Acute coronary syndrome, or ACS, refers to the syndrome of patients presenting with a history compatible with acute myocardial ischemia. ACS encompasses myocardial infarction (MI), including ST elevation and non-ST elevation myocardial infarction, as well as unstable angina. A 12-lead electrocardiogram obtained and interpreted within ten minutes of the patient presenting to the emergency department is a vital triage tool to distinguish STEMI from NSTEMI. Obtaining serial cardiac biomarkers may be the only way to distinguish the difference between NSTEMI and unstable angina.
Acute coronary syndrome is suggested by the sudden onset of symptoms that lasted over thirty minutes and the substernal aching character of the pain. While symptoms may begin with exercise, they often occur without provocation.
Many patients do not perceive the symptoms of acute coronary syndrome as pain. They commonly describe the character of their symptoms as pressure or tightness. Other descriptions include heaviness, aching, distress, discomfort, squeezing, indigestion, burning, and numbness. Acute coronary syndrome may also occur with no symptoms, especially in the elderly or diabetic patient.
The location and radiation of the symptoms of acute coronary syndrome are also variable. It is typically substernal. Other locations and or areas of radiation include the jaw, shoulders, back, arms, wrists, and epigastrium.
Although the patient denied cocaine use, keep in mind that cardiac complications are THE most frequent cause of emergency department visits due to cocaine. This drug can cause ischemia, infarction, cardiomyopathy, and arrhythmias. Chest pain can develop within minutes of its use, although delays of many hours may occur. It is unrelated to dose or frequency of use. A major mechanism is endothelial dysfunction causing coronary spasm and the treatment is nitroglycerin. Beta blockers are contraindicated, since they may potentiate the vasospasm.