Diagnosis and management of acute coronary syndrome

The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min.