Acute coronary syndrome I24.9

Author: Dr. med. S. Leah Schröder-Bergmann

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Last updated on: 29.10.2020

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Synonym(s)

ACS; Acute coronary syndrome

Definition
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Acute coronary syndrome (ACS) is an acutely occurring, life-threatening phase of coronary heart disease (Arntz 2000).

Classification
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The ACS is divided into 2 groups:

  1. Acute coronary syndrome with ST elevation. This includes the
    • ST-segmental elevation infarction (so-called STEMI; old nomenclature: transmural infarction [Stierle 2017])
  2. Acute coronary syndrome without ST elevation. These include:
    • Non-ST-segmental elevation myocardial infarction (so-called NSTEMI; old nomenclature: non-transmural infarction [Stierle 2017]); by definition with myocardial necrosis
    • unstable angina pectoris (so-called NSTE- ACS = Non ST Elevation Acute Coronary Syndrome [Giannitsis 2007]), by definition without myocardial necrosis (Kasper 2015).

The differentiation between a NSTEMI and an unstable AP is only possible by determining the troponin (Giannitsis 2007).

Occurrence/Epidemiology
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In Germany, about 350,000 - 400,000 patients with ACS without ST segment elevation are admitted annually and about 300,000 patients with acute STEMI. In relative terms, the frequency of a NSTEMI increases compared to a STEMI (Kasper 2015).

An ACS without ST elevation affects slightly more than 1/3 of women, in the STEMI about ¾ are male (Kasper 2015). According to ESC 2015, the following causes are found in an emergency room in unselected patients with acute chest pain:

  • 5 % - 10 % STEMI
  • 15 % - 20 % NSTEMI
  • 10 % unstable angina pectoris
  • 15 % other heart diseases
  • 50 % non-cardiac diseases (Roffi 2015)

Associated non-cardiac diseases:

  • Iron deficiency (serum ferritin and transferrin saturation): Iron deficiency has a significant prognostic significance. One study showed that iron deficiency has a high prevalence of ACS. 29.1% of patients with ACS (42.8% of whom were women) had low levels. The risk of cardiovascular mortality and non-fatal myocardial infarction was 73 % higher in these patients over a 4-year follow-up period (Zeller 2018).

Etiopathogenesis
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In ACS, all three manifestations (NSTEMI, STEMI, unstable angina pectoris) are based on a common pathomechanism (Arntz 2002). There is primarily an imbalance between oxygen supply and oxygen demand, which can be triggered by:

  • a thrombus formation on coronary plaque
  • an erosion of the coronary artery endothelium
  • dynamic constrictions (e.g. due to coronary spasm)
  • severe mechanical constrictions (e.g. due to coronary sclerosis)
  • Increased myocardial oxygen demand for e.g.
    • Fever
    • Tachycardia
    • Thyrotoxicosis
    • severe anaemia (Arntz 2002)
    • Hypotension (Arntz 2002, Kasper 2015)

Only <3% of patients with ACS have a >70% reduction in coronary lumen. However, 75% of patients have ruptured atherosclerotic plaques that partially or completely occlude the coronary artery by thrombi. In the remaining cases, dynamic stenoses such as vasospasms, prinzmetal angina, microcirculatory angina, etc. are found. Secondary causes such as fever, hypotension, thyrotoxicosis etc. are extremely rare. (Arntz 2002).

Pathophysiologically, the following three mechanisms can be found:

  • first, the rupture of an atherosclerotic plaque
  • there are different degrees of additional thrombus formation
  • distal embolization occurs (Stierle 2017)

Clinical features
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ACS is characterized by the typical symptoms of angina pectoris at rest or under low stress, such as:

  • retrosternal localized pain with radiation in
    • the neck/neck
    • Lower jaw
    • Teeth
    • Shoulder area
    • both (!) arms (with focus on the ulnar sides of the forearms), which can radiate into the ulnar fingertips (Kasper 2015)

In NSTEMI, thoracic pain persists for > 10 - 15 minutes, occasionally longer (Stierle 20017). In STEMI the pain symptoms last > 20 min. Often there are additional vegetative symptoms such as:

  • Nausea
  • Shortness of breath
  • Vertigo (Herold 2020)
  • cold, pale skin
  • Sinus tachycardia
  • Occurrence of a 3rd and/or 4th heartbeat (Kasper 2015)

Imaging
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Coronary CT

The coronary Ct plays a subordinate role in ACS, since:

  • the diagnostic reliability is lower than with coronary angiography
  • the radiation exposure is high
  • in case of doubt, an additional coronary angiography is indispensable (Kasper 2015)

Heart catheter

Immediate indication for coronary angiography (and subsequent revascularization) exists in patients with:

  • persistent ST- elevation of > 20 min. in ≥ 2 continuous recordings or
  • a newly occurred left bundle branch block or
  • Troponin elevation (Stierle 2017)

In the absence of ST elevation and troponin elevation, the cardiac markers should be checked again after 6 h - 9 h (or with a highly sensitive essay after 3 h). If the results are negative again, a stress test is required. If this test is positive, the usual diagnostic tests for acute angina pectoris are recommended. If the result is negative, further clarification can be carried out on an outpatient basis (Stierle 2017).

