ED ACS Adult Guideline revision 2020

Guideline

Diagnosis and Management of Acute Coronary Syndrome (Adult)

Revision Date

2020

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; this changed the EKG criteria for diagnosis of STEMI.
  • The Fourth Universal Definition of Myocardial Infarction was published in 2018; this introduced the terms "acute myocardial injury" and "chronic myocardial injury".

• Institutional change from conventional troponin assay to a 5th-generation high-sensitivity troponin-T assay
  • 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 such cases are challenging for even the most experienced experts; this guideline will be insufficient for unusual cases and early expert consultation is encouraged.

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).
• Use of the new term NSTEACS (Non-ST-Elevation Acute Coronary Syndrome). This term combines NSTEMI and unstable angina into a single entity because they are now managed the same.

Minor

• N/A

Issues intentionally NOT addressed in this guideline

1. Diagnosis and management of “chest pain” which is not suggestive of acute myocardial 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.

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.

Future Directions

• 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?

Authorship

Lead Author[s]

Andrew W. Swartz, MD