Physiotherapy for Acute Coronary Syndrome | Assessment & Treatment
Introduction & Epidemiology
Acute Coronary Syndrome (ACS) is a manifestation of coronary artery disease and is an umbrella term used to describe a range of conditions associated with a sudden reduced blood flow to the heart. The sudden reduction in blood flow to the heart can result in damage to the heart muscle.
Epidemiology
ACS is the leading cause of morbidity and mortality globally. The Global Burden of Disease Study reported ischemic heart disease (including ACS) as the leading cause of death globally, responsible for nearly 9 million deaths annually. The study reports an age-standardized death rate of 108.7 per 100.000 persons. Sadly, ischemic heart disease was the leading cause of mortality worldwide in 1990, and has not changed over the years.
There appears to be some regional variation. The prevalence of acute coronary syndrome is higher in high-income countries, but access to good healthcare including prevention has improved the rates over the years. Contrastingly, the prevalence of ACS in low-and middle income countries is lower, but unfortunately, a rising incidence is seen due to an increase in risk factors like smoking, diabetes, hypertension,…
The incidence increases with age, particularly after age 45 for men and age 55 for women. ACS is more common in men than in women, particularly at younger ages. Men typically experience their first cardiac event earlier than women. ACS in women tends to occur later in life, often after menopause. The clinical presentation of ACS can be atypical in women (e.g., presenting with fatigue or shortness of breath rather than classic chest pain), which can lead to delays in diagnosis.
The key risk factors for ACS align closely with those for coronary artery disease (CAD):
- Modifiable risk factors:
- Hypertension: Elevated blood pressure is a major risk factor for developing ACS.
- Dyslipidemia: High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol increase risk.
- Smoking: Tobacco use significantly raises the risk of ACS, especially in younger individuals.
- Diabetes mellitus: Increases risk through its association with atherosclerosis and other vascular diseases.
- Obesity: Particularly central obesity, is linked to an increased incidence of ACS.
- Physical inactivity: Lack of exercise is associated with higher rates of ACS.
- Dietary factors: Diets high in saturated fats, trans fats, and refined sugars contribute to cardiovascular risk.
- Alcohol: Excessive alcohol consumption is a risk factor, although moderate alcohol intake may have protective effects in some populations.
Pathomechanism
ACS is often caused by the rupture of a plaque in a coronary artery, leading to the formation of a blood clot that partially or completely blocks blood flow.
ACS includes 3 conditions:
- Unstable Angina: This occurs when chest pain or discomfort is unpredictable and happens at rest or with minimal exertion. It’s a warning sign of a possible heart attack but without significant heart muscle damage.
- Non-ST-Elevation Myocardial Infarction (NSTEMI): In this type of heart attack, the artery is partially blocked, leading to reduced blood flow and damage to a portion of the heart muscle. However, it doesn’t produce the specific changes on an electrocardiogram (ECG) that are seen in a full-blown heart attack (STEMI).
- ST-Elevation Myocardial Infarction (STEMI): This is the most severe form of heart attack, where a coronary artery is completely blocked. It causes significant damage to the heart muscle and shows specific changes on an ECG. Emergency treatment is required to restore blood flow.
Clinical Picture & Examination
The symptoms depend on the location of the reduced blood flow but can encompass:
- Chest pain or discomfort (angina), often described as pressure, squeezing, or heaviness
- Pain that radiates to the shoulders, arms, neck, back or abdomen
- Dyspnea
- Nausea, vomiting, or sweating
- Lightheadedness or fainting
- Excessive, sudden sweating (diaphoresis).
- Fatigue
- Heart palpitations
Examination
Your general practitioner will probably start with a blood test and an electrocardiogram (ECG). In the case of a NSTEMI, blood tests can reveal positive findings, but the ECG will be negative. In the case of a STEMI, which is more severe, blood tests and ECG will display positive results. You may be referred to the cardiology unit for exercises stress tests, and medical imaging by your general practitioner.
Urgent referral to the emergency department may be necessary when acute symptoms arise!
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