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Management of acute coronary syndromes

The acute coronary syndromes consist of two groups: unstable angina and non-Q wave myocardial infarction, and ST segment elevation myocardial infarction. This article reviews the management only of patients with unstable angina and non-Q wave myocardial infarction.

Unstable angina can be defined as ischaemic-type chest pain that is more frequent, severe, or prolonged than the patient's usual angina symptoms, occurs at rest or minimal exertion, or is difficult to control with drugs.1 Angina of recent onset is also classified as unstable. Non-Q wave myocardial infarction presents similarly to unstable angina but is accompanied by a rise in cardiac enzyme concentration without new Q waves on the electrocardiogram. Acute coronary syndromes are major causes of morbidity and mortality. The burden on the health service will be further clarified by the UK prospective registry of acute ischaemic syndromes (PRAIS-UK), which has studied the prevalence and management of unstable angina in the United Kingdom.2

#### Summary points

Patients with acute coronary syndromes are at high risk of myocardial infarction and death unless appropriately treated

Patients at high risk are older than 70 years with pain at rest, acute ST segment depression on the initial electrocardiogram, and raised cardiac troponin T or I concentrations with or without haemodynamic complications

Patients in the medium risk group have one or more high risk features or have recurrent ischaemia, early post-myocardial infarction ischaemia, diabetes mellitus, or a history of myocardial infarction or heart failure or are taking aspirin

Patients at high risk and most at medium risk should receive glycoprotein IIb/IIIa inhibitors within 24 hours of onset of chest pain plus early angiography and intervention

Patients with no risk factors and negative results of exercise testing can be managed out of hospital

The recent growth in treatment options for acute coronary syndromes has followed increased awareness of their …