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The New Acute Coronary Syndromes
New Guidelines
A/Professor Darren Walters
Spark of Life
Perth 2011
ILCOR Consensus on Science 2010
• Cardiovascular Care
• Consensus on Science Document published
October 2010
• Document underpins AHA/ ESC and
Australian Resuscitation Council Guidelines
• Acute Coronary Syndromes
– ARC have published first ACS Guidelines
Feb 2010.
Emergency Medicine Australasia
Managing Acute Coronary Syndromes in the pre Hospital and Emergency Setting -New Guidelines from the Australian Resuscitation Council
-and New Zealand Resuscitation Council. Darren L Walters & Carol Cunningham for
the Australian Resuscitation Council and New Zealand Resuscitation Council.
Emergency Medicine Australasia in press June 2011
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.
• Diagnostic Tests in ACS
• Initial Therapeutic Interventions
• Reperfusion Strategy
• Additional Medical Therapy
• Healthcare Systems Interventions
Diagnostic Tests in ACS
Risk Stratification
Demographic Factors
For patients with ACS, we evaluated whether any specific demographic factors (eg, age, sex,
race, weight) were associated with delayed treatment and classified these delays
according to whether they occurred before or after hospital arrival.
• Various patient-related factors may impede seeking treatment rapidly; these include older
age, racial and ethnic minorities, female gender, low socioeconomic status and residing
alone.
• Indigenous Australians and Maori and Pacific Islanders have higher incidence of CAD, the
present at a younger age with more advanced disease.
• Providers should be trained to expeditiously identify patients with ACS irrespective
of age, gender, socioeconomic status, or living arrangements.
Accuracy of History and Physical Examination for
Diagnosing ACS In patients with suspected ACS in various settings (eg, prehospital, emergency or in-hospital), do specific
historical factors, physical examination findings, and test results, compared with normal, increase the
accuracy of diagnosis ACS and MI?
• Signs and symptoms alone are neither sensitive nor specific and should not be used
without other data for making the diagnosis of ACS.
• Signs and symptoms may be useful in combination with other important information
(biomarkers, risk factors, ECG, and other diagnostic tests) in making triage and some
treatment and investigational decisions for ACS in the out-of hospital and ED setting.
Diagnostic Tests in ACS
ACS and Nitroglycerin In patients with suspected ACS/STEMI in the ED and prehospital settings, does the use of nitroglycerin,
compared with no nitroglycerin, improve diagnosis of ACS/MI?
• A reduction in chest pain following nitroglycerin administration may be unrelated to the presence or
absence of ACS, and should not be used as a diagnostic test or strategy in the prehospital or ED
setting.
ED Interpretation of 12-Lead ECG for STEMI In patients with suspected ACS in various settings (eg, prehospital or emergency), does the use of
prehospital or emergency 12-lead ECG, compared with standard diagnostic techniques,
increase sensitivity and specificity of diagnosis of ACS/MI?
• In patients with suspected ACS, a 12-lead-ECG should be acquired and interpreted by
prehospital or emergency providers as soon as possible after first patient contact.
• The interpretation should be used to for diagnosis and triage, including destination
decisions and activation of the cardiac catheterization laboratory.
• If interpretation of the prehospital ECG is not available on site, field-transmission of the
ECG for expert interpretation may be reasonable.
Diagnostic Tests in ACS
Diagnosis of STEMI by Non physicians
In patients with suspected ACS in the prehospital, ED, or in-hospital settings, can
nonphysicians (eg, paramedics and nurses) accurately diagnose STEMI when compared
to physicians?
• paramedics and nurses are able to identify STEMI on a 12-lead ECG independently as
long as there is a program of mandatory initial training followed by ongoing concurrent
medical oversight of all interpretations.
Diagnostic Tests in ACS
Pre-hospital 12 Lead ECG triage to Pre-Hospital Fibrinolysis and then to
Primary Coronary Intervention
Pre-hospital 12 lead
ECG
confirmed STEMI
Pre-hospital
Fibrinolysis
Primary
Coronary
Intervention
From S Rashford with
permission
Computer-Assisted ECG Interpretation In patients with suspected ACS, does the use of computer-assisted ECG interpretation, compared
with standard diagnostic techniques (emergency physicians), increase accuracy of diagnosis
(eg, of NSTEMI/STEMI)?
