Ep35: Acute Coronary Syndrome Part 1—Diagnosis

Ep35: Acute Coronary Syndrome Part 1—Diagnosis
Date:
3 May 2018
Category:

Fellows of the RACP can claim CPD credits via MyCPD for listening and using resources related to this episode.

This is the first of two episodes on acute coronary syndrome (ACS). Part 1 deals with diagnosis of patients presenting with possible ACS, while Part 2 addresses secondary prevention and new findings about predictors for adherence to therapy.

Chest pain and other symptoms suggestive of ACS make up the majority of presentations to hospital. 11 to 17 per cent of patients presenting to ED with such symptoms end up having the diagnosis confirmed. But follow-up studies of discharged patients show that up to six per cent of diagnoses are missed, and inappropriately discharged patients have a twofold higher mortality rate than those who are admitted.

The 2016 guidelines of the Cardiac Society of Australia and New Zealand were developed to guide the rapid differentiation of patients presenting with suspected ACS. ACS takes in STEMI and non-STEMI heart attacks, and also unstable angina. This episode outlines the investigations used to distinguish these and other differential diagnoses associated with chest pain. First, electrocardiogram recordings are used to identify the occurrence of a myocardial infarction with ST segment elevation. If STEMI is discounted, the next most important step is to rule out other life-threatening causes of chest pain. Third in the diagnostic hierarchy is to establish whether there has been myocardial infarction without ST elevation, or unstable angina. This is where high sensitivity troponin markers become useful, and can feed into stratification protocols for assessing the risk of patients suffering future acute cardiac events.

Credits

Guest
Associate Professor Louise Cullen FACEM (Royal Brisbane and Women's Hospital, University of Queensland).

Production
Written and produced by Mic Cavazzini. Additional audio recording from Michelle Ransom-Hughes. Music courtesy of Jason Shaw ('Minstrel, Pioneers'), Lee Rosevere ('Become Death'), Sergey Cheremisinov ('Pulsar') and Loch Lomond ('Listen, Lisbon'). Image courtesy of Science Photo Libary. Executive producer Anne Fredrickson.
Editorial feedback for this episode was provided by RACP members Paul Jauncey, Pavan Chandrala, Rebecca Grainger, Phillip Gaughwin, Rhiannon Mellor, Alan Ngo, and Mahesh Dhakal.

References

Related RACP 'College Learning Series' Lectures
Management of acute coronary syndromes [Lefkovits]
Update in coronary intervention [Brooks]

Principal Literature
National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016 [Heart and Lung Circulation]
Australian clinical guidelines for the management of acute coronary syndromes 2016: summary (MJA)
Acute Coronary Syndrome: New Zealand Management Guidelines 2013 [CSANZ]
Appropriate use of serum troponin testing in general practice: a narrative review [MJA]
High Sensitivity Troponin Testing [ALiEM]
Stress electrocardiography and stress echocardiography [AFP]

Risk Stratification Protocols
2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker [Cullen, JACC]
Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome [Cullen, JAMA]
Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis [CMAJ Open]
The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain [Heart]
Acute chest pain evaluation using coronary computed tomography angiography compared with standard of care: a meta-analysis of randomised clinical trials [Heart]
Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease [BMJ]

ECG Basics
Top 5 MI ECG Patterns You Must Know [Healio]
ECG Library [Life in the Fast Lane]
Using the ECG to localize myocardial infarction and determine the occluded coronary artery [Clinical ECG Interpretation]
A Noob's Guide to ECG [Irfan Ziad, Slideshare]

Transcript

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