acute coronary syndromes: current evidence for management ... · acute coronary syndromes: current...

Acute Coronary Syndromes: Current Evidence For Management In The Hospital Setting Abstract

Coronary artery disease is the leading cause of death in the United States, and up to 30% of patients who suffer a cardiac event will die within a year of diagnosis. “Acute coronary syndromes” is a general term that describes a spectrum of conditions related to the acute manifestations of coronary artery disease. Acute coronary syndromes include 3 conditions: (1) unstable angina, (2) myocardial infarction with ST-segment elevation, and (3) myocardial infarction with non-ST-segment elevation. The incorporation of evidence-based strategies in evaluation and risk stratification and the determination of treatment strategies appropriate to the diagnosis are vital to successful management of patients with acute coronary syndromes. This issue reviews the evidence for the numerous therapies for acute coronary syndromes, including drug therapies and revascularization strategies. Issues of inhospital complications, special patient circumstances, quality improvement, and risk management are also reviewed.

Premier IssueAuthors

David M. Shavelle, MD, FACC, FSCAIAssociate Professor of Clinical Medicine, Director, Cardiac Catheterization Laboratories, Director, Interventional Cardiology Fellowship, LAC+USC Medical Center, Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CAAmbarish Gopal, MD, FSCCTClinical and Interventional Cardiologist, The Heart Hospital Baylor Plano, Plano, TX

Peer Reviewers

Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESCChief of Cardiology, VA Boston Healthcare System; Director, Integrated Interventional Cardiovascular Program, Brigham and Women’s Hospital and VA Boston Healthcare System; Professor of Medicine, Senior Investigator TIMI Study Group, Harvard Medical School, Boston, MATomas Villaneuva, DO, MBA, FACPE, SFHMAssistant Vice President, Medical Director of Primary Care and Hospital Medicine, Baptist Health Medical Group, Baptist Health South Florida, Coral Gables, FL

CME Objectives

Upon completion of this article, you should be able to:1. Distinguish the different types of ACS.2. Risk stratify a patient presenting with UA/NSTEMI.3. Determine an appropriate management strategy for a

patient with UA/NSTEMI.4. Determine an appropriate management strategy for a

patient with STEMI.5. Cite common medications used in treating patients with

ACS.

Prior to beginning this activity, see the back page for faculty disclosures and CME accreditation information.

Editor-in-ChiefAlpesh N. Amin, MD, MBA, MACP, SFHM Thomas & Mary Cesario Chairman,

Department of Medicine, Professor of Medicine, Business, Public Health, Nursing Science & Biomedical Engineering, Executive Director, Hospitalist Program, University of California – Irvine, Irvine, CA

Editorial BoardAmish A. Dangodara, MD, FACP Professor of Medicine, Director

of Operations, Internal Medicine Hospitalist Program, Director of Inpatient General Internal Medicine Consultation, Director of Hospitalist Preoperative Clinic, Director of the Hospitalist Preoperative Clinic, University of California, Irvine (UCI) School of Medicine, Irvine, CA

Nancy Dawson, MD, FACP Assistant Professor, Hospital Practice

Chair, Division of Hospital Medicine, Mayo Clinic, Jacksonville, FL

Steven Deitelzweig, MD System Chairman, Hospital Medicine,

Regional Vice President of Medical Affairs, Ochsner Health System, New Orleans, LA

Daniel Dressler, MD, MSc, SFHM Associate Professor of Medicine,

Director of Internal Medicine Teaching Services, Emory University Hospital; Associate Director for Education, Emory Division of Hospital Medicine, Associate Program Director, J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, GA

Amir Jaffer, MD Professor of Medicine, Vice

Chair, Patient Safety, Quality, and Compliance, Division Chief, Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL

Solomon Liao, MD Director of Palliative Care Services,

Associate Clinical Professor, Hospitalist Program, University of California – Irvine, Irvine, CA

David Likosky, MD, SFHM Medical Director, Evergreen

Neuroscience Institute, Kirkland, WA; Clinical Faculty, University of Washington, Seattle, WA

Sylvia McKean, MD Associate Professor of Medicine,

Harvard Medical School; Associate Physician, Brigham and Women’s Hospital, Boston, MA

Geno J. Merli, MD Clinical Professor, Jefferson Hospital;

Co-Director, Jefferson Vascular Center, Philadelphia, PA

Franklin A. Michota, MD, FACP, FHM Associate Professor of Medicine,

Director of Academic Affairs, Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH

Michael Pistoria, MD President, Medical Staff, Associate

Chief, Division of General Internal Medicine, Assistant Program Director, Internal Medicine Residency, Lehigh Valley Health Network, Allentown, PA

Daniel Robitshek, MD Medical Director, Hospitalist Program,

Floyd Medical Center, Rome, GA

David J. Rosenberg, MD, MPH, FACP, SFHM

Associate Chairman, Department of Medicine, Section Head, Hospital Medicine, North Shore University Hospital, Manhasset, NY; Assistant

