National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016

These clinical guidelines have been developed to assist in the management of patients presenting with chest pain suspected to be due to an acute coronary syndrome (ACS) and those with confirmed ACS. These guidelines should be read in conjunction with the ACS Clinical Care Standards developed by the Australian Commission for Safety and Quality in Health Care (ACSQHC) [1Australian Commission on Safety and Quality in Health Care. Acute Coronary Syndromes Clinical Care Standard. 2014. Available at: http://www.safetyandquality.gov.au/our-work/clinical-care-standards/acute-coronary-syndromes-clinical-care-standard/. Accessed 30/3/16Google Scholar] and the Australian acute coronary syndromes capability framework developed by the Heart Foundation [2National Heart Foundation of Australia. Australian acute coronary syndromes capability framework. 2015. Available at: https://heartfoundation.org.au/for-professionals/clinical-information/acute-coronary-syndromes. Accessed 30/3/16.Google Scholar]. Additional guidance around the timing and use of therapies is detailed in the accompanying practice advice. Tabled 1RecommendationGRADE strength of recommendationNHMRC Level of Evidence (LOE)Initial assessment of chest painIt is recommended that a patient with acute chest pain or other symptoms suggestive of an ACS receives a 12-lead ECG and this ECG is assessed for signs of myocardial ischaemia by an ECG-experienced clinician within 10 minutes of first acute clinical contact.StrongIIICA patient presenting with acute chest pain or other symptoms suggestive of an ACS should receive care guided by an evidence-based Suspected ACS Assessment Protocol (Suspected ACS-AP) that includes formal risk stratification.StrongIAUsing serial sampling, cardiac-specific troponin levels should be measured at hospital presentation and at clearly defined periods after presentation using a validated Suspected ACS-AP in patients with symptoms of possible ACS.StrongIANon-invasive objective testing is recommended in intermediate-risk patients, as defined by a validated Suspected ACS-AP, with normal serial troponin and ECG testing and who remain symptom-free.WeakIAPatients in whom no further objective testing for coronary artery disease (CAD) is recommended are those at low risk, as defined by a validated Suspected ACS-AP: age 140, dynamic ST-segment and/or T-wave changes on ECG, or rise and/or fall in troponin compatible with MI) an early invasive strategy is recommended (i.e. within 24 hours of admission).WeakICIntermediate risk patients: In the absence of high-risk criteria, for patients with NSTEACS with intermediate-risk criteria (such as recurrent symptoms or substantial inducible ischaemia on provocative testing), an invasive strategy is recommended (i.e. within 72 hours of admission).WeakIICPharmacology for ACSAspirin 300 mg orally initially (dissolved or chewed) followed by 100–150 mg/day is recommended for all patients with ACS in the absence of hypersensitivity.StrongIAAmong patients with confirmed ACS at intermediate to very high- risk of recurrent ischaemic events, use of a P2Y12 inhibitor (ticagrelor 180 mg orally, then 90 mg twice a day or; prasugrel 60 mg orally, then 10 mg daily; or clopidogrel 300–600 mg orally, then 75mg per day) is recommended in addition to aspirin. (Ticagrelor or prasugrel preferred: see practice advice)StrongIAIntravenous glycoprotein IIb/IIIa inhibition in combination with heparin is recommended at the time of PCI among patients with high-risk clinical and angiographic characteristics, or for treating thrombotic complications among patients with ACS.StrongIBEither unfractionated heparin or enoxaparin is recommended in patients with ACS at intermediate to high risk of ischaemic events.StrongIABivalirudin (0.75 mg/kg IV with 1.75 mg/kg/hr infusion) may be considered as an alternative to glycoprotein IIb/IIIa inhibition and heparin among patients with ACS undergoing PCI with clinical features associated with an increased risk of bleeding events.WeakIIBDischarge management and secondary preventionAspirin (100–150 mg/day) should be continued indefinitely unless it is not tolerated or an indication for anticoagulation becomes apparent.StrongIAClopidogrel should be prescribed if aspirin is contraindicated or not tolerated.StrongIADual-antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel or ticagrelor) should be prescribed for up to 12 months in patients with ACS, regardless of whether coronary revascularisation was performed. The use of prasugrel for up to 12 months should be confined to patients receiving PCI.StrongIAConsider continuation of dual-antiplatelet therapy beyond 12 months if ischaemic risks outweigh the bleeding risk of P2Y12 inhibitor therapy; conversely consider discontinuation if bleeding risk outweighs ischaemic risks.WeakIICInitiate and continue indefinitely, the highest tolerated dose of HMG-CoA reductase inhibitors (statins) for a patient following hospitalisation with ACS unless contraindicated or there is a history of intolerance.StrongIAInitiate treatment with vasodilatory beta blockers in patients with reduced left ventricular (LV) systolic function (LV ejection fraction EF ≤40%) unless contraindicated.StrongIIAInitiate and continue angiotensin converting enzyme (ACE) inhibitors (or angiotensin receptor blockers ARBs) in patients with evidence of heart failure, LV systolic dysfunction, diabetes, anterior myocardial infarction or co-existent hypertension.StrongIAAttendance at cardiac rehabilitation or undertaking a