Clinical Review

Acute coronary syndromes without ST segment elevation

BMJ 2007; 334 doi: 10.1136/bmj.39220.618646.AE (Published 14 June 2007)
Cite this as: BMJ 2007;334:1265

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  1. Ron J G Peters, clinical cardiologist1,
  2. Shamir Mehta, clinical cardiologist2,
  3. Salim Yusuf, clinical cardiologist2
  1. 1Department of Cardiology, Academic Medical Center, PO Box 22660, Amsterdam 1100, Netherlands
  2. 2Department of Medicine, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
  1. Correspondence to: R J G Peters r.j.peters{at}amc.uva.nl
  • Accepted 23 April 2007

In the United Kingdom, about 114 000 patients with acute coronary syndromes are admitted to hospital each year.1 More than 5.5 million patients present to a US emergency department with chest pain and other symptoms related to acute coronary syndrome each year.2 Acute coronary syndrome is seen in people of all ages, races, and socioeconomic backgrounds.

Summary points

  • The patient's history is the most important initial diagnostic tool

  • Patients suspected of having an acute coronary syndrome need to be admitted and evaluated by electrocardiography and measurement of cardiac “markers”

  • Acute coronary syndromes are classified on the basis of the presence or absence of ST segment elevation on the admission electrocardiogram

  • All patients with acute coronary syndromes need intensive medical treatment, including combinations of antithrombotic drugs

  • In high risk patients, coronary angiography is indicated, with the aim of revascularisation if they have suitable coronary anatomy

  • Elevation of cardiac markers determines whether a discharge diagnosis of myocardial infarction is made

  • After discharge, treatment is aimed at preventing recurrences and treating the underlying atherosclerotic disease process

The diagnosis and management of acute coronary syndromes have been evolving rapidly in recent years. New antithrombotic agents have improved the results of medical treatment, and new methods of estimating a patient's risk of an adverse outcome help clinicians to decide who may benefit from invasive treatment—that is, coronary angiography and subsequent revascularisation (percutaneous coronary intervention or coronary bypass surgery). As these therapeutic decisions need to be made soon after admission, the classification of acute coronary syndromes is now based on the information that is available on admission.

Acute coronary syndromes generally represent acute complications of chronic atherosclerotic disease of the coronary arteries. The progressive accumulation of inflammatory materials and lipids over the years can ultimately lead to erosions of the intima or rupture of lipid rich plaques. …

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