Effective systems of care are required to deliver optimal care for patients with acute coronary syndromes (ACS), particularly in rural and remote areas.
Systems of care should be regionally based, and have formal links with specialist centres for consultation and acute interhospital transfer.
Systems should include appropriate monitoring, feedback and quality improvement components.
Clinical decisions about care and transfer should take into account patients’ cultural and personal beliefs and wishes.
It is important to establish an initial working diagnosis to guide clinical decision making.
New definitions of myocardial infarction, based heavily on the presence of cardiac biomarkers, have implications for coding and epidemiological studies. However, clinically they do not influence the indications for ongoing prevention therapies.
Use of the ACS Dataset (part of the National Health Data Dictionary) can facilitate the collection of data relating to the presentation and management of ACS that can be compared and collated within and between health care providers.
People experiencing symptoms of an ACS should seek help promptly and activate emergency medical services.
The most important initial need is access to a defibrillator to avoid early cardiac death resulting from reversible arrhythmias.
Aspirin should be given early (ie, by emergency or ambulance personnel) unless already taken or contraindicated.
Oxygen should be given, as well as glyceryl trinitrate and intravenous morphine as required.
As a minimum, medical facilities receiving patients should be given warning of incoming patients in whom there is a high suspicion of an ACS — particularly ST-segment-elevation myocardial infarction (STEMI) — or whose condition is unstable.
Where appropriate, a 12-lead electrocardiogram (ECG) should be taken en route and transmitted to a medical facility.
Where formal protocols are in place, prehospital treatment (including fibrinolysis in appropriate cases) should be facilitated.
The ECG is the sole test required to select patients for emergency reperfusion (fibrinolytic therapy or direct percutaneous coronary intervention [PCI]).
Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have a reperfusion strategy implemented promptly.
Patients with a suspected ACS without ST-segment elevation on ECG should undergo further observation and investigation to rule out other diagnoses, enable risk stratification and determine the most appropriate treatment strategy.
Patients whose ECG and cardiac marker levels are normal after a suitable period of observation should, where practicable, undergo provocative testing (eg, stress test) before discharge.
All patients undergoing reperfusion therapy for STEMI (PCI or fibrinolysis) should be given aspirin and clopidogrel unless these are contraindicated.
Antithrombin therapy should be given in combination with PCI or fibrinolytic therapy with fibrin-specific fibrinolytic agents, but antithrombin therapy in conjunction with streptokinase is optional.
It is reasonable to use abciximab with primary PCI, but glycoprotein (GP) IIb/IIIa inhibitors should generally be avoided with full or reduced doses of fibrinolytic therapy.
Time delay (both to first medical contact and potential PCI or fibrinolytic therapy) plays a major role in determining best management of STEMI.
In general, PCI is the treatment of choice, providing it can be performed promptly by a qualified interventional cardiologist in an appropriate facility.
In general, the maximum acceptable delay from presentation to balloon inflation is:
60 minutes if a patient presents within 1 hour of symptom onset; or
90 minutes if a patient presents later.
Note: for patients who present late (between 3 and 12 hours after symptom onset) to a facility without PCI capability, it is appropriate to consider transfer for primary PCI if balloon inflation can be achieved within 2 hours (including transport time).
All PCI facilities should be able to perform angioplasty within 90 minutes of patient presentation.
Fibrinolysis should be considered early if PCI is not readily available, particularly in rural and remote areas.
When there are major delays to hospitalisation (ie, more than 30 minutes), prehospital fibrinolysis should be considered.
Reperfusion is not routinely recommended in patients who present more than 12 hours after symptom onset and who are asymptomatic and haemodynamically stable.
Second-generation fibrin-specific fibrinolytic agents that are available as a bolus (ie, reteplase, tenecteplase) are the fibrinolytics of choice.
These agents should be available at all centres where fibrinolysis may be required.
Streptokinase is an inappropriate choice in Aboriginal and Torres Strait Islander patients, or in patients with previous exposure to the drug.
