Acute coronary syndromes

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Resident
Survival
Guide

Acute Coronary Syndrome Chapters

Heart Attack Patient Information

Unstable Angina Patient Information

Overview

Classification

Unstable Angina
Non-ST Elevation Myocardial Infarction
ST Elevation Myocardial Infarction

Symptoms

Pathophysiology

Risk Factors

Differential Diagnosis

Prevention

AHA/ACC Guidelines for Acute Coronary Syndrome

Guideline for Risk Stratification in ACS
Guideline for Pre-Hospital Evaluation and Care
Guidelines for Initial Management of ACS
Guidelines for Patients with Atrial Fibrillation Complicating ACS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]; Tarek Nafee, M.D. [3]

Synonyms and Keywords: ACS

Overview

Acute coronary syndrome (ACS) refers to any group of symptoms attributed to obstruction of the coronary arteries. The most common symptom prompting diagnosis of ACS is chest pain, often radiating of the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Acute coronary syndrome usually occurs as a result of one of three problems: ST-elevation myocardial infarction (30%), non ST-elevation myocardial infarction (25%), or unstable angina (38%).[1] These types are named according to the appearance of the electrocardiogram.[2] There can be some variation as to which forms of myocardial infarction (MI) are classified under acute coronary syndrome.

ACS should be distinguished from stable angina, which is chest pain which develops during exertion and resolves at rest. New onset angina however should be considered as a part of acute coronary syndrome, since it suggests a new problem in a coronary artery.Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use.[3] Cardiac chest pain can also be precipitated by anemia, bradycardias or tachycardias.

Classification

Acute coronary syndrome may be classified as follows:

Symptoms

The signs and symptoms of acute coronary syndrome include:[4]

Pathophysiology

For more information on atherosclerotic plaque, click here

The pathophysiology of acute coronary syndromes depends on coronary atherosclerotic plaque which includes:[5][6]

Initiation and progression of coronary atherosclerotic plaque

Plaque vulnerability

The plaque vulnerability depends on the following factors:[8][9][10][10][11]

Pathogenesis

The pathogenesis of acute coronary syndrome depends on:[12][13][14][15]

Following 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 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:[5]

Diagnosis

High-sensitivity cardiac troponin (hs-cTn)

99th percentile of a healthy reference population
(recommended cut-off)[16]
Turnaround time Name and manufacturer FDA Approval?
Troponin T
hs-cTnT
14 ng/L[17][18] 18 minutes[19] Elecsys
(Roche Diagnostics)
Troponin I
hs-cTnI
26.2 ng/L[17][20] ARCHITECTSTAT
(Abbott Laboratories)

High sensitivity troponin assays are available:

  • Troponin T: Elecsys by Roche Diagnostics[19]
  • Troponin I: ARCHITECTSTAT 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[21][22][17].

The agreement between hscTnT and hscTnI measurements is excellent (Cohen's kappa =0.9)[17].

High sensitivity troponin levels have reduced predictive value when prevalence is low[23][24].

Clinical prediction rules

Clinical prediction rules can help diagnose[25]:

  • 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[26]
  • GRACE risk score incorporates 8 findings[27]
  • TIMI risk score[28]

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[29].
  • In the setting of NSTEMI, the GRACE risk score may best predict complications according to a cohort study[30]. However, the HEART risk score was not assessed in this cohort.

Diagnostic pathways

Clinical diagnostic pathways may help[31]. The European Society of Cardiology recommends two pathways[16]:

The last American Health Association guidelines were prepared prior to approval of hs-cTn tests by the FDA[32].

