Acute Coronary Syndrome: Current Treatment

 

Am Fam Physician. 2017 Feb 15;95(4):232-240.

Author disclosure: No relevant financial affiliations.

Acute coronary syndrome continues to be a significant cause of morbidity and mortality in the United States. Family physicians need to identify and mitigate risk factors early, as well as recognize and respond to acute coronary syndrome events quickly in any clinical setting. Diagnosis can be made based on patient history, symptoms, electrocardiography findings, and cardiac biomarkers, which delineate between ST elevation myocardial infarction and non–ST elevation acute coronary syndrome. Rapid reperfusion with primary percutaneous coronary intervention is the goal with either clinical presentation. Coupled with appropriate medical management, percutaneous coronary intervention can improve short- and long-term outcomes following myocardial infarction. If percutaneous coronary intervention cannot be performed rapidly, patients with ST elevation myocardial infarction can be treated with fibrinolytic therapy. Fibrinolysis is not recommended in patients with non–ST elevation acute coronary syndrome; therefore, these patients should be treated with medical management if they are at low risk of coronary events or if percutaneous coronary intervention cannot be performed. Post–myocardial infarction care should be closely coordinated with the patient's cardiologist and based on a comprehensive secondary prevention strategy to prevent recurrence, morbidity, and mortality.

Every 34 seconds, one American has a coronary event.1 It is important for primary care physicians to be able to diagnose and manage acute coronary syndrome (ACS), which comprises two clinical presentations: ST elevation myocardial infarction (STEMI) and non–ST elevation acute coronary syndrome (NSTE-ACS). The term non–ST elevation acute myocardial infarction (NSTEMI) is no longer used in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines as a broad category with separate treatment guidelines. In lieu of this, ACS presentations not resulting in ST elevation are grouped together as NSTE-ACS, including NSTEMI and unstable angina.

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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.

American Society for Clinical Pathology


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

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.

American Society for Clinical Pathology


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Reperfusion therapy, preferably primary PCI, should be administered to eligible patients with STEMI and symptom onset within the previous 12 hours.

A

4

In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated first medical contact to device time at a PCI-capable hospital exceeds 120 minutes.

A

4

Patients with STEMI should be transferred to a PCI-capable hospital for angiography after successful fibrinolysis.

B

4

Fibrinolysis is not recommended for treatment in patients with NSTE-ACS.

B

5

Parenteral anticoagulation, in addition to antiplatelet therapy, is recommended for all patients with NSTE-ACS regardless of initial treatment strategy.

A

5


NSTE-ACS = non–ST elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction.

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

Reperfusion therapy, preferably primary PCI, should be administered to eligible patients with STEMI and symptom onset within the previous 12 hours.

A

4

In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated first medical

The Authors

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TIMOTHY L. SWITAJ, MD, FAAFP, is a physician at U.S. Army Medical Department Center and School, Fort Sam Houston, Tex. At the time the article was submitted, Dr. Switaj was the deputy commander for clinical services at Reynolds Army Community Hospital, Fort Sill, Okla....

SCOTT R. CHRISTENSEN, MD, is a faculty physician at Martin Army Community Hospital Family Medicine Residency Program, Fort Benning, Ga. At the time the article was submitted, Dr. Christensen was a staff physician in the Department of Primary Care at Reynolds Army Community Hospital.

DEAN M. BREWER, DO, is a physician at Guthrie Ambulatory Health Care Clinic, Fort Drum, NY. At the time the article was submitted, Dr. Brewer was chief of the patient-centered medical home at Reynolds Army Community Hospital.

Address correspondence to Timothy L. Switaj, MD, FAAFP (e-mail: timothy.l.switaj.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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