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[[Congestive heart failure digoxin|Digoxin]]
;Shown below is an image that summarizes the steps in the chronic management of patients with heart failure.
{| class="wikitable
!ACE-I !! Starting dose!! Target dose
|-
| Captopril||align="center"|6.25 mg t.i.d.||align="center"|50 mg t.i.d.
|-
| Enalapril||align="center"|2.5 mg b.i.d.||align="center"|10-20 mg b.i.d.
|-
| Lisinopril||align="center"|> 2.5-5 mg daily||align="center"| 20-35 mg daily
|-
| Ramipril||align="center"|> 2.5 mg b.i.d.||align="center"| 5 mg b.i.d.
|-
| Trandolapril||align="center"|> 0.5 mg daily||align="center"| 4 mg daily
|}
: '''[[Congestive heart failure acute pharmacotherapy|Acute Pharmacotherapy]]'''
: '''[[Congestive heart failure with preserved EF pharmacotherapy|Chronic Pharmacotherapy in HFpEF]]
:'''[[Congestive heart failure treatment of underlying causes|Treatment of underlying causes]] | [[Congestive heart failure treatment of associated conditions|Associated conditions]]'''
: [[Congestive heart failure biventricular pacing or cardiac resynchronization therapy|Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)]] | [[Congestive heart failure implantation of intracardiac defibrillator|Implantation of Intracardiac Defibrillator]] | [[Congestive heart failure ultrafiltration|Ultrafiltration]] | [[Congestive heart failure left ventricular assist devices|Left Ventricular Assist Devices (LVADs)]] | [[Congestive heart failure cardiac transplantation|Cardiac Transplantation]] | [[Congestive heart failure cardiac surgery|Cardiac Surgery]]
: '''[[Chronic Pharmacotherapy|Chronic Pharmacotherapy in HFrEF]]:'''
:'''[[Congestive heart failure drugs to avoid|Drugs to Avoid]] | [[Congestive heart failure drug interactions|Drug Interactions]]'''
  | |  |  | [[Congestive heart failure calcium channel blockers|Ca Channel Blockers]] | [[Congestive heart failure vasodilators|Nitrates]] | [[Congestive heart failure vasodilators|Hydralazine]] | [[Congestive heart failure positive inotropics|Positive Inotropics]] | [[Congestive heart failure anticoagulants|Anticoagulants]] |  | [[Congestive heart failure antiarrhythmic Drugs|Antiarrhythmic Drugs]] | [[Congestive heart failure other pharmacotherapies#Nutritional Supplements|Nutritional Supplements]] | [[Congestive heart failure other pharmacotherapies#Hormonal Therapies|Hormonal Therapies]] | [[Congestive heart failure lifestyle modification|Lifestyle modification]]
: '''[[Device therapy for heart failure with reduced ejection fraction]]''': [[Implantable cardioverter-defibrillator]] | [[Cardiac resynchronization therapy]] | [[ Devices under evaluation]]
*Efficacy: Low
*Efficacy: Low
**Sinus rhythm is maintained in <20% of patients
**Sinus rhythm is maintained in <20% of patients
Line 148: Line 189:
* The newer VAST-D trial found that augmentation with [[aripiprazole]] is effective.<ref name="pmid28697253"/> The dose of aripiprazole  was 2 mg of with titration to 5, 10, or 15 mg daily as guided by measurement-based care using the PHQ-9.<ref name="pmid28697253"/> ''However'', aripiprazole led to more [[adverse drug reaction]]s including somnolence, akathisia, and weight gain. The second most effective was augmentation with [[buproprion]] starting at 150 mg sustained release to 300 mg or 400 mg daily as guided by measurement-based care using the PHQ-9.
* The newer VAST-D trial found that augmentation with [[aripiprazole]] is effective.<ref name="pmid28697253"/> The dose of aripiprazole  was 2 mg of with titration to 5, 10, or 15 mg daily as guided by measurement-based care using the PHQ-9.<ref name="pmid28697253"/> ''However'', aripiprazole led to more [[adverse drug reaction]]s including somnolence, akathisia, and weight gain. The second most effective was augmentation with [[buproprion]] starting at 150 mg sustained release to 300 mg or 400 mg daily as guided by measurement-based care using the PHQ-9.


* More recently, [[mirtazapine]], was found not to add to SSRIs<ref name="pmid30381374">{{cite journal| author=Kessler DS, MacNeill SJ, Tallon D, Lewis G, Peters TJ, Hollingworth W et al.| title=Mirtazapine added to SSRIs or SNRIs for treatment resistant depression in primary care: phase III randomised placebo controlled trial (MIR). | journal=BMJ | year= 2018 | volume= 363 | issue=  | pages= k4218 | pmid=30381374 | doi=10.1136/bmj.k4218 | pmc=6207929 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30381374  }} </ref>.
* More recently, [[mirtazapine]], was found not to add to SSRIs<ref name="pmid30381374">{{cite journal| author=Kessler DS, MacNeill SJ, Tallon D, Lewis G, Peters TJ, Hollingworth W et al.| title=Mirtazapine added to SSRIs or SNRIs for treatment resistant depression in primary care: phase III randomised placebo controlled trial (MIR). | journal=BMJ | year= 2018 | volume= 363 | issue=  | pages= k4218 | pmid=30381374 | doi=10.1136/bmj.k4218 | pmc=6207929 | url=https://www.ncbi.nlm.n
 
{| class="wikitable" align="right"
|+ Treatment after SSRI ([[citalopram]]) failure<br/>([http://www.nimh.nih.gov/trials/practical/stard/ STAR*D] Studies)
! colspan="2"|Intervention!!colspan="2"|Outcome
|-
! Medication!! Mean final dose!!Remission %!! Quit 2˚ [[Drug toxicity|ADR]]s (%)
|-
| colspan="4"| Switch meds (NEJM 2006; PMID: 16554525<ref name="pmid16554525">{{cite journal| author=Rush AJ, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME et al.| title=Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 12 | pages= 1231-42 | pmid=16554525 | doi=10.1056/NEJMoa052963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16554525  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17065297 Review in: Evid Based Ment Health. 2006 Nov;9(4):100] </ref>)
|-
| [[Bupropion]] SR||align="right"|283 mg||align="center"|21%||align="center"|27%
|-
| [[Sertraline]] (SSR)||align="right"|136 mg||align="center"| 18%||align="center"|21%
|-
| [[Venlafaxine]] ER (SNRI)||align="right"|194 mg||align="center"| 25%||align="center"|21%
|-
| colspan="4"| Augment meds (NEJM 2006; PMID: 16554526<ref name="pmid16554526">{{cite journal| author=Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D et al.| title=Medication augmentation after the failure of SSRIs for depression. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 12 | pages= 1243-52 | pmid=16554526 | doi=10.1056/NEJMoa052964 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16554526  }} </ref>)
|-
| [[Bupropion]] SR||align="right"|268 mg||style="background-color:lightgreen;text-align:center"|30%||align="center"|13%
|-
| [[Buspirone]]||align="right"|41 mg|| style="text-align:center"|30% || style="background-color:coral;text-align:center"|21%
|}
 
The STAR*D trial has reported the frequency of re-emergence of suicidality for different second levels of treatment.<ref>http://dx.doi.org/10.4088/JCP.12m07777</ref>
 
In level 3 of the STAR*D trials, patients who had failed two trials of a [[second-generation antidepressant]], tended to better with [[nortriptyline]] than [[mirtazapine]].<ref name="pmid16816220">{{cite journal| author=Fava M, Rush AJ, Wisniewski SR, Nierenberg AA, Alpert JE, McGrath PJ et al.| title=A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report. | journal=Am J Psychiatry | year= 2006 | volume= 163 | issue= 7 | pages= 1161-72 | pmid=16816220 | doi=10.1176/appi.ajp.163.7.1161 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16816220  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17255385 Review in: Evid Based Ment Health. 2007 Feb;10(1):16] </ref>
 
