The changing face of acute coronary syndromes

Acute coronary syndrome is a leading cause of ischemic heart disease mortality and morbidity. Despite the rising prevalence of obesity and diabetes, the epidemiology of acute coronary syndrome appears to be shifting with an observed decreased incidence of ST-segment elevation myocardial infarction (STEMI) and hospital mortality accompanied by an increased incidence of non–STEMI across all age groups and in both women and men. Underlying potential contributors to this change include aging of the population, implementation of primary and secondary prevention strategies, which result in changes in atherosclerotic coronary artery disease, and technological improvements that have increased the sensitivity of cardiac diagnostic tests. Appreciation of sex differences in ischemic heart disease, identification of nonobstructive coronary disease, and the diagnosis of coronary microvascular dysfunction as contributors to ischemia with no obstructive coronary artery disease (INOCA) is increasing. Work is ongoing to fill the gaps in knowledge needed for evidence-based guidelines for the changing face of acute coronary syndrome. L Heart Metab. 2018;75:4-8