Professor of Medicine, Hofstra North Shore LIJ School of Medicine, Hempstead, NY

Tomas Villaneuva, DO, MBA, FACPE, SFHM

Assistant Vice President, Medical Director of Primary Care and Hospital Medicine, Baptist Health Medical Group, Baptist Health South Florida, Coral Gables, FL

Mike Wang, MD Director of Hospital Medicine,

Associate Professor of Clinical Medicine, Keck Medical Center of USC, Los Angeles, CA

David Wooldridge, MD, FACP Program Director, Internal Medicine

Residency Program, Associate Professor of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, MO

Nejat Zeyneloglu, MD Medical Director, Hospital Medicine

Program, New York Hospital Queens, Weill-Cornell Medical College, New York, NY

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Dear Hospital Medicine Colleague,

As Editor-in-Chief, I am proud to bring to you the first and only evidence-based, single-topic, monthly journal that is written and peer reviewed by Hospitalists for Hospitalists: OmniaCore In Hospital Medicine.

The name of this new publication – OmniaCore – embodies the essence of who we are: Omnia (Latin for “all things”) and Core (representing the core competencies of Hospital Medicine). This unique journal will give you unbiased, relevant, and practical information for treating the common conditions you see every day as well as the not-so-common conditions that you are often called upon to treat. Each issue covers hospital medicine the way you actually practice it, bringing you real-world solutions that you can trust — because there is absolutely no sponsorship, advertising, or commercial support.

Our goal is to empower hospitalists with evidence-based reviews that will help you continue to excel in your practice of Hospital Medicine. Each issue of OmniaCore In Hospital Medicine includes unique features that were specifically designed by members of our Editorial Board to improve your knowledge and understanding of the topics covered. I’ll highlight several of these features inside this sneak peek guide.

In addition, OmniaCore In Hospital Medicine is published by EB Medicine – an independent medical publisher who has been providing this unique style of content to emergency clinicians for over 12 years, with impressive results. Their readers have shown as much as a 36% improvement in their clinical knowledge of a topic after reading the articles. EB Medicine is also one of the few publishers in the country to have obtained direct accreditation from the Accreditation Council for Continuing Medical Education to provide CME for physicians — and they are one of a very small group that has never accepted advertising or commercial support. I am proud to have partnered with them to deliver this publication to you.

On behalf of the editorial board, authors, peer reviewers, and publisher, I’d like to thank you in advance for your support in helping OmniaCore In Hospital Medicine evolve into the premier journal in Hospital Medicine.

Sincerely,

Alpesh AminAlpesh N. Amin, MD, MBA, MACP, SFHM Editor-in-Chief, OmniaCore In Hospital Medicine

ALPESH N. AMIN, MD, MBA, MACP, SFHM Executive Director, Hospitalist Program, School of Medicine, Thomas and Mary Cesario Endowed Chair, Department of Medicine, Professor of Medicine, Business, Public Health, Nursing Science, & Biomedical Engineering, University of California - Irvine, Irvine, CA


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Editor-in-ChiEfALPESh N. AmIN, mD, mBA, mACP, SFhm Executive Director, Hospitalist Program, School of

Medicine, Thomas and Mary Cesario Endowed Chair, Department of Medicine, Professor of Medicine, Business, Public Health, Nursing Science, & Biomedical Engineering, University of California – Irvine, Irvine, CA

Editorial BoardAmISh A. DANgODArA, mD, FACP Professor of Medicine, Director of Operations, Internal

Medicine Hospitalist Program, Director of Inpatient General Internal Medicine Consultation, Director of Hospitalist Preoperative Clinic, Director of the Hospitalist Preoperative Clinic, University of California, Irvine (UCI) School of Medicine, Irvine, CA

NANCY DAwSON, mD, FACP Assistant Professor, Hospital Practice Chair, Division of

Hospital Medicine, Mayo Clinic, Jacksonville, FL

StEvEN B. DEItELzwEIg, mD, mmm, FACP, FSvmB, rvt Medical Director, Regional Business Development,

System Chairman, Department of Hospital Medicine, Assistant Program Director for Internal Medicine, Ochsner Clinic Foundation; Clinical Associate Professor of Medicine, Tulane University School of Medicine, New Orleans, LA

DANIEL D. DrESSLEr, mD, mSC, SFhm, FACP Associate Professor of Medicine, Director of Internal

Medicine Teaching Services, Emory University Hospital; Associate Director for Education, Emory Division of Hospital Medicine, Associate Program Director, J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, GA

AmIr JAFFEr, mD, SFhm Professor of Medicine, Vice Chair, Patient Safety,

Quality, and Compliance, Division Chief, Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL

SOLOmON LIAO, mD Associate Clinical Professor, Director of Palliative Care

Services, University of California – Irvine, Irvine, CA

DAvID LIkOSkY, mD, SFhm Medical Director, Evergeen Neuroscience Institute,

Evergeen Healthcare, Kirkland, WA; Clinical Faculty, University of Washington, Seattle, WA

SYLvIA mCkEAN, mD, FACP, SFhm Associate Professor of Medicine, Harvard Medical

School; Senior Hospitalist, Brigham and Women’s Hospital, Boston, MA

gENO J. mErLI, mD, FACP, Fhm, FSvm Clinical Professor, Jefferson Hospital; Co-Director,

