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Acute coronary syndrome (ACS) encompasses unstable angina, ST-elevation myocardial infarction (STEMI), and non–ST-elevation myocardial infarction (NSTEMI). It is the symptomatic cardiac end-product of cardiovascular disease (CVD) resulting in reversible or irreversible cardiac injury, and even death.


The diagnosis of ACS requires two of the following: ischemic symptoms, diagnostic electrocardiogram (ECG) changes, and elevated serum marker of cardiac injury.


By themselves, signs and symptoms are not sufficient to diagnose or rule out acute coronary syndrome, but they start the investigatory cascade. Having known risk factors for coronary artery disease (CAD) (Table 19-1) increases the likelihood of ACS. Up to one-third of people with CAD progress to ACS with chest pain. Chest pain is the predominant symptom of ACS, but is not always present. Symptoms include:

Table 19-1. Risk Factors for Coronary Artery Disease

  • Typical or stable angina: substernal pain that occurs with exertion and alleviates with rest
  • Chest pain for >20 minutes
  • Dull, heavy pressure in or on the chest
  • Sensation of a heavy object on the chest
  • Chest pain radiating to the back, neck, jaw, left arm, or shoulder
  • Chest pain unaffected by inspiration
  • Chest pain not reproducible with chest palpation
  • Accompanying diaphoresis
  • Pain initiated by stress, exercise, large meals, sex, or any activity that increases the body's demand upon the heart for blood
  • Extreme fatigue or edema after exercise
  • Shortness of breath
    • This can be the only sign in the elderly
    • More common in black that white patients
    • More common in women than men
  • Right-sided chest pain, occasionally
    • More common in black patients
  • Levine's sign: chest discomfort described as a clenched fist over the sternum (the patient will clench his/her fist and rest it on or hover it over his/her sternum)
  • Angor Anami: great fear of impending doom/death
  • Pain high in the abdomen or chest, nausea, extreme fatigue after exercise, back pain, and edema can occur in anyone, but are more common in women
  • Nausea, lightheadedness, or dizziness
  • Less commonly:
    • Mild, burning chest discomfort
    • Sharp chest pain
    • Pain that radiates to the right arm ...

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