Care Process Model MONTH JUNE 2015 2020 DEVELOPMENTDIAGNOSIS AND AND MANAGEMENT DESIGN OF OF CareACUTE Process CORONARY Models SYNDROME (ACS) 2015 Update 2020 Update These guidelines were developed by Intermountain Healthcare’s Cardiovascular WHAT’S INSIDE? Clinical Program to guide the diagnosis and treatment of patients presenting to Intermountain Healthcare’s emergency departments (ED) with signs and ALGORITHM 1: DIAGNOSIS OF ACUTE symptoms suggestive of acute coronary syndrome (ACS). Recommendations CORONARY SYNDROME (ACS) . 2 are based on ACS-probability categories and capabilities of individual facilities. TABLE 1: MANAGEMENT OF ACUTE They may need to be adapted to meet the needs of a specific patient and should CORONARY SYNDROME . 4 not replace clinical judgment. TABLES 2 – 7: TESTING AND MEDICATION GUIDELINES . 5 BIBLIOGRAPHY . 8 REFERENCES . 8 Why Focus ON ACS? RESOURCES . 8 • Incidence and mortality . In 2018, it was expected that nearly 720,000 Americans would experience their first myocardial infarction (MI) or die from coronary heart disease. BEN • Cost . Between 2012 and 2014, more than $361 billion in direct and PROGRAM GOALS & indirect costs (14 % of total health expenditures) were attributed MEASUREMENTS to coronary vascular disease and stroke. Direct medical costs of cardiovascular disease (CVD) are projected to increase from $318 billion Time from ED arrival to PCI for all to $749 billion between 2015 and 2035. BEN STEMI patients GOAL: <90 minutes from ED • Outcomes are improved when key processes are followed . arrival to intervention Successful reperfusion (percutaneous coronary intervention [PCI] in 60 < 90 minutes OR fibrinolytic infusion in < 30 minutes) usually results in % cTroponin-I testing at 0 and preserved left ventricle function, reduced mortality, and fewer 2 – 3 hours after arrival when long-term complications. AMS appropriate % HEART score assessment of NSTEMI patients What’s new in this update? % of eligible ED patients treated • Updated algorithm for the diagnosis and treatment of ACS (see page 2). with fibrinolytics within 30 minutes of arrival • Use of the HEART score, instead of Thrombolysis in MI (TIMI), to determine the risk of major adverse cardiac events (MACE) (see page 3). % Lipid and HbA1c testing on eligible patients • HbA1c monitoring of all STEMI (ST-elevation MI) patients and those with a moderate-to-high probability of ACS or definite unstable angina (see page 2). Indicates an Intermountain measure • More frequent monitoring of troponin-I (see pages 2-3). ©2008 - 2020 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. 1 DIAGNOSIS AND MANAGEMENT OF ACS JUNE 2020 ALGORITHM 1: DIAGNOSIS OF ACUTE CORONARY SYNDROME (ACS) Patient presents with symptoms of ACS (a) PERFORM ECG (b) Goal: Within 5 min . of arrival at ED INITIATE site-specific STEMI protocol STEMI? yes Goal: Reperfusion < 90 min . from ED arrival no ASSESS HEART Risk Score (c) CONSULT cardiology Is initial cTn-l ≥ 2? yes NSTEMI ADMIT for urgent reperfusion MANAGE according to TABLE 1 no Low Risk Moderate Risk* High Risk* (score 0 - 3) (score 4 - 6) (score ≥ 7) no Is initial cTn-I yes * If patient remains > 0.04? symptomatic, strongly consider serial ECG every 15 min. PERFORM patient-provider shared admission decision no Admit to hospital? yes REPEAT cTn-I testing at 2 hours ADMIT for further workup no Repeat cTn-I ≥ 0.04 yes AND > 50 % increase? MANAGE according to TABLE 1 CONSIDER outpatient imaging (for guidance use Abbreviations: cTn-I – cardiac troponin; ECG – electrocardiogram; Proven Imaging: Known or Suspected CAD CPM) STEMI – ST-elevation myocardial infarction; NSTEMI – non-ST-elevation FOLLOW UP with PCP myocardial infarction; PCP – primary care provider ©2008 - 2020 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. 