Spectrum of ACSs

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ACSs include all clinical syndromes compatible with acute MI resulting from an imbalance between myocardial oxygen demand and supply. In contrast to stable angina, an ACS results primarily from diminished myocardial blood flow secondary to an occlusive or partially occlusive coronary artery thrombus. ACSs are classified according to electrocardiogram (ECG) changes into STE ACS (STE MI) or NSTE ACS (NSTE MI and UA) (Fig. 8-1). An STE MI, formerly known as Q-wave or transmural MI, typically results in an injury that transects the thickness of the myocardial wall. Following an STE MI, pathologic Q waves are frequently seen on the ECG, indicating transmural MI, while such an ECG manifestation is seen less commonly in patients with NSTE MI.5 NSTE MI, formerly known as non-Q-wave or nontransmural MI, is limited to the subendocardial myocardium. Patients in this case do not usually develop a pathologic Q wave on the ECG. Moreover, an NSTE MI is smaller and not as extensive as an STE MI. Approximately two-thirds of all MIs are NSTE MI, whereas one-third of patients with MI present with STE. NSTE MI differs from UA in that ischemia is severe enough to produce myocardial necrosis resulting in the release of a detectable amount of biomarkers, mainly troponins T or I, but also creatine kinase (CK) myocardial band (MB), from the necrotic myocytes in the bloodstream. The clinical significance of serum markers will be discussed in greater detail in later sections of this chapter.

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FIGURE 8-1. Evaluation of the ACS patient. aAs described in Table 8-1. bPositive = above the myocardial infarction decision limit. cNegative = below the myocardial infarction decision limit. (ACSs, acute coronary syndromes; CABG, coronary artery bypass graft; CAD, coronary artery disease; CKMB, creatine kinase myocardial band; ECG, electrocardiogram; min, minute; PCI, percutaneous coronary intervention.) Refer to Figure 9-2 for further details regarding ECG interpretation. (From Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., (eds.) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 251, with permission.)

FIGURE 8-1. Evaluation of the ACS patient. aAs described in Table 8-1. bPositive = above the myocardial infarction decision limit. cNegative = below the myocardial infarction decision limit. (ACSs, acute coronary syndromes; CABG, coronary artery bypass graft; CAD, coronary artery disease; CKMB, creatine kinase myocardial band; ECG, electrocardiogram; min, minute; PCI, percutaneous coronary intervention.) Refer to Figure 9-2 for further details regarding ECG interpretation. (From Spinler SA, de Denus S. Acute Coronary Syndromes. In DiPiro JT, Talbert RL, Yee GC, et al., (eds.) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 251, with permission.)

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