FP Essentials™

Acute Coronary Syndrome

Call for Authors

This edition of FP EssentialsTM will cover recent updates in diagnosis and management of acute coronary syndrome (ACS). The content should include: prehospital evaluation and management of ACS; emergency department (ED) evaluation and management of ACS; inpatient management of myocardial infarction (MI); and posthospital outpatient management of ACS.

This edition of FP Essentials should be approximately 10,000 words in length, divided into 4 sections of approximately 2,500 words each, plus an abstract of no more than 200 words for each section, key practice recommendations, a maximum of 15 tables and figures, recommended readings, and references.  This edition should focus on what is new in each topic and should answer the key questions listed for each section. Each section should begin with an illustrative case, similar to the examples provided, with modifications to emphasize key points; each case should have a conclusion that demonstrates resolution of the clinical situation. The references suggested here include information that should be considered in preparation of this FP Essentials. However, these references are only a useful starting point that should be used to identify additional information to review.

Section 1: Prehospital Evaluation and Management of Acute Coronary Syndrome

Example case: It is a routine day at your office. The schedule is light, as it is Friday, and you are planning to leave for the weekend. The receptionist alerts you that a patient walked in and says he’s having chest pain. The nurse brings him back to an examination room. There, you find Ethan, a 64-year-old man clutching his chest. He is diaphoretic and says he feels like someone is squeezing his chest. He has no known medical conditions.

Example case: You are on an airplane, flying home from a medical meeting. The flight attendant asks on the public address system if there is a physician on the airplane. You respond and are asked to examine Mrs. Johnson, a 71-year-old woman sitting a few rows in front of you. She is pale, diaphoretic, dyspneic, and says she feels a strange sensation in her left arm. She says she had a myocardial infarction several years ago, and it felt like this. The flight attendant asks you whether the pilot should divert the airplane to the nearest airport.

Key questions to consider:

Office Presentation

  • When patients present to an outpatient medical practice (rather than an emergency care center) with symptoms suggestive of acute coronary syndrome (ACS), what evaluations and/or treatments should be undertaken before calling emergency medical services (EMS) and while waiting for EMS to arrive?
  • What are the most common nonserious etiologies of chest pain with symptoms that mimic those of ACS? Can these etiologies be easily and quickly distinguished from ACS or other serious conditions? If so, how?
  • How often do family physicians overlook the diagnosis of coronary artery disease or ACS when evaluating patients with chest pain who present to their practices?
  • Are there prediction rules that can help identify patients with chest pain presenting to a practice who have ACS?
  • What equipment and supplies are considered standard of care in a practice to manage emergency conditions such as ACS?
  • How reliable is a normal 12-lead electrocardiogram (ECG) for excluding ACS?
  • If a physician’s practice is distant from the nearest hospital, such as in a rural or remote area, how would the approach to a patient with chest pain in this practice differ from that of a practice located closer to the hospital? Should it differ?
  • If a physician’s practice is located in a rural area, is it appropriate (or standard of care) to stock thrombolytic drugs or other cardiac drugs in the office? If so, in what situations should these drugs be administered?

Out-of-Office Presentation

  • If a physician is assisting a patient with chest pain in a public place such as an airplane, restaurant, school, shopping mall, or similar venue, what is the best approach while waiting for EMS to arrive?
  • Are automatic defibrillators available in all or most public places? If one is present, what does a physician need to know about operating it? Can the physician expect oxygen to be available?
  • What medical equipment and supplies are routinely available on commercial airplanes?
  • What considerations should factor in a decision to ask a pilot to divert an airplane to the nearest airport because of a medical emergency such as suspected ACS?