More recent strategies include:

  • Single cTnT measurement, combined with a non-ischemic EKG, that reports troponin is below the limits of detection[33].
  • Single cTnI measurement, combined with low-risk clinical prediction rule[25]

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 diagnosis using the clinical prediction rule for ACS for more detail.[34][35] Acute Coronary Syndrome (ACS) may be differentiated from other diseases as follows:[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]

Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Cardiovascular Acute Coronary Syndrome + + + + + + + + + + + Palpitations

Sweating

Aortic Dissection + + + - + + - + •Pain maximal upon onset •Pain difficult to treat with opiates

Weak pulse in one arm compared to other

Syncope

•Symptoms similar to stroke

Smoking

Brugada Syndrome No chest pain + Syncope

Cardiac arrest

ST-segment elevation

•F/H of sudden cardiac death

Takotsubo carditis Sudden onset of chest pain mimicking myocardial infarction + + + + + - •Extreme emotional or physical stresssyncope

•Women>men

ST segment elevation

Left ventricular apical ballooning on echo

Normal coronary arteries

Pericarditis + + + •Relieving factor: Sitting up and leaning forward

•Aggravating factor: Lying down and breathing deep

+ + + + + + + •Other causes:Malignancy, autoimmune disorders, chest trauma

Pericardial friction rub

Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Pulmonary Pleuritis
(pleurisy)
+ + + + Aggravating factor: Deep breathing + + + + + + •Other causesPulmonary embolism, malignancy, autoimmune diseases
Pulmonary Embolism + •Aggravating factors: Deep breathing, coughing, eating, bending and stooping + + + •Other causes: Immobility, pregnancy, oral contraceptive pills
Pneumonia + + + + + + •Complications: Sepsis, ARDS, Lung abscess
Gastrointestinal GERD + + + •Other symptoms: Hoarseness, Dry cough at night, Sensation of lump in throat etc
Esophageal Spasms + + + + + + + • Risk factors: Anxiety or depression and drinking wine, very hot or cold foods
Esophagitis + + + + + + + • Causes: Hiatal hernia, infection, medications, radiation therapy
Gastritis + + + + + + + • Causes: H.pylori infection, bile reflux, alcohol use, alcohol use
Organ System Diseases Presentation Diagnostic Tests Past Medical History Other Findings
Chest Pain GI Symptoms Pulmonary Neck
On Palpation On inspiration Radiating to Extremeties Radiating to Back With Movement Nausea or Vomitting Epigastric Pain Odynophagia or Dysphagia Shortness of Breath Jugular

Distention

Cardiac Biomarkers CBC Findings ESR D-Dimer EKG

Findings

CXR Findings DM Hyperlipidemia Obesity Trauma Inxn* Htn
Musculoskeletal Muscle sprain/Spasm + + + + • Causes: Over use, dehydration, electrolyte abnormalities
Costochondritis + + + + + + + + + + + • Risk factors: Rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome
Rib fracture/Trauma + + + + + + + + + + • Complications: Pneumothorax, hemothorax, surgical emphysema
Psychiatry Anxiety (Panic Attack) Chest tightness + + • Other symptoms: Palpitations, trembling, sweating, choking, light headed, hot or cold flashes.


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:[51][52][53][54][55][56]

Acute Coronary Syndromes History and Symptoms Pathology Diagnostic tests Treatment Complications Prognosis
Chest pain Duration of Chest pain Coronary Artery Plaque Cardiac Biomarkers
(e.g.CK-MB, Troponins)
EKG Findings Medical Therapy Reperfusion
(e.g. PCI, CABG, or Medical)
At Rest Exertion
Unstable Angina + + <30 minutes Partial occlusion Erosion

or

Rupture

(39%)

Normal •Normal EKG findings (some cases)


•Flipped or inverted T waves


•ST segment depression


•Non-specific ST-T changes

+ Arrhythmias

Congestive heart failure

Hypotension

New mitral regurgitation

MI

•Sudden death

•1 year mortality rate is 1.7%
NSTEMI + + >30 minutes Partial or complete occlusion Rupture

(56%)

or

Erosion

Elevated •No EKG findings (some cases)


•Flipped or inverted T waves


•ST segment depression


•Non-specific ST-T changes

New left bundle branch block

+ + Arrhythmias

Congestive heart failure

Hypotension

New mitral regurgitation

Ventricular aneurysms

•Sudden death

•1 year mortality rate is 24.4%

•30 day mortality rate is about 2%

STEMI + + >30 minutes Complete occlusion Rupture

(50%-75%) or

Erosion

Elevated •ST elevation in at least 2

contiguous leads in V2-V3


•ST depression in at least

two precordial leads V1-V4


•ST depression in several

leads plus ST elevation in

lead aVR (suggestive of occlusion of the left main or proximal LAD artery)


