There is a short window of opportunity with ACS, where the prompt establishment of reperfusion therapy dramatically reduces left ventricular dysfunction and improves survival . 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 . Attempts to diagnose every case of ACS can lead to excess false positive diagnoses with resultant high healthcare costs and unnecessary patient anxiety . High-risk populations include late presenters, women, people with diabetes, and the elderly, where signs and symptoms of ACS may be protean . Women with typical anginal symptoms and angiographically normal coronaries can still suffer from poor prognosis due to microvascular dysfunction . 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.
KeywordsAcute Coronary Syndrome Left Bundle Branch Block Reperfusion Therapy Brugada Syndrome Right Bundle Branch Block
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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
Pope JH, Aufderheide TP, Ruthazer R, et al.
Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med
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
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
Bugiardini R, Bairey Merz CN. Angina with “normal” coronary arteries: a changing philosophy. JAMA
Braunwald E. Unstable angina. A classification. Circulation
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
Henrikson CA, Howell EE, Bush DE, et al.
Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med
Zimmerman J, Fromm R, Meyer D, et al.
Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Circulation
Rajagopal V, Bhatt DL. Acute coronary syndrome statistics: what you don’t see can hurt you. Am Heart J
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
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
Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med
Savonitto S, Ardissino D, Granger CB, et al.
Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA
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
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
© Current Medicine Group, a part of Springer Science+Business Media 2008