Acute coronary syndrome: Difference between revisions

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imported>Robert Badgett
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==Diagnosis==
==Diagnosis==
[[Clinical practice guideline]]s jointly written by multiple expert groups anchor the diagnosis on troponin blood assays obtained within 6 hours and again within 8-12 hours of a patient arriving for medical care.<ref name="pmid12383588">{{cite journal |author=Braunwald E, Antman EM, Beasley JW, ''et al'' |title=ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina) |journal=J. Am. Coll. Cardiol. |volume=40 |issue=7 |pages=1366–74 |year=2002 |pmid=12383588 |doi=|url=http://content.onlinejacc.org/cgi/content/full/50/7/652}}</ref>
[[Clinical practice guideline]]s jointly written by multiple expert groups anchor the diagnosis on troponin blood assays obtained within 6 hours and again within 8-12 hours of a patient arriving for medical care.<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=J. Am. Coll. Cardiol. |volume=50 |issue=7 |pages=e1–e157 |year=2007 |pmid=17692738 |doi=10.1016/j.jacc.2007.02.01|url=http://content.onlinejacc.org/cgi/content/full/50/7/e13}}</ref><ref name="pmid12383588">{{cite journal |author=Braunwald E, Antman EM, Beasley JW, ''et al'' |title=ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina) |journal=J. Am. Coll. Cardiol. |volume=40 |issue=7 |pages=1366–74 |year=2002 |pmid=12383588 |doi=|url=http://content.onlinejacc.org/cgi/content/full/50/7/652}}</ref>


The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI), a [[clinical prediction rule]], can help diagnose patients with chest pain and has been shown to improve medical care in a [[randomized controlled trial]].<ref name="pmid9867725">{{cite journal |author=Selker HP, Beshansky JR, Griffith JL, ''et al'' |title=Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial |journal=Ann. Intern. Med. |volume=129 |issue=11 |pages=845–55 |year=1998 |pmid=9867725 |doi=|url=http://www.annals.org/cgi/content/full/129/11_Part_1/845}} [http://www.infopoems.com/irsearch/display_article.cfm?resource=R&article=30 Online calculator at InfoRetriever]</ref><ref name="pmid2072767">{{cite journal |author=Selker HP, Griffith JL, D'Agostino RB |title=A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study |journal=Med Care |volume=29 |issue=7 |pages=610–27 |year=1991 |pmid=2072767 |doi=|url=http://www.jstor.org/view/00257079/ap060296/06a00030/0}}</ref>  
The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI), a [[clinical prediction rule]], can help diagnose patients with chest pain and has been shown to improve medical care in a [[randomized controlled trial]].<ref name="pmid9867725">{{cite journal |author=Selker HP, Beshansky JR, Griffith JL, ''et al'' |title=Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial |journal=Ann. Intern. Med. |volume=129 |issue=11 |pages=845–55 |year=1998 |pmid=9867725 |doi=|url=http://www.annals.org/cgi/content/full/129/11_Part_1/845}} [http://www.infopoems.com/irsearch/display_article.cfm?resource=R&article=30 Online calculator at InfoRetriever]</ref><ref name="pmid2072767">{{cite journal |author=Selker HP, Griffith JL, D'Agostino RB |title=A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study |journal=Med Care |volume=29 |issue=7 |pages=610–27 |year=1991 |pmid=2072767 |doi=|url=http://www.jstor.org/view/00257079/ap060296/06a00030/0}}</ref>  