Jefferson Vascular Center, Philadelphia, PA

FrANkLIN A. mIChOtA, mD, FACP, Fhm Associate Professor of Medicine, Director of Academic

Affairs, Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH

mIChAEL J. PIStOrIA, DO, FACP Associate Program Director, Internal Medicine Program;

Medical Director, Hospitalist Services, Lehigh Valley Hospital, Allentown, PA; Assistant Professor of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA

DANIEL rOBItShEk, mD, SFhm Executive Director, Hospitalist Program, Floyd Medical

Center, Rome, GA; Assistant Professor of Medicine, Medical College of Georgia, Augusta, GA; Assistant Professor of Internal Medicine, Philadelphia College of Osteopathic Medicine, Atlanta, GA

DAvID J. rOSENBErg, mD, mPh, FACP, SFhm Associate Chairman, Department of Medicine, Section

Head, Hospital Medicine, North Shore University Hospital, Manhasset, NY; Assistant Professor of Medicine, Hofstra North Shore LIJ School of Medicine, Hempstead, NY

tOmAS vILLANEuvA, DO, mBA, FACPE, SFhm Assistant Vice President, Medical Director of Primary

Care and Hospital Medicine, Baptist Health Medical Group, Baptist Health South Florida, Coral Gables, FL

mIChAEL D. wANg, mD, FACP Director of Hospital Medicine, Associate Professor of

Clinical Medicine, Keck Medical Center of USC, Los Angeles, CA

DAvID wOOLDrIDgE, mD, FACP Program Director, Internal Medicine Residency

Program, Associate Professor of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, MO

NEJAt zEYNELOgLu, mD Medical Director, Hospital Medicine Program, New York

Hospital Queens, Weill-Cornell Medical College, New York, NY

• Venous Thromboembolism: Evaluation And Management In The Hospital Setting

• Atrial Fibrillation: Current Evidence For Inpatient Treatment

• New Oral Anticoagulants: Management Strategies For Hospitalists

• Stroke: An Evidence-Based Management Plan For Hospitalists

• Sepsis: Current Guidelines For Management In Hospital Medicine

• Congestive Heart Failure: Advances In Diagnosis And Treatment

• Early Diagnosis And Treatment Of Infections In The Hospitalized Elderly Patient

• Transcatheter Aortic Valve Implantation For The Hospitalist

• Inpatient Diabetes And Hyperglycemia Management

• Anemia: Evidence-Based Management For The Hospitalist

• Diagnosis And Treatment Of Healthcare-Associated Pneumonia: One Size Does Not Fit All

• ClostridiumDifficile Management Strategies In Hospital Medicine

EdITOrIAl BOArd UPCOMIng TOPICS


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who’s Behind ? “Our physician authors, supported by our distinguished editorial board and blinded peer review process, seek out the strongest and most relevant literature for each topic. They investigate controversies and point out strengths, weaknesses, and conflicts in the literature. The result is practical and reliable treatment recommendations that you can put immediately — and confidently — into practice.”

— Alpesh N. Amin, mD, mBA, mACP, SFhm, Editor-in-Chief, OmniaCore In Hospital Medicine


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You get actionable diagnosis and treatment recommendations that you can immediately apply in your practice. Throughout each issue, you’ll find dozens of Clinical Pearls that distill the reviews into specific, evidence-based information.

Here’s a sneak peek at the Clinical Pearls from our upcoming issue on acute coronary syndromes (ACS).

The concise clinical points in each issue are exactly what I want to know in my practice.

— thomas Boyer, DO“ ”

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Initial Targeted Evaluation And Decision Making

The first step in the evaluation and management of patients suspected of having ACS is to establish a working diagnosis of either definite ACS, possible ACS, chronic stable angina, or noncardiac chest pain.9 The management of ACS demands a time-efficient history and physical examination with thoughtful and accurate interpretation of the ECG, which should be obtained within 10 minutes of arrival to the hospital. The ECG should be classified into either STEMI or UA/NSTEMI. If it is consistent with STEMI, time is of the utmost im-portance, and urgent primary reperfusion with PCI or thrombolytic therapy should be pursued. Expeditious restoration of flow in the obstructed infarct related artery is a key determinant of short- and long-term outcomes, regardless of whether reperfusion is accomplished by thrombolytic therapy or PCI.10 For patients with ongo-ing symptoms, an initial nondiagnostic ECG, and a high suspicion for ACS, serial ECGs should be performed to look for dynamic ST-segment and T-wave changes.11 Risk assessment can be helpful to evaluate short-term mortality. The TIMI risk score for STEMI includes: age, systolic blood pressure and heart rate, Killip classification, weight, anterior ST elevation or left bundle branch block, diabetes, and history of hypertension or angina. The 30-day mortality for patients with 1 point is < 2%, whereas a score of ≥ 7 is associated with mortality over 20%. If STEMI has been excluded based on the initial ECG in a patient with chest pain, a diagnosis of UA/NSTEMI should be considered. Risk stratification is then required to determine which patients will benefit from an aggressive treatment approach that includes observation in the intensive care unit, referral for early angiography, and aggressive medical therapy. Patients with prolonged and persistent angina, hemodynamic instability, evidence of pulmonary congestion or con-gestive heart failure, dynamic ST-segment and other dynamic ECG changes, or positive cardiac biomarkers are at high risk for recurrent infarction and death. The TIMI risk score for UA/NSTEMI should be used as an objective method for risk stratification. (See Table 4.) A score of 0 to 1 predicts a 14-day risk of death, MI, or recurrent ischemia requiring revascularization of 5%; a score of 6 to 7 is predictive of a 41% risk. From a practical standpoint, a TIMI risk score for UA/NSTEMI of 0 to 2 is regarded as low risk, and a score of ≥ 3 is considered inter-mediate to high risk. Low-risk patients are candidates for a conservative strategy. Intermediate- to high-risk patients may be candidates for an early invasive strategy and ag-gressive medical therapy. However, one must be aware of the individual components of the score that are contribut-ing to the total score. If dynamic ST-segment deviation (see Figures 1 and 2) and elevated cardiac biomarkers are part of the score, the patient should be regarded as high risk even when the total score is only 2, and cardiology should be involved in the ongoing decision making.