• Prehospital ECG interpretation should be augmented with computer interpretation.
• Computer interpretation of the ECG may increase the specificity of diagnosis of STEMI,
especially for clinicians less experienced in reading ECGs.
• The benefit of computer interpretation is dependent on accuracy, and therefore computer-
assisted ECG interpretation should not replace, but may be used as an adjunct to,
interpretation by an experienced clinician. The computer interpretation should be
considered in the clinical context
Diagnostic Tests in ACS
Chest Pain Observation Units In patients with suspected ACS, does the use of chest pain observation units (CPUs),
compared with not using them, increase accuracy of diagnosis and safely identify patients
who require admission or specific management of CAD?
• In patients with suspicion for ACS, normal initial biomarkers and nonischemic ECG, chest
pain (observation) protocols may be recommended as a safe and effective strategy for
evaluating patients in the ED.
• Chest pain observation protocols should include a history and physical examination, a
period of observation, serial electrocardiography, serial measurement of serum cardiac
markers, and either an evaluation for anatomic coronary disease or for inducible
myocardial ischemia at some point after AMI is excluded.
Diagnostic Tests in ACS
Chest Pain Observation Units
• These protocols may be used to improve accuracy in identifying patients requiring in-
patient admission or further diagnostic testing, and those who may be discharged.
– reduce length of stay,
– reduce hospital admissions,
– reduce healthcare costs,
– improve diagnostic accuracy, and
– improve quality of life.
• There is no direct evidence demonstrating that CPUs or (observation protocols) reduce
adverse cardiovascular outcomes, particularly mortality for patients presenting with
possible ACS, normal serum cardiac biomarkers, and a nondiagnostic ECG.
Diagnostic Tests in ACS
Imaging Techniques
Imaging Techniques and Diagnosis In patients with suspected ACS, does the use of specific imaging techniques (eg, CT
angiography, MRI, nuclear, echocardiography), compared with not using them,
increase accuracy of diagnosis (eg, of ACS).
• A noninvasive test (CT angiography, cardiac MR, myocardial perfusion imaging, and
echocardiography) can be useful in making the diagnosis of ACS in patients who
present to the ED with chest pain and initial nondiagnostic conventional work-ups.
• Diagnostic imaging may be considered as an adjunct to serial ECGs and biomarkers
in identifying patients either requiring admission or suitable for discharge from the ED.
• It is reasonable to consider both the exposure to radiation and iodinated contrast
when utilizing MDCT and myocardial perfusion imaging.
Diagnostic Tests in ACS
Chest Pain Assessment
• Full Diagnostic Quality
• Selectable Compression
• Ability to integrate with the RIS
systems
Initial Therapeutic Interventions
• Few studies have been published that directly address out-of-hospital or ED
interventions for ACS. In some situations, extrapolation from in-hospital evidence was
needed to provide some guidance for out-of-hospital and early ED management.
Oxygen Therapy In patients with suspected ACS in various settings (eg, prehospital, emergency or in-hospital) and
normal oxygen saturations, does the use of supplemental oxygen, compared with room air,
improve outcomes (eg, chest pain resolution, infarct size, ECG resolution, survival to discharge,
30/60 days mortality)?
• There is insufficient evidence to support or refute the empirical use of high-flow oxygen therapy in
patients with uncomplicated AMI without signs of hypoxemia and/or heart failure. There are
insufficient data to support or refute the fact that high-flow oxygen therapy might be harmful in this
setting.
• Oxygen therapy should be initiated if breathlessness, hypoxemia, or signs of heart failure or shock
are present. Noninvasive monitoring of oxygen saturation may be used to decide on the need for
oxygen administration.
In the absence of other symptoms or signs of a need
for oxygen therapy O2 need not be given unless sats
<95%.
Aspirin (Acetylsalicylic Acid)
Timing of Aspirin Administration
• In patients with suspected ACS, does dispatcher guided administration of aspirin
by bystanders before arrival of EMS, compared with later administration of
aspirin by paramedic or ED staff, improve outcome?