The ACI-TIPI was studied up through 1993 before troponin assays were widely available and thus does not incorporate the troponin. However, the ACI-TIPI should retain its ability to use the medical history and the EKG to decide who should be observed for serial troponin levels.
The ACI-TIPI was studied up through 1993 before troponin assays were widely available and thus does not incorporate the troponin. However, the ACI-TIPI should retain its ability to use the medical history and the EKG to decide who should be observed for serial troponin levels. It is unclear why this role is not recognized by the ACC/AHA guidelines. One reason may be that the ACI-TIPI is patented.<ref name="USPAT5718233>{{cite web |url=http://www.google.com/patents?vid=USPAT5718233 |title=Continuous monitoring using a predictive instrument|author=Selker HP et al. |accessdate=2007-11-29 |format= |work=}}</ref><ref name="USPAT5724983">{{cite web |url=http://www.google.com/patents?vid=USPAT5724983 |title=Continuous monitoring using a predictive instrument|author=Selker HP et al. |accessdate=2007-11-29 |format= |work=}}</ref>


==Treatment==
==Treatment==

Revision as of 01:50, 30 November 2007

Classification

Unstable angina

Unstable angina is defined as "precordial pain at rest, which may precede a myocardial infarction".[1]

Myocardial infarction

For more information, see: Myocardial infarction.

A myocardial infarction is defined as "gross necrosis of the myocardium, as a result of interruption of the blood supply to the area".[2]

Diagnosis

Clinical practice guidelines jointly written by multiple expert groups anchor the diagnosis on troponin blood assays obtained within 6 hours and again within 8-12 hours of a patient arriving for medical care.[3][4]

The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI), a clinical prediction rule, can help diagnose patients with chest pain and has been shown to improve medical care in a randomized controlled trial.[5][6]

The ACI-TIPI was studied up through 1993 before troponin assays were widely available and thus does not incorporate the troponin. However, the ACI-TIPI should retain its ability to use the medical history and the EKG to decide who should be observed for serial troponin levels. It is unclear why this role is not recognized by the ACC/AHA guidelines. One reason may be that the ACI-TIPI is patented.[7][8]

Treatment

Clinical practice guidelines address the treatment of unstable angina and non-ST-elevation myocardial infarction.[3][4]

Prognosis

The Thrombolysis in Myocardial Infarction (TIMI) Risk Score is a clinical prediction rule that can predict the likelihood of morbidity in patients with unstable angina or NSTEMI.[9] The TIMI risk score is scored as one point for each of the following:

  • Age 65 years or older
  • At least 3 risk factors for coronary artery disease (family history or coronary heart disease, hypertension, hypercholesterolemia, diabetes, current smoking)
  • Prior coronary stenosis of 50% or more
  • ST-segment deviation on electrocardiogram at presentation
  • At least 2 anginal events in prior 24 hours
  • Use of aspirin in prior 7 days
  • Elevated serum cardiac markers

The GRACE Risk Score can also help predict which patients will have complications.

References

  1. ↑ National Library of Medicine. Unstable angina. Retrieved on 2007-10-28.
  2. ↑ National Library of Medicine. Myocardial infarction. Retrieved on 2007-10-28.
  3. ↑ 3.0 3.1 Anderson JL, Adams CD, Antman EM, et al (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". J. Am. Coll. Cardiol. 50 (7): e1–e157. DOI:10.1016/j.jacc.2007.02.01. PMID 17692738. Research Blogging.
  4. ↑ 4.0 4.1 Braunwald E, Antman EM, Beasley JW, et al (2002). "ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)". J. Am. Coll. Cardiol. 40 (7): 1366–74. PMID 12383588. [e]
  5. ↑ Selker HP, Beshansky JR, Griffith JL, et al (1998). "Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial". Ann. Intern. Med. 129 (11): 845–55. PMID 9867725. [e] Online calculator at InfoRetriever
  6. ↑ Selker HP, Griffith JL, D'Agostino RB (1991). "A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study". Med Care 29 (7): 610–27. PMID 2072767. [e]
  7. ↑ Selker HP et al.. Continuous monitoring using a predictive instrument. Retrieved on 2007-11-29.
  8. ↑ Selker HP et al.. Continuous monitoring using a predictive instrument. Retrieved on 2007-11-29.
  9. ↑ Antman EM, Cohen M, Bernink PJ, et al (2000). "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making". JAMA 284 (7): 835–42. PMID 10938172. [e] printable card

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