Advertisement
Previous article
Sarcoidosis: Evaluation and Treatment
Jan 2024
Next article
Acute Asthma Exacerbations: Management Strategies

Acute Coronary Syndrome: Diagnosis and Initial Management

Raman Nohria, MD
Anthony J. Viera, MD, MPH

American Family Physician. 2024;109(1):34-42.

Author disclosure: No relevant financial relationships.

Acute coronary syndrome (ACS) is defined as reduced blood flow to the coronary myocardium manifesting as ST-segment elevation myocardial infarction or non–ST-segment elevation ACS, which includes unstable angina and non–ST-segment elevation myocardial infarction. Common risk factors include being at least 65 years of age or a current smoker or having hypertension, diabetes mellitus, hyperlipidemia, a body mass index greater than 25 kg per m2, or a family history of premature coronary artery disease. Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw. However, chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS. Having a prior abnormal cardiac stress test result indicates increased risk. Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves. No validated clinical decision tool is available to rule out ACS in the outpatient setting. Elevated troponin levels without ST-segment elevation on electrocardiography suggest non–ST-segment elevation ACS. Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization. Other important management considerations include initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy. Additional interventions shown to reduce mortality in patients who have had a recent myocardial infarction include smoking cessation, annual influenza vaccination, and cardiac rehabilitation.

Each year, acute coronary syndrome (ACS) affects more than 7 million people globally.1 ST-segment elevation myocardial infarction (STEMI) is responsible for 30% of cases, whereas non–ST-segment elevation ACS (NSTE ACS) accounts for the remaining 70%.2 Common risk factors include being at least 65 years of age or a current smoker or having hypertension, diabetes mellitus, hyperlipidemia, a body mass index greater than 25 kg per m2, or a family history of premature coronary artery disease (CAD).3 The most common symptom of ACS is acute chest pain, which accounts for approximately 1% of primary care visits and 5% of emergency department visits each year.4,5

WHAT'S NEW ON THIS TOPIC

Acute Coronary Syndrome
The 2021 American College of Cardiology and American Heart Association guidelines no longer recommend classifying chest pain as atypical or typical, because this classification is not useful for identifying the cause and has been misused to classify chest pain as benign. Instead, the guidelines now recommend that chest pain be classified as cardiac, possibly cardiac, or noncardiac.
A systematic review of home-based cardiac rehabilitation studies demonstrated higher patient adherence to home-based cardiac rehabilitation, and that home-based and outpatient cardiac rehabilitation achieved similar improvement in functional capacity, quality of life, and coronary artery disease risk factor control after 12 months.
Despite the high prevalence of depression in patients with acute coronary syndrome, evidence suggests that there is minimal benefit to screening for depression in patients who have had a myocardial infarction within the past 12 months.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations Evidence rating Comments
Patients who present for acute chest pain and a high suspicion for acute coronary syndrome should be referred to the emergency department, where the evaluation should use predictive risk scores to aid in the prognosis, diagnosis, and management. This evaluation should include 12-lead electrocardiography within 10 minutes of presentation, history and physical examination, and high-sensitivity cardiac troponin measurement at initial presentation and three hours after symptom onset.2,7,8,11 C Expert opinion and consensus guidelines
Patients diagnosed with ST-segment elevation myocardial infarction should receive coronary angiography, followed by PCI with a drug-eluting stent within 120 minutes of presenting to the emergency department. When PCI is not available, fibrinolytics can be administered if no contraindications are present, with maximal benefit to the patient if administered within 120 minutes of symptom onset. The patient should then be transferred to a center capable of performing PCI.2,8,25–28 A Consistent results from randomized controlled trials showing reduced mortality
Early invasive therapy is recommended for patients with non–ST-segment elevation acute coronary syndrome and high risk (e.g., patients with heart failure) to reduce cardiovascular events and mortality.6,8,25,30 A Meta-analysis of randomized controlled trials and consensus guidelines
Antithrombotic therapy should be initiated with aspirin, a P2Y12 inhibitor, and a parenteral anticoagulant.2,31–37 A Consistent results from randomized controlled trials showing reduced mortality
Influenza vaccination, smoking cessation, and referral to cardiac rehabilitation improve mortality in patients with recent myocardial infarction.9,49–51 B Consistent results from cohort studies and randomized controlled trials demonstrating improved mortality

PCI = percutaneous coronary intervention.

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 https://www.aafp.org/afpsort.

RAMAN NOHRIA, MD, is an assistant professor in the Department of Family Medicine and Community Health at Duke University School of Medicine, Durham, N.C.

ANTHONY J. VIERA, MD, MPH, is a professor in and chair of the Department of Family Medicine and Community Health at Duke University School of Medicine.