Patients who have had STEMI should be considered for early transfer to a tertiary cardiac centre with PCI facilities and links to cardiac surgical facilities.
If immediate transfer is not possible, patients should be transferred or referred as soon as is practicable for assessment of need for revascularisation (through PCI or coronary artery bypass grafting).
All patients with non-ST-segment-elevation acute coronary syndromes (NSTEACS) should have their risk stratified to direct management decisions (see Risk stratification for stratification criteria).
All patients with NSTEACS should be given aspirin, unless contraindicated.
High-risk patients with NSTEACS should be treated with aggressive medical management (including aspirin, clopidogrel, unfractionated heparin or subcutaneous enoxaparin, intravenous tirofiban or eptifibatide and a β-blocker), and arrangements should be made for coronary angiography and revascularisation, except in those with severe comorbidities.
Intermediate-risk patients with NSTEACS should undergo an accelerated diagnostic evaluation and further assessment to allow reclassification as low or high risk.
Low-risk patients with NSTEACS, after an appropriate period of observation and assessment, may be discharged on upgraded medical therapy for outpatient follow-up.
Before discharge, patients with an ACS should be initiated on a medication regimen, including antiplatelet agent(s), β-blocker, angiotensin-converting enzyme inhibitor, statin and other therapies as appropriate.
Implantable cardiac defibrillators should be considered in some patients who, despite optimal medical therapy, have persistently depressed left ventricular function more than 6 weeks after STEMI.
Patients should be given advice on lifestyle changes that will reduce the risk of further coronary heart disease (CHD) events, including smoking cessation, nutrition, alcohol, physical activity and weight management as relevant.
All patients should have access to, and be actively referred to, comprehensive ongoing prevention and cardiac rehabilitation services.
All patients should be provided with a written action plan for chest pain.
Depression and CHD frequently coexist, and in patients with CHD, the presence of depression is more likely to lead to poorer outcomes. Social isolation and lack of social support are also associated with worse outcomes. All patients with CHD should be assessed for depression and level of social support.
The levels of evidence and grades of recommendations used in these guidelines are adapted from the National Health and Medical Research Council (NHMRC) levels of evidence for clinical interventions and the US National Institutes of Health clinical guidelines. These classifications allow the ability to differentiate between strengths of recommendations and the levels of evidence on which these are based, and allow a classification for recommendations based on panel consensus judgement.
Levels of evidence and grades of recommendation used in these guidelines
RCT = randomised controlled trial.
* National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999.
† Adapted from: US National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr 1998; 68: 899-917.
Acute coronary syndromes (ACS) include “a broad spectrum of clinical presentations, spanning ST-segment-elevation myocardial infarction, through to an accelerated pattern of angina without evidence of myonecrosis”.1 Collectively, they represent one of the most common causes of acute medical admissions to Australian hospitals.
The current guidelines for the management of both ST-segment-elevation ACS and non-ST-segment-elevation ACS have been developed by a joint working party of the National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ).
The aim of these guidelines is to incorporate contemporary information on the diagnosis and management of ACS into a set of recommendations that defines the boundaries of highest quality care. The guidelines expand on previous guidelines2,3 by consolidating recommendations for the management of ST-segment-elevation myocardial infarction (STEMI), non-ST-segment-elevation myocardial infarction and unstable angina, as well as incorporating the newer developments that have arisen since the previous guidelines, Management of unstable angina — 20003 (and addenda, available at: http://www.heartfoundation.com.au) and Reperfusion therapy for acute myocardial infarction (2002).2
These new guidelines provide a general framework for appropriate practice, to be followed subject to clinical judgement in each individual patient. They are primarily for doctors in a hospital environment (emergency physicians, general physicians, rural doctors and cardiologists) who manage patients with ACS, but they also contain information relevant to general practitioners and others, including ambulance personnel. The guidelines are designed to provide information to assist decision making, and are based on the best information available up to September 2005. It should be understood that the context in which clinical trials are performed and the local environment in which practice is undertaken must always be considered when assessing the evidence base for guidelines and, at times, their local implementation.
