From the Guidelines
Acute coronary syndrome (ACS) typically presents with chest pain or discomfort that may feel like pressure, squeezing, fullness, or pain in the center or left side of the chest, and immediate medical attention is crucial if ACS is suspected, as prompt treatment significantly improves outcomes and reduces the risk of permanent heart damage or death. The symptoms of ACS can vary, but common presentations include pain radiating to the shoulders, arms (especially the left arm), neck, jaw, or back; shortness of breath; cold sweats; nausea or vomiting; lightheadedness or dizziness; and unusual fatigue 1. Women, elderly patients, and those with diabetes may experience atypical symptoms such as abdominal pain, indigestion, or just fatigue without prominent chest pain 1.
Key Symptoms and Signs
- Chest discomfort or pain that may feel like pressure, squeezing, fullness, or pain in the center or left side of the chest
- Pain radiating to the shoulders, arms (especially the left arm), neck, jaw, or back
- Shortness of breath
- Cold sweats
- Nausea or vomiting
- Lightheadedness or dizziness
- Unusual fatigue
- Atypical symptoms such as abdominal pain, indigestion, or just fatigue without prominent chest pain in women, elderly patients, and those with diabetes
Importance of Prompt Medical Attention
Prompt treatment of ACS is crucial to improve outcomes and reduce the risk of permanent heart damage or death 1. The American Heart Association estimates that approximately 70% of deaths from acute myocardial infarction (AMI) occur outside of the hospital, most within the first 4 hours after the onset of symptoms 1. Therefore, it is essential to recognize the symptoms of ACS and seek immediate medical attention if they occur.
Recommendations for Patients and Healthcare Providers
- Patients with symptoms of ACS should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives 1
- Healthcare providers should actively address the issues regarding ACS with patients with or at risk for coronary heart disease (CHD) and their families or other responsible caregivers, including how to recognize symptoms of ACS and the advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 minutes 1
- Prehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient 1
From the Research
Acute Coronary Syndrome Symptoms
- The most common presenting symptom of acute coronary syndrome (ACS) is chest discomfort at rest, affecting approximately 79% of men and 74% of women 2.
- Approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or in combination with chest pain 2.
- Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw 3.
- Chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS 3.
Diagnosis and Treatment
- Electrocardiography should be performed immediately (within 10 minutes of presentation) to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 2.
- High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 2.
- Aspirin is recommended for all patients with a suspected ACS unless contraindicated, and addition of a second antiplatelet is also recommended for most patients 4.
- Parenteral anticoagulation, statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine are other medical therapies that should be considered 4, 3.
Management and Treatment Options
- For patients with STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality 2.
- If PCI within 120 minutes is not possible, fibrinolytic therapy should be administered, followed by transfer to a facility with the goal of PCI within the next 24 hours 2.
- For high-risk patients with NSTE-ACS, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death 2.
- Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months is a common strategy, but high-potency and high- to low-potency DAPT may have a lower incidence of major adverse cardiovascular events 5.