Advanced History Taking PearlsNot all ACS patients will have the typical pattern of cardiac pain symptoms. Women and elderly patients may present with atypical symptoms. Patients with long-standing diabetes mellitus may have no pain symptoms and may present only with fatigue, tired-ness, elevated blood sugar levels or ketoacidosis, or asthma-like symptoms. Similarly, elderly patients recovering from recent general anesthesia or pa-tients on chronic narcotic pain therapy may present without pain and with atypical symptoms. A high clinical suspicion in the appropriate setting will help correctly identify the diagnosis and guide further management. History taking should include a discussion of symptoms of cerebrovascular disease, including amaurosis fugax, face/limb weakness or clumsiness, face/limb numbness or sensory loss, ataxia, or vertigo.12 Patients should be questioned about prior bleeding problems.13

• Recognize that symptoms can range from classic cardiac chest pain to atypical angina equivalents, and there can even be a pau-city of symptoms.

• Question each patient to determine their risk of bleeding, as antiplatelet and an-ticoagulant therapy will exacerbate any underlying bleeding risks.

• Approach ACS patients with a rapid and ef-ficient process.

• Make sure that an ECG is completed and read within 10 minutes; this will allow you to rap-idly diagnose or rule out STEMI.

• For STEMI: Quickly establish and implement a reperfusion plan.

• For UA/NSTEMI: Remember that immedi-ate angiography (at the time of presentation) does not improve outcomes compared to early angiography (within 1-2 days of presentation). You have time to decide on the best approach to management. The choice of invasive or conservative management depends on local practice, resources, and (most importantly) the patient’s overall level of risk.

• Risk stratify all NSTEMI patients using the TIMI risk score for UA/NSTEMI. Higher-risk patients derive more benefit from early angiog-raphy and revascularization.

Clinical Pearls

Clinical Pearls


ElectrocardiogramThe electrocardiogram (ECG) is the single most important tool in the initial evaluation and triage of patients in whom ACS is suspected.1 STEMI is diagnosed when there are presenting symptoms of myocardial ischemia and ST elevation > 0.1 mV in 2 contiguous leads or a new (or presumably-new) left bundle branch block (LBBB) on the presenting ECG.16 Very early in the course of a STEMI, giant hyperacute T waves may precede ST elevation.17 A true posterior MI may present with tall R waves in the right pre-cordial leads and ST-segment depression in leads V1 through V4, especially when the T waves are up-right.18 A repeat ECG and incorporation of additional leads (such as V7 through V9) are more specific for the detection of posterior infarction.19,20 Patients with new or presumed-new LBBB or anterior ST-segment elevations are at a greater inherent risk from MI and achieve greater benefit with reperfusion therapy.21 Patients with an inferior MI and ST elevation in V1, V4R, or both are more likely to have concomitant right ventricular infarction.22,23 Additional ECG leads (right sided and/or posterior) or an echocardiogram may help clarify the location and extent of infarction and the risk of complications. However, the acquisition of this ancillary information should not interfere with providing timely reperfusion in STEMI patients.24

Advanced Physical Examination PearlsA heart rate > 100 beats per minute combined with a systolic blood pressure < 90 mm Hg identify an ACS patient who is high risk for cardiogenic shock. The physical examination should be performed efficiently to aid in the diagnosis and assessment of the extent, loca-tion, and presence of complications of ACS.15 A “quick-focused-limited” neurological examination to look for evidence of prior stroke or cognitive deficits should be performed on STEMI patients before the administration of thrombolytic therapy.1 If a patient is dyspneic with labored respirations secondary to pulmonary edema, a decision must be quickly made to intubate for mechani-cal ventilation prior to transporting the patient to the cardiac catheterization laboratory for emergent PCI, in order to avoid subsequent unnecessary delays in the middle of the PCI procedure.

