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Guidelines for the management of acute coronary syndromes 2006

Acute Coronary Syndrome Guidelines Working Group
Med J Aust 2006; 184 (8 Suppl): S1-S32.
Summary of key recommendations
Systems of care for patients with acute coronary syndromes
  • 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.

New acute coronary syndrome terminology and implications for diagnosis
  • 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.

Acute management of chest pain
  • 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.

Investigations
  • 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.

Management of patients with ST-segment-elevation myocardial infarction
Adjuvant therapy in association with reperfusion
  • 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.

Choice of reperfusion strategy
  • 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.

Choice of fibrinolytic agent
  • 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.

Transfer after STEMI
  • 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).

Management of patients with non-ST-segment-elevation acute coronary syndromes
  • 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.

Long-term management after control of myocardial ischaemia
  • 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.

Levels of evidence and grades of recommendation

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.

Introduction

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.

Key recommendations are summarised at the beginning of these guidelines.

Systems of care for patients with acute coronary syndromes

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.

The systems of care should address:

  • 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);

  • education; and

  • 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.

The key elements of successful systems include:

  • 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.

Taking patient preferences into account

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

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.

Key messages
  • 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.

Acute Coronary Syndrome Guidelines Working Group
Acknowledgements: 

These guidelines were developed by means of a consensus approach which involved an independent assessment of key Australian and international evidence-based clinical guidelines, scientific articles and trial data, which are incomplete in some areas.
Recommendations are not necessarily congruent with current Pharmaceutical Benefits Scheme criteria for eligibility for subsidy in all areas.
The guidelines provide a general framework for appropriate practice, to be followed subject to the practitioner’s judgement in each individual case. All treatments should be individualised according to the patient’s comorbidities, drug tolerance, lifestyle and living circumstances, and wishes.
For all medications, observe usual contraindications, be mindful of the potential for significant and possibly adverse drug interactions and allergies, and monitor and review patients carefully and regularly.
Where drug therapy is recommended for indefinite use, these recommendations have been based on the extrapolated findings of clinical trials which are by their nature of limited duration.
These guidelines were published in April 2006 and are based on the literature up to September 2005.
Please check Heartsite regularly for updates and amendments.

Author details
Core writing group

Constantine N Aroney, Co-chair
Philip Aylward, Co-chair
Anne-Maree Kelly
Derek P B Chew
Eleanor Clune
on behalf of the Acute Coronary Syndrome Guidelines Working Group

Acute Coronary Syndrome Guidelines Working Group

Associate Professor Constantine N Aroney, MD, FRACP, Director, Cardiac Services, Holy Spirit Northside Hospital, Brisbane, QLD.

Professor Philip Aylward, BM BCh, PhD, FRACP, FCSANZ, Director of Cardiology, Flinders Medical Centre, Adelaide, SA.

Dr Roger M Allan, MB BS, FRACP, FCSANZ, FACC, Chair, Cardiac Clinical Division, Prince of Wales Hospital, Sydney, NSW.

Dr Andrew N Boyden, MB BS, MPH, FRACGP, Medical Affairs Manager, National Heart Foundation of Australia, Canberra, ACT.

Associate Professor David Brieger, PhD, FRACP, Cardiologist, Concord Hospital, Sydney, NSW.

Dr Alex Brown, BMed, MPH, National Heart Foundation of Australia Indigenous Scholar, and Senior Research Fellow, Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Alice Springs, NT.

Associate Professor Gerard E Carroll AM, MB BS(Hons), FRACP, Associate Professor of Medicine, University of New South Wales, Sydney, NSW, and Consultant Physician and Cardiologist, Wagga Wagga, NSW.

Associate Professor Derek P B Chew, MB BS, MPH, FRACP, Cardiologist, Flinders Medical Centre and Flinders University, Adelaide, SA.

Ms Eleanor Clune, BSc, GradDipSciComm, Medical Affairs Project Officer, National Heart Foundation of Australia, Melbourne, VIC.

Dr Michael Flynn, MB BS, DObsRCOG, DVen, FRACGP, FAFOM, Medical Director, Ambulance Service of NSW, Sydney, NSW.

Associate Professor David Hunt, MD, FRACP, Cardiologist, Royal Melbourne Hospital, Melbourne, VIC.

