Acute coronary syndrome

Acute coronary syndrome is a term used to describe a range of conditions associated with
sudden, reduced blood flow to the heart.
One condition under the umbrella of acute coronary syndrome is myocardial infarction
(heart attack) when cell death results in damaged or destroyed heart tissue. Even when
acute coronary syndrome causes no cell death, the reduced blood flow alters heart
function and indicates a high risk of heart attack.
Acute coronary syndrome often causes severe chest pain or discomfort. It is a medical
emergency that requires prompt diagnosis and care. Treatment goals include improving
blood flow, treating complications and preventing future problems.

Symptoms
The signs and symptoms of acute coronary syndrome, which usually begin abruptly,
include the following:
Chest pain (angina) or discomfort, often described as aching, pressure, tightness or
burning / Pain radiating from the chest to the shoulders, arms, upper abdomen, back,
neck or jaw/ Nausea or vomiting/ Indigestion/ Shortness of breath (dyspnea)/Sudden,
heavy sweating (diaphoresis)/ Lightheadedness, dizziness or fainting/ Unusual or
unexplained fatigue/ Feeling restless or apprehensive
While chest pain or discomfort is the most common symptom associated with acute
coronary syndrome, signs and symptoms may vary significantly depending on your age,
sex and other medical conditions. People who are more likely to have signs and
symptoms without chest pain or discomfort are women, older adults and people with
diabetes.

When to see a doctor

Acute coronary syndrome is a medical emergency, and chest pain or discomfort can
indicate any number of serious, life-threatening conditions. Call 911 or get immediate
emergency services to get a prompt diagnosis and appropriate care. Do not drive
yourself to an emergency department.

Causes
Acute coronary syndrome usually results from the buildup of fatty deposits (plaques) in
and on the walls of coronary arteries, the blood vessels delivering oxygen and nutrients
to heart muscles.
When a plaque deposit ruptures or splits, a blood clot forms. This clot obstructs the flow
of blood to heart muscles.
When the supply of oxygen to cells is too low, cells of the heart muscles can die. The
death of cells resulting in damage to muscle tissues is a heart attack (myocardial
infarction).
Even when there is no cell death, an inadequate supply of oxygen still results in heart
muscles that don't work correctly or efficiently. This dysfunction may be temporary or
permanent. When acute coronary syndrome doesn't result in cell death, it is called
unstable angina.

Risk factors
The risk factors for acute coronary syndrome are the same as those for other types of
heart disease. Acute coronary syndrome risk factors include:
Older age (older than 45 for men and older than 55 for women)
High blood pressure/ High blood cholesterol/ Cigarette smoking/ Lack of physical activity
Unhealthy diet/ Obesity or overweight/ Diabetes Family history of chest pain, heart
disease or stroke
For women, a history of high blood pressure, preeclampsia or diabetes during pregnancy

Diagnosis
If you have signs or symptoms associated with acute coronary syndrome, an
emergency room doctor will likely order several tests. Some tests may be
performed while your doctor is asking you questions about your symptoms or
medical history. Tests include:
Electrocardiogram (ECG). This test measures electrical activity in your
heart via electrodes attached to your skin. Abnormal or irregular impulses can

indicate poor heart function due to a lack of oxygen to the heart. Certain
patterns in electrical signals may indicate the general location of a blockage.
The test may be repeated several times.
Blood tests. Certain enzymes may be detected in the blood if cell death
has resulted in damage to heart tissue. A positive result indicates a heart
attack.
The information from these two tests as well as signs and symptoms
may provide the primary basis for a diagnosis of acute coronary syndrome
and may determine whether the condition can be classified as a heart attack
or unstable angina.
Other tests may be ordered to characterize the condition more thoroughly,
rule out other causes of symptoms, or combine diagnostic and treatment
interventions.
Coronary angiogram. This procedure uses X-ray imaging to see your
heart's blood vessels. A long, tiny tube (catheter) is threaded through an
artery, usually in your arm or groin, to the arteries in your heart. A liquid dye,
which can be detected by X-rays, is sent through the tube to your arteries.
Multiple X-ray images of your heart can reveal blockage or narrowing of the
arteries. The catheter may also be used for treatments.
Echocardiogram. An echocardiogram uses sound waves, directed at your
heart from a wand-like device, to produce a live image of your heart. An
echocardiogram can help determine whether the heart is pumping correctly.
Myocardial perfusion imaging (MPI). This test shows how well blood flows
through your heart muscle. A tiny, safe amount of radioactive substance is
injected into your blood. A specialized camera detects the blood as it moves
through your heart to reveal whether enough blood is flowing through heart
muscles and where blood flow is reduced.
Computerized tomography (CT) angiogram. A CT angiogram uses a
specialized X-ray technology that can produce multiple images crosssectional 2-D slices of your heart. These images can detect narrowed or
blocked coronary arteries.
Stress test. A stress test assesses how well your heart functions when you
exercise when your heart needs to work harder. In some cases, you may
receive a medication to increase your heart rate rather than exercising. This
test is only done when there is no evidence of acute coronary syndrome or
another life-threatening heart condition when you are at rest. During the
stress test, heart function may be assessed by an ECG, echocardiogram or

myocardial perfusion imaging.

Treatment
Immediate treatment goals are to relieve pain and distress, improve blood flow, and
restore heart function as quickly and as best as possible. Long-term treatment goals are to
improve overall heart function, manage risk factors and lower the risk of a heart attack. A
combination of drugs and surgical procedures may be used to meet these goals.

Medications
Depending on your diagnosis, medications for emergency care or ongoing management
and in some cases both may include the following:

Thrombolytics, also called clot busters, help dissolve a blood clot that's blocking
an artery.

Nitroglycerin improves blood circulation by temporarily widening blood vessels.

Antiplatelet drugs, which help prevent blood clots from forming, include aspirin,
clopidogrel (Plavix), prasugrel (Effient) and others.

Beta blockers help relax your heart muscle and slow your heart rate, thereby
decreasing the demand on your heart and lowering your blood pressure. These
include metoprolol (Lopressor), nadolol (Corgard) and several others.

Angiotensin-converting enzyme (ACE) inhibitors expand blood vessels and

improve blood flow, allowing the heart to work more easily and efficiently. They
include lisinopril (Prinivil, Zestril), benazepril (Lotensin) and several others.

Angiotensin receptor blockers (ARBs), which help control blood pressure,

include irbesartan (Avapro), losartan (Cozaar) and several others.

Statins lower the amount of cholesterol circulating in the blood and may stabilize
plaque deposits, making them less likely to rupture. Statins include atorvastatin
(Lipitor), simvastatin (Zocor) and several others.

Surgery and other procedures

If medications aren't enough to restore blood flow to your heart muscles, your doctor may
recommend one of these procedures:

Angioplasty and stenting. In this procedure, your doctor inserts a long, tiny tube
(catheter) into the blocked or narrowed part of your artery. A wire with a deflated
balloon is passed through the catheter to the narrowed area. The balloon is then
inflated, opening the artery by compressing the plaque deposits against your
artery walls. A mesh tube (stent) is usually left in the artery to help keep the artery
open.

Coronary bypass surgery. With this procedure, a surgeon takes a piece of blood
vessel (graft) from another part of your body and creates a new route for blood
that goes around, or bypasses, a blocked coronary artery