Clinical Review

Acute coronary syndromes

BMJ 2015; 351 doi: (Published 20 October 2015) Cite this as: BMJ 2015;351:h5153

Acute coronary syndrome infographic
Click here to see an infographic, showing how to distinguish between types of ACS, as well as treatment and management of patients.

This article has a correction. Please see:

  1. Adam Timmis, professor of clinical cardiology
  1. 1NIHR Biomedical Research Unit, Barts Heart Centre, London EC1A 7BE, UK
  1. a.d.timmis{at}

The bottom line

  • In the United Kingdom and most other developed countries, incidence rates of acute coronary syndrome are diminishing, but they remain a major cause of premature death in adults

  • Death before reaching hospital occurs in nearly 25% of cases of acute myocardial infarction but can usually be prevented by rapid access to a defibrillator

  • Prompt reperfusion therapy in ST elevation myocardial infarction reduces infarct size and helps prevent death from heart failure and ventricular arrhythmias

  • Lifestyle modification—particularly smoking cessation—and secondary prevention drugs protect against recurrent acute coronary syndrome

  • Adherence to guideline recommendations for treatment with an implantable cardioverter defibrillator protects against sudden arrhythmic death late after acute coronary syndrome

Acute coronary syndromes, or “heart attacks,” include unstable angina and acute myocardial infarction. The latter is further classified according to electrocardiographic changes as non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI), which comprise 61% and 39%, respectively, of admissions for acute myocardial infarction recorded in the UK national registry.1 In most developed countries incidence rates of acute coronary syndrome are diminishing; a recent UK study using linked hospital and mortality data reported 33% and 31% reductions in rates for adults in 2010 compared with 2002.2 Similar reductions have been reported from Denmark.3 Another registry based study from the United States found that the reduction was largely confined to ST elevation myocardial infarction, whereas rates of non-ST elevation myocardial infarction have tended to increase.4 Yet, despite parallel reductions in 30 day case fatality rates, the British Heart Foundation reports that acute coronary syndromes remain one of the major causes of premature death in men and women in the UK.5 This review will provide a comprehensive account of the pathophysiology, clinical presentation, management, and outcomes of acute coronary syndrome, designed to update clinicians involved in caring …

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