Acute Coronary Syndrome: Diagnostic Evaluation

 

Myocardial infarction (MI), a subset of acute coronary syndrome, is damage to the cardiac muscle as evidenced by elevated cardiac troponin levels in the setting of acute ischemia. Coronary artery disease is the leading cause of mortality in the United States. Chest pain is a common presentation in patients with MI; however, there are multiple non-cardiac causes of chest pain, and the diagnosis cannot always be made based on initial presentation. The assessment of a possible MI includes evaluation of risk factors and presenting signs and symptoms, rapid electrocardiography, and serum cardiac troponin measurements. A validated risk score, such as the Thrombolysis in Myocardial Infarction score, may also be useful. Electrocardiography should be performed within 10 minutes of presentation. ST elevation MI is diagnosed with ST segment elevation in two contiguous leads on electrocardiography. In the absence of ST segment elevation, non–ST elevation ACS can be diagnosed. An elevated cardiac troponin level is required for diagnosis, and an increase or decrease of at least 20% is consistent with MI. In some patients with negative electrocardiography findings and normal cardiac biomarkers, additional testing may further reduce the likelihood of coronary artery disease. Cardiac catheterization is the standard method for diagnosing coronary artery disease, but exercise treadmill testing, a stress myocardial perfusion study, stress echocardiography, and computed tomography are noninvasive alternatives.

Chest pain affects 20% to 40% of the general population during their lifetime. Each year, approximately 1.5% of the population consults a primary care physician for symptoms of chest pain. The rate is even higher in the emergency department, where more than 5% of visits and up to 40% of admissions are because of chest pain.1,2  Chest pain is often the presenting symptom of myocardial infarction (MI), which is damage to the cardiac muscle caused by ischemia (Table 1).3 This can be caused by a thrombotic occlusion of a coronary vessel (type 1) or by the myocardial oxygen demand surpassing the oxygen supply (type 2).3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with chest pain, the evaluation should include 12-lead electrocardiography within 10 minutes of presentation, risk stratification using history and physical examination findings, and cardiac troponin measurements at presentation and three to six hours after symptom onset.

C

5

Risk scores should be used for prognosis in patients with acute coronary syndrome, and they may be useful in diagnosis and management.

C

5

If a patient has normal serial electrocardiography results and normal troponin levels, an exercise treadmill test, a stress myocardial perfusion study, or stress echocardiography can be considered. These tests can be performed before discharge or as an outpatient if the test is scheduled within 72 hours of discharge.

C

3, 5


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with chest pain, the evaluation should include 12-lead electrocardiography within 10 minutes of presentation, risk stratification using history and physical examination findings, and cardiac troponin measurements at presentation and three to six hours after symptom onset.

C

5

Risk scores should be used for prognosis in patients with acute coronary syndrome, and they may be useful in diagnosis and management.

C

5

If a patient has normal serial electrocardiography results and normal troponin levels, an exercise treadmill test, a stress myocardial perfusion study, or stress echocardiography can be considered. These tests can be performed before discharge or as an outpatient if the test is scheduled within 72 hours of discharge.

C

3, 5


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN CARDIOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not test for myoglobin or creatine kinase MB in the diagnosis of acute myocardial infarction. Instead, use troponin I or T measurements.

American Society for Clinical Pathology

Do not use coronary computed tomography angiography in high-risk emergency department patients pre

The Authors

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CRAIG BARSTOW, MD, is director of the Family Medicine Hospitalist Fellowship at Womack Army Medical Center, Fort Bragg, N.C....

MATTHEW RICE, MD, is a fellow in the Family Medicine Hospitalist Fellowship at Womack Army Medical Center.

JONATHAN D. McDIVITT, MD, is head of the Department of Internal Medicine and a staff cardiologist at Naval Hospital Jacksonville, Fla.

Address correspondence to Craig Barstow, MD, Womack Army Medical Center, 2817 Reilly Rd., Fort Bragg, NC 28310 (e-mail: craig.h.barstow.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliation.

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