Acute coronary syndrome
Heart attack - ACS; Myocardial infarction - ACS; MI - ACS; Acute MI - ACS; ST elevation myocardial infarction - ACS; Non ST-elevation myocardial infarction - ACS; Unstable angina - ACS; Accelerating angina - ACS; Angina - unstable-ACS; Progressive angina
Acute coronary syndrome is a term for a group of conditions that suddenly stop or severely reduce blood from flowing to the heart muscle. When blood cannot flow to the heart muscle, the heart muscle can become damaged. Heart attack and unstable angina are both acute coronary syndromes (ACS).
Causes
A fatty substance called plaque can build up in the arteries that bring oxygen-rich blood to your heart. Plaque is made up of cholesterol, fat, cells, and other substances.
Plaque can block blood flow in two ways:
- It can cause an artery to become so narrow over time that it becomes blocked enough to cause symptoms.
- The plaque tears suddenly and a blood clot forms around it, severely narrowing or blocking the artery.
Many risk factors for heart disease may lead to an ACS.
You feel a tight band of pain around your chest. The pain moves from your chest to your arms, shoulder, and neck. What could your pain mean? Could it be a heart attack, could it be the big one? Heart attacks are caused by interruption of blood supply to part of the heart. If the blood flow is blocked, your heart is starved of oxygen and heart cells die. A hard substance called plaque can build up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells. A heart attack can occur as a result of plaque buildup or the rupture of one of these plaques. We're not sure why heart attacks occur when they do. You may have a heart attack when you are resting or asleep, or after a sudden increase in physical activity, when you are outside in cold weather, or after a sudden, severe emotional or physical stress, including an illness. So, how is a heart attack treated? If you go to the hospital for a suspected heart attack, a doctor or nurse will listen to your chest with a stethoscope. You will have a blood test to look for heart damage. A coronary angiography test can show your doctor how well blood is moving through your heart. If blood moves slowly, or not at all through your coronary arteries, you have either a narrowed, or blocked artery. Other tests can look at the valves and chambers of your heart and check for abnormal heart rhythms. If you've had a heart attack, doctors can do an emergency procedure called angioplasty. This surgery or procedure can open narrowed or blocked blood vessels. Usually they'll place a small, metal mesh tube, called a stent, in your artery to help keep it open. You may also receive drugs to break up the clot in your artery. Sometimes, doctors will do heart bypass surgery to get blood flowing to your heart muscle again. After you are treated in the hospital for a heart attack, you may need to take medicines to thin your blood, to protect your heart, or to improve your cholesterol levels. You may need to take these medicines for the rest of your life. Most people who have had a heart attack also need cardiac rehabilitation. This will help you slowly increase your exercise level and learn how to follow a healthy lifestyle. After you have a heart attack, your chance of another is higher. How well you do after a heart attack depends on the damage to your heart and where the damage is, and what steps you take to prevent another one. If your heart can no longer pump blood to your body as well as it used to, you may have heart failure and will need lifelong treatment. Usually a person who has had a heart attack can slowly go back to normal activities, but you will need to take steps to prevent another heart attack.
Symptoms
The most common symptom of ACS is chest pain. The chest pain may come on quickly, come and go, or get worse with exercise or rest. Other symptoms can include:
- Pain in the shoulder, arm, neck, jaw, back, or belly area
- Discomfort that feels like tightness, squeezing, crushing, burning, choking, or aching
- Discomfort that occurs at rest and does not easily go away when you take medicine
- Shortness of breath
- Anxiety
- Nausea
- Sweating
- Feeling dizzy or lightheaded
- Fast or irregular heartbeat
Women and older people often experience these other symptoms, although chest pain is common for them as well.
Exams and Tests
Your health care provider will do an exam, listen to your chest with a stethoscope, and ask about your medical history.
Tests for ACS include:
- Electrocardiogram (ECG) -- An ECG is usually the first test your doctor will run. It measures your heart's electrical activity. During the test, you will have small pads taped to your chest and other areas of your body.
- Blood test -- Some blood tests help show the cause of chest pain and see if you are at a high risk for a heart attack. A troponin blood test can show if the cells in your heart have been damaged. This test can confirm you are having a heart attack.
- Echocardiogram -- This test uses sound waves to look at your heart. It shows if your heart has been damaged and can find some types of heart problems.
Coronary angiography may be done right away or when you are more stable. This test:
- Uses a special dye and x-rays to see how blood flows through your heart
- Can help your provider decide which treatments you need next
Other tests to look at your heart that may be done while you are in the hospital include:
Treatment
Your provider may use medicines, surgery, or other procedures to treat your symptoms and restore blood flow to your heart. Your treatment depends on your condition and the amount of blockage in your arteries. Your treatment may include:
- Medicine -- Your provider may give you one or more types of medicine, including aspirin, beta blockers, statins, blood thinners, clot dissolving drugs, angiotensin converting enzyme (ACE) inhibitors, or nitroglycerin. These medicines may help prevent or break up a blood clot, treat high blood pressure or angina, relieve chest pain, and stabilize your heart.
- Angioplasty -- This procedure opens the clogged artery using a long, thin tube called a catheter. The tube is placed in the artery and the provider inserts a small deflated balloon. The balloon is inflated inside the artery to open it up. Your doctor may insert a wire tube, called a stent, to keep the artery open.
- Bypass surgery -- This is surgery to route the blood around the artery that is blocked.
Outlook (Prognosis)
How well you do after an ACS depends on:
- How quickly you get treated
- The number of arteries that are blocked and how bad the blockage is
- Whether or not your heart has been damaged, as well as the extent and location of the damage, and where the damage is
In general, the quicker your artery gets unblocked, the less damage you will have to your heart. People tend to do best when the blocked artery is opened within a few hours from the time symptoms start.
Possible Complications
In some cases, ACS can lead to other health problems including:
- Abnormal heart rhythms
- Death
- Heart attack
- Heart failure, which happens when the heart cannot pump enough blood
- Rupture of part of the heart muscle causing tamponade or severe valve leakage
- Stroke
When to Contact a Medical Professional
An ACS is a medical emergency. If you have symptoms, call 911 or the local emergency number quickly.
Do not:
- Try to drive yourself to the hospital.
- Wait - If you are having a heart attack, you are at greatest risk for sudden death in the early hours.
Prevention
There is a lot you can do to help prevent ACS.
- Eat a heart-healthy diet. Have plenty of fruits, veggies, whole grains, and lean meats. Try to limit foods high in cholesterol and saturated fats, since too much of these substances can clog your arteries.
- Get exercise. Aim to get at least 30 minutes of moderate exercise most days of the week.
- Lose weight, if you are overweight.
- Quit smoking. Smoking can damage your heart. Ask your doctor if you need help quitting.
- Get preventive health screenings. You should see your doctor for regular cholesterol and blood pressure tests and learn how to keep your numbers in check.
- Manage health conditions, such as high blood pressure, high cholesterol, or diabetes.
References
Amsterdam EA, Wenger NK, Brindis RG, et al. 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. J Am Coll Cardiol. 2014;64(24):e139-e228. PMID: 25260718
Bohula EA, Morrow DA. ST-elevation myocardial infarction: management. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 38.
Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-S99. PMID: 24222015
Giugliano RP, Braunwald E. Non-ST elevation acute coronary syndromes. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 39.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):529-555. PMID: 23247303
Scirica Benjamin M, Libby P, Morrow DA. ST-elevation myocardial infarction: pathophysiology and clinical evolution. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 37.
Version Info
Last reviewed on: 5/8/2022
Reviewed by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