structured secondary prevention service is recommended for all patients hospitalised with ACS.StrongIANote: Refer to Appendix 4 for details on the National Health and Medical Research Council (NHMRC) guideline development methodology, including grades of evidence, and Appendix 5 for details on the GRADE methodology. Open table in a new tab Note: Refer to Appendix 4 for details on the National Health and Medical Research Council (NHMRC) guideline development methodology, including grades of evidence, and Appendix 5 for details on the GRADE methodology. Acute coronary syndromes (ACS) – myocardial infarction (MI) and unstable angina (UA) – are the result of unstable atheromatous plaques or endothelial disruption with associated transient or permanent thrombotic occlusion of the coronary vascular tree leading to myocardial ischaemia and infarction. As a result of the improved sensitivity of troponin assays, incidence of unstable angina is decreasing with a proportionate increase in the incidence of MI. In 2012, the Australian Institute of Health and Welfare estimated there were 68,200 ACS events [3Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Prevalence and incidence. Cardiovascular, diabetes and chronic kidney disease series no. 2.(Cat. no. CDK 2.)Google Scholar]. Chest pain and other symptoms suggestive of possible ACS are common presenting complaints in the emergency department (ED) [4Bhuiya F.A. Pitts S.R. McCaig L.F. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008.NCHS data brief. 2010; : 1-8PubMed Google Scholar]. It is estimated that over 500,000 patients present in Australia each year with chest pain, but more than 80% of all patients investigated for ACS will not have this diagnosis confirmed [5Cullen L. Greenslade J. Merollini K. Graves N. Hammett C.J. Hawkins T. et al.Cost and outcomes of assessing patients with chest pain in an Australian emergency department.Med J Aust. 2015; 202: 427-432Crossref PubMed Scopus (5) Google Scholar]. In unselected patients presenting with acute chest pain to the ED in the Australian setting, the prevalence of different diagnostic groups are: 2-5% ST elevation MI (STEMI), 5-10% Non-STEMI (NSTEMI), 5-10% UA, 15-20% other cardiac conditions and 50-70% non-cardiac diseases 5Cullen L. Greenslade J. Merollini K. Graves N. Hammett C.J. Hawkins T. et al.Cost and outcomes of assessing patients with chest pain in an Australian emergency department.Med J Aust. 2015; 202: 427-432Crossref PubMed Scopus (5) Google Scholar, 6Kelly A.-M. How useful are the Heart Foundation risk criteria for assessment of emergency department patients with chest pain?.EMA. 2012; 24: 260-265Google Scholar, 7Macdonald S.P. Nagree Y. Fatovich D.M. Flavell H.L. Loutsky F. Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome.Emergency Medicine Australasia: EMA. 2011; 23: 717-725Crossref PubMed Scopus (0) Google Scholar. The costs and burden of the diagnostic process to patients, clinicians and the healthcare system are significant. Patient level estimates of overall 30-day outcomes and 12-month mortality rates within Australian contemporary practice, as ascertained by recent clinical audits, are provided as a reference for estimating the absolute benefits for various guideline recommended therapies and strategies (Table 1) in the 'average' patient. In deriving estimates of the absolute reduction or increase in events as a result of specific treatments, the relative effects for each treatment seen in trials is applied to the estimated baseline absolute event rates seen in audits. This absolute change in events is then used to calculate the number needed to treat to benefit (NNTB) (e.g. reducing recurrent MI) and the number needed to treat to harm (NNTH) (e.g. treatment-related bleeding or adverse events). These figures should be considered an approximation as clinical audits comprise patients who have received varying intensities of different interventions, as opposed to clinical trials where, apart from the specific intervention under study, all other forms of care are provided equally. When considering the use of evidence-based recommendations in individual patients, patient-specific disease and treatment risks, and therefore potential benefits and harms from therapies, should be weighed. The relative increase in both risks associated with key clinical and demographic characteristics within the Australian and New Zealand clinical experience is provided in Table 2.Table 1Kaplan-Meier event rates for ACS diagnosis adjusted for age from SNAPSHOT ACSSTEMINSTEMIUnstable anginaChest painDeath or MI by 30 days12.7%6.8%1.2%0.7%In hospital major bleeding2.4%1.4%1.0%0.2%Death by 12 months9.8%6.0%1.7%2.9%Death or MI by 12 months17.7%15.1%5.1%4.9%Death/MI/stroke by 12 months18.6%16.2%7.0%5.9% Open table in a new tab Table 2Relative increase in ischaemic and bleeding events with key clinical characteristics from SNAPSHOT ACSRelative increase in in-hospital MACE OR (95% CI)Relative increase in in-hospital bleeding events OR (95% CI)Age >75 years vs age ≤75 years1.69 (1.15–2.45)1.36 (0.58–3.00)Female gender vs male gender1.19 (0.83–1.72)0.91 (0.40–1.97)Diabetes vs non-diabetes1.53 (1.05–2.21)1.60 (0.73–3.40)CKD Stage 3-5 vs CKD Stage 1-22.81 (1.96–4.04)1.91 (0.89–4.03)CKD=chronic kidney disease; CI=confidence interval; OR=odds ratio; MACE=Major adverse cardiac events Open table in a new tab CKD=chronic kidney disease; CI=confidence interval; OR=odds ratio; MACE=Major adverse cardiac events This clinical guideline for the management of ACS seeks to provide guidance regarding the clinical care of