[[Aripiprazole]], originally introduced as an atypical antipsychotic agent, is approved as an adjunct to other antidepressants.<ref>{{citation
| title = Beneficial acute antidepressant effects of aripiprazole as an adjunctive treatment or monotherapy in bipolar patients unresponsive to mood stabilizers: results from a 16-week open-label trial
| date = December 2008 | volume = 9 | issue = 18 | pages = 3145-3149 | doi =10.1517/14656560802504490
| journal = Expert Opinion on Pharmacotherapy
| author = Marianna Mazza, Maria Rosaria Squillacioti1, Riccardo Daniele Pecora, Luigi Janiri1 & Pietro Bria
| url = http://informahealthcare.com/doi/abs/10.1517/14656560802504490}}</ref>
 
===Stopping medications===
Patients are generally advised not to stop taking an antidepressant suddenly and to continue its use for at least four to months to prevent the chance of recurrence.<ref name="ngc24158 >American Psychiatric Association (APA). [http://www.guideline.gov/content.aspx?id=24158 Practice guideline for the treatment of patients with major depressive disorder]. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p. [1170 references]</ref> For patients that have chronic depression, medication may need to be continued for the remainder of their life.
 
 
Patients should be treated indefinitely if they have "three or more prior major depressive episodes or who have chronic major depressive disorder should proceed to the maintenance phase of treatment after completing the continuation phase."<ref name="ngc24158 >American Psychiatric Association (APA). [http://www.guideline.gov/content.aspx?id=24158 Practice guideline for the treatment of patients with major depressive disorder]. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p. [1170 references]</ref>
 
 
{| class="wikitable"
| colspan="3" align="center" style="background: #4479BA; color: #FFFFFF " |'''Distinguishing the Jugular Venous Pulse frm the Carotid Pulse'''
|-
| align="center" |'''Feaure'''
| align="center" |'''Internal Jugular Vein'''
| align="center" |'''Carotid Artery'''
|-
|[[Appearance of pulse]]
 
|Biphasic
 
|Monophasic
 
|-
|Response to inspiration
|Inspiration generally decreases the pressure (the height of column decrease and troughs become more prominent)
|No respiratory change
 
 
|-
|Pulpabillity
|Not palpable (exception: severe TR)
|Palpable
|-
|Effect of pressure
 
 
|
|}
 
 
 
 
 
 
{| class="wikitable"
| colspan="3" align="center" style="background: #4479BA; color: #FFFFFF " |'''Distinguishing the Jugular Venous Pulse frm the Carotid Pulse'''
|-
| align="center" |'''Feaure'''
| align="center" |'''Internal Jugular Vein'''
| align="center" |'''Carotid Artery'''
|-
|[[Appearance of pulse]]
 
|Biphasic
 
|Monophasic
 
|-
|Response to inspiration
|Inspiration generally decreases the pressure (the height of column decrease and troughs become more prominent)
|No respiratory change
 
 
|-
|Pulpabillity
|Not palpable (exception: severe TR)
|Palpable
|-
|Effect of pressure
 
 
|
|}
 
==Table==
 
 
{| class="wikitable"
| colspan="5" align="center" style="background: #4479BA; color: #FFFFFF " |'''Therapies to maintain sinus rhythm'''
|-
| align="center" |'''Treatment'''
| align="center" |'''Efficacy'''
| align="center" |'''Adverse effects'''
| align="center" |'''Contraindications'''
| align="center" |'''Precausions'''
|-
| colspan="5" align="left" style="background: #4479BA; color: #FFFFFF " |'''Drug therapy'''
|-
|[[Beta-blockers]]
|
*Low
*Sinus rhythm is maintained in <20% of patients
*Symptoms are reduced in >=20% of patients
|
*Fatigue
*Bradycardia
*Monitor for bradycardia
|
*Bradycardia
*Hypotension
|
*Monitor for bradycardia
|-
|Nondihydropyridine Calcium Channel Blockers:
*[[Verapamil]]
*[[Diltiazem]]
|
*Low
*Sinus rhythm is maintained in <20% of patients
*Symptoms are reduced in >=20% of patients
|
*Edema
*Bradycardia
*Hypotension
|
*[[Bradycardia]]
*[[Hypotension
*[[Heart failure with reduced ejection fraction]]
|
|-
|[[Flecainide]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*Uncommon
*Proarrhythmia risk in patients with structural heart disease
|
*Structural heart disease (proarrhythmia risk)
|
*Evaluate for ischemic heart disease before initiation of therapy
|-
|[[Propafenone]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*Dysgeusia
|
*Structural heart disease (proarrhythmia risk)
|
*Evaluate for ischemic heart disease before initiation of therapy
|-
|[[Quinidine]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*Gastrointestinal side effects
|
*QT prolongation
|
*Monitor for QT prolongation, polymorphic ventricular tachycardia
|-
|[[Disopyramide]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*Antimuscarinic effects
*Urinary retention
|
*QT prolongation
*Heart failure
|
*Monitor for QT prolongation,
|-
|[[Dronendrone]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*Uncommon
|
*Heart failure
|
*Monitor for:
**Fluid retention
**Hepatitis
|-
|[[Dofetilide]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*QT prolongation
|
*QT prolongation
*Advanced renal disease
|
*Monitor for QT prolongation (should be initiated in hospital)
|-
|[[Sotalol]]
|
*Moderate
*AF is prevented or reduced in 50-70% of patients
|
*QT prolongation
*Fatigue
*Bradycardia
*Hypotension
|
*QT prolongation
*Advanced renal disease
*Bradycardia
|
*Monitor for QT prolongation
|-
|[[Amiodarone]]
|
*High
*AF is prevented or reduced in 80% of patients
|
*Bradycardia
*Thyroid diseases
*Hepatitis
*Interstitial lung disease (pulmonary fibrosis)
*Neurologic dysfunction
*Photosensitivity
|
*Bradycardia
*Hyperthyroidism
|
*Monitor for systemic toxicities involving the thyroid, liver, lungs, and nervous system
*Monitor for druginteractions
|-
| colspan="5" align="left" style="background: #4479BA; color: #FFFFFF " |'''Interventional procedures'''
|-
|[[Catheter ablation]]
|
*High
**60-80% of patients with paroxysmal AF are free from AF at 1 year
**50% of patients with persistent AF are free from AF at 1 year
**Reduced AF burden
|
*Procedure-related adverse effects
*Risks associated with sedation and anesthesia
*Transient arrhythmia (for 3 months)
*For patients with persistent AF, a second procedure s often needed
|
|
|-
|Surgery ([[Maze procedure]])
|
*High
*AF is prevented in 80% patients
|
*Risks associated with anesthesia and surgery
|
*Surgical contraindications
|
*Monitor for complications of surgery
|-
|}
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link=Acute coronary syndrome resident survival guide]]|| <br> || <br>
| [[Acute coronary syndrome resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Acute coronary syndrome}}
{{CMG}} {{AE}} {{YK}}; {{TarekNafee}}; {{sab}}
 