These new guidelines represent a local synthesis of the most recent evidence including recent international guidelines. Where relevant, the evidence has been interpreted with regard to the Australian context in which the guidelines will be implemented.
The ability to implement best-practice guidelines for the management of ACS will depend on local resources and systems of care. The following guidance is offered to assist practitioners and organisations in facilitating the most effective systems of care for the communities they serve.
Effective management of ACS requires collaborative systems of care to ensure that patients have access to the services that they need in a timeframe commensurate with their clinical condition and the potential benefit of treatments available in larger or specialised centres. The guiding principles for developing these systems are equity of access, equity of care and evidence-based care, taking into account patients’ preferences.
The systems of care should be regionally based, formal rather than ad-hoc, and should cover the continuum of care from the first point of presentation to a health professional to definitive care and rehabilitation. Responsibility for establishing these systems should be at board or executive level within health services.
clinical issues such as consultation, treatment and acute inter-hospital transfer protocols (note that systems should enhance options for patients without disempowering decision making by appropriate local clinicians);
quality monitoring, such as time to specific treatments and outcomes.
The structure of these systems will vary depending on the features of the region in which they are placed. In a metropolitan setting, a hospital without percutaneous coronary intervention (PCI) capabilities may have arrangements with a local PCI-capable facility for timely transfer of selected patients. In a rural or remote setting, the system is usually considerably more complex and involves general practitioners or community health centres, prehospital care providers, retrieval services (such as Careflight, Victorian Adult Emergency Retrieval and Coordination Service, Royal Flying Doctor Service), and regional and metropolitan referral hospitals. The systems should be tailored to a region’s needs.
clear lines of communication (eg, single points of contact for consultation or referral and coordination of acute interhospital transfers; the consultation component is particularly important as the benefits of some treatments for ACS are time-dependent, so early decision making is vital);
clear triage protocols where appropriate, recognising the fact that the closest hospital may not be the most suitable in all cases (algorithms can be developed to guide decisions about the best primary destination for patients);
effective and timely feedback (this should be two-way, and should address ways to improve the process as well as collecting outcomes information; the latter should be both specific for the patient referred and pooled so that trends in outcomes and issues for improvement can be identified);
agreed treatment protocols, with processes to facilitate drug availability if required;
agreed acute interhospital transfer protocols and processes;
program quality monitoring, including analysis of adverse events and system breakdowns;
identified leaders (these may be drawn from across the system, but leaders should jointly accept responsibility for monitoring the system, providing education and feedback, developing improvements to the system if required, facilitating arrangements with relevant extra-regional organisations and acting as public spokespeople for the system); and
ownership of the established systems at a senior level within hospital or health service management.
On occasion, the pathway of care may recommend that patients be transferred from their local community or region to a distant centre. There may be strong personal or cultural reasons that make this difficult or unacceptable for some patients. Every effort should be made to overcome these barriers by appropriate explanation and discussion, involvement of family and community members and preferential transfer to centres that have specific programs and resources for relevant cultural groups (eg, Aboriginal Liaison Officers). If the barriers to transfer cannot be overcome and the patient asserts his or her right to be treated more locally, the patient should have the best care that can be delivered in that setting. This includes consultation with specialists.
Aboriginal and Torres Strait Islander peoples have a high rate of ACS, and lower intervention rates and poorer outcomes than non-Indigenous people.4 The reasons for this are complex and include barriers to health care access and language and cultural differences. To optimise outcomes for Indigenous people, systems of care that recognise these factors are needed in both metropolitan and rural and remote areas. These might include:
providing culturally appropriate education and information to Indigenous patients and their families through Aboriginal Health Workers and Hospital Liaison Officers; and
facilitating interhospital transfer arrangements by involving the local Aboriginal health sector and metropolitan hospital Aboriginal Liaison Officers.
Effective systems of care are required to deliver optimal care for people with ACS, particularly in rural and remote areas.