+ + Reinfarction

Arrhythmias

Left ventricular aneurysm

Pseudoaneurysm

rupture of papillary muscle,

interventricular septum and LV free wall

•Sudden death

•30 day mortality rate is

1.1% in <45 yrs and 20.4% in >75 yrs patients

Other Coronary Artery Diseases
Chronic stable angina - + ≤ 5 minutes Severely narrowed

coronary vessels

Stable plaque Normal •Normal EKG in 50% of cases

•Down sloping, up sloping or

horizontal ST segment depression

•T wave inversion

+ Heart failure •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%

Prinzmetal's angina •Occur at rest

(Mid night to early morning)

•Not associated with exertion

5-30 minutes Coronary artery vasospasm - Normal •Transient ST segment elevation + Arrhythmias

MI

•5 year survival is excellent (90%-95%)

Treatment

Coronary angiography

Coronary angiography within 12 hours likely benefits high risk (elevated cardiac biomarkers at baseline or diabetes or a GRACE score[57] more than 140) patients[58].

Prevention

Primary prevention

The primary prevention strategies include:[59]

  • Dietary modifications:
  • Physical exercise
  • 30 minutes of moderate exercise

Secondary prevention

The secondary prevention strategies include:[60][61][62]

References

  1. Torres M, Moayedi S (2007). "Evaluation of the acutely dyspneic elderly patient". Clin. Geriatr. Med. 23 (2): 307–25, vi. doi:10.1016/j.cger.2007.01.007. PMID 17462519. Unknown parameter |month= ignored (help)
  2. Grech ED, Ramsdale DR (2003). "Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction". BMJ. 326 (7401): 1259–61. doi:10.1136/bmj.326.7401.1259. PMC 1126130. PMID 12791748. Unknown parameter |month= ignored (help)
  3. Achar SA, Kundu S, Norcross WA (2005). "Diagnosis of acute coronary syndrome". Am Fam Physician. 72 (1): 119–26. PMID 16035692.
  4. Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
  5. 5.0 5.1 Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J (1988). "Insights into the pathogenesis of acute ischemic syndromes". Circulation. 77 (6): 1213–20. PMID 3286036.
  6. Libby P (2001). "Current concepts of the pathogenesis of the acute coronary syndromes". Circulation. 104 (3): 365–72. PMID 11457759.
  7. Fuster V, Badimon L, Badimon JJ, Chesebro JH (1992). "The pathogenesis of coronary artery disease and the acute coronary syndromes (2)". N Engl J Med. 326 (5): 310–8. doi:10.1056/NEJM199201303260506. PMID 1728735.
  8. Moreno PR, Falk E, Palacios IF, Newell JB, Fuster V, Fallon JT (1994). "Macrophage infiltration in acute coronary syndromes. Implications for plaque rupture". Circulation. 90 (2): 775–8. PMID 8044947.
  9. Davies MJ, Richardson PD, Woolf N, Katz DR, Mann J (1993). "Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content". Br Heart J. 69 (5): 377–81. PMC 1025095. PMID 8518056.
  10. 10.0 10.1 Sukhova GK, Schönbeck U, Rabkin E, Schoen FJ, Poole AR, Billinghurst RC; et al. (1999). "Evidence for increased collagenolysis by interstitial collagenases-1 and -3 in vulnerable human atheromatous plaques". Circulation. 99 (19): 2503–9. PMID 10330380.
  11. Herman MP, Sukhova GK, Libby P, Gerdes N, Tang N, Horton DB; et al. (2001). "Expression of neutrophil collagenase (matrix metalloproteinase-8) in human atheroma: a novel collagenolytic pathway suggested by transcriptional profiling". Circulation. 104 (16): 1899–904. PMID 11602491.
  12. Davies MJ (1990). "A macro and micro view of coronary vascular insult in ischemic heart disease". Circulation. 82 (3 Suppl): II38–46. PMID 2203563.