Table 4. TIMI Risk Score For UA/NSTEMI

Characteristic Points

Historical

Age ≥ 65 years 1

≥ 3 coronary artery disease risk factors (family history,

hypertension, hyperlipidemia, diabetes mellitus,

current smoker)

1

Known coronary artery disease (≥ 50% stenosis) 1

Aspirin use within 7 days 1

Presentation

2 or more anginal events in prior 24 h 1

ST segment deviation > 0.05 mV 1

Elevated cardiac biomarkers 1

Risk Score = Total Points 0-7

Risk Score Group

Low risk 0-2

Intermediate risk 3-4

High risk 5-7

Figure 1. T-wave Inversion In V3-V6 and II: Unstable Angina

Figure 2. ST-segment Depression In Anterior And Lateral Leads: NSTEMI

Diagnostic Studies

• The ECG is essential in the triage and diagnosis of ACS.

• Make certain that additional testing (ad-ditional ECG leads, echocardiogram, and chest x-ray) do not interfere with providing timely reperfusion.

• Utilize echocardiography when the diag-nosis of ACS or cardiac ischemia has been difficult to establish.

Clinical Pearls


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1. “The patient was already on aspirin, so I did not want to start clopidogrel.” For patients with acute coronary syndromes, including unstable angina, NSTEMI, and STEMI, dual antiplatelet therapy with aspirin and clopidogrel is more beneficial than aspirin alone.

2. “The patient had a small myocardial infarction, so I ordered a stress test.” Patients that are diagnosed with NSTEMI require risk stratification. Those who are found to be intermediate or high risk may benefit from an invasive approach to management with coronary angiography; patients who are found to be low risk can be managed with medical therapy and a noninvasive stress test. The most common way to risk stratify patients with NSTEMI is by using the TIMI risk score for NSTEMI.

3. “The patient can be discharged to home; I don’t need to see him prior to discharge.” Patients that receive a coronary stent for treatment of obstructive coronary artery disease require a detailed evaluation prior to hospital discharge. An evaluation for vascular complications (including hematoma formation, pseudoaneurysm, arteriovenous fistula, and retroperitoneal hemorrhage) should be completed prior to hospital discharge.

4. “I use IV beta blockers in all patients with an acute myocardial infarction.” While beta blocker therapy is beneficial in patients with an acute MI, indiscriminate use of IV agents may precipitate progressive heart failure and cardiogenic shock. IV beta blockers should not be used in high-risk patients; they should only be used in patients who are hemodynamically stable and those without evidence of congestive heart failure. Oral beta blockers should be used within the first 24 hours in acute MI patients with no contraindications to beta blockers.

5. “This patient does not have a STEMI because the troponin value is normal.” The diagnosis of a STEMI is based upon the presence of angina or anginal symptoms and an ECG that shows ST-segment elevation. In the early phase of a STEMI, the troponin value will be normal. Waiting for an abnormal troponin value delays the initiation of reperfusion therapy.

6. “Another physician stopped the clopidogrel.” For patients that have received a coronary stent, dual antiplatelet therapy is required without interruption for 1 month for a bare-metal stent and for 1 year for a drug-eluting stent. Premature cessation of dual antiplatelet therapy is associated with stent thrombosis, which can be fatal. The treating cardiologist should be involved in all decisions involving stopping dual antiplatelet therapy.

7. “The initial ECG was normal, so I didn’t think the patient was having a STEMI.” Acute coronary syndromes are a dynamic process characterized by plaque rupture or erosion with subsequent activation of platelets, thrombus formation, and occlusion or near occlusion of the coronary artery lumen. Given that this is a dynamic process, the initial ECG in patients presenting with chest pain may be normal. Repeating the ECG at 5- to 10-minute intervals, especially in the setting of recurrent symptoms, may identify STEMI.

8. “I gave the thrombolytic agent, but I did not have a chance to review the medical record or ask the patient about potential contraindications.” Primary reperfusion with thrombolytic therapy or PCI is beneficial for patients with STEMI. For patients being evaluated for thrombolytic therapy, a physician must review all of the absolute and relative contraindications prior to initiating therapy. For patients with absolute contraindications, primary PCI or transfer to another hospital for primary PCI should be considered.

9. “The patient told me he could not take clopido-grel, so I used aspirin alone.” For patients with a prior documented allergy to clopidogrel, 2 newer antiplatelet agents are now available (prasugrel and ticagrelor). Both of these agents have a faster onset of action compared to clopidogrel and have been shown to have improved efficacy in randomized trials.

10. “I did not want to refer this patient for primary PCI because he was 75 years old.” Age should not be used to exclude patients for primary PCI as the reperfusion therapy for STEMI. While elderly patients have an increased risk for complications compared to young patients, they do derive benefit from primary PCI. Primary PCI is generally a better treatment option than thrombolytic therapy for reperfusion in elderly STEMI patients because of the increased risk of bleeding complications associated with thrombolytics.

Risk Management Pitfalls To Avoid For Acute Coronary Syndromes – NSTEMI And STEMI














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how Is Different?

