Acute coronary syndromes without ST segment elevation

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Abstract
How are acute coronary syndromes classified?Until recently, the two typical clinical presentations were generally referred to as unstable angina and acute myocardial infarction. A diagnosis of acute myocardial infarction requires evidence of myocardial necrosis. Whether myocardial infarction (that is, necrosis of cardiac muscle) is present usually becomes clear at a later stage, on the basis of laboratory tests (elevation of markers such as creatine kinase MB or cardiac troponins) or on the electrocardiogram (loss of QRS voltage or development of pathological Q waves). Because of the therapeutic decisions that need to be made on admission of patients with acute chest pain, before myocardial necrosis may be detected, new terms for the admission diagnosis have been introduced. These are based primarily on the findings on the admission electrocardiogram (table⇓). View this table: In this window In a new window Classification of discharge diagnosesIf ST segment elevation (suggestive of transmural ischaemia) is present, a diagnosis of ST segment elevation acute coronary syndrome is made. These patients have an indication for urgent reperfusion treatment, either by percutaneous coronary intervention or by administration of a thrombolytic agent. If no ST segment elevations are present (normal or depressed ST segments or T wave inversion), a diagnosis of non-ST segment elevation acute coronary syndrome is made. If myocardial necrosis is documented, as indicated above, a discharge diagnosis of ST segment elevation myocardial infarction or non-ST segment elevation myocardial infarction is made. According to current guidelines, any elevation of cardiac markers qualifies as a myocardial infarction.3 Depending on the development of the electrocardiogram after admission, myocardial infarction may be subclassified as Q wave or non-Q wave myocardial infarction. If no evidence of myocardial necrosis exists, a discharge diagnosis of acute coronary syndrome or unstable angina is generally used. In this review, we focus on non-ST segment elevation acute coronary syndrome.

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