Associate Professor Ian G Jacobs, BAppSc, DipEd, PhD, FRCNA, FACAP, RN, Chairman, Australian Resuscitation Council.

Professor Anne-Maree Kelly, MD BS, MClinED, FACEM, Professor and Director, Department of Emergency Medicine, Western Hospital, Melbourne, VIC, and Director, Joseph Epstein Centre for Emergency Medicine Research, Melbourne, VIC.

Mr Traven M Lea, MAE(IH), DipPHTM, National Program Manager — Aboriginal and Torres Strait Islander Program, National Heart Foundation of Australia, Brisbane, QLD.

Dr Kok Shiong Tan, MB BS, FRACGP, Clinical Advisor, Department of Health, Perth, WA.

Professor Andrew M Tonkin, MB BS, MD, FRACP, Chief Medical Officer, National Heart Foundation of Australia, Melbourne, VIC.

Mr Tony Walker, ASM, BParamedStud, CertMICAParamedic, GradDipEd, GradCertAppMgt, Manager Operations — Clinical and Education Services, Rural Ambulance Victoria, Ballarat, VIC.

Dr Warren Walsh, MB BS, FRACP, FACC, Cardiologist, Prince of Wales Hospital, Sydney, NSW.

Professor Harvey White, DSc, FCSANZ, Director of Coronary Care and Cardiovascular Research, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.

Correspondence:

Ms Eleanor Clune, National Heart Foundation of Australia, 411 King St, West Melbourne, VIC, 3003. Eleanor.CluneATheartfoundation.com.au

Others who contributed or acted as reviewers for these guidelines were: Chris Bladin, Carmel Brophy, Stephen Colagiuri, Sophie Couzos, Carol Cunningham, Leeanne Grigg, Sue Huckson, Peter Hunter, Sue Ieraci, Garry Jennings, Leo Mahar, Richard McCluskey, Tom Marwick, Tim Mathew, Patricia O’Hara, David Ross, Sue Sanderson, Noella Sheerin, Wayne Stafford, Darren Walters, and Glen Young.

Competing interests: 
The following working group members are consultants, advisory committee members, or receive honoraria, fees for service, or travel assistance (independent of research related meetings) from, or have research or other associations with the organisations listed: Roger Allan — Merck Sharpe & Dohme, Sanofi; Con Aroney — CSL, Merck Sharpe & Dohme, Sanofi-aventis; Phil Aylward — Sanofi-aventis, Pfizer, Merck, Bristol-Myers Squibb, Boehringer Ingelheim, AstraZeneca, Procter & Gamble, Eli Lilly, The Medicines Co, Servier, CSL, Schering Plough; David Brieger — Aventis, Sanofi, Boehringer Ingelheim, Merck Sharpe & Dohme; Alex Brown — National Heart Foundation of Australia, Australian Indigenous Doctors’ Association, Alice Springs Hospital Management Board, Bristol-Myers Squibb, Pfizer; Gerard Carroll — Aventis, Bristol-Myers Squibb, AstraZeneca, Merck Sharpe & Dohme, Servier, Solvay, Roche; Derek Chew — Merck Sharpe & Dohme, Sanofi, Pfizer; Ian Jacobs — St John Ambulance, Australian Government Department of Health and Ageing, Convention of Ambulance Authorities Australia, National Health and Medical Research Council, Laerdal Foundation, National Heart Foundation of Australia, Health Department of Western Australia; Anne-Maree Kelly — Proctor & Gamble/Alexion, Boehringer Ingelheim; Shiong Tan — Health Department of Western Australia (Office of Safety & Quality and Sentinel event review group), Royal Australian College of General Practitioners (Quality Care National Standing Committee), National Prescribing Service (Director), Royal Australian College of General Practitioners (WA) Faculty (Director); Andrew Tonkin — AstraZeneca, Bristol-Myers Squibb, Pfizer, Sankyo, Fournier, Servier, Merck Sharpe & Dohme; Warren Walsh — Roche; Harvey White — The Medicines Company, AstraZeneca, Aventis, Bayer, Boehringer Ingelheim, Eli Lilly, Merck Sharpe & Dohme, Novartis, Pfizer, Roche, Servier, Wyeth Ayerst.
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