  13. Conti CR, Brawley RK, Griffith LS, Pitt B, Humphries JO, Gott VL; et al. (1973). "Unstable angina pectoris: morbidity and mortality in 57 consecutive patients evaluated angiographically". Am J Cardiol. 32 (6): 745–50. PMID 4542757.
  14. Moreno PR, Bernardi VH, López-Cuéllar J, Murcia AM, Palacios IF, Gold HK; et al. (1996). "Macrophages, smooth muscle cells, and tissue factor in unstable angina. Implications for cell-mediated thrombogenicity in acute coronary syndromes". Circulation. 94 (12): 3090–7. PMID 8989114.
  15. Weiss EJ, Bray PF, Tayback M, Schulman SP, Kickler TS, Becker LC; et al. (1996). "A polymorphism of a platelet glycoprotein receptor as an inherited risk factor for coronary thrombosis". N Engl J Med. 334 (17): 1090–4. doi:10.1056/NEJM199604253341703. PMID 8598867.
  16. 16.0 16.1 Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F; et al. (2016). "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)". Eur Heart J. 37 (3): 267–315. doi:10.1093/eurheartj/ehv320. PMID 26320110.
  17. 17.0 17.1 17.2 17.3 van der Linden N, Wildi K, Twerenbold R, Pickering JW, Than M, Cullen L; et al. (2018). "Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction". Circulation. 138 (10): 989–999. doi:10.1161/CIRCULATIONAHA.117.032003. PMID 29691270.
  18. Giannitsis E, Kurz K, Hallermayer K, Jarausch J, Jaffe AS, Katus HA (2010). "Analytical validation of a high-sensitivity cardiac troponin T assay". Clin Chem. 56 (2): 254–61. doi:10.1373/clinchem.2009.132654. PMID 19959623.
  19. 19.0 19.1 Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T; et al. (2015). "Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis". BMJ. 350: h15. doi:10.1136/bmj.h15. PMC 4300724. PMID 25646632.
  20. Koerbin G, Tate J, Potter JM, Cavanaugh J, Glasgow N, Hickman PE (2012). "Characterisation of a highly sensitive troponin I assay and its application to a cardio-healthy population". Clin Chem Lab Med. 50 (5): 871–8. doi:10.1515/cclm-2011-0540. PMID 22628331.
  21. 21.0 21.1 Pickering JW, Greenslade JH, Cullen L, Flaws D, Parsonage W, Aldous S; et al. (2016). "Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction". Circulation. 134 (20): 1532–1541. doi:10.1161/CIRCULATIONAHA.116.022677. PMID 27754881.
  22. 22.0 22.1 Twerenbold R, Neumann JT, Sörensen NA, Ojeda F, Karakas M, Boeddinghaus J; et al. (2018). "Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction". J Am Coll Cardiol. 72 (6): 620–632. doi:10.1016/j.jacc.2018.05.040. PMID 30071991.
  23. Lee KK, Noaman A, Vaswani A, Gibbins M, Griffiths M, Chapman AR; et al. (2019). "Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments". Am J Med. 132 (1): 110.e8–110.e21. doi:10.1016/j.amjmed.2018.10.002. PMC 6310691. PMID 30580773.
  24. Shah ASV, Sandoval Y, Noaman A, Sexter A, Vaswani A, Smith SW; et al. (2017). "Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study". BMJ. 359: j4788. doi:10.1136/bmj.j4788. PMC 5683043. PMID 29114078.
  25. 25.0 25.1 Reaney PDW, Elliott HI, Noman A, Cooper JG (2018). "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". Emerg Med J. 35 (7): 420–427. doi:10.1136/emermed-2017-207172. PMID 29622596.
  26. Six AJ, Backus BE, Kelder JC (2008). "Chest pain in the emergency room: value of the HEART score". Neth Heart J. 16 (6): 191–6. PMC 2442661. PMID 18665203.
  27. Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP; et al. (2003). "Predictors of hospital mortality in the global registry of acute coronary events". Arch Intern Med. 163 (19): 2345–53. doi:10.1001/archinte.163.19.2345. PMID 14581255.
  28. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G; et al. (2000). "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making". JAMA. 284 (7): 835–42. PMID 10938172.