• In the absence of true allergy, aspirin should be administered as soon as
possible in patients with suspected ACS.
• It is reasonable to consider EMS or dispatcher-guided bystander aspirin
administration, despite limited direct evidence to support or refute the practice.
Initial Therapeutic Interventions
Clopidogrel and Other Platelet ADP-
Receptor Antagonists
• Administration of Clopidogrel in addition to standard care (aspirin,
anticoagulants, and/or reperfusion) for patients determined to have
moderate to high-risk non-ST elevation ACS and STEMI is recommended.
• The ideal oral loading dose of clopidogrel in patients >75 years of age is
dependent on the planned approach: 600 mg in a planned invasive strategy;
or 300 mg in a planned noninvasive strategy or together with fibrinolysis.
• The ideal dose in patients >75 years of age has not yet been delineated,
but may range from 75 to 600 mg.
Initial Therapeutic Interventions
Prasugrel • Prasugrel may be administered after angiography to patients with NSTEMI presenting with stenoses
amenable to PCI.
• ED or prehospital administration of clopidogrel should be withheld even in patients who are not at high
risk for bleeding (age >75 years, no history of previous stroke or TIA, and body weight [mt]60 kg),
pending consideration of prasugrel administration following angiography.
• In patients who are not at high risk for bleeding with planned PCI, prasugrel (60-mg oral loading dose)
may be substituted for clopidogrel for patients determined to have STEMI less than 12 hours after the
initial symptoms.
• Prasugrel is not recommended in STEMI patients receiving fibrinolysis.
• The risks and/or benefits of combining these agents (clopidogrel, prasugrel, and/or ticagrelor) for
loading and maintenance dosing has not been sufficiently determined.
Initial Therapeutic Interventions
22
0
5
10
15
0 30 60 90 180 270 360 450
HR 0.81
(0.73-0.90)
P=0.0004
Prasugrel
Clopidogrel
Days
En
dp
oin
t (%
)
12.1
9.9
HR 1.32
(1.03-1.68)
P=0.03
Prasugrel
Clopidogrel 1.8
2.4
138
events
35
events
Balance of
Efficacy and Safety
CV Death / MI / Stroke
TIMI Major
NonCABG Bleeds
NNT = 46
NNH = 167
Adapted with permission from Wiviott SD et al
NEJM 357:2007
TRITON: Results
Reperfusion Strategies
Choice of Reperfusion Strategy in the Hospital
PPCI Versus Fibrinolytic Therapy for STEMI
• For patients presenting within 12 hours of symptom onset and with ECG findings
consistent with STEMI, reperfusion should be initiated as soon as possible
independently of the method chosen.
• The benefit of mechanical intervention over fibrinolysis varies considerably
depending on the patient’s condition and the duration of PPCI-related delays.
• PCI-related delays of between 40 and 179 minutes may mitigate the benefit of
mechanical intervention over fibrinolysis.
• If PCI cannot be accomplished within 40 to 179 minutes of FMC independent of the
need for emergent transfer, then immediate fibrinolysis may be considered. For those
patients with a contraindication to fibrinolysis, PCI should still be pursued despite the
delay, rather than offering no reperfusion therapy.
• For those STEMI patients presenting in shock, PCI (or coronary artery bypass
surgery) is the preferred reperfusion treatment. Fibrinolysis should only be
considered if there is a substantial delay to PCI.
Primary PCI vs In-Hospital Fibrinolysis
Keeley and Grines Lancet. 2003.