{{SK}} ACS
 
<small>
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="3" |<small>Symptoms</small>
! colspan="3" |<small>Physical Examination</small>
! colspan="4" |<small>Diagnostic tests
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>Dyspnea on Exertion</small>
!<small>Chest Pain</small>
!<small>Hemoptysis</small>
!<small>Fever</small>
!<small>Tachypnea</small>
!<small>Tachycardia</small>
!<small>Chest X-ray</small> 
!<small>ECG</small>
!<small>Echocardiography>
!<small>CT scan and CMRI</small>
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated heart failure|COVID-19-associated heart failure]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiomegaly]]
*[[Pulmonary edema]] (interstitial, alveolar)
| style="background: #F5F5F5; padding: 5px;" |
*[[Left ventricular hypertrophy]]
*[[Low-voltage]] QRS
*Non-specific ST-T change
| style="background: #F5F5F5; padding: 5px;" |
*Systoloic dysfunction (in HFrEF)
*Diastoic dysfunction (in HFpEF)
*[[COVID-19-associated stress cardiomyopathy|COVID-19-associated stress cardiomyopathy]] [[(apical ballooning)]]
| style="background: #F5F5F5; padding: 5px;" |
*CT: [[Cardiomegaly]], [[Pulmonary edema]]
*CMR: Signs of underlying [[myocarditis]] may be seen.
| style="background: #F5F5F5; padding: 5px;" | Increased [[NT-proBNP]] and cardiac [[troponin]]s levels
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |✔ (Usually high)
| style="background: #F5F5F5; padding: 5px;" |✔ ([[Pleuritic]])
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Lobar Consalidation]]
| style="background: #F5F5F5; padding: 5px;" |
*Prolonged PR interval
*Transient T wave inversions
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*CT: [[Lobar Consalidation]]
| style="background: #F5F5F5; padding: 5px;" | Increased inflammatory markers, including [[ESR]], [[hs-CRP]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated acute respiratory distress syndrome|COVID-19-associated acute respiratory distress syndrome
]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*Bilateral [[ground-glass opacities]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*Signs of RV dysfunction/RV dilatation may be seen.
| style="background: #F5F5F5; padding: 5px;" |
*CT: Bilateral [[ground-glass opacities]]
| style="background: #F5F5F5; padding: 5px;" | -
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated myocarditis]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Pericardial effusion]] may be detectable
| style="background: #F5F5F5; padding: 5px;" |
* Non-specific:may show nonspecific ST-T abnormalities, [[sinus tachycardia]] and [[conduction abnormalities]] (such as bundle-branch blocks or atrioventricular conduction delays)
| style="background: #F5F5F5; padding: 5px;" |
*Non-specific: In [[fulminant myocarditis]], cardiac chamber sizes are usually normal with an increased septal thickness (secondary to acute myocardial edema), whereas in acute [[myocarditis]] marked left ventricular dilation and normal wall thickness might be seen.
*[[Pericardial effusion]] may be be seen.
| style="background: #F5F5F5; padding: 5px;" |
*CMR: T2-weighted edema imaging shows the presence of “acute myocardial inflammation”. "[[Late gadolinium enhancement (LGE)]] imaging” can demonstrate myocardial damage.
| style="background: #F5F5F5; padding: 5px;" | Increased cardiac [[troponin]]s level
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated pulmonary embolism]]
| style="background: #F5F5F5; padding: 5px;" |✔ (Usually sudden-onset)
| style="background: #F5F5F5; padding: 5px;" |✔ ([[Pleauritic]])
| style="background: #F5F5F5; padding: 5px;" |✔ (If massive PE)
| style="background: #F5F5F5; padding: 5px;" |✔ (Low-grade)
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*May show [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton hump]], [[Westermark's sign]]
| style="background: #F5F5F5; padding: 5px;" |
* Non-specific:may show [[S1Q3T3]] pattern
| style="background: #F5F5F5; padding: 5px;" |
*May show signs of RV strain, Rv dilatation, Rv dysfunction (if large PE)
| style="background: #F5F5F5; padding: 5px;" |
*On CT angiography: Intra-luminal filling defect
*On MRI: Narrowing of involved vessel
*No contrast seen distal to obstruction
*Polo-mint sign (partial filling defect surrounded by contrast)
| style="background: #F5F5F5; padding: 5px;" |
*Increased [[D-dimer]], [[fibrinogen]], and [[fibrin degradation products]] levels
*May have symptoms and/or signs of accompanying [[DVT]]
 
==Classification==
Acute coronary syndrome may be classified as follows:
 
* [[Unstable Angina]]
* [[Non ST Elevation Myocardial Infarction]]
* [[ST Elevation Myocardial Infarction]]
==Symptoms==
The signs and symptoms of acute coronary syndrome include:
*[[Chest pain]]
:*[[Chest pain|Substernal chest pain]]
:*Occurs at rest or [[exertion]]
:*Radiation to neck, jaw, left shoulder and left arm
:*Aggravated by physical activity and emotional stress
:*Relieved by rest, [[nitroglycerin]] or both
*Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
*[[Dyspnea]]
*[[Diaphoresis]]
*[[Nausea]] and [[vomiting]]
*[[Fatigue]]
*[[Syncope]]
 
==Pathophysiology==
For more information on atherosclerotic plaque, click [[Atherosclerosis |here]].
 
The pathophysiology of acute coronary syndromes depends on [[atherosclerosis|coronary atherosclerotic plaque]] which includes:
 
'''Initiation and Progression of Coronary Atherosclerotic Plaque'''
*The [[endothelium]] of [[coronary arteries]] are damaged by the risk factors resulting in [[endothelium|endothelial dysfunction]], leading to the formation of [[Atherosclerosis|atherosclerotic plaque]].
*The [[macrophages]] in the atherosclerotic plaque release matrix [[metalloproteinases]], leading to plaque disruption.
*The balance between [[smooth muscle cells]] and [[macrophages]] in the plaque plays a major role in plaque vulnerability and the propensity to rupture.
'''Plaque Vulnerability'''
 
The plaque vulnerability depends on the following factors:<ref name="pmid10330380">{{cite journal| author=Sukhova GK, Schönbeck U, Rabkin E, Schoen FJ, Poole AR, Billinghurst RC et al.| title=Evidence for increased collagenolysis by interstitial collagenases-1 and -3 in vulnerable human atheromatous plaques. | journal=Circulation | year= 1999 | volume= 99 | issue= 19 | pages= 2503-9 | pmid=10330380 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10330380  }} </ref>
*[[Inflammation]] (A high density of [[macrophages]] and [[T-lymphocytes]] are marker of unstable [[atherosclerotic plaque]])
*Large [[lipid]] core
*Locally increased matrix [[metalloproteinases]] that degrade [[collagen]]
*Thin [[fibrous cap]]
*Relative paucity of [[smooth muscle cells]]
*Increase in plaque [[Neovascularization|neovascularity]] and plaque [[hemorrhage]]
*Eccentric outward remodelling
 
===Pathogenesis===
 
The pathogenesis of acute coronary syndrome depends on:
*[[Endothelium|Endothelial integrity]]
*[[Inflammation]]
*[[Thrombogenicity]] of the blood
 
Following [[atherosclerosis|plaque]] rupture or endothelial erosion, the subendothelial matrix is exposed to the circulating [[platelets]], which get activated leading to [[thrombus]] formation. Two types of thrombi can form:
*White clots: Platelet-rich [[thrombi|clots]] which partially occludes the artery
*Red clots: [[Fibrin]] rich clots superimposed on white clots and cause total occlusion of the artery
 
==Risk Factors==
Common risk factors in the development of acute coronary syndrome are:<ref name="pmid3286036">{{cite journal| author=Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J| title=Insights into the pathogenesis of acute ischemic syndromes. | journal=Circulation | year= 1988 | volume= 77 | issue= 6 | pages= 1213-20 | pmid=3286036 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3286036  }} </ref>
*Age (men >45 and women >55)
*[[Diabetes mellitus]]
*[[Hypercholesterolemia]]
*[[Hypertension]]
*[[Smoking]]
*[[Obesity]]
*Lack of physical activity
*Family history of [[heart disease]]
*History of [[HTN]], [[DM]] and [[pre-eclampsia]] during [[pregnancy]]
 
==Diagnosis==
 
===High-sensitivity Cardiac Troponin (hs-cTn)===
{| class="wikitable"
 
|- caption = "High sensitivity cardiac troponin assays"
 