Systems of care should be regionally based, with formal links with specialist centres for consultation and acute interhospital transfer.
Systems should include appropriate monitoring, feedback and quality improvement components.
Clinical decisions about care and transfer should take into account patients’ cultural and personal beliefs and wishes.
- 1. Chew D, Allan R, Aroney C, Sheerin N. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl): S1-S16. <MJA full text>
- 2. National Heart Foundation of Australia. Reperfusion therapy for acute myocardial infarction (2002). Available at: http://www.heartfoundation.com.au/index.cfm?page=35 (accessed Feb 2006).
- 3. The National Heart Foundation of Australia, The Cardiac Society of Australia and New Zealand. Management of unstable angina. Guidelines — 2000. Med J Aust 2000; 173 (8 Suppl): S65-S88.
- 4. Coory MD, Walsh WF. Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients. Med J Aust 2005; 182: 507-512. http://www.mja.com.au/public/issues/182_10_160505/coo10081_fm.html
- 5. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined — a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36: 959-969.
- 6. Data set specification — acute coronary syndrome (clinical). Available at: http://meteor.aihw.gov.au/content/index.phtml/itemId/284654 (accessed Jun 2005).
- 7. Tierney WM, Fitzgerald J, McHenry R, et al. Physicians’ estimates of the probability of myocardial infarction in emergency room patients with chest pain. Med Decis Making 1986; 6: 12-17.
- 8. Lee H, Bahler R, Park OJ, et al. Typical and atypical symptoms of myocardial infarction among African-Americans, whites, and Koreans. Crit Care Nurs Clin North Am 2001; 13: 531-539.
- 9. Hamm CW, Ravkilde J, Gerhardt W, et al. The prognostic value of serum troponin T in unstable angina. New Engl J Med 1992; 327: 146-150.
- 10. Volpi A, Cavalli A, Santoro L, Negri E. Incidence and prognosis of early primary ventricular fibrillation in acute myocardial infarction — results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI-2) database. Am J Cardiol 1998; 82: 265-271.
- 11. Gupta R, Birnbaum Y, Uretsky BF. The renal patient with coronary artery disease: current concepts and dilemmas. J Am Coll Cardiol 2004; 44: 1343-1353.
- 12. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110: e82-292.
- 13. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction — summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002; 40: 1366-1374.
- 14. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311-322.
- 15. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Lancet 1986; 1: 397-402.
- 16. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988; 2: 349-360.
- 17. De Luca G, Suryapranata H, Zijlstra F, et al. Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol 2003; 42: 991-997.
- 18. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation 2004; 109: 1223-1225.
- 19. Eagle KA, Guyton RA, Davidoff R, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery; American Society for Thoracic Surgery; Society of Thoracic Surgeons. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol 2004; 44: 1146-1154, e213-310.
- 20. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324: 71-86.
- 21. Mehta SR, Yusuf S, Peters RJ, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001; 358: 527-533.
- 22. Steinhubl SR, Berger PB, Mann JT, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 288: 2411-2420.
- 23. Patti G, Colonna G, Pasceri V, et al. Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: results from the ARMYDA-2 (Antiplatelet therapy for reduction of MYocardial Damage during Angioplasty) study. Circulation 2005; 111: 2099-2106.
- 24. Sabatine MS, Cannon CP, Gibson CM, et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005; 352: 1179-1189.
- 25. Reducing risk in heart disease 2004. Guidelines for preventing cardiovascular events in people with coronary heart disease: National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand, 2004. Available at: http://www.heartfoundation.com.au/index.cfm?page=37 (accessed Feb 2006).
- 26. de Bono DP, Simoons ML, Tijssen J, et al. Effect of early intravenous heparin on coronary patency, infarct size, and bleeding complications after alteplase thrombolysis: results of a randomised double blind European Cooperative Study Group trial. Br Heart J 1992; 67: 122-128.