Fre
quency
, %
50
40
30
20
10
0
25
20
15
10
5
0
Death Death, Excluding
SHOCK Data
Non-fatal Myocardial Infarction
Recurrent Ischemia
Total Stroke
Haemorrhagic Stroke
Major Bleed
Death, Non-fatal Reinfarction,
or Stroke
Long-Term Outcomes
Short-Term Outcomes
P = 0.0019 P = 0.0053 P < 0.0001
P < 0.0001
P < 0.0001
P = 0.0002 P = 0.0003 P < 0.0001
P < 0.0001
P < 0.0001
P = 0.0032 P < 0.0001 P = 0.0004
- - -
PTCA
Thrombolytic therapy
Death Death, Excluding
SHOCK Data
Non-fatal Myocardial Infarction
Recurrent Ischemia
Total Stroke
Haemorrhagic Stroke
Major Bleed
Death, Non-fatal Reinfarction,
or Stroke
0.8
1.25
1.5
Estimated Treatment Effect and 95% Confidence Intervals
Conditional on PCI Related Delay (DB-DN)(min)After Adjusting for Covariates
Est
imate
d T
reatm
en
t Effect
0.5
1.0
2.0
PCI Related Delay (DB-DN) (min)
60 75 90 105 120 135 150 165 180114
Od
ds o
f D
ea
th w
ith
Fib
rin
oly
sis
PC
I B
ette
r F
ibrin
oly
sis
Be
tte
r
Pinto et al. Circulation, 2006
PCI vs. Lysis: Importance of PCI-related Delay
Data from NRMI 2,3 and 4 Registries
CSANZ/NHF Guidelines
MJA • Volume 184 Number 8 • 17 April 2006
Reperfusion Strategies
Out-of-Hospital Fibrinolytics for STEMI
Prehospital Fibrinolytics for STEMI
In patients with STEMI in the prehospital setting, does the use of prehospital fibrinolytics,
compared with in-hospital fibrinolytics, improve outcomes (eg, chest pain resolution,
infarct size, ECG resolution, survival to discharge, 30/60 days mortality)?
• In patients with STEMI diagnosed in the prehospital setting, reperfusion may be
achieved by administration of fibrinolytics by healthcare providers in the field.
Alternately, fibrinolytic therapy may be administered on arrival at hospital.
• Fibrinolysis should be started as soon as possible,
– ideally in the prehospital setting, and should be administered by paramedics,
nurses, or doctors
– using well-established protocols, competency training programs, and
– quality assurance programs, under medical oversight.
Copyright restrictions may apply.
Stenestrand, U. et al. JAMA 2006;296:1749-1756.
Unadjusted Cumulative Mortality During the First Year After the Index Event Admission
Healthcare System Interventions for ACS
• Several systems-related strategies have been
developed to improve quality of care for patients
with ACS and reduce reperfusion delays for
patients with STEMI.
• Strategies exist for patients identified in the
prehospital setting and in the ED.
Healthcare System Interventions for ACS
12-Lead Out-of-Hospital ECG and Advance ED Notification
Prehospital ECGs
• Prehospital 12-lead ECGs facilitate earlier diagnosis of STEMI and provide the
opportunity for rapid prehospital reperfusion or for rapid triage of patients to awaiting
institutions able to provide such reperfusion.
• EMS personnel should acquire a prehospital 12-lead ECG on all patients exhibiting
signs and symptoms of ACS and provide advance notification to receiving institutions
for patients diagnosed with STEMI.
• Advance notification may be achieved with direct transmission of the ECG or with
interpretation of the ECG by prehospital personnel. Advance notification should
prompt preparations at the receiving institution for rapid reperfusion of the arriving
STEMI patient.
Healthcare System Interventions for ACS
Improving Systems of Care for ACS • Hospitals should implement prehospital activation of the catheterization
laboratory for patients with suspected STEMI who arrive by EMS and should
implement first-physician-contact activation of the catheterization laboratory for
patients suspected of having STEMI arriving by other means.
Strategies to improve Door –Balloon Times
• Arranging single-call activation of the catheterization laboratory
• Requiring the catheterization laboratory to be ready in 20 minutes
• Having the interventional cardiologist immediately available at the hospital
• Providing real-time data feedback
• Fostering the commitment of senior management
• Encouraging a team-based approach
Out-of-Hospital Triage for PCI In patients with ST-elevation identified on prehospital ECG, does the use of
direct transport to primary PCI, compared with transport to the closest
hospital, improve outcomes (mortality, left ventricular function, re-infarction,
or stroke) as compared with other standard strategies?
• It is reasonable to consider direct transport to PCI capable facilities for PPCI
for patients diagnosed with STEMI by EMS in the prehospital setting,
bypassing closer EDs as necessary, in systems where time intervals
between first medical contact and balloon time are brief. In patients
presenting early after the onset of chest pain ([lt]2 hours) and in certain
clinical subsets ([lt]65 years-of-age, anterior STEMI), prehospital fibrinolysis
may offer similar outcomes compared to PPCI.