Initial references to consider:

  • Baldwin LM, Chan L, Andrilla HA, Huff ED, Hart G. Quality of care for myocardial infarction in rural and urban hospitals. J Rural Health. 2010;26(1):51–57.
  • Westfall JM, Kiefe CI, Weissman NW, et al. Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the Cardiovascular Cooperative Project. BMC Cardiovasc Disord. 2008;8:22.
  • Turnipseed SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med. 2009;16(6):495-499.
  • McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177-182.
  • Mant J, McManus RJ, Oakes RA, et al. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technol Assess. 2004;8(2):iii, 1-158.
  • Bösner S, Bönisch K, Haasenritter J, Schlegel P, Hüllermeier E, Donner-Banzhoff N. Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? A cross sectional study. BMC Fam Pract. 2013;14:154.
  • Kamali A, Söderholm M, Ekelund U. What decides the suspicion of acute coronary syndrome in acute chest pain patients? BMC Emerg Med. 2014;14:9.
  • Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH. Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med. 2006;166(20):2237-2243.
  • Gencer B, Vaucher P, Herzig L, et al. Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score. BMC Med. 2010;8:9.
  • Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075-2083.
  • Federal Aviation Administration. Advisory circular: emergency medical equipment. January 12, 2006. Available at http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-33B.pdf(www.faa.gov).
  • Sand M, Gambichler T, Sand D, Thrandorf C, Altmeyer P, Bechara FG. Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis. 2010;8(6):388-394.

Section 2: Emergency Department Evaluation and Management of Acute Coronary Syndrome

Example case: Ethan, the 64-year-old male patient described in Section 1, whom you sent to the emergency department (ED) because of chest pain, arrives by ambulance and is quickly evaluated. In addition to aspirin and oxygen, he was given nitroglycerin twice in the ambulance, and it relieved his chest pain. Ethan’s vital signs are now stable. He is diaphoretic, but his examination results are otherwise reassuring.

Key questions to consider:

  • What are the most frequent causes of chest pain in patients who present to EDs for evaluation of chest pain?
  • What findings on history, physical examination, and electrocardiogram (ECG) results are most closely associated with acute coronary syndrome (ACS)? In patients with cardiogenic pain, which symptoms are associated with higher risk? What diagnostic findings reliably indicate noncardiovascular etiologies of chest pain?
  • How often is the diagnosis of ACS overlooked in patients presenting to EDs with chest pain? What are common scenarios that lead to overlooked diagnoses?
  • What diagnostic algorithms can help physicians efficiently evaluate patients with recent onset of chest pain?
  • For patients with suspected ACS, what are the standards of care for timeliness of key interventions such as aspirin and ECG? What windows should physicians consider for time-sensitive interventions such as percutaneous coronary intervention and fibrinolytic therapy?
  • When are ECG and high-sensitivity cardiac troponin most accurate for identifying or excluding ACS? What value do additional biomarkers (eg, heart-type fatty acid binding protein, copeptin, N-terminal pro-B-type natriuretic peptide) offer?
  • What risk scores (eg, Thrombolysis in Myocardial Infarction [TIMI], Global Registry of Acute Coronary Events [GRACE]) can be used to stratify risk for patients presenting to EDs for chest pain? How accurate are they?
  • Does cardiac imaging have a role in the ED evaluation of patients presenting with chest pain? If so, which imaging tests are most accurate? How accurate are they?
  • How common are acute chest pain units? How are they different from regular emergency care centers? Are acute chest pain units any more effective than standard EDs in terms of diagnostic accuracy and outcomes?
  • What are the indications for observation in the hospital setting? When is outpatient management appropriate? When can ACS safely be ruled out? What accelerated diagnostic protocols have proven safe, accurate, and cost-effective in low-risk patients presenting with chest pain?

Initial references to consider:

  • Wertli MM, Ruchti KB, Steurer J, Held U. Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis. BMC Med. 2013;11:239.
  • Argulian E, Agarwal V, Bangalore S, et al. Meta-analysis of prognostic implications of dyspnea versus chest pain in patients referred for stress testing. Am J Cardiol. 2014;113(3):559-564.
  • Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342(16):1163-1170.
  • Kontos MC, Roberts BD, Jesse RL, et al. Utility of the presenting electrocardiogram to predict mortality when troponin level is used to diagnose myocardial infarction. Am J Emerg Med 2009;27(2):146-152.
  • Collinson P, Gaze D, Goodacre S. Comparison of contemporary troponin assays with the novel biomarkers, heart fatty acid binding protein and copeptin, for the early confirmation or exclusion of myocardial infarction in patients presenting to the emergency department with chest pain. Heart 2014;100(2):140-145.
  • Gravning J, Smedsrud MK, Omland T, et al. Sensitive troponin assays and N-terminal pro-B-type natriuretic peptide in acute coronary syndrome: prediction of significant coronary lesions and long-term prognosis. Am Heart J. 2013;165(5):716-724.
  • Haaf P, Zellweger C, Reichlin T, et al. Utility of C-terminal proendothelin in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction. Can J Cardiol. 2014;30(2):195-203.
  • Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol. 2013;62(14):1242-1249.
  • Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61(8):880-892.
  • D’Ascenzo F, Cerrato E, Biondi-Zoccai G, et al. Coronary computed tomographic angiography for detection of coronary artery disease in patients presenting to the emergency department with chest pain: a meta-analysis of randomized clinical trials. Eur Heart J Cardiovasc Imaging. 2013;14(8):782-789.
  • Amin ST, Morrow DA, Braunwald E, et al. Dynamic TIMI risk score for STEMI. J Am Heart Assoc. 2013;2(1):e003269.
  • Abelin AP, David RB, Gottschall CA, et al. Accuracy of dedicated risk scores in patients undergoing primary percutaneous coronary intervention in daily clinical practice. Can J Cardiol. 2014;30(1):125-131.
  • Amsterdam EA, Kirk JD, Bluemke DA, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776. Erratum in Circulation. 2010;122(17):e500-e501.
  • Hess EP, Brison RJ, Perry JJ, et al. Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med. 2012;59(2):115-125.e1.
  • Scheuermeyer FX, Innes G, Grafstein E, et al. Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. Ann Emerg Med. 2012;59(4):256-264.e3.
  • Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.

Section 3: Inpatient Management of Acute Coronary Syndrome

Example case: When evaluated in the emergency department, Ethan, the patient described in Section 1 and Section 2, undergoes an electrocardiogram (ECG) that shows sinus rhythm with 2-mm ST-segment depression in leads V3 and V4. Initial cardiac troponin testing shows a normal result, but he is admitted to the intensive care unit. Repeat cardiac troponin testing 8 hours later shows a significantly elevated level.

Key questions to consider:

  • Describe the key features of ST-segment elevation myocardial infarction (MI) and non-ST segment elevation MI. Briefly compare and contrast their evaluation and acute management.
  • What are the indications for emergent reperfusion therapy with percutaneous coronary intervention (PCI), fibrinolytic therapy, or surgery? What protocols can ensure that these interventions are offered in a timely manner (including the role of early risk stratification such as the Thrombosis in Myocardial Infarction [TIMI] risk score)? How soon after MI should patients undergo PCI?
  • Discuss the role and appropriate dosing of dual antiplatelet therapy and anticoagulants in the management of acute MI and current supporting evidence. How should patients be managed if they have risk factors for bleeding? When should glycoprotein IIb/IIIa inhibitors be used?
  • What is the evidence for oxygen supplementation during acute management of acute coronary syndrome (ACS)? Are there potential risks for patients who are not hypoxemic?
  • How soon should beta blockers be started in patients with acute MI? How should the doses be titrated? Are cardioselective beta blockers contraindicated in patients with asthma or chronic obstructive pulmonary disease? What considerations should be undertaken for patients who use cocaine?
  • Which patients benefit most from angiotensin-converting enzyme (ACE) inhibitors? How soon after MI should ACE inhibitors be started? When should aldosterone antagonists be considered?
  • What doses of statin therapy are recommended for management of ACS?
  • What is the optimal threshold for red blood cell transfusion in the setting of ACS?
  • What are the potential roles of new oral anticoagulants (ieg, direct thrombin inhibitors, factor-Xa inhibitors) and novel treatment strategies (eg, intracoronary bone marrow cell therapy) in the management of acute MI?
  • What new ACS treatments are under investigation?