2 DIAGNOSIS AND MANAGEMENT OF ACS JUNE 2020 ALGORITHM NOTES (a) Symptoms of ACS High-probability ACS: STEMI Moderate-probability ACS Low-probability ACS (NSTEMI or definite UAP) Strongly suggestive of Typical of or consistent with ischemia / infarction Strongly suggestive of ischemia Suggestive but atypical for ischemia ischemia / infarction (b) ECG Findings High-probability ACS: STEMI Moderate-probability ACS Low-probability ACS (NSTEMI or definite UAP) Ischemic ST elevation at the J point in 2 or more New ST depression ≥ 1 mm Normal or non-specific, with or Normal or non-specific, with or contiguous leads (≥ 2 mm in men or ≥ 1.5 mm OR without pain. without pain. in women in leads V2 – V3 or ≥ 1 mm in other Deep T-wave inversion contiguous chest leads or limb leads) OR Note: Must be normal at 0 Note: Must be normal at 0 hours ST depression in ≥ 2 leads (V1 – V4) (may indicate and at 3 to 6 hours from ED arrival. Note: If symptoms persist, strongly and 3 hours from ED arrival, acute posterior MI) If abnormal, continue with consider serial ECG every 15 minutes. and consider ECG at 6, 12, OR “High-probability ACS” column. New or presumably new left bundle branch block and 18 hours. If abnormal, (LBBB) that obscures ST-segment analysis, with continue with “High-probability MI symptoms ACS” column. OR Rarely, hyperacute T-waves (in very early phase of STEMI, before ST elevation develops) Note: Multilead ST depression combined with ST elevation in lead aVR has been noted in left main or proximal left anterior descending (LAD) artery occlusion. (c) HEART Risk Score for NSTEMI / UAPFRI This score predicts the short-term risk of subsequent mortality, new / recurrent MI, or severe ischemia for patients with NSTEMI or unstable angina pectoris (UAP). A higher score may warrant a higher ACS probability and more aggressive treatment. Diagnosis of STEMI is primarily based on ECG findings, and rapid reperfusion is the goal for all STEMI patients, regardless of estimated mortality . HEART Score How to score: composition Highly suspicious 2 Scores 0 – 3: 0.9 – 1.7 % MACE over next 6 weeks Low Risk History Moderately suspicious 1 Scores 4 – 6: 12 – 16.6 % MACE over next 6 weeks Moderate Risk Slightly suspicious 0 Scores ≥ 7: 50 – 65 % MACE over next 6 weeks High Risk Significant ST depression 2 ECG Nonspecific polarization disturbance 1 Notes: Normal 0 • Critical actions: Do not use this classification if new ST elevation requiring immediate intervention or clinically unstable patient. ≥ 65 years 2 • MACE is defined as all-cause mortality, MI, or coronary Age 45 – 64 1 revascularization. ≤ 44 0 • Risk factors: Diabetes mellitus (DM), current or recent (< 1 month) smoker, hypertension, hyperlipidemia, family history of coronary artery ≥ 3 risk factors or history of atherosclerotic disease 2 disease (CAD), and obesity. Risk factors 1 – 2 risk factors 1 No risk factors 0 > 2 x normal limit 2 Troponin-I (cTn-I) 1– 2 x normal limit 1 < normal limit 0 ©2008-2020 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. 