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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): S1-S32. || doi: 10.5694/j.1326-5377.2006.tb00304.x
Published online: 17 April 2006
Summary of key recommendations
Management of patients with ST-segment-elevation myocardial infarction
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:

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:

  • Acute Coronary Syndrome Guidelines Working Group



Correspondence: 

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
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.

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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