Which clinical history findings are characteristic of acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

The severity and duration of coronary artery obstruction, the volume of myocardium affected, the level of demand, and the ability of the rest of the heart to compensate are major determinants of a patient's clinical presentation and outcome. A patient may present to the ED because of a change in pattern or severity of symptoms.

Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It is usually described as a sensation of chest pressure or heaviness that is reproduced by activities or conditions that increase myocardial oxygen demand. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).

However, not all patients experience chest pain. They may present with only neck, jaw, ear, arm, or epigastric discomfort. Some patients, including some who are elderly or who have diabetes, present with no pain, complaining only of episodic shortness of breath, severe weakness, light-headedness, diaphoresis, or nausea and vomiting. Elderly persons may also present only with altered mental status. Those with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints.

In addition, evidence exists that women more often have coronary events without typical symptoms, which may explain the frequent failure of clinicians to initially diagnose ACS in women.

A summary of patient complaints is as follows:

  • Palpitations

  • Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm

  • Exertional dyspnea that resolves with pain or rest

  • Diaphoresis from sympathetic discharge

  • Nausea from vagal stimulation

  • Decreased exercise tolerance

Stable angina involves episodic pain lasting 5-15 minutes, is provoked by exertion, and is relieved by rest or nitroglycerin. In unstable angina, patients have increased risk for adverse cardiac events, such as myocardial infarction or death. New-onset exertional angina can occur at rest and is of increasing frequency or duration or is refractory to nitroglycerin. Variant angina (Prinzmetal angina) occurs primarily at rest, is triggered by smoking, and is thought to be due to coronary vasospasm.


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