The issues get straight to the point and provide information so relevant that I feel they are written specifically for my practice. The risk management advice is spot on.

— Eduardo F. talavera, mD

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OmniaCore is the only journal specifically developed for hospitalists that delivers extensively researched evidence-based reviews of a single topic. Each monthly 20- to 24-page issue gives you solid recommendations to help you implement the right treatment plans and, most importantly, determine which patients can be safely discharged home.

Plus, every issue includes a special risk management section — written in our unique format — that helps you avoid common errors in diagnosis, management, and disposition.

Check out the risk management advice from our upcoming issue on ACS here.














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The clinical pathways are practical and effective — and no other publication compares to its clinical utility, its ease of interpretation and assimilation, and its low cost.

— Joseph Calderazzo, mD

“”

how Can You use In Your Practice?We analyze the data from hundreds of articles and then give you concise summaries to aid in real-time decision making. To make implementing the recommendations even easier (and to give you tools to aid in the development of hospital protocols), each issue includes clinical pathways, so you have an at-a-glance visual reference for optimal medical management, from diagnosis to discharge.

Take a peek at this pathway from our ACS issue — we think you’ll especially like the class of evidence ratings for each recommendation, which enable you to judge the quality of the evidence for yourself.

OmniaCore In Hospital Medicine © 2013 14 www.OmniaCore.com • Premier Issue

Clinical Pathway For Acute Coronary Syndromes: STEMI And UA/NSTEMI

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright © 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Class I• Always acceptable, safe

Level of Evidence:• One or more large prospective studies

are present (with rare exceptions)• High-quality meta-analyses• Study results consistently positive and

compelling

Class II• Safe, acceptable• Probably useful

Level of Evidence:• Generally higher levels of evidence• Non-randomized or retrospective stud-

ies: historic, cohort, or case control studies

• Less robust randomized controlled trials• Results consistently positive

Class III• May be acceptable• Possibly useful• Considered optional or alternative treat-

ments

Level of Evidence:• Generally lower or intermediate levels

of evidence• Case series, animal studies,

consensus panels• Occasionally positive results

Indeterminate• Continuing area of research• No recommendations until further

research

Level of Evidence:• Evidence not available• Higher studies in progress• Results inconsistent, contradictory• Results not compelling

Class Of Evidence DefinitionsEach action in the clinical pathways section of OmniaCore In Hospital Medicine

ACS

Perform ECG within 10 minutes(Class I)

Reperfusion successful? (ST-segmentelevation improves by more than

50% and chest pain resolves)

Continue guideline-directed medicalmanagement (Class I)

Risk stratification:treadmill stresstest (Class I)

Rescue PCI

Continueguideline-directed

medical management(Class I)

TIMI risk score:0-2 (low risk)

EF < 40%, recurrent chest pain,or positive stress test

Conservative approach: noninvasive stress test (Class I)

Invasive approach: coronaryangiography (Class I)

Data compiled from guidelines from the American College of Cardiology, the American Heart Association, the Canadian Cardiovascular Society, and theSociety for Cardiac Angiography and Interventions.Abbreviations: ACS, acute coronary syndromes; CAD, coronary artery disease; EF, ejection fraction; NSTEMI, non-ST-segment elevation myocardialinfarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; TIMI, Thrombolysis in Myocardial Infarction; UA,unstable angina.

EF < 40% orsignificantischemia

Coronaryangiography

TIMI risk score:≥ 3 (intermediate

to high risk)

Thrombolytic therapy Primary PCI

EF ≥ 40%EF ≥ 40%

Obtain cardiac biomarkers (Class I)

Use TIMI risk score for UA/NSTEMI(assign 1 point for each of the following):

• Age > 65 y• ≥ 3 CAD risk factors• Known CAD (≥ 50% stenosis)• Aspirin use within 7 days• Severe angina • ST-segment deviation > 0.05 mV• Elevated cardiac biomarkers

Urgent reperfusion (Class I)Considerations:

• PCI capabilities at your institution• Time from symptom onset• High-risk features• Risks of thrombolytic therapy(contraindications)

• Time to achieve balloon inflation with PCI

YES NO

ECG findings consistent with STEMI(ST-segment elevation in > 2 contiguous leads)

ECG findings consistent with UA/NSTEMI (ST-segment depression and/or T-wave inversion)



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OmniaCore In Hospital Medicine © 2013 14 www.OmniaCore.com • Premier Issue

Clinical Pathway For Acute Coronary Syndromes: STEMI And UA/NSTEMI

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright © 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Class I• Always acceptable, safe

Level of Evidence:• One or more large prospective studies

are present (with rare exceptions)• High-quality meta-analyses• Study results consistently positive and

compelling

Class II• Safe, acceptable• Probably useful

Level of Evidence:• Generally higher levels of evidence• Non-randomized or retrospective stud-

ies: historic, cohort, or case control studies

• Less robust randomized controlled trials• Results consistently positive

Class III• May be acceptable• Possibly useful• Considered optional or alternative treat-

ments

Level of Evidence:• Generally lower or intermediate levels

of evidence• Case series, animal studies,

consensus panels• Occasionally positive results

Indeterminate• Continuing area of research• No recommendations until further

research

Level of Evidence:• Evidence not available• Higher studies in progress• Results inconsistent, contradictory• Results not compelling

