Diagnosing Acute Coronary Syndrome In An Accident And Emergency Department
Atypical presentations of Acute Coronary Syndrome (ACS) are common as ACS accounts for 25% of myocardial infarction. The mortality rate is high due to delay in diagnosis and treatment.
Acute Coronary Syndrome covers the following range of diagnoses:-
- Unstable angina
- Non-ST segment elevation myocardial infarction (NSTEMI)
- ST segment elevation myocardial infarction (STEMI)
The typical symptoms of ACS are:-
- Chest pain
- Pain radiating down one or both arms to the neck
- Nausea, vomiting, dizziness or light headaches, feeling faint, weakness and palpitations
- Pins and needles in one or both hands
- Anxiety
Every patient with cardiac chest pains should have a series of ECGs. However, it is the history of the chest pain which is more important than the ECG which is secondary to diagnosing the condition.
A competent physician will not send someone home with normal cardiac markers if there are other symptoms.
After the heart has an attack it requires more oxygen. The emphasis therefore is to slow the heart down with the appropriate drugs.
If unstable angina or NSTEMI is diagnosed, a patient will be admitted to a cardiac care unit for appropriate treatment. If a STEMI is diagnosed with a time onset of over 12 hours then the same thing will happen. However, if the STEMI is less than 12 hours then early Thrombolysis (the breakdown of blood clots by pharmacological means and colloquially known as clot busters) will be considered together with a procedure called Percutaneous Coronary Intervention (PCI) which is a therapeutic procedure used to treat narrowed coronary arteries of the heart. PCI is usually performed by an interventional cardiologist.
The main point is that the earlier the diagnosis and the earlier the treatment is given then a lot of myocardial muscle can be saved.
It is of note that the absence of chest pain in a diabetic who actually has Acute Coronary Syndrome is very common.
The risk factors for ACS are:-
- Smoking
- Hypotension
- Diabetes
- Mellitus
- High cholesterol
- Recent chest pain of cardiac origin
- Previous history
- Previous aspirin use for ACS
Minor risk factors are:-
- Male sex
- Use of drugs such as cocaine
- Age above 35 years
- Family history of ACS at a relatively young age
- Obesity
So why are so many patients admitted to the accident and emergency department who are actually suffering from Acute Coronary Syndrome not diagnosed?
Taking a proper history of the patient can be one reason, along with failing to recognise that the following could be signs of ACS:-
- Epigastric discomfort or pain
- Musculoskeletal pain without identifiable origin
- Pain lasting less than 15 minutes but occurring at frequent intervals
- Chest pain in the elderly
- An unwell diabetic without chest pain
- Chest pains in patient below the age of 35 years
- Cocaine or similar drug misuse
- Failure to stratify the risk
- Failing to identify and document patients who are not suitable for Thrombolitic therapy
Investigation Pitfalls
These are as follows:-
- A failure to document a reasonable time from the onset of chest pain or other symptoms suggestive of ACS
- A failure to perform serial ECGs and enzyme tests
- The assumption that a normal ECG or normal cardiac enzymes during pain excludes ACS
Should The Patient Have Been Admitted Or Discharged
The competent clinician should use 7 variables in patients with suspected ACS to make this decision:-
- In some one older than 65
- Whether there are 3 or more cardiac risk factors
- ST deviation
- Aspirin use within 7 days
- 2 or more anginal events over 24 hours
- A history of coronary stenosis
- Elevated troponin levels
In conclusion therefore it is important in the A &E department to recognise the different presentations of Acute Coronary Syndrome and to diagnose it within a short time frame and then start early treatment.
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