Issue 01/April 2024

Navigating the Complexities of Acute Coronary Syndrome in Emergency Care

By: Dr. Abhishek Sharma

Coronary artery disease (CAD) is one of the most common non-communicable diseases in the world. In this disease, a layer of fat streak in the lining of the coronary arteries, which progresses very quickly, weakens the coronary arteries and impairs the cardiac perfusion. The American Heart Association estimates a person has a heart attack every 41 seconds. Heart disease is the Second leading cause of death in the India. Chest pain is among the top reasons for emergency department visits. Chest pain is a common presentation to the emergency department and can be caused by a range of conditions including Acute Coronary Syndrome.

Acute coronary syndrome refers to a group of diseases in which blood flow to the heart is decreases. Some examples include ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and Unstable angina. However only 1 in 10 patients with symptoms suggestive of acute myocardial infarction are ultimately diagnosed with myocardial infarction.

The classic symptom of ACS is substernal chest pain, often described as crushing or pressure-like feeling, radiating to the jaw and/or left arm. This classic presentation is not seen always, and the presenting complaint can be very vague and subtle with chief complaints often being difficulty breathing, light headedness, isolated jaw or left arm pain, nausea, epigastric pain, diaphoresis, and weakness.

The first step of evaluation is an ECG, which helps differentiate between STEMI and NSTEMI unstable angina. American Heart Association guidelines maintain that any patient with complaints suspicious of ACS should get an ECG within 10 minutes of arrival. Cath lab should be activated as soon as STEMI is confirmed in a percutaneous coronary intervention (PCI) center.

Cardiac enzymes especially troponin, CK-MB/CK ratio is important in assessing the NSTEMI versus myocardial ischemia without tissue destruction. A chest x-ray is useful in diagnosing causes other than MI presenting with chest pain like pneumonia and pneumothorax. The same applies for blood work like complete blood count (CBC), chemistry, liver function test, and lipase which can help differentiate intra-abdominal pathology presenting with chest pain. Aortic dissection and pulmonary emboli should be kept in differential and investigated when the situation warrants.

The protocol also aids in to implement the comprehensive care for ACS patient coming to Emergency and to ensure multidisciplinary approach for all ACS patients. As such effective pathways are required to enable the prompt and safe rule-out of majority of patients with non-cardiac presentations and the rapid identification of those with myocardial infarction. Clinical pathways are now one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practise and improves outcomes in Acute Coronary Care (ACS) care.

Sterling Hospitals, Ahmedabad has adapted ACS (Acute Coronary Syndrome) Pathway ensuring all patients get quality healthcare.

The pathways have inclusion and exclusion criteria,

Inclusion criteria

To be eligible for inclusion, patients had to be ≥18 years old and alive at hospital presentation, admitted for an ACS as a presumptive diagnosis (i.e., have symptoms consistent with acute ischaemia), and have at least one of the following: ECG changes consistent with ACS, serial increases in serum biochemical markers of cardiac necrosis, and/or documentation of coronary artery disease. The qualifying ACS must not have been precipitated by significant non-cardiovascular comorbidity such as trauma or surgery.


Patients were diagnosed with STEMI when they had new or presumed new ST-segment elevation ≥1 mm seen in any location, or new LBBB on the index or subsequent ECG with at least one positive cardiac biochemical marker of necrosis (including troponin measurements). The ECG changes were assumed to be new unless there was documented evidence that the changes were old. Those who had a myocardial infarction at presentation, or evolving myocardial infarction during the first 24 hours, were identified as myocardial infarction at presentation.


Cases of NSTEMI required at least one elevated cardiac biochemical marker of necrosis without new STEMI on the index or subsequent ECGs.

Unstable angina

Unstable angina was diagnosed when markers of myocardial necrosis were below the diagnostic threshold for myocardial infarction. Patients originally admitted because of unstable angina but in whom myocardial infarction evolved during the hospital stay (beyond 24 hours) were classified as having a myocardial infarction as an endpoint.

Sterling Hospitals, Ahmedabad has been following this pathway in the Emergency Department, In the year 2024, the first Quarter Approximately over 115 patients were seen in the Emergency with ACS.

The common risk factors for the disease are smoking, hypertension, diabetes, hyperlipidaemia, male sex, physical inactivity or sedentary lifestyle, family obesity, and poor nutritional practices. Having a primary relative (Parents or siblings) suffered with Acute Coronary Syndrome.

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