Initial references to consider:

  • O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-425. Erratum in Circulation. 2013;128(25):e481.
  • Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(23):e663-e828. Erratum in Circulation. 2013;127(24):e863-e864.
  • Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev. 201;(10):CD002130.
  • Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev. 2013;(8):CD007160.
  • Rajpurohit N, Garg N, Garg R, et al. Early versus delayed percutaneous coronary intervention for patients with non-ST segment elevation acute coronary syndrome: a meta-analysis of randomized controlled clinical trials. Catheter Cardiovasc Interv. 2013;81(2):223-231. Erratum in Catheter Cardiovasc Interv. 2013;81(7):1255.
  • Delewi R, Andriessen A, Tijssen JG, Zijlstra F, Piek JJ, Hirsch A. Impact of intracoronary cell therapy on left ventricular function in the setting of acute myocardial infarction: a meta-analysis of randomised controlled clinical trials. Heart. 2013;99(4):225-232.
  • Oldgren J, Wallentin L, Alexander JH, et al. New oral anticoagulants in addition to single or dual antiplatelet therapy after an acute coronary syndrome: a systematic review and meta-analysis. Eur Heart J. 2013;34(22):1670-1680.
  • Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2):124-131.e3.
  • Steg PG, Bhatt DL, Hamm CW, et al; CHAMPION Investigators. Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. Lancet. 2013;382(9909):1981-1992.

Section 4: Posthospital Outpatient Management of Myocardial Infarction

Example case: During hospitalization, Ethan, the patient described in Sections 1, 2, and 3 undergoes cardiac catheterization. The procedure reveals two-vessel disease, for which medical management is advised. The patient is discharged home with many new drugs, including aspirin, ticagrelor (Brilinta), isosorbide mononitrate, carvedilol (Coreg), losartan (Cozaar), eplerenone (Inspra), rosuvastatin (Crestor), esomeprazole, and bupropion. He reports feeling better but states that he cannot afford all of the new drugs, and he has difficulty adhering to the drug regimen.

Key questions to consider:

  • Discuss the role of a standardized patient-centered discharge process after acute myocardial infarction (MI). What elements of the discharge plan have been shown to improve patient safety and decrease readmission rates?
  • How common is drug nonadherence after hospitalization for MI? What factors are associated with early discontinuation of drugs? Which strategies can improve adherence?
  • What lifestyle interventions and dietary recommendations should physicians emphasize for patients after MI? What resources are available to help physicians educate patients and address barriers to success?
  • What is the role of cardiac rehabilitation after MI? How soon can patients return to sedentary work? When can they resume physical activity? Is stress testing required before resuming vigorous activity such as running? When can patients resume sexual activity?
  • How long should dual antiplatelet therapy be continued after MI (with versus without coronary stents)?
  • How long should beta blockers be continued after MI (with impaired versus preserved systolic function)?
  • When should lipid levels be reevaluated after hospitalization for MI? What are the current recommendations for statin dosing after MI?
  • Is varenicline (Chantix) safe for patients who want to stop smoking after MI?
  • What influence do depressive symptoms and their treatment have on cardiovascular morbidity and mortality after MI?

Initial references to consider:

  • Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(23):e663-e828. Erratum in Circulation. 2013;127(24):e863-e864.
  • Mercado MG, Smith DK, McConnon ML. Myocardial infarction: management of the subacute period. Am Fam Physician. 2013;88(9):581-588.
  • Böhm M, Schumacher H, Laufs U, et al. Effects of nonpersistence with medication on outcomes in high-risk patients with cardiovascular disease. Am Heart J. 2013;166(2):306-314.e7.
  • Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06029-4 [Epub ahead of print].
  • Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013 Nov 7. pii: S0735-1097(13)06028-2 [Epub ahead of print]
  • Ware JH, Vetrovec GW, Miller AB, et al. Cardiovascular safety of varenicline: patient-level meta-analysis of randomized, blinded, placebo-controlled trials. Am J Ther. 2013;20(3):235-246.
  • Meijer A, Conradi HJ, Bos EH, et al. Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis. Br J Psychiatry. 2013;203(2):90-102.
  • Roest AM, Carney RM, Freedland KE, et al. Changes in cognitive versus somatic symptoms of depression and event-free survival following acute myocardial infarction in the Enhancing Recovery In Coronary Heart Disease (ENRICHD) study. J Affect Disord. 2013;149(1-3):335-341.
  • Rashid MA, Edwards D, Walter FM, Mant J. Medication taking in coronary artery disease: a systematic review and qualitative synthesis. Ann Fam Med. 2014;12(3):224-232.