Address correspondence to Raman Nohria, MD, Duke University School of Medicine, 2200 West Main St., Ste. 400, Durham, NC 27705 (raman.nohria@duke.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.Reed GW, Rossi JE, Cannon CP. Acute myocardial infarction [published correction appears in Lancet. 2017; 389(10065): 156]. Lancet. 2017;389(10065):197-210.
  2. 2.Bhatt DL, Lopes RD, Harrington RA. Diagnosis and treatment of acute coronary syndromes: a review [published correction appears in JAMA. 2022; 327(17): 1710]. JAMA. 2022;327(7):662-675.
  3. 3.Roth GA, Johnson CO, Abate KH, et al.; Global Burden of Cardiovascular Diseases Collaboration. The burden of cardiovascular diseases among US states, 1990–2016. JAMA Cardiol. 2018;3(5):375-389.
  4. 4.Santo L, Okeyode T. National ambulatory medical care survey: 2018 national summary tables. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2018-namcs-web-tables-508.pdf
  5. 5.Cairns C, Kang K. National hospital ambulatory medical care survey: 2019 emergency department summary tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2019-nhamcs-ed-web-tables-508.pdf
  6. 6.Collet JP, Thiele H, Barbato E, et al.; ESC Scientific Document Group. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [published corrections appear in Eur Heart J. 2021; 42(19): 1908; Eur Heart J. 2021; 42(19): 1925; and Eur Heart J. 2021; 42(23): 2298]. Eur Heart J. 2021;42(14):1289-1367.
  7. 7.Harskamp RE, Fanaroff AC, Zhen SW, et al. Recognising acute coronary syndrome. BMJ. 2022;377:e069591.
  8. 8.Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. 2021; 144(22): e455]. Circulation. 2021;144(22):e368-e454.
  9. 9.van Oosterhout REM, de Boer AR, Maas AHEM, et al. Sex differences in symptom presentation in acute coronary syndromes: a systematic review and meta-analysis. J Am Heart Assoc. 2020;9(9):e014733.
  10. 10.Ferry AV, Anand A, Strachan FE, et al. Presenting symptoms in men and women diagnosed with myocardial infarction using sex-specific criteria. J Am Heart Assoc. 2019;8(17):e012307.
  11. 11.Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have acute coronary syndrome?: The rational clinical examination systematic review. JAMA. 2015;314(18):1955-1965.
  12. 12.Klinkman MS, Stevens D, Gorenflo DW; Michigan Research Network. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract. 1994;38(4):345-352.
  13. 13.Will JC, Loustalot F, Hong Y. National trends in visits to physician offices and outpatient clinics for angina 1995 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7(1):110-117.
  14. 14.Harskamp RE, Laeven SC, Himmelreich JC, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.
  15. 15.Haasenritter J, Bösner S, Vaucher P, et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract. 2012;62(599):e415-e421.
  16. 16.Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158.
  17. 17.Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295-1300.
  18. 18.Six AJ, Cullen L, Backus BE, et al. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013;12(3):121-126.
  19. 19.Melki D, Jernberg T. HEART score: a simple and useful tool that may lower the proportion of chest pain patients who are admitted. Crit Pathw Cardiol. 2013;12(3):127-131.
  20. 20.Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281-286.
  21. 21.Tan NS, Goodman SG, Yan RT, et al. Comparative prognostic value of T-wave inversion and ST-segment depression on the admission electrocardiogram in non-ST-segment elevation acute coronary syndromes. Am Heart J. 2013;166(2):290-297.
  22. 22.Shah ASV, Sandoval Y, Noaman A, et al. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study [published correction appears in BMJ. 2018; 360: k495]. BMJ. 2017;359:j4788.
  23. 23.Volz KA, McGillicuddy DC, Horowitz GL, et al. Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain. Am J Emerg Med. 2012;30(1):188-190.
  24. 24.Piccioni A, Franza L, Rosa F, et al. Use of POCUS in chest pain and dyspnea in emergency department: what role could it have?. Diagnostics (Basel). 2022;12(7):1620.
  25. 25.Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. 2022; 145(11): e772]. Circulation. 2022;145(3):e18-e114.
  26. 26.Ibanez B, James S, Agewall S, et al.; ESC Scientific Document Group. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177.
  27. 27.Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20.
  28. 28.Armstrong PW, Gershlick AH, Goldstein P, et al.; STREAM Investigative Team. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med. 2013;368(15):1379-1387.
  29. 29.Bhatt DL. Percutaneous coronary intervention in 2018. JAMA. 2018;319(20):2127-2128.
  30. 30.Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol. 2006;48(7):1319-1325.
  31. 31.Bhatt DL, Hulot JS, Moliterno DJ, et al. Antiplatelet and anticoagulation therapy for acute coronary syndromes. Circ Res. 2014;114(12):1929-1943.
  32. 32.Kamran H, Jneid H, Kayani WT, et al. Oral antiplatelet therapy after acute coronary syndrome: a review [published correction appears in JAMA. 2021; 326(2): 190]. JAMA. 2021;325(15):1545-1555.