!
! 99th percentile of a healthy reference population<br/>(recommended cut-off)
! Turnaround time
! Name and manufacturer
! FDA Approval?
|-
! Troponin T<br />hs-cTnT
| 14 ng/L<ref name="pmid29691270" />
| 18 minutes<ref name="pmid25646632" />
| Elecsys<br/>(Roche Diagnostics)
|
|-
! Troponin I<br />hs-cTnI
| 26.2 ng/L<ref name="pmid29691270" />
|
| ARCHITECT''STAT''<br/>(Abbott Laboratories)
|
|}
 
=== Clinical Implications of High-sensitivity Cardiac Troponin Assays ===
{| class="wikitable"
|+
!Compared with standard cardiac troponin assays, high-sensitivity assays:
|-
|Have higher negative predictive value for acute MI.
|-
|Reduce the “troponin-blind” interval leading to earlier detection of acute MI.
|-
|Reduce the “troponin-blind” interval leading to earlier detection of acute MI.
|-
|Are associated with a 2-fold increase in the detection of type 2 MI.
|-
!Levels of high-sensitivity cardiac troponin should be interpreted as quantitative markers of cardiomyocyte damage
 
(i.e. the higher the level, the greater the likelihood of MI):
|-
|Elevations beyond 5-fold the upper reference limit have high (>90%) positive predictive value for acute type 1 MI.
|-
|Elevations up to 3-fold the upper reference limit have only limited (50–60%) positive predictive value for acute MI
 
and may be associated with a broad spectrum of conditions.
|-
|It is common to detect circulating levels of cardiac troponin in healthy individuals.
|-
!Rising and/or falling cardiac troponin levels differentiate acute from chronic cardiomyocyte damage
 
(the more pronounced the change, the higher the likelihood of acute MI).
|-
|<small>Adapted from ''European Heart Journal'' (2016) 37, 267–315</small>
|}
 
 
 
 
Available high sensitivity troponin assays:
 
* Troponin T: Elecsys by Roche Diagnostics
* Troponin  I: ARCHITECT''STAT'' by Abbott Laboratories
 
When both tests have sensitivity of > 99%, cTnT can exclude infarction in more patients with a sensitivity of 90% according to meta-analysis.
 
The agreement between hscTnT and hscTnI measurements is excellent (Cohen's kappa =0.9)<ref name="pmid29691270">{{cite journal| author=van der Linden N, Wildi K, Twerenbold R, Pickering JW, Than M, Cullen L et al.| title=Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction. | journal=Circulation | year= 2018 | volume= 138 | issue= 10 | pages= 989-999 | pmid=29691270 | doi=10.1161/CIRCULATIONAHA.117.032003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29691270  }} </ref>.
 
High sensitivity troponin levels have reduced predictive value when prevalence is low.
 
===Clinical Prediction Rules===
 
[[Clinical prediction rule]]s can help diagnose:
 
* HEART risk score (History, EKG, Age, Risk factors, and troponin) is the only one of these three prediction rules designed for use prior to diagnosis
* [[The GRACE risk score|GRACE risk score]] incorporates 8 findings
* [[TIMI risk score]]
Regarding the comparative performance of the prediction rules:
 
* In the setting of acute chest pain, the HEART score  may best predict complications according to a [[cohort study]].
*In the setting of NSTEMI, the [[The GRACE risk score|GRACE risk score]] may best predict complications according to a [[cohort study]]. However, the HEART risk score was not assessed in this cohort.
 
===Diagnostic Pathways===
 
Clinical diagnostic pathways may help. The European Society of Cardiology recommends two pathways<ref name="pmid26320110">{{cite journal| author=Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F et al.| title=2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2016 | volume= 37 | issue= 3 | pages= 267-315 | pmid=26320110 | doi=10.1093/eurheartj/ehv320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26320110  }} </ref>:
 
* 0 h/3 h
* 0 h/1 h<ref name="pmid30071991">{{cite journal| author=Twerenbold R, Neumann JT, Sörensen NA, Ojeda F, Karakas M, Boeddinghaus J et al.| title=Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction. | journal=J Am Coll Cardiol | year= 2018 | volume= 72 | issue= 6 | pages= 620-632 | pmid=30071991 | doi=10.1016/j.jacc.2018.05.040 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30071991  }} </ref><ref name="pmid27754881">{{cite journal| author=Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S et al.| title=Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. | journal=Circulation | year= 2016 | volume= 134 | issue= 20 | pages= 1532-1541 | pmid=27754881 | doi=10.1161/CIRCULATIONAHA.116.022677 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27754881  }} </ref>
The last American Health Association guidelines were prepared prior to approval of hs-cTn tests by the FDA.
 
More recent strategies include:
 
* Single cTnT measurement, combined with a non-ischemic EKG, that reports troponin is below the limits of detection.
 
* Single cTnI measurement, combined with low-risk clinical prediction rule<ref name="pmid29622596">{{cite journal| author=Reaney PDW, Elliott HI, Noman A, Cooper JG| title=Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events. | journal=Emerg Med J | year= 2018 | volume= 35 | issue= 7 | pages= 420-427 | pmid=29622596 | doi=10.1136/emermed-2017-207172 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29622596  }} </ref>
 
==Differential Diagnosis==
Diagnosis of ACS is initiated by a clinical suspicion based on a thorough history of the patient's symptoms. Subsequently, confirmatory tests should be ordered to confirm the diagnosis, identify the specific cause of ACS, or to rule out other possible differentials. In some circumstances, utilizing a clinical prediction tool may be beneficial in guiding the clinician's diagnosis. View the page on [[Clinical prediction rule#Acute MI / Unstable Angina|diagnosis using the clinical prediction rule]] for ACS for more detail.
Acute Coronary Syndrome (ACS) may be differentiated from other diseases as follows:
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |<small>Organ System</small>
! rowspan="3" |<small>Diseases</small>
! colspan="10" |<small>Presentation</small>
! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
! colspan="6" rowspan="2" |<small>Past Medical History</small>
! rowspan="3" | <SMALL>Other Findings</SMALL>
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="5" |<SMALL>Chest Pain</SMALL>
! colspan="3" |<SMALL>GI Symptoms</SMALL>
!<SMALL>Pulmonary</SMALL>
!<SMALL>Neck</SMALL>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<SMALL><SMALL>On Palpation</SMALL></SMALL>
!<SMALL><SMALL>On inspiration</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
!<SMALL><SMALL>With Movement</SMALL></SMALL>
!<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
!<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
!<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
!<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
!<SMALL><SMALL>Jugular
Distention</SMALL></SMALL>
!<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
!<SMALL><SMALL>CBC Findings</SMALL></SMALL>
!<SMALL><SMALL>ESR</SMALL></SMALL>
!<SMALL><SMALL>D-Dimer</SMALL></SMALL>
!<SMALL><SMALL>EKG
Findings</SMALL></SMALL>
!<SMALL><SMALL>CXR Findings</SMALL></SMALL>
!<SMALL><SMALL>DM</SMALL></SMALL>
!<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
!<SMALL><SMALL>Obesity</SMALL></SMALL>
!<SMALL><SMALL>Trauma</SMALL></SMALL>
!<SMALL><SMALL>Inxn*</SMALL></SMALL>
!<SMALL><SMALL>Htn</SMALL></SMALL>
|-
! rowspan="5" style="background: #DCDCDC; padding: 5px; text-align: center;" |<small>Cardiovascular</small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>Acute Coronary Syndrome</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |<small>•[[Palpitation|Palpitations]]</small>
 
<small>•[[Perspiration|Sweating]]</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Aortic dissection|Aortic Dissection]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |<small>•Pain maximal upon onset</small> <small>•Pain difficult to treat with opiates</small>
 
<small>•'''Weak pulse in one arm compared to other'''</small>
 
<small>•[[Syncope]]</small>
 
<small>•Symptoms similar to [[stroke]]</small>
 
<small>•'''[[Smoking]]'''</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Brugada syndrome|Brugada Syndrome]]</SMALL>
| colspan="5" style="background: #F5F5F5; padding: 5px;" |No chest pain
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•</small><SMALL>[[Syncope]]</SMALL>
 
