Part 9: Acute Coronary Syndromes

Abstract

These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

From Door to Recovery: A Collaborative Approach to the Development of a Post–Cardiac Arrest Center

“…Comatose patients undergoing induced hypothermia can be cared for safely in the cardiac catheterization laboratory. 41 Nichol et al 15 suggest that assessment of providers or hospital performance for patients receiving PCI after cardiac arrest should be reported separately, thereby alleviating any hesitance to intervene in this population of patients with known high morbidity and mortality.…”

Reducing case fatality from acute myocardial infarction in cienfuegos, Cuba, 1994-2009

“…Use of the clinical pathway in UCIC facilitated adherence to the treatment strategy spelled out in the CPG and later served as an indicator for the cardiology service's quality assurance plan. Changes in therapy As part of the CPG work, internationally recommended drugs of proven effi cacy were used, [1,[11][12][13] and efforts were made to inform and train hospital physicians in the their use. A post-intervention evaluation showed greater use of aspirin and beta blockers in 1999, associated with a signifi cant drop in AMI hospital case fatality.…”

“…A post-intervention evaluation showed greater use of aspirin and beta blockers in 1999, associated with a signifi cant drop in AMI hospital case fatality. [14,15] A key therapy in AMI treatment is reperfusion [6,11], and at HGAL the only reperfusion option available is thrombolysis. Recanalization of the artery associated with the infarction-if early, complete and maintained-improves prognosis, limits infarction size and preserves ventricular function.…”

“…Furthermore, optimal use of the drugs described above and rapid hospital administration of thrombolytics are currently recognized as essential to AMI treatment [11] and are included among indicators for quality of hospital management of AMI. [16] Organizational change To achieve the therapeutic goal, organizational change was also necessary.…”

“…No signifi cant delays seen in other studies were associated with socioeconomic factors, age, skin color or sex. [11,19] After snapshot II, all chest pain was considered an emergency and given the highest treatment priority, but time taken to administer thrombolytics remained long, at 120 minutes (snapshot III, from April 11 through May 10, 1999). Thrombolysis location was then changed from the intensive care unit to the emergency department, cutting door-to-drug time to 53 minutes (snapshot IV, from July 9 through August 8, 1999).…”