# Diagnosis and Management of Type 2 Acute Coronary Syndrome in Patients Without Pre-existing Cardiomyopathy in Centers With and Without Percutaneous Coronary Intervention

## TL;DR

This study examines how type 2 acute coronary syndrome is diagnosed and managed in patients without prior heart disease, finding that it is rarely diagnosed and often lacks clear rationale.

## Contribution

The study provides insights into the underdiagnosis of type 2 ACS and highlights the need for clearer clinical guidelines and increased awareness.

## Key findings

- Only 1.3% of cases were diagnosed as type 2 ACS despite high cardiology consultations.
- Significant coronary lesions were found in 64.2% of patients who underwent exploration.
- No rationale was documented for 74.7% of patients who did not undergo exploration.

## Abstract

Introduction

Type 2 acute coronary syndrome (ACS) is defined as myocardial infarction caused by an imbalance between myocardial oxygen supply and demand. Although several observational studies have been conducted, they have not led to the development of clear clinical guidelines, partly due to heterogeneous definitions and the absence of consensus regarding diagnostic criteria and management strategies.

Aims

To assess diagnostic practices and management of type 2 ACS in patients without pre-existing heart disease and to analyze these practices based on the availability of coronary angiography at the inclusion center.

Methods

We retrospectively reviewed the records of 25,225 patients who received a troponin assay in the emergency departments of two centers, one with and the other without coronary angiography facilities, from 2018 to 2019. We selected 224 patients without pre-existing heart disease who had type 2 ACS according to objective criteria. The study was designed as a retrospective, descriptive, and comparative analysis. Data on clinical characteristics, diagnostic labeling, and management strategies, including cardiology consultations and ischemic investigations, were collected and analyzed.

Results

The study populations from both centers were similar. Clinicians diagnosed type 2 ACS in only three (1.3%) cases, despite a high rate of cardiology consultations (180, 80.4%). Exploration was performed in 78 (34.8%) patients, revealing significant coronary lesions in 43 (64.2%) cases. In 118 (74.7%) patients without exploration during hospitalization, no rationale was documented. The presence of on-site coronary angiography did not significantly influence the decision to explore (p = 0.067). Exploration decisions were influenced by age (p < 0.001), family history (p = 0.006), ECG presentation (p = 0.034), left ventricular ejection fraction (LVEF) (p = 0.02), and cardiology consultation request (p < 0.001).

Conclusion

Objective criteria allowed the selection of a homogeneous type 2 ACS population. The diagnosis is rarely made, highlighting the need for increased awareness among emergency physicians and cardiologists. Integrating objective criteria into clinical guidelines could be considered. Given the high rate of underlying coronary lesions, patients with type 2 ACS and no pre-existing heart disease should be prioritized for coronary exploration.