<small>•</small><SMALL>[[Cardiac arrest]]</SMALL>
 
<small>•'''ST-segment elevation'''</small>
 
<small>•F/H of sudden cardiac death</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Takotsubo cardiomyopathy|Takotsubo carditis]]</SMALL>
| colspan="5" style="background: #F5F5F5; padding: 5px;" |Sudden onset of chest pain mimicking myocardial infarction
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Extreme emotional or physical stress</small><small>•</small>syncope
 
<small>•Women>men</small>
 
<small>•'''ST segment elevation'''</small>
 
<small>•'''Left ventricular apical ballooning on echo'''</small>
 
<small>•'''Normal coronary arteries'''</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pericarditis]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |<small>•Relieving factor: Sitting up and leaning forward</small>
 
<small>•Aggravating factor: Lying down and breathing deep</small>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Other causes:Malignancy, autoimmune disorders, chest trauma</small>
 
<small>•'''[[Pericardial friction rub]]'''</small>
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |<small>Organ System</small>
! rowspan="3" |<small>Diseases</small>
! colspan="10" |<small>Presentation</small>
! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
! colspan="6" rowspan="2" |<small>Past Medical History</small>
! rowspan="3" | <SMALL>Other Findings</SMALL>
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="5" |<SMALL>Chest Pain</SMALL>
! colspan="3" |<SMALL>GI Symptoms</SMALL>
!<SMALL>Pulmonary</SMALL>
!<SMALL>Neck</SMALL>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<SMALL><SMALL>On Palpation</SMALL></SMALL>
!<SMALL><SMALL>On inspiration</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
!<SMALL><SMALL>With Movement</SMALL></SMALL>
!<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
!<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
!<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
!<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
!<SMALL><SMALL>Jugular
Distention</SMALL></SMALL>
!<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
!<SMALL><SMALL>CBC Findings</SMALL></SMALL>
!<SMALL><SMALL>ESR</SMALL></SMALL>
!<SMALL><SMALL>D-Dimer</SMALL></SMALL>
!<SMALL><SMALL>EKG
Findings</SMALL></SMALL>
!<SMALL><SMALL>CXR Findings</SMALL></SMALL>
!<SMALL><SMALL>DM</SMALL></SMALL>
!<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
!<SMALL><SMALL>Obesity</SMALL></SMALL>
!<SMALL><SMALL>Trauma</SMALL></SMALL>
!<SMALL><SMALL>Inxn*</SMALL></SMALL>
!<SMALL><SMALL>Htn</SMALL></SMALL>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" |<small>Pulmonary</small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pleuritis]]<br>(pleurisy)</SMALL>
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |<small>•'''Aggravating factor: Deep breathing'''</small>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Other causes[[:Pulmonary embolism]], [[malignancy]], [[autoimmune diseases]]</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pulmonary embolism|Pulmonary Embolism]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Aggravating factors: Deep breathing, [[coughing]], eating, bending and stooping</small>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Other causes: Immobility, [[pregnancy]], oral contraceptive pills</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Pneumonia]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Complications: [[Sepsis]],</small> <small>[[ARDS]]</small><small>,</small> <small>[[Lung abscess]]</small>
 
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="4" |<small>Gastrointestinal</small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[GERD]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>•Other symptoms: Hoarseness,</small> <small>Dry cough at night</small><small>,</small> <small>Sensation of lump in throat</small> <small>etc</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Esophageal spasm|Esophageal Spasms]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |<small>• Risk factors: [[Anxiety]] or [[depression]] and drinking wine, very hot or cold foods</small>
 
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Esophagitis]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Causes: [[Hiatal hernia]], infection, medications, [[radiation therapy]]</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Gastritis]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Causes: [[Helicobacter pylori infection|H.pylori infectio]]<nowiki/>n, bile reflux, alcohol use, alcohol use</small>
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" |<small>Organ System</small>
! rowspan="3" |<small>Diseases</small>
! colspan="10" |<small>Presentation</small>
! colspan="6" rowspan="2" |<small>Diagnostic Tests</small>
! colspan="6" rowspan="2" |<small>Past Medical History</small>
! rowspan="3" | <SMALL>Other Findings</SMALL>
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="5" |<SMALL>Chest Pain</SMALL>
! colspan="3" |<SMALL>GI Symptoms</SMALL>
!<SMALL>Pulmonary</SMALL>
!<SMALL>Neck</SMALL>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<SMALL><SMALL>On Palpation</SMALL></SMALL>
!<SMALL><SMALL>On inspiration</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Extremeties</SMALL></SMALL>
!<SMALL><SMALL>Radiating to Back</SMALL></SMALL>
!<SMALL><SMALL>With Movement</SMALL></SMALL>
!<SMALL><SMALL>Nausea or Vomitting</SMALL></SMALL>
!<SMALL><SMALL>Epigastric Pain</SMALL></SMALL>
!<SMALL><SMALL>Odynophagia or Dysphagia</SMALL></SMALL>
!<SMALL><SMALL>Shortness of Breath</SMALL></SMALL>
!<SMALL><SMALL>Jugular
Distention</SMALL></SMALL>
!<SMALL><SMALL>Cardiac Biomarkers</SMALL></SMALL>
!<SMALL><SMALL>CBC Findings</SMALL></SMALL>
!<SMALL><SMALL>ESR</SMALL></SMALL>
!<SMALL><SMALL>D-Dimer</SMALL></SMALL>
!<SMALL><SMALL>EKG
Findings</SMALL></SMALL>
!<SMALL><SMALL>CXR Findings</SMALL></SMALL>
!<SMALL><SMALL>DM</SMALL></SMALL>
!<SMALL><SMALL>Hyperlipidemia</SMALL></SMALL>
!<SMALL><SMALL>Obesity</SMALL></SMALL>
!<SMALL><SMALL>Trauma</SMALL></SMALL>
!<SMALL><SMALL>Inxn*</SMALL></SMALL>
!<SMALL><SMALL>Htn</SMALL></SMALL>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" |<small>Musculoskeletal<small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>Muscle sprain/Spasm</SMALL>
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Causes: Over use, dehydration, electrolyte abnormalities</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<SMALL>[[Costochondritis]]</SMALL>
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Risk factors: [[Rheumatoid arthritis]], [[ankylosing spondylitis]], [[Reiter's syndrome]]</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Rib fracture]]/Trauma</SMALL>
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Complications: [[Pneumothorax]], [[hemothorax]], surgical [[emphysema]]</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |<small>Psychiatry</small>
| style="background: #DCDCDC; padding: 5px; text-align: center;" | <SMALL>[[Anxiety]] ([[Panic attack|Panic Attack]])</SMALL>
| colspan="5" style="background: #F5F5F5; padding: 5px;" |Chest tightness
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |<small>• Other symptoms: [[Palpitations]], trembling, [[Perspiration|sweating]], choking, light headed, hot or cold flashes.</small>
|-
|}
 
 
 
The following table summarizes the significant history, and diagnostic test findings that will help differentiate the acute coronary syndromes from one another, as well as from other coronary artery diseases:
 
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="3" colspan="1" |Acute Coronary Syndromes
! rowspan="1" colspan="3" |History and Symptoms
! rowspan="1" colspan="2" |Pathology
! colspan="2" rowspan="1" |Diagnostic tests
! rowspan="1" colspan="2" |Treatment
! rowspan="3" colspan="1" |Complications
! rowspan="3" colspan="1" |Prognosis
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="1" colspan="2" |Chest pain
! rowspan="2" colspan="1" style="vertical-align:top;" |Duration of Chest pain
! rowspan="2" colspan="1" style="vertical-align:top;" |<SMALL>Coronary Artery</SMALL>
! rowspan="2" colspan="1" style="vertical-align:top;" |<SMALL>Plaque</SMALL>
! rowspan="2" colspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Cardiac Biomarkers <br> <SMALL>(e.g.CK-MB, Troponins)</SMALL>
! rowspan="2" style="vertical-align:top;" |EKG Findings
! rowspan="2" colspan="1" style="width: 50x; vertical-align:top;" |Medical Therapy
! rowspan="2" colspan="1" style="width: 50x; vertical-align:top;"|Reperfusion<br><SMALL>(e.g. PCI, CABG, or Medical)</SMALL>
|-
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" | <SMALL>At Rest </SMALL>
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" | <SMALL>Exertion </SMALL>
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Unstable Angina]]
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |<30 minutes
|style="background: #F5F5F5; padding: 5px;" |Partial occlusion
|style="background: #F5F5F5; padding: 5px;" |Erosion
or
 