3 DIAGNOSIS AND MANAGEMENT OF ACS JUNE 2020 TABLE 1: Management of ACS High-probability ACS STEMI Diagnosis Non-ST-elevation MI (NSTEMI) (ST-elevation MI) OR definite unstable angina pectoris (UAP) Admit status Cath lab / CCU / ICU CCU / ICU Goal Urgent reperfusion Rapid reperfusion For onsite urgent Elective invasive intervention or early invasive or transport patient (ideally If ≤ 90 minutes: If > 90 minutes: intervention Patient criteria <48 hours after onset of (< 12 hours after onset symptoms) of symptoms) • PERFORM ECG. • PERFORM ECG. • PERFORM serial ECG • PERFORM serial ECG every every 15 minutes. 15 minutes. • ARRANGE • GIVE fibrinolytic in Initial for immediate ≤ 30 minutes (see TABLE 3). • ARRANGE for possible • TRANSFER to interventional diagnostics percutaneous Do not give GPI (GP percutaneous coronary center immediately if ongoing coronary IIb / IIIa inhibitor) intervention (PCI) pain or within 24 hours and with fibrinolytic . (immediately for therapeutics intervention (PCI).1 (≤ 12 hours preferred). • TRANSFER immediately ongoing chest pain (See STEMI Power to interventional center or hemodynamic Plan in iCentra.) for PCI. instability). Emergency • Aspirin, NTG, and O2 • Aspirin, NTG and O2 • Aspirin, NTG, and O2 • Aspirin, NTG, and O2 Department • Atorvastatin (80 mg) • Atorvastatin (80 mg) • Atorvastatin (80 mg) • Atorvastatin (80 mg) • Heparin bolus only • Clopidogrel: • Heparin bolus only • Enoxaparin (see TABLE 5) or (see TABLE 4) – Age <75: 300 mg PO (see TABLE 4) Heparin (see TABLE 6) Drugs • Morphine PRN – Age ≥75: 75 mg PO • Morphine PRN 5 • Tirofiban or P2Y12 agent • Enoxaparin (see TABLE 5) per cardiologist (see TABLE 7) Contraindications • Morphine PRN • Morphine PRN (see pages 6 - 7) • GPI or anticoagulant per cardiologist (e.g., for high clot burden) GPI is contraindicated with TNKase . SELECT one: SELECT one: SELECT one: • Clopidogrel 600 mg • Clopidogrel 600 mg • Clopidogrel 600 mg • Ticagrelor 180 mg • Ticagrelor 180 mg • Ticagrelor 180 mg • Prasugrel 2 60 mg PO • Prasugrel 2 60 mg PO • Prasugrel 2 60 mg PO (loading doses) (loading doses) (loading doses) 2 Cath Lab Drugs AND AND AND • Anticoagulant: • Anticoagulant: heparin • Additional enoxaparin heparin or bivalirudin or bivalirudin per guideline May consider GPI per May consider GPI per cardiologist (e.g., for cardiologist (e.g., high clot high clot burden) burden Diagnosis STEMI, NSTEMI, and UAP PERFORM ECG at 6, 12, and 18 hours after admission. Initial • • PERFORM troponin-I testing at 6, 12, and 18 hours after admission. testing • SCHEDULE lipid and HbA1c for morning after admission. Hospital- Based Care 3 • Aldosterone blocker: CONSIDER if EF <40% and • Oral beta blocker : PRESCRIBE at discharge post-MI or symptomatic heart failure or diabetes are present. CONSIDER if ejection fraction (EF) < 40 % Drugs as contraindications and follow up. 4 ACE inhibitor (ACEI) or ARB: PRESCRIBE when blood • • P2Y12 inhibitor for at least 12 months : PRESCRIBE one of the needed pressure becomes stable (required for EF < 40 %). following: clopidogrel (75 -150 mg / day for 1 week followed Aspirin: PRESCRIBE 81 mg per day. by 75 mg / day) OR ticagrelor (90 mg twice daily) OR prasugrel • (10 mg / day) 2. 1. Immediate Cath / PCI: On-site cath lab or transferable to interventional center in < 60 minutes from ED to receiving hospital cath lab.