Clinical manifestations

  • Anthony A Bavry
  • Deepak L Bhatt


There is a short window of opportunity with ACS, where the prompt establishment of reperfusion therapy dramatically reduces left ventricular dysfunction and improves survival [1]. Accordingly, the initial aim with ACS is to expeditiously make the correct diagnosis. While this may seem overly simplistic, many patients are slow to seek medical attention or there is a long delay in establishing a correct diagnosis. Even when a correct diagnosis is made, delays may exist in bringing optimal therapy to patients who are most in need. Moreover, many patients who present to emergency departments with ACS are incorrectly diagnosed [2]. Attempts to diagnose every case of ACS can lead to excess false positive diagnoses with resultant high healthcare costs and unnecessary patient anxiety [3]. High-risk populations include late presenters, women, people with diabetes, and the elderly, where signs and symptoms of ACS may be protean [4]. Women with typical anginal symptoms and angiographically normal coronaries can still suffer from poor prognosis due to microvascular dysfunction [5]. Additionally, individuals presenting with left bundle branch block or paced rhythms, renal insufficiency, ACS within the peri-operative period and post-myocardial infarction angina are all important populations that require extra vigilance for adverse outcomes. This section will discuss the standard diagnosis of ACS that consists of signs and symptoms, biomarkers, and electrocardiograms, but will also focus on the special populations that need heightened awareness and the different strategies that can be used to make a prompt and accurate diagnosis.


Acute Coronary Syndrome Left Bundle Branch Block Reperfusion Therapy Brugada Syndrome Right Bundle Branch Block 
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  1. 1.
    Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319–1325.CrossRefGoogle Scholar
  2. 2.
    Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163–1170.CrossRefGoogle Scholar
  3. 3.
    Lewis WR, Amsterdam EA, Turnipseed S, et al. Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain. J Am Coll Cardiol 1999; 33:1843–1847.CrossRefGoogle Scholar
  4. 4.
    Milner KA, Vaccarino V, Arnold AL, et al. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol 2004; 93:606–608.CrossRefGoogle Scholar
  5. 5.
    Bugiardini R, Bairey Merz CN. Angina with “normal” coronary arteries: a changing philosophy. JAMA 2005; 293:477–484.CrossRefGoogle Scholar
  6. 6.
    Braunwald E. Unstable angina. A classification. Circulation 1989; 80:410–414.CrossRefGoogle Scholar
  7. 7.
    Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145:65–69.CrossRefGoogle Scholar
  8. 8.
    Henrikson CA, Howell EE, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003; 139:979–986.CrossRefGoogle Scholar
  9. 9.
    Zimmerman J, Fromm R, Meyer D, et al. Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Circulation 1999; 99:1671–1677.CrossRefGoogle Scholar
  10. 10.
    Rajagopal V, Bhatt DL. Acute coronary syndrome statistics: what you don’t see can hurt you. Am Heart J 2005; 149:955–956.CrossRefGoogle Scholar
  11. 11.
    Aviles RJ, Askari AT, Lindahl B, et al. Troponin T levels in patients with acute coronary syndromes, with or without renal dysfunction. N Engl J Med 2002; 346:2047–2052.CrossRefGoogle Scholar
  12. 12.
    Galla JG, Mahaffey KW, Sapp SK, et al. Elevated creatine kinase-MB with normal creatine kinase predicts worse outcomes in patients with acute coronary syndromes: results from 4 large clinical trials. Am Heart J 2006; 151:16–24.CrossRefGoogle Scholar
  13. 13.
    Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128–2135.CrossRefGoogle Scholar
  14. 14.
    Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999; 281:707–713.CrossRefGoogle Scholar
  15. 15.
    Cannon CP, McCabe CH, Stone PH, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol 1997; 30:133–140.CrossRefGoogle Scholar
  16. 16.
    Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996; 334:481–487.CrossRefGoogle Scholar

Copyright information

© Current Medicine Group, a part of Springer Science+Business Media 2008

Authors and Affiliations

  • Anthony A Bavry
    • 1
  • Deepak L Bhatt
    • 1
  1. 1.Department of Cardiovascular MedicineCleveland ClinicUSA

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