Acute Coronary Syndrome (ACS) vs. Chronic Coronary Syndrome (CCS)
Note: Stable Angina is NOT part of ACS. Stable angina is chest pain on exertion that is relieved by rest and or nitroglycerin. Stable angina is part of chronic coronary syndrome (CCS). CCS is also called chronic angina syndrome.
Acute Coronary Syndrome (ACS)
The three types/presentations of ACS are 1) Unstable angina (UA), 2) acute non-ST elevation myocardial infarction (NSTEMI), and 3) acute ST elevation myocardial infarction (STEMI). In other words, ACS is an umbrella term that covers three conditions: Unstable angina, NSTEMI, and STEMI.
“ACS is divided into ST-elevation MI (STEMI) and non-ST elevation ACS, which includes unstable angina and non–ST elevation MI (NSTEMI) because the two entities are often indistinguishable at presentation” AAFP 2017.
Another way to put it is that ACS= STE-ACS and NSTE-ACS. STEMI=STE-ACS and NSTE-ACS is made up of UA and NSTEMI
| Type of ACS | Description | EKG | Troponin | Coronary thrombosis | Action | |
| NSTE-ACS | UA | CP at rest/exertion, New-onset CP, Change in duration, exercise tolerance, frequency, timing, or associated symptoms. |
No ST elevation. EKG can be: -Normal, have T wave inversions, ST depression, Left or Right BBB, conduction delays, PVCs, etc. |
Negative.
UA produces symptoms suggestive of cardiac ischemia without elevated cardiac troponin levels |
Subtotal | Heparin drip / Parenteral anticoagulation. |
| NSTEMI | Persistent symptoms with elevated cardiac troponin levels but no ST-segment elevation. | No ST elevation. EKG can be: -Normal, have T wave inversions, ST depression, Left or Right BBB, conduction delays, PVCs, etc. |
Positive + Elevated (troponin) |
Subtotal | Heparin drip / parenteral anticoagulation.
Call cardiology. |
|
| STEMI | CP at rest | ST elevation. LBBB + Sgarbossa Criteria |
Positive ++ | Total | Call cardiology. Door-to-balloon time is 90 mins. Parenteral anticoagulation, cardiology to decided. |
|
Troponin rise 4-6 hours
Troponin peak 12 hours.
Give parenteral anticoagulant therapy in all patients with an acute non-ST elevation ACS (NSTEACS), which includes both unstable angina and acute non-ST elevation myocardial infarction.
“Myocardial infarction (MI), a subset of acute coronary syndrome, is damage to the cardiac muscle as evidenced by elevated cardiac troponin levels in the setting of acute ischemia.”AAFP 2017
Reference
https://www.ncbi.nlm.nih.gov/pubmed/21787900
Dr. Julie Sayegh, MD, an ER Physician, went over some of this material with me while on rotation with her. I have modified and added to it.
Am Fam Physician. 2017 Feb 15;95(4):232-240. http://www.aafp.org/afp/2017/0215/p232.html
Am Fam Physician. 2017 Feb 1;95(3):170-177. http://www.aafp.org/afp/2017/0201/p170.html