[[Plaque rupture|Rupture]]
 
(39%)
|style="background: #F5F5F5; padding: 5px; text-align:center;" |Normal
|style="background: #F5F5F5; padding: 5px;" | •Normal EKG findings (some cases)
<br>•Flipped or inverted T waves
 
<br>•ST segment depression
 
<br>•Non-specific ST-T changes
|style="background: #F5F5F5; padding: 5px;" |+
| style="background: #F5F5F5; padding: 5px;" |
|style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
 
•[[Congestive heart failure]]
 
•[[Hypotension]]
 
•[[Mitral regurgitation|New mitral regurgitation]]
 
•[[MI]]
 
•Sudden death
|style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 1.7%
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[NSTEMI]]
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |>30 minutes
|style="background: #F5F5F5; padding: 5px;" |Partial or complete occlusion
|style="background: #F5F5F5; padding: 5px;" |[[Plaque rupture|Rupture]]
(56%)
 
or
 
Erosion
|style="background: #F5F5F5; padding: 5px; text-align:center;" |Elevated
|style="background: #F5F5F5; padding: 5px;" |•No EKG findings (some cases)
<br>•Flipped or inverted T waves
 
<br>•ST segment depression
 
<br>•Non-specific ST-T changes
 
•[[Left bundle branch block|New left bundle branch block]]
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
 
•[[Congestive heart failure]]
 
•[[Hypotension]]
 
•[[Mitral regurgitation|New mitral regurgitation]]
 
•[[Left ventricular aneurysm|Ventricular aneurysms]]
 
•Sudden death
|style="background: #F5F5F5; padding: 5px;" |•1 year mortality rate is 24.4%
•30 day mortality rate is about 2%
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[STEMI]]
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |>30 minutes
|style="background: #F5F5F5; padding: 5px;" |Complete occlusion
|style="background: #F5F5F5; padding: 5px;" |[[Plaque rupture|Rupture]]
(50%-75%)    or
 
Erosion
|style="background: #F5F5F5; padding: 5px; text-align:center;" |Elevated
|style="background: #F5F5F5; padding: 5px;" |•ST elevation in at least 2
contiguous leads in V2-V3
 
<br>•ST depression in at least
 
two precordial leads V1-V4
 
<br>•ST depression in several
 
leads plus ST elevation in
 
lead aVR (suggestive of occlusion of the [[Coronary ateries|left main
 
or proximal LAD artery]])
 
<br>
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |•[[Reinfarction]]
 
•[[Arrhythmias]]
 
•[[Left ventricular aneurysm]]
 
•[[Pseudoaneurysm]]
 
•[[papillary muscle rupture|rupture of papillary muscle]],
 
[[interventricular septum]] and LV free wall
 
•Sudden death
|style="background: #F5F5F5; padding: 5px;" |•30 day mortality rate is
 
1.1% in <45 yrs and 20.4% in >75 yrs patients
|-
! colspan="12" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: left;" |'''Other Coronary Artery Diseases'''
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic stable angina]]
| style="background: #F5F5F5; padding: 5px;" |-
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |≤ 5 minutes
|style="background: #F5F5F5; padding: 5px;" |Severely narrowed
[[coronary vessels]]
|style="background: #F5F5F5; padding: 5px;" |Stable plaque
|style="background: #F5F5F5; padding: 5px;" |Normal
|style="background: #F5F5F5; padding: 5px;" |•Normal EKG in 50% of cases
 
•Down sloping, up sloping or
 
horizontal ST segment depression
 
•T wave inversion
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |
|style="background: #F5F5F5; padding: 5px;" |•[[Heart failure]]
|style="background: #F5F5F5; padding: 5px;" |•Estimated annual mortality rate is 0.9%-1.4%
 
•Annual incidence of non-fatal MI between 0.5%-2.6%
 
•1 year mortality rate is 1.3%
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Prinzmetal's angina]]
|style="background: #F5F5F5; padding: 5px;" colspan="2" |•Occur at rest
(Mid night to early morning)
 
•Not associated with exertion
|style="background: #F5F5F5; padding: 5px;" |5-30 minutes
|style="background: #F5F5F5; padding: 5px;" |Coronary artery [[vasospasm]]
| style="background: #F5F5F5; padding: 5px;" |-
|style="background: #F5F5F5; padding: 5px;" |Normal
|style="background: #F5F5F5; padding: 5px;" |•Transient ST segment elevation
|style="background: #F5F5F5; padding: 5px;" |+
|style="background: #F5F5F5; padding: 5px;" |
|style="background: #F5F5F5; padding: 5px;" |•[[Arrhythmias]]
 
•[[MI]]
|style="background: #F5F5F5; padding: 5px;" |•5 year survival is excellent (90%-95%)
 
|-
|}<br />
 
=== Differential Diagnoses of Acute Coronary Syndromes in the Setting of Chest Pain ===
<br />
{| class="wikitable"
|+
!Cardiac
!Pulmonary
!Vascular
!Gastrointestinal
!Orthopedic
!Other
|-
!'''Myopericarditis'''
'''Cardiomyopathies'''<sup>a</sup>
!Pulmonary embolism
!Aortic dissection
!Esophagitis, reflex or spasm
!Musculoskeletal disorders
!Anxiety disorders
|-
|[[Tachyarrhythmias]]
|([[Tension Pneumothorax|Tension]])-[[Pneumothorax]]
|[[Symptomatic]] [[aortic aneurysm]]
|[[Peptic ulcer]], [[gastritis]]
|[[Chest trauma]]
|[[Herpes zoster]]
|-
|[[Acute heart failure]]
|[[Bronchitis]], [[pneumonia]]
|[[Stroke]]
|[[Pancreatitis]]
|[[Muscle]] [[injury]]/[[inflammation]]
|[[Anemia]]
|-
|[[Hypertensive emergency|Hypertensive emergencies]]
|[[Pleuritis]]
|
|[[Cholecystitis]]
|[[Costochondritis]]
|
|-
|[[Aortic stenosis|Aortic valve stenosis]]
|
|
|
|[[Cervical spine]] [[Pathology|pathologies]]
|
|-
|[[Takosubo cardiomyopathy|Tako-Tsubo cardiomyopathy]]
|
|
|
|
|
|-
|[[Coronary spasm]]
|
|
|
|
|
|-
|[[Heart|Cardiac]] [[trauma]]
|
|
|
|
|
|-
| colspan="6" |Bold = Common and/or important [[Differential diagnosis|differential diagnoses]]
<sup>a</sup>[[Dilated cardiomyopathy|Dilated]], [[Hypertrophic cardiomyopathy|hypertrophic]] and [[Restrictive cardiomyopathy|restrictive cardiomyopathies]] may cause [[angina]] or [[chest discomfort]]
|}
 
==Treatment==
 
===Coronary Angiography===
 
[[Coronary angiography]] within 12 hours likely benefits high risk (elevated [[cardiac biomarkers]] at baseline or [[diabetes]] or a [[GRACE score]] more than 140) [[Patient|patients]].
 