Laboratory
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Troponin T:

  • at STEMI ≥ 1.0
  • from NSTEMI ≥ 0.01 to ≤ 1.0
  • with unstable AP ≤ 0.01 (Stierle 2017)

Serum tits: often humiliated (Zeller 2018)

Transferrin saturation (see below transferrin): often lowered (standard value: 15-45%)

Diagnosis
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With the help of the so-called Grace Risk Score, a risk assessment can be made for an ACS. With a point value:

  • < 108, the risk of dying in hospital is < 1%.
  • between 109 - 140 the risk of dying in hospital is 1 % - 3 %
  • > 140, the risk of dying in hospital is > 3 % (Herold 2020)

Inspection and palpation: Typically, patients hold the clenched fist in the middle of the sternum (Levine's sign) when describing pain, the hand is placed flat on the sternum or both hands, fingertips facing each other, are placed on the sternum from the side to indicate belt-shaped tightness. The sensitivity to cardiac pain is about 80%, the specificity is about 49% (Edmondstone 1995)

Auscultation: Occurrence of a 3rd and/or 4th heartbeat possible (Kasper 2015)

ECG:

STEMI may be present:

  • persistent ST elevation of > 20 min. in ≥ 2 recordings
  • newly appeared left thigh block (Stierle 2015)

With NSTEMI can be present:

  • at 20 % - 25 % reductions of the ST line, which can persist for several days (Kasper 2015)
  • transient ST elevations. T waves can be normal or negative (Stierle 2017)

With the unstable AP there are mostly:

  • ST waves normal or decreased
  • transient ST-lifts possible
  • T waves reduced or normal (Stierle 2017)

Note: In the absence of ST elevation and troponin elevation, the cardiac markers should be checked again after 6 h - 9 h (or with a highly sensitive essay after 3 h). If the results are again negative, a stress test is required. If this test is positive, the usual diagnostic tests for acute angina pectoris are recommended. If the result is negative, further clarification can be carried out on an outpatient basis (Stierle 2017).

Differential diagnosis
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The so-called "big five" of thoracic pain include - besides ACS:

  • pulmonary embolism
  • Aortic dissection
  • Boerhaave syndrome (spontaneous rupture of the esophagus after strong vomiting)
  • Tension pneumothorax (Herold 2020)

Furthermore, the following diseases are possible by differential diagnosis:

1. cardiac chest pain triggered by e.g.

2. non-cardial chest pain caused by:

  • pleural or pulmonary causes such as:
    • pulmonary embolism
    • chronic cor pulmonale
    • Pleuritis (respiratory pain)
    • Lung Carcinoma
    • Pancoast tumor
    • Pleurodynia due to e.g. Coxsackie B virus infection, Bornholm disease
    • Tension) Pneumothorax
  • mediastinal or aortic disorders such as:
    • Mediastinal tumor
    • Mediastinitis
    • Aortic dissection
    • intramural haematomas of the aorta
  • Diseases of the esophagus and stomach such as:
    • Reflux Disease
    • Motility disorders of the esophagus such as diffuse esophageal spasm (so-called Barsony Teschendorf syndrome), nutcracker esophagus (hypertensive peristalsis [Siewert 2006]), achalasia
    • Mallory-Weiss syndrome (tears in the mucosa and/or submucosa of the oesophagus following strong vomiting)
    • Boerhaave syndrome (spontaneous rupture of the esophagus after strong vomiting)
    • Ventriculous ulcer (Pinger 2019)
  • Diseases of the ribs such as:
    • Tietze syndrome (pressure dolent swelling of the ribs in the area of the bone-cartilage boundary)
    • Rib fracture
    • Torso Trauma
  • Diseases in the area of the spinal column such as:
  • Diseases of the nervous system such as:
  • abdominal disorders which may radiate to the thorax such as:
    • acute pancreatitis
    • Biliary Colic
    • Cholecystitis
    • Roemheld syndrome (postprandial thoracic pain that is independent of CHD)
  • functional chest pain such as:
    • Da-Costa syndrome (functional pain in the heart area without organic cause)
  • genetic diseases such as..:
    • Severe pain in the thorax or upper abdomen in sickle cell anaemia (v. Schweinitz 2009)
    • psychiatric diseases such as heart neurosis (Pinger 2019).