Healthcare System Interventions for ACS
PCI Centre
Cath Lab
Community
Hospital
Emergency
Department
Cath / PCI within 6
hrs regardless of
reperfusion status
Cath and
Rescue PCI GP
IIb/IIIa Inhibitor
TNK + ASA + Heparin or Enoxaparin + Clopidogrel
Pharmacoinvasive
Strategy
Urgent Transfer to PCI
Centre
Assess chest pain, ST resolution
at 60-90 minutes after randomization
High Risk ST Elevation MI within 12 hours of symptom onset
Failed Reperfusion** Successful Reperfusion
Elective Cath
PCI
> 24 hrs later
Standard Treatment
** ST segment resolution < 50% & persistent chest pain, or hemodynamic instability
Repatriation of stable patients
within 24 hrs of PCI
Randomization
Kaplan-Meier Curves for the
Primary Endpoint* at 30 Days
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
*Primary endpoint was death, reinfarction, recurrent ischemia,
new or worsening heart failure, or cardiogenic shock at 30 days
36
CARESS-IN-AMI: Primary Outcome primary outcome (composite of all cause mortality, reinfarction, & refractory MI within 30 days)
occurred significantly less often in the immediate PCI group vs. standard care/rescue PCI group
10.7%
4.4%
HR=0.40 (0.21-0.76)
Di Mario et al. Lancet 2008;371.
System factors
• System-based approaches to deliver timely reperfusion should be undertaken at
local level.
• Establishment of clinical networks and efficient protocols to maximise the
proportion of patients receiving timely reperfusion should be considered.
• Routine audit should be integrated into all clinical services that provide care to
patients with ACS.
• In the absence of ready access to primary PCI services, systems should be
developed to train local general practitioners and other health workers to initiate
fibrinolysis in patients with STEMI, to maintain practitioners’ skills, and to ensure
practitioners are supported by ready access to expert cardiology consultation.
TPCH -RBWH
Drip and Ship
Daytime Process
ACS Referral Manager
ACS Referral Schema
Referral Site
ACS Co-ordinatorACS
Patient
ACS Coordinator
reviews the ACS
referral request and
advises relevent Acceptance
Site Coordinator
i.e. RBWH or
TPCH
Referral Site enters ACS data
into Web Based ACS Referral
System
Acceptance Site
Physician undertakes
clinical assessment of
referral
Referral
Not
Accepted
Email notification to
Referral Site of non
acceptance of referral
Referral
Accepted
Email notification to
Referral Site of Referral
Acceptance
Acceptance Site Referral Coordinator
updates the Web Based ACS Referral with
assessment outcome,
manages the patients transfer and
updates the status of the ACS Referral
through to its completion
Updating the Web Based ACS
Referral status to Scheduled Awaiting
Transfer forwards an additional email
notification to the Referral Site
Accepted patient added to
Transfer pending queue
In CardioSchedule
CardioScheduleCardioStar Database
Demographics / Procedure Queue
Record Updated
PCI Following ROSC In patients with ROSC after cardiac arrest, does the routine use of PCI, compared
with standard management (without PCI), improve outcomes (eg, survival,
rearrest, etc)?
• Ischemic heart disease in the majority of patients who have an OHCA.
• Acute coronary artery occlusion the precipitating factor in many
• coronary artery occlusion can also occur in the absence of specific ECG
findings.
• In OHCA patients with STEMI or new LBBB on ECG following ROSC,
immediate angiography and PCI should be considered.
• despite the absence of ST-segment elevation on the ECG or prior clinical
findings,such as chest pain.
• Coma should not be a contraindication
• Include cardiac catheterization in standardized post–cardiac arrest protocols
• Therapeutic hypothermia is recommended in combination with PPCI
Patients post-ROSC admitted to the intensive care unit.
Dumas F et al. Circ Cardiovasc Interv 2010;3:200-207
Copyright © American Heart Association
Multivariable logistic regression analysis of early predictors of survival
in patients with OHCA without obvious extracardiac causes.
Dumas F et al. Circ Cardiovasc Interv 2010;3:200-207
Copyright © American Heart Association
