1 ACP patients require effective risk stratification to ensure timely initiation of proper treatment in high-risk cases to achieve better prognoses. Of the 4,000,000 who are admitted, about 1.4M are non-cardiac chest pain 910,000 are non-ischemic cardiac causes (eg: congestive heart failure, arrhythmias) 900,000 are cardiac ischemia (stable and unstable angina) And 830,000 are AMI.Acute chest pain (ACP) is a common symptom accounting for a significant proportion of attendance and burden in the emergency department (ED). It is the number 1 reason for medical malpractice dollars lost by ED physicians in the USA. Chest pain is the second most common reason for emergency department presentation (abdominal pain is #1) This is the breakdown of patient categories by discharge diagnosis Of the 2,000,000 discharged rapidly, about 24,000 are missed ACS, and many of these people go on to die.Approximately 600,000 patients per year exhibit ECG changes consistent with STEMI and another 1.4 million patients show ECG changes reflecting NSTEMI or unstable angina (UA). Each year, there are 2 million patients admitted to hospitals in the US with ACS who present in 2 broad categories: ST-segment elevation MI (STEMI) and non-ST-segment elevation (NSTE) ACS.

One quarter had the onset of ACS within 24 hours Mean age was 60, 25% were female, 56% of patients had an MI at presentation and 9% presented with signs of congestive heart failure defined by Killip class.

The baseline characteristics of the population were well matched between the three treatment groups.

In the larger group of patients who have ischemic ECG changes other than persistent ST-segment elevation (eg, ST-segment depression, transient ST-segment elevation, T-wave inversions), measurement of cardiac markers is essential for distinguishing those who have UA (no elevation of cardiac markers) and those with NSTEMI (elevated cardiac markers). Patients with persistent ST-segment elevation demonstrated on an ECG are diagnosed as having STEMI, regardless of whether their cardiac markers are elevated. By evaluating ECG results and identifying cardiac markers, a patient’s overall risk may be assessed and the level of aggressiveness for therapy can be determined. The final diagnosis of a specific ACS incorporates both the ECG findings and results of assays for cardiac markers, such as CK-MB and troponins. Patients complaining of chest pain are first evaluated for the presence of ECG changes in the emergency department to determine if the pain is caused by coronary disease.

This slide represents a diagnostic paradigm for patients presenting with ACS.

Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction.

Platelet Receptor inhibition for Ischemic Syndrome Management in Patients Limited to very Unstable Signs and Symptoms (PRISM-PLUS.

Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events (ESSENCE).

A small degree of rupture leads to a small thrombus, which heals over, leading to the progression of a plaque 1 This current understanding of how atherosclerosis progresses emphasizes the key role that acute and chronic antithrombotic therapy plays in all patients with unstable coronary syndromes 1 Reference 1. Our current understanding of unstable coronary syndromes is that they include a spectrum of disease and begin with a coronary plaque rupture 1 The degree of thrombus occlusion determines the severity of the clinical syndrome, with total occlusion in ST-segment elevation MI (STEMI) or severe (90%) stenosis in patients with non-ST-segment elevation MI (NSTEMI) or unstable angina (UA) 1 In addition, it is worthwhile to note that 99% of all plaque ruptures are clinically silent.

Interpretation of timi score