  33. 33.Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients [published correction appears in BMJ. 2002; 324(7330): 141]. BMJ. 2002;324(7329):71-86.
  34. 34.Yusuf S, Zhao F, Mehta SR, et al.; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published corrections appear in N Engl J Med. 2001; 345(23): 1716, and N Engl J Med. 2001; 345(20): 1506]. N Engl J Med. 2001;345(7):494-502.
  35. 35.Wiviott SD, Braunwald E, McCabe CH, et al.; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015.
  36. 36.Cannon CP, Harrington RA, James S, et al.; PLATelet Inhibition and Patient Outcomes Investigators. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet. 2010;375(9711):283-293.
  37. 37.Schüpke S, Neumann FJ, Menichelli M, et al.; ISAR-REACT 5 Trial Investigators. Ticagrelor or prasugrel in patients with acute coronary syndromes. N Engl J Med. 2019;381(16):1524-1534.
  38. 38.Angiolillo DJ, Bhatt DL, Cannon CP, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: a North American perspective: 2021 update. Circulation. 2021;143(6):583-596.
  39. 39.Kim J, Kang D, Park H, et al. Long-term β-blocker therapy and clinical outcomes after acute myocardial infarction in patients without heart failure: nationwide cohort study. Eur Heart J. 2020;41(37):3521-3529.
  40. 40.Cannon CP, Blazing MA, Giugliano RP, et al.; IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372(25):2387-2397.
  41. 41.Safi S, Sethi NJ, Nielsen EE, et al. Beta-blockers for suspected or diagnosed acute myocardial infarction. Cochrane Database Syst Rev. 2019(12):CD012484.
  42. 42.Pfeffer MA, Claggett B, Lewis EF, et al.; PARADISE-MI Investigators and Committees. Angiotensin receptor-neprilysin inhibition in acute myocardial infarction [published correction appears in N Engl J Med. 2021; 385(27): 2592]. N Engl J Med. 2021;385(20):1845-1855.
  43. 43.Zelniker TA, Wiviott SD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials [published correction appears in Lancet. 2019; 393(10166): 30]. Lancet. 2019;393(10166):31-39.
  44. 44.Anker SD, Butler J, Filippatos G, et al.; EMPEROR-Preserved Trial Investigators. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451-1461.
  45. 45.Packer M, Anker SD, Butler J, et al.; EMPEROR-Reduced Trial Investigators. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413-1424.
  46. 46.Giugliano D, Maiorino MI, Bellastella G, et al. GLP-1 receptor agonists for prevention of cardiorenal outcomes in type 2 diabetes: an updated meta-analysis including the REWIND and PIONEER 6 trials. Diabetes Obes Metab. 2019;21(11):2576-2580.
  47. 47.Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2019; 73(24): 3234–3237]. J Am Coll Cardiol. 2019;73(24):3168-3209.
  48. 48.Udell JA, Jones WS, Petrie MC, et al. Sodium glucose cotransporter-2 inhibition for acute myocardial infarction: JACC review topic of the week. J Am Coll Cardiol. 2022;79(20):2058-2068.
  49. 49.Biery DW, Berman AN, Singh A, et al. Association of smoking cessation and survival among young adults with myocardial infarction in the Partners YOUNG-MI Registry. JAMA Netw Open. 2020;3(7):e209649.
  50. 50.Fröbert O, Götberg M, Erlinge D, et al. Influenza vaccination after myocardial infarction: a randomized, double-blind, placebo-controlled, multicenter trial. Circulation. 2021;144(18):1476-1484.
  51. 51.Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA. 2013;310(16):1711-1720.
  52. 52.Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol. 2016;67(1):1-12.
  53. 53.Thomas RJ, Beatty AL, Beckie TM, et al. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019;140(1):e69-e89.
  54. 54.Nieuwsma JA, Williams JW, Namdari N, et al. Diagnostic accuracy of screening tests and treatment for post-acute coronary syndrome depression: a systematic review. Ann Intern Med. 2017;167(10):725-735.
  55. 55.Kronish IM, Moise N, Cheung YK, et al. Effect of depression screening after acute coronary syndromes on quality of life: The CODIACS-QoL randomized clinical trial [published correction appears in JAMA Intern Med. 2019; 179(12): 1739]. JAMA Intern Med. 2020;180(1):45-53.
  56. 56.Switaj TL, Christensen SR, Brewer DM. Acute coronary syndrome: current treatment. Am Fam Physician. 2017;95(4):232-240
  57. 57.Barstow C, Rice M, McDivitt JD. Acute coronary syndrome: diagnostic evaluation. Am Fam Physician. 2017;95(3):170-177.
  58. 58.Achar SA, Kundu S, Norcross WA. Diagnosis of acute coronary syndrome. Am Fam Physician. 2005;72(1):119-126.
  59. 59.Wiviott SD, Braunwald E. Unstable angina and non–ST-segment elevation myocardial infarction: part I. Initial evaluation and management, and hospital care. Am Fam Physician. 2004;70(3):525-532.
Previous article
Sarcoidosis: Evaluation and Treatment
Jan 2024
Next article
Acute Asthma Exacerbations: Management Strategies

Current issue

September 2026

September 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.