Class Of Evidence DefinitionsEach action in the clinical pathways section of OmniaCore In Hospital Medicine

ACS

Perform ECG within 10 minutes(Class I)

Reperfusion successful? (ST-segmentelevation improves by more than

50% and chest pain resolves)


Risk stratification:treadmill stresstest (Class I)

Rescue PCI

Continueguideline-directed

medical management(Class I)

TIMI risk score:0-2 (low risk)

EF < 40%, recurrent chest pain,or positive stress test

Conservative approach: noninvasive stress test (Class I)

Invasive approach: coronaryangiography (Class I)

Data compiled from guidelines from the American College of Cardiology, the American Heart Association, the Canadian Cardiovascular Society, and theSociety for Cardiac Angiography and Interventions.Abbreviations: ACS, acute coronary syndromes; CAD, coronary artery disease; EF, ejection fraction; NSTEMI, non-ST-segment elevation myocardialinfarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; TIMI, Thrombolysis in Myocardial Infarction; UA,unstable angina.

EF < 40% orsignificantischemia

Coronaryangiography

TIMI risk score:≥ 3 (intermediate

to high risk)

Thrombolytic therapy Primary PCI

EF ≥ 40%EF ≥ 40%

Obtain cardiac biomarkers (Class I)

Use TIMI risk score for UA/NSTEMI(assign 1 point for each of the following):

• Age > 65 y• ≥ 3 CAD risk factors• Known CAD (≥ 50% stenosis)• Aspirin use within 7 days• Severe angina • ST-segment deviation > 0.05 mV• Elevated cardiac biomarkers

Urgent reperfusion (Class I)Considerations:

• PCI capabilities at your institution• Time from symptom onset• High-risk features• Risks of thrombolytic therapy(contraindications)

• Time to achieve balloon inflation with PCI

YES NO

ECG findings consistent with STEMI(ST-segment elevation in > 2 contiguous leads)

ECG findings consistent with UA/NSTEMI (ST-segment depression and/or T-wave inversion)



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OmniaCore In Hospital Medicine © 2013 www.OmniaCore.com • Premier IssueOmniaCore In Hospital Medicine © 2013 www.OmniaCore.com • Premier Issue

9. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary interven-tion: a report of the American College of Cardiology Founda-tion/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2011. PMID: 22065485. (Guideline)

10. Boden WE, O'Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a con-servative management strategy. Veterans Affairs non-q-wave infarction strategies in hospital (VANQWISH) trial investiga-tors. N Engl J Med. 1998;338(25):1785-1792. PMID: 9632444. (Randomized trial; 920 patients)

11. Lloyd-Jones D, Adams RJ, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46-e215. PMID: 20177011. (Expert consensus guideline)

12. Neumann FJ, Kastrati A, Pogatsa-Murray G, et al. Evalua-tion of prolonged antithrombotic pretreatment ("cooling-off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA. 2003;290(12):1593-1599. PMID: 14506118. (Randomized trial; 410 patients)

13. Krumholz HM, Anderson JL, American College of Cardiol-ogy/American Heart Association Task Force on Performance Measures, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on performance measures (Writing Committee to develop performance measures for ST-elevation and non-ST-elevation myocardial infarction): developed in collaboration with the American Academy of Family Physicians and the American College of Emergency Physicians: endorsed by the American Associa-tion of Cardiovascular and Pulmonary Rehabilitation, Soci-ety for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine. Circulation. 2008;118(24):2596-2648. PMID: 19001027. (Expert consensus guideline)

14. Roger VL, Go AS, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011;123(4):e18-e209. PMID: 21160056. (Expert consensus guideline)

15. Spacek R, Widimský P, Straka Z, et al. Value of first day angiography/angioplasty in evolving non-ST segment eleva-tion myocardial infarction: an open multicenter randomized trial. The VINO Study. Eur Heart J. 2002;23(3):230-238. PMID: 11792138. (Randomized trial; 131 patients)

16. Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA focused update of the guidelines for the manage-ment of patients with unstable angina/ non-ST-elevation myocardial infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/Ameri-can Heart Association Task Force on practice guidelines. Circulation. 2011;123(18):2022-2060. PMID: 21444889. (Expert consensus guideline)

17. Jneid H, Anderson JL, American College of Cardiology Foundation, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Founda-tion/American Heart Association Task Force on practice guidelines. Circulation. 2012;126(7):875-910. PMID: 22800849. (Expert consensus guideline)

References

Evidence-based medicine requires a critical ap-praisal of the literature based upon study methodol-ogy and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the references, where available. The most informa-tive references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference. 1.* O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/

AHA guideline for the management of ST-elevation myocar-dial infarction: a report of the American College of Cardiol-ogy Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. PMID: 23256914. (Guideline)

2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. Lancet. 2003;361(9351):13-20. PMID: 12517460. (Economic analysis; 87,057 patients)

3. Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombo-lytic therapy for acute myocardial infarction: a quantitative review. JAMA. 1997;278(23):2093-2098. PMID: 9403425. (Quantitative review; 2606 patients)

4. The TIMI IIIB Investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conserva-tive strategies in unstable angina and non-Q-wave myocar-dial infarction: results of the TIMI IIIB Trial. Thrombolysis in myocardial ischemia. Circulation. 1994;89:1545–1556. PMID: 8149520. (Randomized trial; 1473 patients)

5. De Winter RJ, Windhausen F, Invasive versus Conserva-tive Treatment in Unstable Coronary Syndromes (ICTUS) Investigators, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med. 2005;353(11):1095-1104. PMID: 16162880. (Randomized trial; 1200 patients)

6. Fox KA, Poole-Wilson PA, Randomized Intervention Trial of unstable Angina Investigators, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Interven-tion Trial of unstable angina. Lancet. 2002;360(9335):743-751. PMID: 12241831. (Randomized trial; 1810 patients)

7. McCullough PA, O'Neill WW, Graham M, et al. A pro-spective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial. J Am Coll Cardiol. 1998;32(3):596-605. PMID: 9741499. (Randomized trial; 201 patients)

8. Cannon CP, Weintraub WS, TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy), et al. Comparison of early inva-sive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344(25):1879-1887. PMID: 11419424. (Randomized trial; 2220 patients)

Disposition And Transitions Of Care

All patients with ACS need a formal assessment of the ejection fraction prior to hospital discharge (or earlier in the setting of hemodynamic instability). For patients who are in the hospital, the treating hospitalist should directly discuss their care with the cardiologist; pertinent issues to relay include the exact diagnosis (UA/NSTEMI or STEMI), the location of infarction for STEMI patients, a summary of recent complications (vascular access issues, bleeding, etc), current medications (including ongoing IV medica-tions and antiplatelet agents), hemodynamic status, and plans for hospital disposition. Hospital follow-up appointments should be made prior to discharge. Nursing staff should review all new medications and enforce the need for compliance with dual (or triple) antiplatelet therapy. Patients should be instructed to contact their cardiologist if another healthcare provider recommends discontinuing antiplatelet therapy. Patients should be educated by the treating hospitalist and primary team regarding compliance with medications, compliance with a cardiac diet, and the amount of physical activity to pursue. Following hospital discharge, patients should be seen within 1 to 2 weeks in an outpatient clinic by their treating car-diologist to review compliance with medications and diet and progress with cardiac rehabilitation as well as to examine the arterial access site for any complica-tions (such a hematoma).

Summary

ACS covers a spectrum of diseases including un-stable angina, NSTEMI, and STEMI. Patients with STEMI have a high likelihood of a coronary throm-bus occluding the infarct related artery and should be evaluated for reperfusion therapy with either thrombolytic therapy or primary PCI. Patients with UA/NSTEMI require risk assessment to determine the appropriate medical therapy and treatment approach. Moderate- and high-risk patients ben-efit from aggressive medical therapy and an early invasive approach with coronary angiography and PCI. Medical therapy for ACS includes antiplatelet, antithrombotic, anti-anginal, anti-ischemic, and cho-lesterol-lowering medications as well as other drugs aimed to improve myocardial remodeling, such as angiotension converting enzyme (ACE) inhibitors.

Markers Of Quality Care

Adopting a “Get with the Guidelines” approach helps obtain better outcomes for patients. In 2011, Wang et al analyzed Medicare and Medicaid data, examining hospitals for adherence to the “Get with the Guidelines” recommendations after MI and heart failure. Hospitals that adhered to guidelines for both had lower in-hospital mortality (hazard ratio, 0.79) compared to those who adhered to only 1 guideline or no guidelines.101

Many hospitals have adopted dedicated observa-tion units to rapidly triage and evaluate patients with chest pain. Various protocols and treatment algo-rithms can expedite the care of patients with ACS and also reduce unnecessary hospital admissions for pa-tients without a cardiac cause for their symptoms.102 Following initial screening, laboratory assessment, and review of the ECG, patients can be classified as low, intermediate, or high risk. Low-risk patients are those with a normal ECG and normal cardiac bio-markers at 6 and/or 12 hours; these patients should be subsequently referred for an exercise treadmill stress test, cardiac computed tomography scan, or an-other rapid imaging study.103 Patients with a normal cardiac study are discharged to home, and those with an abnormal study are admitted to the hospital for coronary angiography and/or additional diagnostic testing. Intermediate- and high-risk patients identi-fied on the initial assessment are admitted to the hospital for definitive cardiovascular testing.

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how Do You know the Evidence Is valid?OmniaCore doesn’t just report guidelines or excerpt textbooks. Our authors search out and critically evaluate the literature and then draw conclusions based upon the best available evidence. To help you judge the strength of each reference at a glance, the authors include the type of study and the number of patients in the study in bold following each reference. We’re proud to be the first hospital medicine journal to offer this unique feature, and we know you’ll find it valuable as well.

Examine the quality of the evidence from our ACS issue for yourself by scanning the references excerpted here.


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