Acute Coronary Syndrome Diagnosis and Management

Introduction to Acute Coronary Syndrome

The European Society of Cardiology recommends that patients with chest pain should undergo urgent cardiac evaluation with ECG and troponin testing, regardless of current symptom absence, as nitroglycerin response does not reliably distinguish cardiac from non-cardiac chest pain 1
The European Society of Cardiology explicitly warns against using nitroglycerin response as a diagnostic maneuver, stating it "can be misleading" 1

A 12-lead ECG should be obtained within 10 minutes to look for ST-segment elevation, new Q-waves, T-wave inversions, or ST-segment depression suggesting ischemia, and compared with any prior ECGs if available 1, 2
Troponin and CK-MB levels should be obtained immediately, and serial troponins may be needed if initial values are normal but suspicion persists 2, 3

If ECG shows ST-elevation or new LBBB, the patient should be diagnosed with STEMI and emergency reperfusion protocol should be activated immediately, regardless of current symptom status 1, 2
If ECG shows ST-depression, T-wave inversions, or troponin elevation, the patient should be diagnosed with NSTEMI/unstable angina, admitted for cardiology evaluation, and considered for early angiography within 24 hours 1, 3
If ECG and initial troponins are normal, the patient still requires observation with serial troponins at 3-6 hours, and consideration of stress testing or coronary CT angiography before discharge if biomarkers remain negative 3

Atypical symptoms such as dyspnea, nausea, or fatigue may be present in elderly patients, women, and diabetics, and should not delay cardiac evaluation 2, 3
Even complete symptom resolution does not exclude ongoing acute coronary syndrome, and silent ischemia and intermittent coronary occlusion can present this way 3

The patient should be educated on the importance of seeking immediate medical attention if chest pain recurs or worsens, and instructed not to take more than 3 nitroglycerin doses before seeking emergency care 3
The exact nature of the chest pain should be documented, including location, radiation, duration, associated symptoms, and response to nitroglycerin 2