ACS1GAMBAR

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of
midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is
the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of
ongoing symptoms and electrocardiogram (ECG) changes, nitrates titrated to 10% reduction in blood
pressure and symptoms, beta blockers, and heparin are all indicated. If the patient continues to have
persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be
considered.
 A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new
chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest
tightness. Her initial vital signs are blood pressure = 140/90 mm Hg and heart rate = 98. Her
electrocardiogram (ECG) is as shown. She is given nitroglycerin sublingually, and her pressure decreases
to 80/palpation. Right ventricular ischemia should be considered in this patient.

This plot shows changes in cardiac markers over time after the onset of symptoms. Peak A is the early
release of myoglobin or creatine kinase isoenzyme MB (CK-MB) after acute myocardial infarction
(AMI). Peak B is the cardiac troponin level after infarction. Peak C is the CK-MB level after infarction.
Peak D is the cardiac troponin level after unstable angina. Data are plotted on a relative scale, where 1.0
is set at the myocardial-infarction cutoff concentration. Courtesy of Wu et al (1999). ROC = receiver
operating characteristic.
 Suggested algorithm for triaging patients with chest pain. ACS = ACS; ASA = aspirin; EKG = ECG;
MI = myocardial infarction; Rx = treat; STEMI = ST-elevation myocardial infarction. Courtesy of Wu et
al (1999).
Use of cardiac markers in the ED. Studies on troponins in ACS.

Use of cardiac markers in the ED. Troponin I levels and cardiac mortality in ACS.
 Use of cardiac markers in the ED. Cardiac event rates in the platelet receptor inhibition for ischemic
syndrome (PRISM) study based on troponin I results.

Use of cardiac markers in the ED. Effect of time to treatment in patients with acute coronary syndrome
(ACS) who are treated with the GIIb/IIIa inhibitor eptifibatide.