This document summarizes trends and developments in the management of acute coronary syndromes (ACS). It discusses improvements in pre-hospital care like early ECGs that aid diagnosis and direct transport to catheterization labs. In-hospital, point-of-care testing of biomarker panels can safely rule out heart attacks within 90 minutes and allow more patients to be discharged earlier from emergency departments. Adherence to guidelines for evidence-based medical therapies and quality improvement standards is associated with better outcomes for ACS patients.

1. Acute coronary syndromes: trends and
developments
http://www.igetbetter.com/acute-coronary-syndrome/
Dr John Albarran, DPhil, RN, BSc(Hons), MSc
Associate Professor in Critical and Cardiovascular Nursing
Associate Head of Department for Research and Knowledge Exchange
Co-Editor of Nursing in Critical Care

2. Trends and developments (challenges)
Briefly review pathophysiology of ACS
Provide a general overview of management
approaches to ACS
Explore trends and developments in three
areas
Pre-hospital initiatives
In-hospital developments
Auditing of practice guidelines and pathways

3. Definitions of acute coronary syndrome
(Bench studies, clinical trials, epidemiology and public policy)
Pathophysiological
element
Electrocardiographic
element
Biochemical markers
of myocardial cell
necrosis
Early risk
stratification
Plaque disruption
European Heart Journal (2011) ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST elevation of the European Society of
Cardiology 32: 2999-3054

4. Pathogenesis of arthrosclerosis
Disruption of vulnerable plaque/fibrous cap
(fissuring or rupture due sheer force, wall
thickness etc)
Exposure of lipids, smooth
muscle and foam cells
Generation of thrombin
and fibrin deposits
Promotion of platelet
aggregation and adhesion
(binding enhanced by glycoprotein
IIb/IIIa receptor)
Platelet activation leads to
thrombus formation = occlusion

5. Features of ACS
Unstable Angina NSTEMI STEMI
Symptoms Pain with radiation (at
rest >20 mins,
anginal symptoms
more frequent,
severity increasing)
Pain with or without
radiation to arm, neck
and chest
Shortness of breath,
nausea, sweating,
Tachycardia, BP  or
,dysrhythmias
Chest pain, with or
without radiation to
arm, neck or back
Shortness of breath,
nausea, sweating,
Tachycardia, BP  or
,dysrhythmias
Pain duration >20mins
and more severe
ECG features ST Segment
depression or T wave
inversion
ST segment depression,
or T wave inversion
ST elevation in two or
more contiguous leads
Q Wave formation, or
new LBBB
Serum cardiac
enzymes*
(For diagnosis and
prognosis measure
within12 hr of symptom
onset)
Generally not
elevated
<0.01μg/L
Elevation of markers
>0.01 and <1.0μg/L
> 1.0μg/L
Actions Anti-ischaemic and
thrombotic treatment
and risk stratification
Anti-ischaemic and
thrombotic treatment
and risk stratification
Early reperfusion eg
thrombolysis or PCI
(Adapted from : Grech and Ramsdale 2003,SIGN 2013 guidelines, Overbaugh 2009)

6. TIMI- Prognostic indicators for
adverse events eg: re-infarction,
recurrent
ischaemia requiring
revascularisation and death-
GRACE score – has higher
accuracy
Better outcomes
in high risk
patients from
invasive approach
Development of Integrated pathways
A word of caution, a recent Cochrane review of
randomised clinical trials identified no evidence for
the continued practice of administering inhaled
oxygen in MI patients. There was no evidence
across patients with ACS of improved outcome or
reduction or infarct size with inhaled oxygen (Cabello JB,
Burls A, Emparanza JI, Bayliss S, Quinn T. (2010) Oxygen therapy for acute myocardial infarction (Cochrane Review). In: The
Cochrane Library , Issue 6, 2010. London: John Wiley &Sons Ltd)

7. Developments in manipulating clotting cascade
Disruption of intimal plaque
(fissuring or rupture)
Exposure of lipids, smooth
muscle and foam cells
Generation of thrombin
and fibrin deposits
Promotion of platelet
aggregation and adhesion
(binding enhanced by glycoprotein
IIb/IIIa receptor)
Platelet activation leads to
thrombus formation
Thrombolysis, PCI*
Anti-ischaemic:
Nitrates, β-Blockers,
Ca Channel Blockers
Aggregation: Aspirin, IV
unfractionated Heparin,
LMW Heparin
Adhesion: Clopidogrel,
*Glycoprotein IIb/IIIa
inhibitors
Patients with ACS and
elevated troponins benefit
more from LMWHs,
Glycoprotein IIb/IIIa
inhibitors and early PCI

8. ACS definitions, prognosis based on Troponin T
concentration
12hr serum TnT <0.01 >0.01 and <0.1 >1.0
ESC/ACC US MI STEMI
WHO US US STEMI
30 day mortality 4.5% 10.4% 12.9%
6-month
8.6% 18.7% 19.2%
mortality
Scottish Intercollegiate Guidelines Network (SIGN) 2013

9. Trends and developments (challenges)
Pre-hospital care Acute hospital
care
Quality improvement
and standards

10. Pre-hospital care- factors affecting delays and decisions
 Despite availability of emergency services, only 63% activate ambulance
services while experiencing chest pain
 Many patients visit their home doctor in the first instance rather than calling
EMS and tend to use family and friends for transport which is associated with
delay to urgent treatment
 Delays are also due to poor recognition and response by members of the
public
Around 75% of patients with STEMI are diagnosed on admission to hospital
and this impacts on administration of early reperfusion therapies and
outcomes (Diercks et al (2009) Journal of American Colle of Cardiology 53: 161-66)

