Acute Coronary Syndrome: Diagnosis and Initial Management.

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Acute coronary syndrome (ACS) is defined as reduced blood flow to the coronary myocardium manifesting as ST-segment elevation myocardial infarction or non-ST-segment elevation ACS, which includes unstable angina and non-ST-segment elevation myocardial infarction. Common risk factors include being at least 65 years of age or a current smoker or having hypertension, diabetes mellitus, hyperlipidemia, a body mass index greater than 25 kg per m2, or a family history of premature coronary artery disease. Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw. However, chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS. Having a prior abnormal cardiac stress test result indicates increased risk. Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves. No validated clinical decision tool is available to rule out ACS in the outpatient setting. Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation ACS. Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization. Other important management considerations include initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy. Additional interventions shown to reduce mortality in patients who have had a recent myocardial infarction include smoking cessation, annual influenza vaccination, and cardiac rehabilitation.







Raman Nohria

Assistant Professor in Family Medicine and Community Health

Raman Nohria, MD received his MD from the Lewis Katz School of Medicine at Temple University. He completed his residency training with the Lawrence Family Medicine Residency Program and hospital fellowship with the Duke Department of Family Medicine and Community Health. He currently serves as a teaching hospitalist on the Family Medicine Inpatient Service at Duke Regional Hospital as well as a core faculty member for the Duke Department of Family Medicine and Community Health. His expertise and scholarly interests include the social drivers of health, community-healthcare partnerships, and multi-stakeholder collaborations for health promotion and behavioral change.


Anthony Joseph Viera

Leonard J. & Margaret Goldwater Distinguished Professor of Family Medicine and Community Health

My major area of research is cardiovascular disease prevention. I am particularly interested in improving detection and control of hypertension. Since assessment of blood pressure begins with measurement, my studies often include out-of-office BP measurement techniques including 24-hour ambulatory BP monitoring and home BP monitoring.

I am also interested in obesity prevention, and in another line of research am examining the effectiveness of food labeling policies (such as calorie-labeling) on people's food and physical activity decisions.

As a family physician, I enjoy providing full-scope primary care (acute care, chronic illness care, preventive services) to patients of all ages and from all walks of life.

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