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Essentials of Diagnosis

• At least two of the following findings: ischemic symptoms, diagnostic electrocardiogram (ECG) changes, and an elevated serum marker of cardiac injury.
• Chest pain, often accompanied by diaphoresis, is common; pain often radiates to the left arm, shoulder, jaw, or neck.
• Shortness of breath is more common in patients who are elderly, black, or female.

General Considerations

Acute coronary syndrome (ACS) is an umbrella term that encompasses unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST-elevation myocardial infarction (NSTEMI). It is the symptomatic cardiac end product of cardiovascular disease, resulting in reversible or irreversible cardiac injury, and even death.

Cultural issues can affect the diagnosis, treatment, and outcome of ACS. Some clinical symptoms are more common in certain patient populations (see Symptoms and Signs, later). Other notable differences exist between patient populations that relate to diagnosis and treatment of cardiac disease. Both men and women with ACS respond to early invasive treatment. Women tend to have more severe first ACS, are less likely to receive thrombolysis, and are at greater risk for death and hospital readmission at 6 months. Patients experiencing ACS are less often hospitalized, thus increasing their mortality, if they are women younger than 55 years of age, are nonwhite, have shortness of breath as their chief complaint, or have a normal or indeterminate ECG.

Patients are more likely to adhere to treatment plans they can afford, and this should be taken into account when deciding which medication to prescribe and which diet and exercise plans to recommend. In addition to promoting healthy habits, family physicians provide continuity of care for patients with ACS and can help monitor adherence and response to treatment.

Glaser R et al: Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA 2002;288:3124. [PMID: 12495392]

Link N, Tanner M: Coronary artery disease: Part I. Epidemiology and diagnosis. WJM 2001;174:257. [PMID: 11290684]

Pathogenesis

Cardiovascular disease includes all diseases of the heart and vasculature (eg, stroke and hypertension). Coronary artery disease (CAD), synonymous with coronary heart disease (CHD), affects the coronary arteries, diminishing their ability to supply oxygenated blood to the heart.

Progression of Atherosclerosis

Atherosclerotic disease is the thickening and hardening (loss of elasticity) of the arterial wall due to the accumulations of lipids, macrophages, T lymphocytes, smooth muscle cells, extracellular matrix, calcium, and necrotic debris. Figures 18-1, 18-2, and 18-3 grossly depict the multifactorial and complex depository, inflammatory, and reactive processes that collaborate to occlude coronary arteries.

 (Reproduced, with permission, from Grech ED: Pathophysiology and investigation of coronary artery disease. BMJ 2003;326:1027.)

Prevention

The cascade of events that leads to ACS can be interrupted, delayed, or treated. Primary prevention tries to prevent disease before it develops (ie, prevent or delay development of risk factors). Secondary prevention attempts to prevent disease progression by identifying and treating risk factors or preclinical, asymptomatic disease. Tertiary prevention involves treatment of established disease to restore and maintain highest function, minimize negative disease effects, and prevent complications (ie, help recovery from and prevent recurrence of ACS).

Primary Prevention

Primary prevention of ACS should begin in childhood by avoiding tobacco use, eating a diet rich in fruits and vegetables and low in saturated fats, engaging in regular exercise of 20-30 minutes five times a week, and maintaining a body mass index (BMI) between 18 and 25 (calculated by dividing weight in kilograms by height in meters squared).

Secondary and Tertiary Prevention

Secondary and tertiary prevention involves progressively more aggressive management of patients who have known risk factors for or have experienced ACS (Figure 18-4 and Table 18-2). Although the association between cholesterol and ACS death is weaker in those older than 65 years, statin drugs can still have a positive impact on morbidity and mortality in this age group.

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