From the Guidelines
Acute chest syndrome (ACS) should be diagnosed and managed based on the clinical presentation and electrocardiogram (ECG) findings, with a focus on prompt recognition and treatment of the underlying cause, whether it be cardiac or non-cardiac in nature, to reduce morbidity, mortality, and improve quality of life. The diagnosis of ACS involves identifying the leading symptom, which is often acute chest discomfort described as pain, pressure, tightness, and burning, and may also include chest pain-equivalent symptoms such as dyspnoea, epigastric pain, and pain in the left arm 1. Based on the ECG, patients with ACS can be differentiated into two groups: those with persistent ST-segment elevation, which generally reflects an acute total or subtotal coronary occlusion, and those with non-ST-segment elevation ACS (NSTE-ACS), which may exhibit transient ECG changes 1. Key management strategies for ACS include:
- Immediate reperfusion by primary percutaneous coronary intervention (PCI) or fibrinolytic therapy for patients with ST-segment elevation ACS
- Aggressive medical management, including antiplatelet and anticoagulant therapy, for patients with NSTE-ACS
- Prompt evaluation and treatment of any underlying conditions that may be contributing to the development of ACS, such as coronary artery disease or sickle cell disease
- Close monitoring of the patient's clinical status, including frequent assessments of chest pain, vital signs, and ECG findings, to quickly identify any changes or worsening of the condition
- Consideration of the potential for ACS to rapidly progress to more severe complications, such as respiratory failure or cardiogenic shock, and the need for early recognition and aggressive management of these complications to reduce morbidity and mortality.
From the Research
Diagnosis of Acute Chest Syndrome (ACS)
- The diagnostic criteria for ACS include a new infiltrate on pulmonary imaging combined with any of the following: fever > 38.5°C (101.3°F), cough, wheezing, hypoxemia (PaO2 < 60 mm Hg), tachypnea, or chest pain 2
- Chest radiograph is considered the gold standard for imaging modality 2
- Diagnosis is made through physical exam, blood work, and chest imaging 2
Management of Acute Chest Syndrome (ACS)
- Management of ACS includes hydration with IV crystalloid solutions, antibiotics, judicious analgesia, oxygen, and, in severe cases, transfusion 2
- Blood transfusion is often used as a therapeutic intervention for ACS to increase blood's oxygen-carrying capacity and reduce complications by reducing hemoglobin S (HbS) percentage, based on the very low quality of the evidence about its efficacy 3
- The benefit of RBC transfusion for ACS has been described in case series and observational studies, but randomized studies comparing simple transfusion vs. exchange transfusions for ACS are lacking 3
- Early diagnosis and timely management of ACS results in better outcomes 4
Treatment Modalities for ACS
- Randomized controlled trials have evaluated the efficacy of different treatment modalities in ACS management, including incentive spirometry, positive expiratory pressure device, intravenous dexamethasone, oral vs. intravenous morphine, inhaled nitric oxide, unfractionated heparin, and blood transfusion 4
- Although there are guidelines for ACS treatment, the available evidence is very limited to delineating the effectiveness of various interventions in ACS management 4
- More high-quality studies and trials with a larger patient population can benefit this area to support the recommendations with stronger evidence 4