Brigham and Women's Hospital Heart and Vascular Institute, Harvard Medical School, Boston, Massachusetts.
Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
JAMA. 2022 Feb 15;327(7):662-675. doi: 10.1001/jama.2022.0358.
Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.
Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by transfer to a facility with the goal of PCI within the next 24 hours. High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI. In high-risk patients with NSTE-ACS and no contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9%.
Each year, an estimated more than 7 million people are diagnosed with ACS worldwide. For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI. For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death.
急性冠状动脉综合征（ACS）的特征是向心脏供血突然减少，包括 ST 段抬高型心肌梗死（STEMI）、非 ST 段抬高型心肌梗死（NSTEMI）和不稳定型心绞痛。每年，全世界估计有超过 700 万人被诊断为 ACS，其中包括美国超过 100 万住院患者。
静息时的胸痛是 ACS 最常见的首发症状，约 79%的男性和 74%的女性 ACS 患者出现该症状，尽管约 40%的男性和 48%的女性出现非特异性症状，如呼吸困难，要么单独出现，要么更常见的是与胸痛一起出现。对于可能患有 ACS 的患者，应立即进行心电图检查（就诊后 10 分钟内），并可区分 STEMI 和非 ST 段抬高型 ACS（NSTE-ACS）。STEMI 由冠状动脉完全闭塞引起，约占 ACS 的 30%。ACS 中，心电图上无明显 ST 段抬高，称为 NSTE-ACS，约占 ACS 的 70%，由动脉部分或间歇性闭塞引起，与 ST 段压低（约 31%）、T 波倒置（约 12%）、ST 段压低伴 T 波倒置（16%）或两者均无（约 41%）有关。当心电图提示 STEMI 时，在 120 分钟内进行经皮冠状动脉介入治疗（PCI）的直接再灌注可将死亡率从 9%降低至 7%。如果 120 分钟内不能进行 PCI，则应在无禁忌症的情况下对年龄小于 75 岁的患者给予全剂量阿替普酶、瑞替普酶或替奈普酶溶栓治疗，年龄在 75 岁或以上的患者给予半剂量（如果考虑成本，则给予链激酶全剂量），然后转至可在接下来的 24 小时内进行 PCI 的医疗机构。高敏肌钙蛋白检测是评估 NSTEMI 的首选检测方法。在无禁忌症的高危 NSTE-ACS 患者中，在 24 至 48 小时内进行即刻有创冠状动脉造影术和经皮或手术血运重建与死亡率从 6.5%降至 4.9%相关。
每年，全世界估计有超过 700 万人被诊断为 ACS。对于 STEMI 患者，在就诊后 2 小时内进行冠状动脉造影术和 PCI 可降低死亡率，溶栓治疗仅限于无法立即进行 PCI 的患者。对于无禁忌症的高危 NSTE-ACS 患者，立即进行有创冠状动脉造影术，然后进行经皮或手术血运重建，与死亡率降低相关。