- 27. Hsia J, Hamilton WP, Kleiman N, et al. A comparison between heparin and low-dose aspirin as adjunctive therapy with tissue plasminogen activator for acute myocardial infarction. Heparin-Aspirin Reperfusion Trial (HART) Investigators. N Engl J Med 1990; 323: 1433-1437.
- 28. Collins R, Peto R, Baigent C, Sleight P. Aspirin, heparin, and fibrinolytic therapy in suspected acute myocardial infarction. N Engl J Med 1997; 336: 847-860.
- 29. Topol EJ, Neumann FJ, Montalescot G. A preferred reperfusion strategy for acute myocardial infarction. J Am Coll Cardiol 2003; 42: 1886-1889.
- 30. Montalescot G, Barragan P, Wittenberg O, et al. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001; 344: 1895-1903.
- 31. Stone GW, Grines CL, Cox DA, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002; 346: 957-966.
- 32. Topol EJ. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Lancet 2001; 357: 1905-1914.
- 33. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy investigators. N Engl J Med 1997; 336: 1621-1628.
- 34. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: 13-20.
- 35. Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol 2003; 92: 824-826.
- 36. Guidelines for competency in coronary angioplasty. Cardiac Society of Australia and New Zealand. Available at: http://www.csanz.edu.au/guidelines/training/Angioplasty_Guidelines.pdf (accessed Jun 2005).
- 37. Magid DJ, Calonge BN, Rumsfeld JS, et al. Relation between hospital primary angioplasty volume and mortality for patients with acute MI treated with primary angioplasty vs thrombolytic therapy. JAMA 2000; 284: 3131-3138.
- 38. Widimsky P, Budesinsky T, Vorac D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial — PRAGUE-2. Eur Heart J 2003; 24: 94-104.
- 39. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003; 349: 733-742.
- 40. Steg PG, Bonnefoy E, Chabaud S, et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation 2003; 108: 2851-2856.
- 41. Van de Werf F, on behalf of the ASSENT-4 PCI investigators. ASSENT-4 PCI: the ASsessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction. ESC 2005 Congress: Abstract 2578. Available at: http://www.escardio.org/NR/rdonlyres/DDD650CD-3EF8-4001-8B00-EB6255935752/0/Van_De_Werf_FP2578.pdf (accessed Sep 2005).
- 42. Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348: 771-775.
- 43. Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6–24 hours after onset of acute myocardial infarction. Lancet 1993; 342: 759-766.
- 44. Schomig A, Mehilli J, Antoniucci D, et al. Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 hours from symptom onset: a randomized controlled trial. JAMA 2005; 293: 2865-2872.
- 45. NACCHO discussion paper — thrombolysis. Canberra: National Aboriginal Community Controlled Health Organisation, 2001.
- 46. Kelly AM, Kerr D, Patrick I, Walker T. Call-to-needle times for thrombolysis in acute myocardial infarction in Victoria. Med J Aust 2003; 178: 381-385. http://www.mja.com.au/public/issues/178_08_210403/kel10643_fm.html
- 47. Morrison LJ, Verbeek PR, McDonald AC, et al. Mortality and prehospital thrombolysis for acute myocardial infarction: a meta-analysis. JAMA 2000; 283: 2686-2692.
- 48. Ong MA, Weeramanthri TS. Delay times and management of acute myocardial infarction in indigenous and non-Indigenous people in the Northern Territory. Med J Aust 2000; 173: 201-204.
- 49. Grzybowski M, Clements EA, Parsons L, et al. Mortality benefit of immediate revascularization of acute ST-segment elevation myocardial infarction in patients with contraindications to thrombolytic therapy: a propensity analysis. JAMA 2003; 290: 1891-1898.
- 50. Beggs AD, Al-Rawi H, Parfitt A. Chest pain and fleeting neurological signs. Lancet 2005; 365: 1514.
- 51. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. SHould we emergently revascularize Occluded coronaries for Cardiogenic ShocK. N Engl J Med 1999; 341: 625-634.
