Difference between revisions of "ED ACS Adult Guideline revision 2020"

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* Morphine is no longer recommended (though neither is it recommended against).
 
* Morphine is no longer recommended (though neither is it recommended against).
 
* Fibrinolytic contraindications are on the fibrinolytic checklist and are not duplicated on the guideline.
 
* Fibrinolytic contraindications are on the fibrinolytic checklist and are not duplicated on the guideline.
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* Inclusion of '''DAPT''' (Dual Anti-Platelet Therapy, which refers specifically to combining aspirin with a P2G<small>12</small> inhibitor).
  
  
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: UpToDate: [https://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes ''Anticoagulant therapy in non-ST elevation acute coronary syndromes''] (Current: Dec 2019, Updated: 02-02-2019)<br>
 
: UpToDate: [https://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes ''Anticoagulant therapy in non-ST elevation acute coronary syndromes''] (Current: Dec 2019, Updated: 02-02-2019)<br>
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== Additional Information Sources for Guideline Revision ==
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=== STEMI ===
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: [https://www.ahajournals.org/doi/full/10.1161/CIR.0b013e3182742cf6 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction]
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=== NSTE-ACS ===
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: [https://www.sciencedirect.com/science/article/pii/S0735109714062792?via%3Dihub 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines]
  
  

Revision as of 16:17, 8 February 2020

Guideline
Diagnosis and Management of Acute Coronary Syndrome (Adult)
Revision Date
2020

This is a sub-page of the page titled ACS (Acute Coronary Syndome) in the Emergency Department.


Target population

This guideline is intended to expedite the diagnosis and management of ED patients presenting with signs/symptoms suggestive of acute myocardial ischemia. In this context, “suggestive” should be interpreted to mean that ACS is the most likely etiology; or, from a different perspective, the clinician feels that the probability of ACS is high enough that the condition is “ACS until proven otherwise.” Such patients are only a subset of those who present complaining of “chest pain” and thus this guideline is not intended to inform the management of all patients complaining of chest pain.


Impetus for guideline revision

  • Last update was in 2011, and several interim events have occurred:
    • The Third Universal Definition of Myocardial Infarction was published in 2012[1]; this changed the EKG criteria for diagnosis of STEMI.
    • For purposes of immediate management, 2014[2] and 2015[3] international ACS guidelines combined NSTEMI and unstable angina into the composite NSTE-ACS (Non-ST-Elevation ACS).
    • The Fourth Universal Definition of Myocardial Infarction was published in 2018[4]; this introduced the terms "acute myocardial injury" and "chronic myocardial injury".
    • On November 12, 2019, the Yukon-Kuskokwim Delta Regional Hospital (YKDHR) switched cardiac troponin assay to the Roche Diagnostics Elecsys® Troponin T Gen 5 STAT. Details are available in the manufacturer's package insert.


Goals

  1. The guideline should be quickly useful without having previously studied it.
  2. All necessary medications and doses should be included in the guideline.
  3. Major cautions and contraindications should be included in the guideline.
  4. Clinicians with basic ED and/or Urgent Care skills who rarely diagnose and treat ACS should be able to use this guideline to correctly diagnose and manage most straightforward ACS cases (i.e. the majority of them) without external information sources. Unfortunately, some cases are not straightforward and can be challenging for even the most experienced experts; such cases are frequently not amenable to guideline-based management and early expert consultation may be warranted in order to individualize care.


Changes

Major

  • This is a ground-up rewrite without significant inheritance.
  • Utilization of high-sensitivity troponin-T test.
  • New STEMI diagnostic criteria from the Third Universal Definition of Myocardial Infarction (2012).[1]
  • Use of the new term NSTE-ACS (Non-ST-Elevation Acute Coronary Syndrome).
  • Oxygen is no longer mandatory, but rather titrated to achieve normoxemia.
  • Enoxaparin dosing (in STEMI) is now adjusted for age and renal function.
  • Morphine is no longer recommended (though neither is it recommended against).
  • Fibrinolytic contraindications are on the fibrinolytic checklist and are not duplicated on the guideline.
  • Inclusion of DAPT (Dual Anti-Platelet Therapy, which refers specifically to combining aspirin with a P2G12 inhibitor).


