Acute coronary syndrome
Aortitis as a
cause of acute coronary syndrome. Severe ostial stenosis of the LMA
Aortitis as a
cause of acute coronary syndrome. Severe RCA ostial stenosis
Acute coronary syndrome (ACS) is a group of cardiac diagnoses along a spectrum of severity due to the interruption of coronary blood flow to the myocardium, which in decreasing severity are:
- ST elevation myocardial infarction (STEMI)
- non-ST elevation myocardial infarction (NSTEMI)
- unstable angina
Stable angina is not considered an ACS.
Epidemiology
Of all patients who present to emergency departments with symptoms of ACS, only 20-25% will have ACS confirmed as their discharge diagnosis .
Pathology
Etiology
The most common cause by far is atherosclerotic plaque rupture in coronary artery disease. Other less common causes include:
- aortic or coronary artery dissection
- vasculitis
- connective tissue diseases
- drugs: cocaine
- coronary artery spasm
Unusual variants:
- Kounis syndrome: allergic / hypersensitivity precipitant
Differential diagnosis
Several other pathological entities may mimic an acute coronary syndrome in both electrocardiographic appearance and clinical presentation;
- the differential diagnosis for ST segment elevation on the ECG includes :
- myocarditis and/or pericarditis
- left ventricular hypertrophy
- left ventricular aneurysm
- Tako-tsubo cardiomyopathy
- electrolyte abnormalities
- including hyperkalemia and hypercalcemia
- acute pulmonary embolism
- coronary artery vasospasm
- acute CNS pathology
- including subarachnoid hemorrhage and intracranial hemorrhage
- benign early repolarization
- elevated intraabdominal/intrathoracic pressure
- critically ill patients with free fluid and/or air in their thorax/abdominal cavity may, rarely, present with bizarre ECG patterns, including ST segment elevations
- the "spiked helmet sign" refers to the characteristic appearance of the sharp upstroke of the baseline leading into ST elevation
- most commonly noted to occur in massive gastric dilatation, small bowel obstruction, and pneumothorax
- critically ill patients with free fluid and/or air in their thorax/abdominal cavity may, rarely, present with bizarre ECG patterns, including ST segment elevations
Other serious causes of acute chest pain which may mimic the presentation of ACS include;
- thoracic aortic dissection
- esophageal rupture
- pulmonary embolism
- pneumothorax
- cardiac tamponade
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