Acute Coronary Syndrome: Out-of-Hospital Evaluation and Management

Identifying acute coronary syndrome (ACS) in family medicine settings can be challenging, partly because it is uncommon in office practice and partly because symptoms can be atypical. Initial evaluation includes review of the patient's symptoms, an assessment of risk factors, and an electrocardiogram (ECG). When symptoms are typical, such as chest pain and diaphoresis, patients should be transported rapidly by emergency medical services (EMS) to the nearest emergency department. If not contraindicated, aspirin and nitroglycerin should be administered before transport. Oxygen should be administered if hypoxemia is present. Patients with atypical symptoms and ECG results consistent with ACS also should be transported by EMS. When patients have atypical symptoms and nondiagnostic ECG results, consider risk factors for ACS. These include older age; female sex; nonwhite race; and history of heart failure, stroke, diabetes, or hypertension. If any of these risk factors is present and there is concern about ACS, the patient should be transported to an emergency department. Family practices in remote or rural areas are not always able to easily transport patients to emergency departments. These remote or rural practices should have ECG capabilities and consider acquiring the ability to obtain point-of-care troponin assays.