Acute coronary syndrome pre-hospital evaluation and care

Acute Coronary Syndrome Chapters
Heart Attack Patient Information
Unstable Angina Patient Information
Overview
Classification Unstable Angina Non-ST Elevation Myocardial Infarction ST Elevation Myocardial Infarction
Causes
Differential Diagnosis
Treatment
AHA/ACC Guidelines for Acute Coronary Syndrome
Guideline for Risk Stratification in ACS
Guideline for Pre-Hospital Evaluation and Care
Guidelines for Initial Management of ACS
Guidelines for Long-term management and secondary prevention
Guidelines for Patients with Atrial Fibrillation Complicating ACS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. ; Jair Basantes de la Calle, M.D.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes

Recommendation for Regional System of STEMI Care

Class I

"1. All communities should create and maintain regional systems of STEMI care that coordinate prehospital and hospital-based STEMI care processes with the goal of reducing total ischemic time and improving survival in patients with STEMI (Level B-NR)"

Recommendations for Prehospital Assessment and Management Considerations for Suspected ACS

Class I

"1. In patients with suspected ACS, a 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC)* to identify patients with STEMI (Level B-NR)"

"2. In patients with suspected ACS in which the initial ECG is nondiagnostic of STEMI, serial ECGs to detect potential ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates (Level C-LD)" †

"3. In patients with suspected STEMI, immediate emergency medical services (EMS) transport to a PCI-capable hospital for primary PCI (PPCI‡) is the recommended triage strategy, with an FMC–to-first-device time system goal of ≤90 minutes (Level B-NR)"

"4. In patients with suspected STEMI, early advance notification of the receiving PCI-capable hospital by EMS personnel and activation of the cardiac catheterization team is recommended to reduce time to reperfusion (Level B-NR)"

*FMC indicates the time point when the patient is initially assessed by a health care professional who can obtain and interpret the ECG and deliver initial interventions (eg, defibrillation). †Modified from the “2021 AHA/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.”  ‡PPCI refers to emergency PCU in the setting of STEMI to achieve reperfusion in patients without previous fibrinolytic treatment.

Care system pathway for patients experiencing ischemic symptoms suggestive of ACS

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Preprocedural assessment and the Heart Team (Please do not edit)

The heart Team

Class I

"1. In patients for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology is recommended to improve patient outcomes (Level of evidence B-NR)

Predicting Patient Risk of Death With CABG

Class I

"1. In patients who are being considered for CABG, calculation of the STS risk score is recommended to help stratify patient risk (Level of evidence B-NR)

ACC / AHA 2007 Guidelines - Acute Coronary Syndrome - Initial Evaluation and Management (Clinical Assessment) (DO NOT EDIT)

Class I

"1. Patients with symptoms that may represent ACS should not be evaluated solely over the telephone but should be referred to a facility that allows evaluation by a physician and the recording of a 12-lead ECG and biomarker determination (e.g., an ED or other acute care facility). (Level C)"

"2. Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s], back, neck, jaw, or epigastrium; shortness of breath; weakness; diaphoresis; nausea; lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives. (Level B)"

"3. Health care providers should actively address the following issues regarding ACS with patients with or at risk for CHD and their families or other responsible caregivers: a. The patient’s heart attack risk; (Level C') b. How to recognize symptoms of ACS; (Level C) c. The advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 min, despite feelings of uncertainty about the symptoms and fear of potential embarrassment; (Level C) d. A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access emergency medical services (EMS), generally 9-1-1. (Level C)"

"4. Prehospital EMS providers should administer 162 to 325 mg of aspirin (ASA; chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)"

Class IIa

"1. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients without a history of ASA allergy who have symptoms of ACS to chew ASA (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric- coated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level B)"

"2. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients who tolerate NTG to repeat NTG every 5 min for a maximum of 3 doses while awaiting ambulance arrival. (Level C)"

"3. It is reasonable that all prehospital EMS providers perform and evaluate 12-lead electrocardiograms (ECGs) in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions. Electrocardiographs with validated computer-generated interpretation algorithms are recommended for this purpose. (Level B)"

"4. If the 12-lead ECG shows evidence of acute injury or ischemia, it is reasonable that prehospital ACLS providers relay the ECG to a predetermined medical control facility and/or receiving hospital. (Level B)"

Sources

• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction

References

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