11. (3) Bypass Emergency
department and
directly to PCI service
(2) Non-PCI centre (DIDO)
85% of muscle damage
takes place in first
three hours – Golden
hours
(1) General
practitioner
Thrombolysis

12. Trends in pre-hospital care
• The triage of patients aids pre-hospital diagnosis
• Reduce door to needle time
• Reduce door to PCI time
• Pre-activate catheter laboratory staff to be ready
• Improves patient outcomes for those with ACS
(Postma et al 2012)
Integration of pre-hospital
ECG helps
• Antiplatelet* and antithrombotic therapies initiated
if appropriate
• Ticagrelor and Prasugel* prescribed for STEMI
• Treatments tailored to individual patients
(therapies might depend on distance to PCI centre,
Johnson et al 2006)
Vascular access/early
anti-platelet and anti-thrombotic
• Direct ambulance transport to catheter suite, avoid
emergency department delays
• Good practice standards for management of ACS
patients
Direct transportation
to PCI centre
For PCI capable hospitals,
recommendations include a D2B of
90 mins of arrival, (150 mins from
patient call). Co-ordination of
professionals, protocols and
purpose built facilities are essential
(2013 ACCF/AHA Guideline for the management of STEMI. JACC 61 (4) e78-e140)
ESC Guidelines (2012) Guidelines for the management of acute myocardial infarction
patients presenting with ST elevation European Heart Journal
eurheartj.oxfordjournals.org/content/33/20/2569

13. Developments in bio-markers
The role of biomarkers is key diagnosis and prognosis in
patients with ACS (not in isolation)
Not all patients with chest pain or have clear evidence of
ischaemic changes on ECG (25% of ED admissions), so cardiac
biomarkers are invaluable
Guidance suggests that sampling for changes in Troponins
should be 6-12hrs after onset of symptoms, thus requiring
many patients (with initial negative cardiac biomarkers) to be
admitted to hospital which may be costly and stressful for
individuals
Acknowledgement Collison et al http://spo.escardio.org/eslides/view.aspx?eevtid=40&fp=5243 (3rd of November 2014)

14. Randomised Assessment of Treatment using Panel Assay of
Cardiac markers (RATPAC) -point of care test (Goodacre et al 2011 Heart 17: 190-196)
• Combined panel of biomarkers which are released earlier
reflecting aspects of underlying atherosclerotic process
• Cardiac troponin
• Myoglobin
• MB isoenzyme of creatitine kinanse (myocardial type)
• This panel would include early and late markers, allowing rapid
rule-out ACS
• Point-of-care testing reduces time to decisions through rapid
availability of biomarker data
• Baseline measures and at 90mins have been studies before for
rapid diagnosis and management of patients in ED

15. Aim
• Determine whether using a POC biomarker panel translates to
uncomplicated discharge home from ED
• Determine the effects of biomarker cardiac test on treatments,
admissions to hospital and adverse events
Outcome measures
• Successful discharge of patients after 4 hours without adverse
events at 3 months
• Length of stay, use of coronary care, cardiac intervention, ED
attendances, subsequent readmissions and adverse major events

16. • Pragmatic multi-centre study of six
acute hospitals in UK
DESIGN and SETTING
• Patients presenting with sudden
chest pain suspicious of ACS
• 2243 patients met criteria
PARTICIPANTS
• Point of care biomarker panel
measured at baseline and 90mins
• Compared to standard care without
point-of-care panel
INTERVENTIONS
(Data collection)

17. Results
POC Standard care
Rate of successful
discharged at
4hours
358/1125(32%) 146/118 (13%) OR 3.81, 95% CI
3.01-4.82; p<0.001
Reduced median
length of stay
8.8 hrs 14.2hrs P<0.001
Use of coronary
care
50/1125(4%) 31/1118 (3%) P=0.041
No differences in other variables studied were observed. Overall POC panel increases
discharge of patients home and reduces median LOS but not mean LoS
POC biomarker panel can safely rule out MI in patients with chest pain within 90mins

18. Trends ~Quality improvement and standards
Adherence
guidelines
Impact of
outcomes
ACC
guidelines
Applied in
practice
EBP
medical
therapies

19. Compliance and adherence
Adherence to 9 ACC/AHA class I guidelines translated to reduced
in-hospital mortality rates, however 26% 0f centres did not
comply- A significant association was found between care
processes and outcomes such metrics can help improve hospital
performance (Peterson et al (2006), JAMA 295 16: 1912-1920)
Adherence for combination EBP medical therapy (antiplatelet,
Beta-blockers, ACE inhibitors and lipid lowering agents) with 1264
patients demonstrated an association of lower 6 month ACS
mortality (Mukherjee et al 2004, Circulation 109: 745-49)
Using a before and after study design, 30 day (10.4 – 13.6 vs 21-
26%) and 1 year (16-21.6% vs 33-38%) mortality reduced once
Cardiology guidelines Applied in practice were implemented.
Benefits are clearer when using EBP tools (Engle et al 2005, JACC 46 (7): 1242-48

20. Conclusion
Our knowledge and understanding of ACS is evolving and informed by
greater insights into the pathogenesis of atherosclerosis
Current trends and developments in management of ACS seem to
revolve around pre-hospital interventions, safety of anti-platelet
therapies, novel multiple panel biomarkers and the integration and
adherence of evidence base guidelines
Success in patient outcomes is a team effort
The role of the nurse needs to remain at the forefront of these changes
and make a difference to the lives of our patients
Thank you for listening