakis E, Stravopodis P, et al. The association between occupational stress and the risk of developing acute coronary syndromes: the CARDIO2000 Study. Cent Eur J Public Health. Mar 2003;11(1):25-30. [Medline].

  42. PRISM Study Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) Study Investigators. N Engl J Med. May 21 1998;338(21):1498-505. [Medline].

  43. PRISM-PLUS Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med. May 21 1998;338(21):1488-97. [Medline].

  44. PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. Aug 13 1998;339(7):436-43. [Medline].

  45. Roig S, Gomez JA, Fiol M, Guindo J, Perez J, Carrillo A, et al. Spontaneous coronary artery dissection causing acute coronary syndrome: an early diagnosis implies a good prognosis. Am J Emerg Med. Nov 2003;21(7):549-51. [Medline].

  46. Sharma GV, Deupree RH, Khuri SF, Parisi AF, Luchi RJ, Scott SM. Coronary bypass surgery improves survival in high-risk unstable angina. Results of a Veterans Administration Cooperative study with an 8-year follow-up. Veterans Administration Unstable Angina Cooperative Study Group. Circulation. Nov 1991;84(5 Suppl):III260-7. [Medline].

  47. Soejima H, Miyamoto S, Kojima S, Hokamaki J, Tanaka T, Kawano H, et al. Coronary spastic angina in patients with connective tissue disease. Circ J. Apr 2004;68(4):367-70. [Medline].

  48. Turnipseed SD, Richards JR, Kirk JD, Diercks DB, Amsterdam EA. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med. May 2003;24(4):369-73. [Medline].

  49. Watkins S, Thiemann D, Coresh J, Powe N, Folsom AR, Rosamond W. Fourteen-year (1987 to 2000) trends in the attack rates of, therapy for, and mortality from non-ST-elevation acute coronary syndromes in four United States communities. Am J Cardiol. Nov 15 2005;96(10):1349-55. [Medline].

  50. Wilcken DE. Overview of inherited metabolic disorders causing cardiovascular disease. J Inherit Metab Dis. 2003;26(2-3):245-57. [Medline].

  51. Wu AH, Abbas SA, Green S, Pearsall L, Dhakam S, Azar R, et al. Prognostic value of cardiac troponin T in unstable angina pectoris. Am J Cardiol. Nov 1 1995;76(12):970-2. [Medline].

  52. Yuichi S, Takako I, Fumio I, Akihiro Y, Takahiro F, Toshiyuki H, et al. Detection of atherosclerotic coronary artery plaques by multislice spiral computed tomography in patients with acute coronary syndrome: report of 2 cases. Circ J. Mar 2004;68(3):263-6. [Medline].

  53. Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. Mar-Apr 1985;27(5):335-71. [Medline].

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines

Clinical policy: critical issues in the evaluation and management of adult patients with non-ST-segment elevation acute coronary syndromes.Fesmire FM, Decker WW, Diercks DB, Ghaemmaghami CA, Nazarian D, Brady WJ, Hahn S, Jagoda AS, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients with non-ST-segment elevation acute coronary syndromes. Ann Emerg Med 2006 Sep;48(3):270-301 Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ, Steg G, Guyatt GH, Goodman SG. Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):670S-707S.

Use of cardiac biomarkers for acute coronary syndromes. Laboratory medicine practice guidelines: evidence-based practice for point-of-care testing. Storrow AB, Apple FS, Wu AH, Jesse R, Francis G, Christenson RH. Use of cardiac biomarkers for acute coronary syndromes. In: Laboratory medicine practice guidelines: evidence-based practice for point-of-care testing. Washington (DC): National Academy of Clinical Biochemistry (NACB); 2006. p. 13-20.

[ CLOSE WINDOW ]

Keywords

acute coronary syndrome, ACS, ACS treatment, ACS causes, ACS symptoms, ST-elevation myocardial infarction, STEMI, non-ST-elevation myocardial infarction, NSTEMI, ACS, angina, myocardial ischemia, acute myocardial ischemia, myocardial infarction, MI, coronary artery disease, coronary heart disease, heart disease, chest pain

atherosclerotic plaques, variant angina, Prinzmetal angina, coronaryvasospasm, stable angina, unstable angina, hypertension, diabetes mellitus, smoking, hypercholesterolemia, hyperlipidemia

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Drew Evan Fenton, MD, Hospitalist, Our Health Care Consultants
Drew Evan Fenton, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.