- 52. Prasad A, Lennon RJ, Rihal CS, et al. Outcomes of elderly patients with cardiogenic shock treated with early percutaneous revascularization. Am Heart J 2004; 147: 1066-1070.
- 53. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Assessment of the Safety and Efficacy of a New Thrombolytic Investigators. Lancet 1999; 354: 716-722.
- 54. A comparison of reteplase with alteplase for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. N Engl J Med 1997; 337: 1118-1123.
- 55. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med 1993; 329: 673-682.
- 56. White HD, Barbash GI, Califf RM, et al. Age and outcome with contemporary thrombolytic therapy. Results from the GUSTO-I trial. Global Utilization of Streptokinase and TPA for Occluded coronary arteries trial. Circulation 1996; 94: 1826-1833.
- 57. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet 2001; 358: 605-613.
- 58. Antman EM, Giugliano RP, Gibson CM, et al. Abciximab facilitates the rate and extent of thrombolysis: results of the thrombolysis in myocardial infarction (TIMI) 14 trial. The TIMI 14 Investigators. Circulation 1999; 99: 2720-2732.
- 59. Urdahl KB, Mathews JD, Currie B. Anti-streptokinase antibodies and streptokinase resistance in an Aboriginal population in northern Australia. Aust N Z J Med 1996; 26: 49-53.
- 60. Vetrano A, Carotenuto R, Corsini F, et al. Effectiveness of tirofiban for failed thrombolysis during acute myocardial infarction. Am J Cardiol 2004; 93: 914-916.
- 61. Ellis SG, da Silva ER, Heyndrickx G, et al. Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute anterior myocardial infarction. Circulation 1994; 90: 2280-2284.
- 62. Madsen JK, Grande P, Saunamaki K, et al. Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction. Circulation 1997; 96: 748-755.
- 63. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 1995; 91: 2325-2334.
- 64. Davis KB, Chaitman B, Ryan T, et al. Comparison of 15-year survival for men and women after initial medical or surgical treatment for coronary artery disease: a CASS registry study. Coronary Artery Surgery Study. J Am Coll Cardiol 1995; 25: 1000-1009.
- 65. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation 2001; 104: 2767-2771.
- 66. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344: 1879-1887.
- 67. Conaway DG, O’Keefe J H, Reid KJ, Spertus J. Frequency of undiagnosed diabetes mellitus in patients with acute coronary syndrome. Am J Cardiol 2005; 96: 363-365.
- 68. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39 (2 Suppl 1): S1-S266.
- 69. Keeley EC, Kadakia R, Soman S, et al. Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with acute coronary syndromes. Am J Cardiol 2003; 92: 509-514.
- 70. Keeley EC, McCullough PA. Coronary revascularization in patients with end-stage renal disease: risks, benefits, and optimal strategies. Rev Cardiovasc Med 2003; 4: 125-130.
- 71. Anavekar NS, McMurray JJ, Velazquez EJ, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 2004; 351: 1285-1295.
- 72. Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339: 489-497.
- 73. Tonelli M, Moye L, Sacks FM, et al. Effect of pravastatin on loss of renal function in people with moderate chronic renal insufficiency and cardiovascular disease. J Am Soc Nephrol 2003; 14: 1605-1613.
- 74. McCullough PA, Sandberg KR, Borzak S, et al. Benefits of aspirin and beta-blockade after myocardial infarction in patients with chronic kidney disease. Am Heart J 2002; 144: 226-232.
- 75. McCullough PA, Sandberg KR, Yee J, Hudson MP. Mortality benefit of angiotensin-converting enzyme inhibitors after cardiac events in patients with end-stage renal disease. J Renin Angiotensin Aldosterone Syst 2002; 3: 188-191.
- 76. Ruggenenti P, Perna A, Remuzzi G. ACE inhibitors to prevent end-stage renal disease: when to start and why possibly never to stop: a post hoc analysis of the REIN trial results. Ramipril Efficacy in Nephropathy. J Am Soc Nephrol 2001; 12: 2832-2837.
