Acute coronary syndrome initial management: Difference between revisions

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(/* ACC / AHA Guidelines for Initial Management (DO NOT EDIT) {{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wrig...)
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==Initial Management==
==Initial Management==


===ACC / AHA Guidelines for Initial Management (DO NOT EDIT) <ref name="pmid21444888">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS |title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>===
===ACC / AHA 2011 and 2007 Guidelines - Acute Coronary Syndrome - Initial Management (DO NOT EDIT) <ref name="pmid21444888">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS |title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>; <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-11}}</ref>===


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<nowiki>"</nowiki>1. The history, [[physical examination]], [[12 lead ECG]], and initial [[cardiac biomarker tests]] should be integrated to assign patients with [[chest pain]] into 1 of 4 categories: '''a non cardiac diagnosis''', [[chronic stable angina]], '''possible ACS''', and '''definite ACS'''. ''(Level of Evidence: C)''<nowiki>"</nowiki>
<nowiki>"</nowiki>1. The history, [[physical examination]], [[12 lead ECG]], and initial [[cardiac biomarker tests]] should be integrated to assign patients with [[chest pain]] into 1 of 4 categories: '''a non cardiac diagnosis''', [[chronic stable angina]], '''possible ACS''', and '''definite ACS'''. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>2. Patients with probable or possible [[ACS]] but whose initial [[12 lead ECG]] and [[cardiac biomarker]] levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. ''(Level of Evidence: B)''<nowiki>"</nowiki>
<nowiki>"</nowiki>2. Patients with probable or possible [[ACS]] but whose initial [[12 lead ECG]] and [[cardiac biomarker]] levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level B]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>3. In patients with suspected [[ACS]] in whom [[ischemic heart disease]] is present or suspected, if the follow-up [[12 lead ECG]] and [[cardiac biomarker]]s measurements are normal, a [[stress test]] (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. ''(Level of Evidence: C)''<nowiki>"</nowiki>
<nowiki>"</nowiki>3. In patients with suspected [[ACS]] in whom [[ischemic heart disease]] is present or suspected, if the follow-up [[12 lead ECG]] and [[cardiac biomarker]]s measurements are normal, a [[stress test]] (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., [[ASA]], sublingual [[NTG]], and/or [[beta blocker]]s) should be given while awaiting results of the stress test. ''(Level of Evidence: C)''<nowiki>"</nowiki>
<nowiki>"</nowiki>4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., [[ASA]], sublingual [[NTG]], and/or [[beta blocker]]s) should be given while awaiting results of the stress test. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>5. Patients with definite [[ACS]] and ongoing ischemic symptoms, positive [[cardiac biomarker]]s, new [[ST-segment deviation]]s, new deep [[T-wave]] inversions, hemodynamic abnormalities, or a positive [[stress test]] should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. ''(Level of Evidence: C)''<nowiki>"</nowiki>
<nowiki>"</nowiki>5. Patients with definite [[ACS]] and ongoing ischemic symptoms, positive [[cardiac biomarker]]s, new [[ST-segment deviation]]s, new deep [[T-wave]] inversions, hemodynamic abnormalities, or a positive [[stress test]] should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>6. Patients with possible [[ACS]] and negative [[cardiac biomarker]]s who are unable to exercise or who have an abnormal resting [[ECG]] should undergo a [[pharmacological stress test]]. ''(Level of Evidence: B)''<nowiki>"</nowiki>
<nowiki>"</nowiki>6. Patients with possible [[ACS]] and negative [[cardiac biomarker]]s who are unable to exercise or who have an abnormal resting [[ECG]] should undergo a [[pharmacological stress test]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level B]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>7. Patients with definite [[ACS]] and [[ST-segment elevation]] in leads V7 to V9 due to [[left circumflex artery]] occlusion should be evaluated for immediate [[reperfusion therapy]]. ''(Level of Evidence: A)''<nowiki>"</nowiki>
<nowiki>"</nowiki>7. Patients with definite [[ACS]] and [[ST-segment elevation]] in leads V7 to V9 due to [[left circumflex artery]] occlusion should be evaluated for immediate [[reperfusion therapy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level A]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. ''(Level of Evidence: C)''<nowiki>"</nowiki>
<nowiki>"</nowiki>8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>'''9.''' Health care providers should instruct patients with suspected [[ACS]] for whom [[nitroglycerin]] ([[NTG]]) has been prescribed previously to take not more than 1 dose of [[NTG]] sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 [[NTG]] dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access [[EMS]] before taking additional [[NTG]]. In patients with [[chronic stable angina]], if symptoms are significantly improved by 1 dose of [[NTG]], it is appropriate to instruct the patient or family member/friend/caregiver to repeat [[NTG]] every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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<nowiki>"</nowiki>'''10.''' Patients with a suspected [[ACS]] with chest discomfort or other [[ischemic symptoms]] at rest for greater than 20 min, hemodynamic instability, or recent [[syncope]] or presyncope should be referred immediately to an [[ED]]. Other patients with a suspected [[ACS]] who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an [[NTG]] dose, may be seen initially in an [[ED]] or an outpatient facility able to provide an acute evaluation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])''<nowiki>"</nowiki>
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Revision as of 15:11, 10 October 2012

Template:ACS Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar M.B.B.S; Lakshmi Gopalakrishnan M.B.B.S.

Overview

Initial Management

ACC / AHA 2011 and 2007 Guidelines - Acute Coronary Syndrome - Initial Management (DO NOT EDIT) [1][2]; [2]

Class I

"1. The history, physical examination, 12 lead ECG, and initial cardiac biomarker tests should be integrated to assign patients with chest pain into 1 of 4 categories: a non cardiac diagnosis, chronic stable angina, possible ACS, and definite ACS. (Level C)"

"2. Patients with probable or possible ACS but whose initial 12 lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. (Level B)"

"3. In patients with suspected ACS in whom ischemic heart disease is present or suspected, if the follow-up 12 lead ECG and cardiac biomarkers measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. (Level C)"

"4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., ASA, sublingual NTG, and/or beta blockers) should be given while awaiting results of the stress test. (Level C)"

"5. Patients with definite ACS and ongoing ischemic symptoms, positive cardiac biomarkers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. (Level C)"

"6. Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test. (Level B)"

"7. Patients with definite ACS and ST-segment elevation in leads V7 to V9 due to left circumflex artery occlusion should be evaluated for immediate reperfusion therapy. (Level A)"

"8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. (Level C)"

"9. Health care providers should instruct patients with suspected ACS for whom nitroglycerin (NTG) has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (Level C)"

"10. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED. Other patients with a suspected ACS who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (Level C)"

Class IIa

"1. In patients with suspected ACS with a low or intermediate probability of CAD, in whom the follow up 12 lead ECG and cardiac biomarkers measurements are normal, performance of a non invasive coronary imaging test (i.e., Cardiac / Coronary CT Angiography) is reasonable as an alternative to stress testing. (Level of Evidence: B)"

See Also

Sources

  • 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[1]
  • The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [2]

References

  1. ↑ 1.0 1.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 2.2 Anderson JL, Adams CD, Antman EM; et al. (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter |month= ignored (help)

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