  29. Poldervaart JM, Langedijk M, Backus BE, Dekker IMC, Six AJ, Doevendans PA; et al. (2017). "Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department". Int J Cardiol. 227: 656–661. doi:10.1016/j.ijcard.2016.10.080. PMID 27810290.
  30. de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R (2005). "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS". Eur Heart J. 26 (9): 865–72. doi:10.1093/eurheartj/ehi187. PMID 15764619.
  31. Than MP, Pickering JW, Dryden JM, Lord SJ, Aitken SA, Aldous SJ; et al. (2017). "ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway". Circulation. doi:10.1161/CIRCULATIONAHA.117.031984. PMID 29138293.
  32. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR; et al. (2014). "2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. 130 (25): e344–426. doi:10.1161/CIR.0000000000000134. PMID 25249585.
  33. Pickering JW, Than MP, Cullen L, Aldous S, Ter Avest E, Body R; et al. (2017). "Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis". Ann Intern Med. 166 (10): 715–724. doi:10.7326/M16-2562. PMID 28418520. Review in: Ann Intern Med. 2017 Aug 15;167(4):JC23 Review in: Evid Based Med. 2017 Dec;22(6):226
  34. Christenson J, Innes G, McKnight D, Thompson CR, Wong H, Yu E; et al. (2006). "A clinical prediction rule for early discharge of patients with chest pain". Ann Emerg Med. 47 (1): 1–10. doi:10.1016/j.annemergmed.2005.08.007. PMID 16387209.
  35. Jalili M, Hejripour Z, Honarmand AR, Pourtabatabaei N (2012). "Validation of the vancouver chest pain rule: a prospective cohort study". Acad Emerg Med. 19 (7): 837–42. doi:10.1111/j.1553-2712.2012.01399.x. PMID 22805631.
  36. Kumar A, Cannon CP (2009). "Acute coronary syndromes: diagnosis and management, part I." Mayo Clin Proc. 84 (10): 917–38. doi:10.1016/S0025-6196(11)60509-0. PMC 2755812. PMID 19797781.
  37. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A; et al. (2001). "Diagnosis and management of aortic dissection". Eur Heart J. 22 (18): 1642–81. doi:10.1053/euhj.2001.2782. PMID 11511117.
  38. Khan IA, Nair CK (2002). "Clinical, diagnostic, and management perspectives of aortic dissection". Chest. 122 (1): 311–28. PMID 12114376.
  39. Antzelevitch C (2006). "Brugada syndrome". Pacing Clin Electrophysiol. 29 (10): 1130–59. doi:10.1111/j.1540-8159.2006.00507.x. PMC 1978482. PMID 17038146.
  40. Troughton RW, Asher CR, Klein AL (2004). "Pericarditis". Lancet. 363 (9410): 717–27. doi:10.1016/S0140-6736(04)15648-1. PMID 15001332.
  41. Kass SM, Williams PM, Reamy BV (2007). "Pleurisy". Am Fam Physician. 75 (9): 1357–64. PMID 17508531.
  42. Goldhaber SZ, Bounameaux H (2012). "Pulmonary embolism and deep vein thrombosis". Lancet. 379 (9828): 1835–46. doi:10.1016/S0140-6736(11)61904-1. PMID 22494827.
  43. Pachon J, Prados MD, Capote F, Cuello JA, Garnacho J, Verano A (1990). "Severe community-acquired pneumonia. Etiology, prognosis, and treatment". Am Rev Respir Dis. 142 (2): 369–73. doi:10.1164/ajrccm/142.2.369. PMID 2382902.
  44. Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
  45. Roman S, Kahrilas PJ (2012). "Distal esophageal spasm". Dysphagia. 27 (1): 115–23. doi:10.1007/s00455-011-9388-3. PMID 22215281.
  46. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA; et al. (2013). "ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)". Am J Gastroenterol. 108 (5): 679–92, quiz 693. doi:10.1038/ajg.2013.71. PMID 23567357.
  47. Sipponen P, Kekki M, Seppälä K, Siurala M (1996). "The relationships between chronic gastritis and gastric acid secretion". Aliment Pharmacol Ther. 10 Suppl 1: 103–18. PMID 8730265.