- 77. Januzzi JL, Cannon CP, DiBattiste PM, et al. Effects of renal insufficiency on early invasive management in patients with acute coronary syndromes (The TACTICS-TIMI 18 Trial). Am J Cardiol 2002; 90: 1246-1249.
- 78. Januzzi JL Jr, Snapinn SM, DiBattiste PM, et al. Benefits and safety of tirofiban among acute coronary syndrome patients with mild to moderate renal insufficiency: results from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial. Circulation 2002; 105: 2361-2366.
- 79. Lindahl B, Andren B, Ohlsson J, et al. Noninvasive risk stratification in unstable coronary artery disease: exercise test and biochemical markers. FRISC Study Group. Am J Cardiol 1997; 80: 40E-44E.
- 80. Lindahl B, Andren B, Ohlsson J, et al. Risk stratification in unstable coronary artery disease. Additive value of troponin T determinations and pre-discharge exercise tests. FRISK Study Group. Eur Heart J 1997; 18: 762-770.
- 81. Farkouh ME, Smars PA, Reeder GS, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med 1998; 339: 1882-1888.
- 82. Aroney CN, Dunlevie HL, Bett JH. Use of an accelerated chest pain assessment protocol in patients at intermediate risk of adverse cardiac events. Med J Aust 2003; 178: 370-374. http://www.mja.com.au/public/issues/178_08_210403/aro10527_fm.html
- 83. Lewis HD Jr, Davis JW, Archibald DG, et al. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study. N Engl J Med 1983; 309: 396-403.
- 84. Cairns JA, Gent M, Singer J, et al. Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. N Engl J Med 1985; 313: 1369-1375.
- 85. Cohn PF. Concomitant use of nitrates, calcium channel blockers, and beta blockers for optimal antianginal therapy. Clin Cardiol 1994; 17: 415-421.
- 86. Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. The RISC Group. Lancet 1990; 336: 827-830.
- 87. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345: 494-502.
- 88. Antman EM, Cohen M, Radley D, et al. Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction. TIMI 11B-ESSENCE meta-analysis. Circulation 1999; 100: 1602-1608.
- 89. Goodman S, Langer A, Demers C, et al. One year follow-up of the ESSENCE trial (enoxaparin vs heparin in unstable angina/non-Q-wave myocardial infarction): sustained clinical benefit. Can J Cardiol 1998; 14 (suppl F): 122F.
- 90. Oler A, Whooley MA, Oler J, Grady D. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. JAMA 1996; 276: 811-815.
- 91. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med 1998; 338: 1488-1497.
- 92. Bhatt DL, Topol EJ. Current role of platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. JAMA 2000; 284: 1549-1558.
- 93. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA 1988; 260: 2259-2263.
- 94. Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol 1995; 26: 57-65.
- 95. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000; 284: 835-842.
- 96. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997; 337: 447-452.
- 97. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348: 1309-1321. Epub 2003 Mar 31.
- 98. National Aboriginal Community Controlled Health Organisation, The Chronic Disease Alliance of Non-government organisations, and Royal Australian College of General Practitioners. National Guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples. Melbourne: RACGP, 2005.
- 99. Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander Peoples: a guide for health professionals. National Health and Medical Research Council (NHMRC). Available at: http://www.nhmrc.gov.au/publications/synopses/ind1syn.htm (accessed Oct 2005).
- 100. Marchioli R, Barzi F, Bomba E, et al. Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione. Circulation 2002; 105: 1897-1903.
- 101. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico. Lancet 1999; 354: 447-455.
- 102. Bunker SJ, Colquhoun DM, Esler MD, et al. “Stress” and coronary heart disease: psychosocial risk factors. Med J Aust 2003; 178: 272-276. http://www.mja.com.au/public/issues/178_06_170303/bun10421_fm.html
- 103. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation 2002; 106: 2145-2161.
- 104. Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140-2150.
- 105. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352: 225-237.
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