Therapy
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The acute treatment of a patient with ACS should consist of:

  • Raising the upper part of the body (for breathing difficulties)
  • O2 Administration of 4 - 8 l / min via a nasal probe, provided that the oxygen saturation is < 90
  • Administration of nitroglycerin: ambulant sublingual 1 - 3 strokes, after reaching the clinic via perfusor (1mg - 5 mg / h i. v.); contraindications: systolic RR values < 90 mmHg, taking PDE-5-inhibitors such as Viagra
  • Morphine for severe pain (3 mg - 5 mg i. v., then 2 mg every 5 - 15 min. until the pain is relieved; side effects: nausea, respiratory depression, hypotension)
  • for nausea: administration of an antiemetic, e.g. metoclopramide
  • in case of a vagal reaction administration of atropine 0.5 mg i. v.
  • Administration of an inhibitor of thrombocyte aggregation
    • ASS (initially 160 mg - 325 mg parenterally or see left, then 75 mg - 100 mg/d p. o. [Stierle 2017])
    • dual platelet inhibition: heparin in patients with STEMI and NSTEMI (e.g. enoxaparin 2 x 1 mg / kg bw / d s. c. - Stierle 2017; Herold 2020)
  • Beta-blocker in symptomatic patients with systolic blood pressure values > 100 mmHg at a heart rate of > 55 / min; dosage: 5 mg - 15 mg i. v. (Stierle 2017)

Once the diagnosis and validation of the risk has been secured, the following should be carried out:

In STEMI: There is an urgent indication for revascularization (for detailed information on revascularization, see coronary artery disease)

For NSTEMI: Patients with NSTEMI should be immediately admitted for coronary angiography (within 72 h).

In unstable angina pectoris: Patients with unstable angina pectoris (troponin values at admission and also inconspicuous after 3 - 6 h) should have ischemia tests such as stress ECG, stress echocardiography, myocardial scintigraphy in addition to primary stabilization. A positive result indicates coronary angiography (Herold 2020).

In case of existing iron deficiency: i. v. iron carboxymaltose (see above "Occurrence": associative non-cardiac diseases) (Zeller 2018)

Progression/forecast
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Mortality is dependent on the triggering disease of ACS.

The 30-day mortality for:

  • STEMI 12.9%
  • NSTEMI 10,4
  • unstable AP 4,5 %

The 6-month leths lethality is:

  • STEMI 19.2%
  • NSTEMI 18,7
  • unstable AP 8.6 % (Stierle 2017)

Literature
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  1. Apitz J et al (2002) Pediatric Cardiology: Diseases of the heart in newborns, infants, children and adolescents. Steinkopff Publishing House 424
  2. Arntz H R et al (2000) Emergency treatment for acute myocardial infarction Springer Verlag 54 - 59
  3. Arntz H R et al (2002) Emergency treatment of acute coronary syndrome: pre- and intrahospital diagnosis and therapy. Springer publishing house 99 - 131
  4. Edmondstone WM (1995) Cardiac chest pain: does body language help the diagnosis? Brit Med J (311) 1660 - 1661
  5. Giannitsis E et al (2007) Management of acute coronary syndrome. Pocket atlas special. Georg Thieme Publishing House
  6. Herold G et al (2020) Internal medicine. Herold Verlag 237, 240, 248 - 249
  7. Kasper D L et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 1593 - 1598
  8. Kasper D L et al (2015) Harrison's Internal Medicine. Georg Thieme Publishing House 1938 - 1952
  9. Pinger S (2019) Repetitorium Kardiologie: For clinic, practice, specialist examination. German medical publisher. 85 – 123
  10. Roffi M et al (2015) ESC Pocket Guidelines: Acute coronary syndrome without ST elevation (NSTE-ACS). German Society for Cardiology - Heart and Circulation Research e. V. Börm Bruckmeier Verlag GmbH
  11. von Schweinitz D et al (2009) Pediatric Surgery: Visceral and General Surgery in Children. Springer publishing house 473
  12. Stierle U et al (2014) Clinical Guide to Cardiology. Elsevier Urban and Fischer 104 - 128
  13. Zeller T et al (2018)Adverse Outcome Prediction of Iron Deficiency in Patients with Acute Coronary Syndrome. Biomolecules 8 (3) 60

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020