=== Recommendations for Anti-ischemic Drugs in the Acute Phase of Non-ST-elevation Acute Coronary Syndromes===
{| class="wikitable"
|+
!style="background:yellow"|Recommendations
!style="background:yellow"|Class
of Recommendations
!style="background:yellow"|Level
of Evidence
|-
|Early initiation of beta-blocker treatment is recommended
 
in patients with ongoing ischemic symptoms and without contraindications.
!style="background:green; color:white"|I
!style="background:blue; color:white"|B
|-
|It is recommended to continue chronic beta-blocker therapy,
 
unless the patient is in Killip class III or higher.
!style="background:green; color:white"|I
!style="background:blue; color:white"|B
|-
|Sublingual or i.v. nitrates are recommended to relieve angina;<sup>a</sup> intravenous treatment is recommended
 
in patients with recurrent angina, uncontrolled hypertension or signs of heart failure.
!style="background:green; color:white"|I
!style="background:indigo; color:white"|C
|-
|In patients with suspected/confirmed vasospastic angina, calcium channel blockers and
 
nitrates should be considered and beta-blockers avoided.
!style="background:orange; color:white"|IIa
!style="background:blue; color:white"|B
|-
| colspan="3" |<small><sup>a</sup>Should not be administered in patients with recent intake of sildenafil or vardenafil (< 24 h) or tadalafil (< 48 h).</small>
|}
 
==Prevention==
 
'''Primary Prevention'''
 
The [[Prevention (medical)|primary prevention]] strategies include:
*Dietary modifications:
 
:*Regular consumption of [[Fruit|fruits]], [[Vegetable|vegetables]], [[whole grains]] and lean meats
:*Limit foods high in [[cholesterol]] and [[saturated fats]]
*Physical exercise
:*30 minutes of moderate exercise
*[[Weight loss]]
*[[Smoking cessation]]
*Regular [[blood pressure]], [[blood sugar]] and [[cholesterol]] check
 
'''Secondary Prevention'''
 
The [[Prevention (medical)|secondary prevention]] strategies include:
*Dietary modifications
*Regular [[blood pressure]], [[blood sugar]] and [[cholesterol]] check
*Compliance with [[therapy]] for post acute coronary syndrome event
*[[Cardiac rehabilitation]] programs
 
==References==
{{Reflist|2}}
 
{{WH}}{{WS}}
 
[[CME Category::Cardiology]]
 
[[Category:Cardiology]]
<references />

Latest revision as of 13:58, 19 September 2021

Digoxin

Shown below is an image that summarizes the steps in the chronic management of patients with heart failure.
ACE-I Starting dose Target dose
Captopril 6.25 mg t.i.d. 50 mg t.i.d.
Enalapril 2.5 mg b.i.d. 10-20 mg b.i.d.
Lisinopril > 2.5-5 mg daily 20-35 mg daily
Ramipril > 2.5 mg b.i.d. 5 mg b.i.d.
Trandolapril > 0.5 mg daily 4 mg daily



Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF


Treatment of underlying causes | Associated conditions



Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) | Implantation of Intracardiac Defibrillator | Ultrafiltration | Left Ventricular Assist Devices (LVADs) | Cardiac Transplantation | Cardiac Surgery
Chronic Pharmacotherapy in HFrEF:
Drugs to Avoid | Drug Interactions
 | |  |  | Ca Channel Blockers | Nitrates | Hydralazine | Positive Inotropics | Anticoagulants |  | Antiarrhythmic Drugs | Nutritional Supplements | Hormonal Therapies | Lifestyle modification
Device therapy for heart failure with reduced ejection fraction: Implantable cardioverter-defibrillator | Cardiac resynchronization therapy | Devices under evaluation


  • Efficacy: Low
    • Sinus rhythm is maintained in <20% of patients
    • Symtoms are reduced in >=20%.
Adverse effects
  • Bradycardia
  • Hypotension
  • Edema
Contraindications
  • Bradycardia
  • Hypotension
  • Heart failure with depressed ejection fraction


Contraindications
Precautions during treatment


[1]

[2]

Books by Psychologists and Psychiatrists

  • Beck, A. T., Rush, A. J., Shaw, B. F., Emery, G. (1987). Cognitive therapy of depression. New York: Guilford.
  • Burns, David D. (1999). Feeling Good : The New Mood Therapy. Avon.
  • Griffin, J., Tyrrell, I. (2004) How to lift Depression – Fast. HG Publishing. ISBN 1-899398-41-4
  • Jacobson, Edith: "Depression; Comparative Studies of Normal, Neurotic, and Psychotic Conditions", International Universities Press, 1976, ISBN 0-8236-1195-7
  • Klein, D. F., & Wender, P. H. (1993). Understanding depression: A complete guide to its diagnosis and treatment. New York: Oxford University Press.
  • Kramer, Peter D. (2005). Against Depression. New York: Viking Adult.
  • Plesman, J. (1986). Getting off the Hook, Sydney Australia. A self-help book available on the internet.
  • Rowe, Dorothy (2003). Depression: The way out of your prison. London: Brunner-Routledge.
  • Sarbadhikari, S. N. (ed.) (2005) Depression and Dementia: Progress in Brain Research, Clinical Applications and Future Trends. Hauppauge, Nova Science Publishers. ISBN 1-59454-114-0.
  • Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.
  • Bieling, Peter J. & Anthony, Martin M. (2003) Ending The Depression Cycle. New Harbinger Publications. ISBN 1572243333
  • For books on male depression, see Terrence Real

Historical Account

  • Healy, David. (1999). The Antidepressant Era, Paperback Edition, Harvard University Press. ISBN 0-674-03958-0

af:Kliniese depressie ar:الاكتئاب عند الإنسان bs:Klinička depresija ca:Depressió cs:Deprese (psychologie) da:Depression de:Depression et:Depressioon el:Κλινική κατάθλιψη eo:Deprimo ko:우울증 hr:Klinička depresija id:Depresi it:Depressione (malattia) he:דיכאון ku:Klînîk depresyon la:Depressio (psychiatria) lt:Depresija hu:Depresszió ms:Kemurungan nl:Klinische depressie nds-nl:Depressie (psychologie) no:Depresjon (sykdom) nn:Depresjon oc:Depression uz:Klinik depressiya simple:Depression (illness) sk:Depresia (psychológia) sr:Klinička depresija fi:Masennus sv:Depression uk:Депресія (медицина) yi:קלינישע דעפרעסיע

Template:WH Template:WS

Medical Therapy

Antidepressant drugs include selective serotonin reuptake inhibitors, such as escitalopram oxalate (Lexapro), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), are the primary medications considered for patients, having fewer side effects than the older monoamine oxidase inhibitors (MAOIs).

The effect size is very small for moderate depression but increased with severity reaching the NICE criteria for 'clinical significance' for very severe depression.[3] This result is consistent with the earlier clinical studies where only patients with severe depression benefited from the treatment with a tricyclic antidepressant imipramine or from psychotherapy more than from the placebo treatment.[4][5][6] According to the STAR*D randomized controlled trial, about 50% of patients with major depression have a response and about 30% of have remission of symptoms with usage of citalopram.[7]

Bupropion (Wellbutrin, Zyban), an atypical antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor, is also considered to be effective in the treatment of depression,[8] without sexual dysfunction or sexual side effects[9] and without weight gain. Bupropion has also been shown to be more effective than SSRIs at improving symptoms such as hypersomnia and fatigue in depressed patients.[10]

Measurement-based care, which guides mediation based on serial measurement of psychometric testing, improves outcomes according to randomized controlled trials[7][11].

Predictors of a response to treatment

Severity of depression

The effectiveness is antidepressants may[12] or may not[13][14] depend on the severity of a patient's depression. This relationship may be due to the declining effect of placebo among more severely depressed patients.