  48. Proulx AM, Zryd TW (2009). "Costochondritis: diagnosis and treatment". Am Fam Physician. 80 (6): 617–20. PMID 19817327.
  49. Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S; et al. (2003). "A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management". Eur J Cardiothorac Surg. 24 (1): 133–8. PMID 12853057.
  50. Craske MG, Rauch SL, Ursano R, Prenoveau J, Pine DS, Zinbarg RE (2009). "What is an anxiety disorder?". Depress Anxiety. 26 (12): 1066–85. doi:10.1002/da.20633. PMID 19957279.
  51. Iannaccone M, Quadri G, Taha S, D'Ascenzo F, Montefusco A, Omede' P; et al. (2016). "Prevalence and predictors of culprit plaque rupture at OCT in patients with coronary artery disease: a meta-analysis". Eur Heart J Cardiovasc Imaging. 17 (10): 1128–37. doi:10.1093/ehjci/jev283. PMID 26508517.
  52. Dong L, Mintz GS, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL; et al. (2015). "Comparison of plaque characteristics in narrowings with ST-elevation myocardial infarction (STEMI), non-STEMI/unstable angina pectoris and stable coronary artery disease (from the ADAPT-DES IVUS Substudy)". Am J Cardiol. 115 (7): 860–6. doi:10.1016/j.amjcard.2015.01.008. PMID 25661569.
  53. Bassand JP (2003). "[Classification of acute coronary syndromes]". Rev Prat. 53 (6): 597–601. PMID 12749143.
  54. Roe MT, Chen AY, Thomas L, Wang TY, Alexander KP, Hammill BG; et al. (2011). "Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score". Am Heart J. 162 (5): 875–883.e1. doi:10.1016/j.ahj.2011.08.010. PMID 22093204.
  55. Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C, Degrandsart A; et al. (2007). "STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry)". Eur Heart J. 28 (12): 1409–17. doi:10.1093/eurheartj/ehm031. PMID 17412730.
  56. Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N; et al. (2001). "Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban". N Engl J Med. 344 (25): 1879–87. doi:10.1056/NEJM200106213442501. PMID 11419424. Review in: ACP J Club. 2002 Jan-Feb;136(1):4
  57. Deharo P, Ducrocq G, Bode C, Cohen M, Cuisset T, Mehta SR; et al. (2017). "Timing of Angiography and Outcomes in High-Risk Patients With Non-ST-Segment-Elevation Myocardial Infarction Managed Invasively: Insights From the TAO Trial (Treatment of Acute Coronary Syndrome With Otamixaban)". Circulation. 136 (20): 1895–1907. doi:10.1161/CIRCULATIONAHA.117.029779. PMID 28893843.
  58. Jobs A, Mehta SR, Montalescot G, Vicaut E, Van't Hof AWJ, Badings EA; et al. (2017). "Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials". Lancet. 390 (10096): 737–746. doi:10.1016/S0140-6736(17)31490-3. PMID 28778541. Review in: Evid Based Med. 2017 Dec;22(6):227
  59. Acute Coronary Syndrome https://medlineplus.gov/ency/article/007639.htm (2016) Accessed on November 17, 2016
  60. Lee HY, Cooke CE, Robertson TA (2008). "Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge". J Manag Care Pharm. 14 (3): 271–80. doi:10.18553/jmcp.2008.14.3.271. PMID 18439049.
  61. Diamantis E, Troupis T, Mazarakis A, Kyriakos G, Diamanti S, Troupis G; et al. (2014). "Primary and Secondary Prevention of Acute Coronary Syndromes: The Role of the Statins". Recent Adv Cardiovasc Drug Discov. 9 (2): 97–105. PMID 26152179.
  62. Islam AM, Patel PM (2010). "Preventing serious sequelae after an acute coronary syndrome: the consequences of thrombosis versus bleeding with antiplatelet therapy". J Cardiovasc Pharmacol. 55 (6): 585–94. doi:10.1097/FJC.0b013e3181d9f81f. PMID 20224426.


Cardiology


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