ED ACS Adult Guideline revision 2020

Guideline: Diagnosis and Management of Acute Coronary Syndrome (Adult)

Revision Date: 2020

Impetus for guideline revision

1. Last update was 2011
2. Institutional change from conventional troponin assay to Gen5 high-sensitivity troponin assay

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 such cases are challenging for even the most experienced experts; this guideline will be insufficient for unusual cases and early expert consultation is encouraged.

Issues intentionally NOT addressed in this guideline

1. Diagnosis and management of “chest pain” unlikely to be acute cardiac ischemia.
2. HS-troponin diagnostic algorithms other than the FDA-approved cutoffs.
3. Use of the terminology “acute cardiac injury” and “chronic cardiac injury”.
4. Diagnosis/Management of type-2 MI’s.

Changes

Major

• This is a ground-up rewrite without significant inheritance.
• Utilization of high-sensitivity troponin-T test.
• New STEMI diagnostic criteria from the Fourth Universal Definition of Myocardial Infarction (2018).

Minor

• N/A

Target population

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.

Author[s]

Andrew W. Swartz, MD