The effectiveness of antidepressants depending on severity of depression[12]
American Psychiatric Association
classification of severity[15]
Hamilton Depression Rating Scale
(HDRS)
Number needed to treat[12] Clinical significance
(NICE)[16]
Mild to moderate < 19 16 No
Severe 19 - 22 11 No
Very severe > 22  4 Yes
Genetic variations

Variations in the GRIK4 (glutamate receptor, ionotropic, kainate 4 protein) and HTR2A (5-hydroxytryptamine receptor) genes predict response to citalopram.[17]

Treatment failure

Treatment after monotherapy failure
(VAST-D Study)[18]
Intervention Outcome
Medication Mode final dose Remission % Quit 2˚ ADRs (%)
Switch medications
Bupropion SR 200 mg twice daily 22.3% 10%
Augment medications
Aripiprazole 10 mg 29% 5%
Bupropion SR 300 mg daily 27% 7%

After starting medications, treatment should be switched if there is no response within one month.[19]

When treated with monotherapy for depression, approximately 30% of patients have remission of symptoms while 50% have a response to medications.[7]

For patients with inadequate response, randomized controlled trials provide guidance.[18][20]

  • The original VAST-D trial, that did not include aripiprazole, confirms that augmenting with bupropion is the most effective of options other than augmentation with aripiprazole. In this trial, either adding sustained-release bupropion ("bupropion was 200 mg per day during weeks 1 and 2, increasing to 300 mg per day by week 4 and to 400 mg per day (the final dose) during week 6") or buspirone (up to 60 mg per day) for augmentation as a second drug can cause remission in approximately 30% of patients (bupropion may be more effective than buspirone)[20], while switching medications can achieve remission in about 25% of patients[21]. Alternatively, "extended-release venlafaxine, the starting daily dose of 37.5 mg for 7 days was increased to 75 mg from day 8 to 14, to 150 mg from day 15 to 27, to 225 mg from day 28 to 41, to 300 mg from day 42 to 62, and to 375 mg from day 63 onward."[21]
  • The PReDICT trial found that among patients who initially were treated with either an SSRI or CBT, remission was increased when the opposite treatment (CBT or SSRI) was added to non-remitters[22].
  • The newer VAST-D trial found that augmentation with aripiprazole is effective.[18] The dose of aripiprazole was 2 mg of with titration to 5, 10, or 15 mg daily as guided by measurement-based care using the PHQ-9.[18] However, aripiprazole led to more adverse drug reactions including somnolence, akathisia, and weight gain. The second most effective was augmentation with buproprion starting at 150 mg sustained release to 300 mg or 400 mg daily as guided by measurement-based care using the PHQ-9.
  • More recently, mirtazapine, was found not to add to SSRIs<ref name="pmid30381374">{{cite journal| author=Kessler DS, MacNeill SJ, Tallon D, Lewis G, Peters TJ, Hollingworth W et al.| title=Mirtazapine added to SSRIs or SNRIs for treatment resistant depression in primary care: phase III randomised placebo controlled trial (MIR). | journal=BMJ | year= 2018 | volume= 363 | issue= | pages= k4218 | pmid=30381374 | doi=10.1136/bmj.k4218 | pmc=6207929 | url=https://www.ncbi.nlm.n
  1. LastName, FirstName (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Arlington, VA Washington, D.C: American Psychiatric Association,American Psychiatric Association. ISBN 978-0-89042-554-1.
  2. ....
  3. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT (February 2008). "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration" (htm). PLoS Medicine. Retrieved 2008-02-26.
  4. Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP (1989). "National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments". Arch. Gen. Psychiatry. 46 (11): 971–82, discussion 983. PMID 2684085.
  5. Elkin I, Gibbons RD, Shea MT, Sotsky SM, Watkins JT, Pilkonis PA, Hedeker D (1995). "Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program". J Consult Clin Psychol. 63 (5): 841–7. PMID 7593878.
  6. Sotsky SM, Glass DR, Shea MT, Pilkonis PA, Collins JF, Elkin I, Watkins JT, Imber SD, Leber WR, Moyer J (1991). "Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program". Am J Psychiatry. 148 (8): 997–1008. PMID 1853989.
  7. 7.0 7.1 7.2 Trivedi MH, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L; et al. (2006). "Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice". Am J Psychiatry. 163 (1): 28–40. doi:10.1176/appi.ajp.163.1.28. PMID 16390886.
  8. Fava M, Rush AJ, Thase ME, Clayton A, Stahl SM, Pradko JF, Johnston JA. (2005). "15 years of clinical experience with bupropion HCl: from bupropion to bupropion SR to bupropion XL". Prim Care Companion J Clin Psychiatry. 7 (3): 106–113. PMID 16027765.
  9. For the review, see: Clayton AH (2003). "Antidepressant-Associated Sexual Dysfunction: A Potentially Avoidable Therapeutic Challenge". Primary Psychiatry. 10 (1): 55–61.
  10. Baldwin DS, Papakostas GI (2006). "Symptoms of Fatigue and Sleepiness in Major Depressive Disorder". J Clin Psychiatry. 67 (suppl 6): 9–15. PMID 16848671.
  11. Yeung AS, Jing Y, Brenneman SK, Chang TE, Baer L, Hebden T; et al. (2012). "Clinical Outcomes in Measurement-based Treatment (Comet): a trial of depression monitoring and feedback to primary care physicians". Depress Anxiety. 29 (10): 865–73. doi:10.1002/da.21983. PMID 22807244.
  12. 12.0 12.1 12.2 Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC; et al. (2010). "Antidepressant drug effects and depression severity: a patient-level meta-analysis". JAMA. 303 (1): 47–53. doi:10.1001/jama.2009.1943. PMID 20051569.
  13. Hieronymus F, Lisinski A, Nilsson S, Eriksson E (2019). "Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis". Lancet Psychiatry. doi:10.1016/S2215-0366(19)30216-0. PMID 31303567.
  14. Gibbons RD, Hur K, Brown CH, Davis JM, Mann JJ (2012). "Benefits From Antidepressants: Synthesis of 6-Week Patient-Level Outcomes From Double-blind Placebo-Controlled Randomized Trials of Fluoxetine and Venlafaxine". Arch Gen Psychiatry. doi:10.1001/archgenpsychiatry.2011.2044. PMID 22393205.
  15. First, Michael B. (2007). Handbook of Psychiatric Measures, Second Edition. American Psychiatric Publishing, Inc. ISBN 1-58562-218-4.
  16. National Institute for Clinical Excellence. Depression: Management of Depression in Primary and Secondary Care. London, England: National Institute for Clinical Excellence; 2009.
  17. Paddock S, Laje G, Charney D, Rush AJ, Wilson AF, Sorant AJ; et al. (2007). "Association of GRIK4 with outcome of antidepressant treatment in the STAR*D cohort". Am J Psychiatry. 164 (8): 1181–8. doi:10.1176/appi.ajp.2007.06111790. PMID 17671280.
  18. 18.0 18.1 18.2 18.3 Mohamed S, Johnson GR, Chen P, Hicks PB, Davis LL, Yoon J; et al. (2017). "Effect of Antidepressant Switching vs Augmentation on Remission Among Patients With Major Depressive Disorder Unresponsive to Antidepressant Treatment: The VAST-D Randomized Clinical Trial". JAMA. 318 (2): 132–145. doi:10.1001/jama.2017.8036. PMID 28697253.
  19. American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p. [1170 references]
  20. 20.0 20.1 Trivedi MH, Fava M, Wisniewski SR; et al. (2006). "Medication augmentation after the failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1243–52. doi:10.1056/NEJMoa052964. PMID 16554526.
  21. 21.0 21.1 Rush AJ, Trivedi MH, Wisniewski SR; et al. (2006). "Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1231–42. doi:10.1056/NEJMoa052963. PMID 16554525.
  22. Dunlop BW, LoParo D, Kinkead B, Mletzko-Crowe T, Cole SP, Nemeroff CB; et al. (2019). "Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression". Am J Psychiatry: appiajp201818091075. doi:10.1176/appi.ajp.2018.18091075. PMID 30764648.