patients presenting with suspected or confirmed ACS. It is intended to replace the National Heart Foundation of Australia (NHFA)/Cardiac Society of Australia and New Zealand (CSANZ) ACS guideline published in 2006, 2008 and 20118Aroney C.N. Aylward P. Chew D.P. Huang N. Kelly A.M. White H. et al.2007 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006.Med J Aust. 2008; 188: 302-303PubMed Google Scholar, 9Chew D.P. Aroney C.N. Aylward P.E. Kelly A.M. White H.D. Tideman P.A. et al.2011 Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes (ACS) 2006.Heart Lung Circ. 2011; 20: 487-502Abstract Full Text PDF PubMed Scopus (90) Google Scholar, 10Acute Coronary Syndrome Guidelines Working GroupGuidelines for the management of acute coronary syndromes 2006.Med J Aust. 2006; 184: S1-S30Google Scholar. The methodology used in the development of this guideline was guided by the methodological expertise of working group members [11Scott I.A. Guyatt G.H. Suggestions for improving guideline utility and trustworthiness.Evidence-based Medicine. 2014; 19: 41-46Crossref PubMed Scopus (0) Google Scholar]. •In mid-2014, officers of the NHFA and a small group of senior cardiologists representing the CSANZ, together with a methodologist, formed an ad hoc group to initiate the process of developing the 2016 guideline.•This group approached the Cardiac Clinical Networks around Australia seeking feedback regarding the content and development process for the guideline.•In December 2014, the ad hoc group, under a formal partnership between NHFA and CSANZ, and acting on advice from the previous expert panel responsible for prior editions of the guideline, sought representation from key stakeholder organisations for experts in ACS management to contribute to the process of guideline development.•Among those canvassed as recognised clinical experts in chest pain and ACS management, proposed contributors where offered roles in either a reference group, which had the role of critical review of the entire guideline content, or work groups focussing on guideline writing related to specific topics. •This group comprised nominated representatives of identified key stakeholder organisations with national relevance in the provision of ACS care in Australia.•The roles of the group were to review and provide input into the scope of the guidelines, the questions being submitted for literature review, draft guideline content and recommendations, and issues of implementation. •Work groups were established for each of four topics: chest pain assessment, STEMI, non-ST segment elevation ACS (NSTEACS) and secondary prevention. For each work group, among all those who agreed to join the group, a primary author and senior advisor were appointed by group consensus on the basis of expertise and previous experience in guideline development.•Each work group was then supplemented with members with recognised expertise from stakeholder groups and the clinical community.•Members of each work group met on several occasions to discuss the content of each of the four sections of the guideline. •The primary author and senior advisor from each of the four workgroups and representatives from the NHFA formed an executive group with overall responsibility for the progression, content and consistency of the guideline, and for resolving disputes within or between work groups relating to guideline content and recommendations or conflicts of interest.•The executive group had several meetings throughout 2015 and 2016, to discuss and refine the full content of the draft guidelines, with particular focus on the wording and grading of final recommendations.•The executive group had the authority for final approval of guideline content and recommendations. •Informed by stakeholder consultation, each of the work groups proposed sentinel questions, presented in PICO format (population, intervention, comparator and outcome), for external literature review. These questions were reviewed and refined by the reference group. The questions proposed for literature review are provided in the appendix.•The literature reviewer was appointed through an open tender process. The literature review sought published studies from 2010 to 2015. The process of literature review was commenced in the second quarter of 2015 and completed in the fourth quarter of 2015. Evidence summaries were reviewed and signed off by the work groups and, where deemed appropriate, were supplemented with additional studies published after the literature search dates. •In December 2015, the full first draft of the guideline was given to members of the reference group for detailed comments. These comments were received and responses drafted in February 2016.•A public consultation period of 30 days was conducted in April 2016.