Minor

  • N/A


Rationale for Specific Recommendations

EKG prior to Immediate Interventions
YKDRH has limited inpatient capabilities in this context (no cardiologist, no telemetry). Dynamic ST/T changes are diagnostic for unstable angina and therefore an indication for MedEvac transfer to a higher level of care. Lack of EKG done while in pain (i.e. prior to NTG) can substantially delay diagnosis of unstable angina.
Enoxaparin for anticoagulation
- Time to angiography will be at least 6 hours and possibly up to 12-18 hours.
- Our ED has limited resources, and in this setting more complexity increases the likelihood of errors.
- Care will transition to a MedEvac crew; again, more complexity increases likelihood of errors.



Issues intentionally NOT addressed in this revision

  1. Diagnosis and management of “chest pain” which is not suggestive of acute myocardial ischemia.
  2. Diagnosis/Management of type-2 MI’s.
  3. HS-troponin diagnostic algorithms other than the FDA-approved cutoffs.
  4. Use of the terminology “acute cardiac injury” and “chronic cardiac injury”.
  5. Diagnosis/management of suspected ACS in a village clinic.
  6. Different f/u strategies based upon risk stratification.


Future Directions (i.e. for future revisions)

  • Review/update this guideline every two years. Given the importance of the topic and the vast amount of active research, frequent updates are indicated.
  • Evidence-based troponin algorithm/cutoffs.
- Based upon institutional data or published data?
  • Evidence-based use of anticoagulation.
A cochrane review of RCT's found that anticoagulation (i.e. heparins, both unfractionated and low-molecular-weight) for ACS yielded no effect on patient-important outcomes, a possible small decrease in subsequent nonfatal-MI, and increased bleeding.[5] Yet other respected evidence-based reviews have criticized that conclusion as optimistic and concluded harm without meaningful benefit.[6],[7],[8] However, anticoagulation persists in most guidelines, apparently due to an unhealthy combination of tradition and liability concerns. We should consider reviewing this topic and developing the clinical courage to remove heparin from the ACS guideline.
  • Develop a similar guideline for suspected ACS in a village clinic.
- It differs enough to warrant being a standalone guideline; incorporating it into the ED guideline risks making the ED guideline too unwieldy to be quickly usable.


Credits

Lead Author[s]

Andrew W. Swartz, MD

Co-author[s]

Reviewer[s]


Primary Information Sources for Guideline Revision

ACS

Barstow C, Rice M, McDivitt JD. Acute Coronary Syndrome: Diagnostic Evaluation. Am Fam Physician. 2017;95(3):170-177. (archived)

STEMI

UpToDate: Overview of the acute management of ST-elevation myocardial infarction (Current: Dec 2019, Updated: 01-28-2019)
UpToDate: Antiplatelet agents in acute ST-elevation myocardial infarction (Current: Dec 2019, Updated: 09-17-2019)
UpToDate: Anticoagulant therapy in acute ST-elevation myocardial infarction (Current: Dec 2019, Updated: 02-20-2019)

NSTE-ACS

UpToDate: Overview of the acute management of non-ST elevation acute coronary syndromes (Current: Dec 2019, Updated: 12-13-2018)
UpToDate: Antiplatelet agents in acute non-ST elevation acute coronary syndromes (Current: Dec 2019, Updated: 09-17-2018)
UpToDate: Anticoagulant therapy in non-ST elevation acute coronary syndromes (Current: Dec 2019, Updated: 02-02-2019)


Additional Information Sources for Guideline Revision

STEMI

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

NSTE-ACS

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines


Additional Reading

UpToDate: Electrocardiogram in the diagnosis of myocardial ischemia and infarction


References

  1. 1.0 1.1 Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60(16):1581-1598. doi:10.1016/j.jacc.2012.08.001
  2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-e228. doi:10.1016/j.jacc.2014.09.017
  3. Roffi M, Patrono C, Collet J-P, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267-315. doi:10.1093/eurheartj/ehv320
  4. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). Journal of the American College of Cardiology. 2018;72(18):2231-2264. doi:10.1016/j.jacc.2018.08.1038
  5. Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Magee K. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014;(6):CD003462. doi:10.1002/14651858.CD003462.pub3
  6. Group GW and TN. Heparin for Acute Coronary Syndromes. TheNNT. https://www.thennt.com/nnt/heparin-for-acute-coronary-syndromes/. Accessed February 2, 2020.
  7. Helman A. Heparin for ACS and STEMI | Journal Jam Podcast. Emergency Medicine Cases. January 2020. https://emergencymedicinecases.com/journal-jam-heparin-acs-stemi/. Accessed February 2, 2020. (Archived)
  8. No More Heparin for NSTEMI? REBEL EM - Emergency Medicine Blog. February 2019. https://rebelem.com/no-more-heparin-for-nstemi/. Accessed February 2, 2020. (Archived)