•Final approval and submission for publication was undertaken in June 2016. Conflicts of interest were considered within a framework of both the relationship (direct or indirect) of the participating individual to any third party with interest in the topic under consideration within the guideline development process, and the nature (financial and non-financial) of the potential conflict. All members of the work groups and reference group were asked to declare all potential conflicts of interest and these declarations were updated every six months and at each meeting. Individuals with pecuniary or academic conflicts of interest deemed to be high were excluded from the drafting of specific recommendations. All other conflicts of interest were managed by the work group chair or senior advisor, under guidance from the executive group. The executive group was responsible for managing conflicts of interest. A summary of the conflicts of interest and executive group responses is provided in the online appendix and a full description of the governance process for the development of this guideline will be available on the NHFA website. In developing this document, we sought to provide practical guidance for contemporary ACS care in Australia derived from the extensive evidence base regarding the clinical effectiveness of different interventions and treatment strategies. In addition to reviews of published trials and systematic reviews, guideline content was informed by other international clinical guidelines, the Acute Coronary Syndrome Clinical Care Standard and local clinical expertise. In formulating recommendations, we focussed on clinical actions likely to be associated with the largest impact on patient-important outcomes. The guidelines are presented in the format described below. The key 'Recommendations' are presented up-front for easy identification. In these recommendations, we to provide a strength of or to the of and system to Appendix the National Health and Medical Research Council (NHMRC) level of evidence Health and Medical Research additional levels of evidence and grades for recommendations for of Available at: Accessed on 30/3/16.Google Scholar] to Appendix The executive group considered that a regarding the strength of the – benefit clinicians seeking to use of interventions in clinical practice, systems to provide more or for clinical of the final recommendations was reviewed and refined by the work groups and the reference group, with final review and by the executive group. The of consensus was of all members of the executive group. The a very summary of the key In this treatment effects are presented in relative risk or an OR of a relative reduction in the have confined the of treatment effects to those that were to a of with the of mortality outcomes where to the of the assist in the of these treatment effects into clinical we have to estimates of the absolute changes in outcomes as ischaemic or adverse events for the 'average' in the and This been used to assist clinicians in with patients by the likely absolute benefits or risks associated with each guideline In formulating recommendations, we were of for use of there is a of for all ACS interventions within the Australian regarding the key or other system are in the and other where of care associated with a very evidence base and on consensus or where the impact of interventions on clinical outcomes was considered to be are in the sections of the guideline. is clinicians are to to additional as the Australian for and adverse The writing groups were that of the evidence focussed on clinical events as recurrent MI and As a the recommendations and practice advice are by this which been used to estimates of treatment within the benefits and harms within clinical practice, it is recognised that these are not as the highest by patients with other outcomes as of It is recognised that the evidence base for ACS care is very in regards to patients with substantial which specific recommendations being for this patient group for ACS In of these guidelines on clinical and a decision-making process individual patients that and clinical should into the and of in particular the and advice sections comments published focussed on The consideration in the assessment of patients presenting with chest pain to an emergency medical is to all patients with ACS or The of patients with acute MI and unstable angina (UA) from the emergency department (ED) is associated with a substantial increase in mortality with patients et of acute cardiac in the emergency J PubMed Scopus Google Scholar] P. of chest pain patients from a emergency a 2012; Full Text Full Text PDF PubMed Scopus (0) Google Scholar] The of of Acute Emergency 2006; Full Text Full Text PDF PubMed Scopus Google Scholar]. the sensitivity and of Suspected ACS Assessment (Suspected ACS-AP) for the of ACS is It is to use and assessment that and for ACS in reducing and in the to or from the with ACS may present with a of (e.g. chest and atypical (e.g. symptoms to signs of a heart The symptoms of ischaemia other than chest and abdominal of and there are for chest pain and other symptoms of possible the recommendations in this of the guidelines to patients with symptoms suggestive of a coronary and in whom a diagnosis of an ACS or to be It is beyond the scope of these recommendations to provide detailed assessment, and management strategies for all conditions chest Chest pain assessment is a time diagnostic process the history of the presenting serial serial for myocardial and an assessment of the risk of an ACS. The chest pain diagnostic process can be by a series of clinical this patient have a ST elevation MI alternative or other high-risk conditions (e.g. to be considered in the in the of cardiac this patient have evidence of ACS the patient have coronary artery disease patients at low of major adverse cardiac events be identified with a high of high-risk the patient to in the event of of chest pain or other symptoms after clinical assessment including ECG and troponin testing are to a diagnosis of ACS by For this patients who present to primary care or to clinicians in other with chest pain 24 and suspected ACS should be as as possible to the ED or a of risk stratification and diagnosis of ACS. presenting with high-risk features as chest pain, or should be to the For these patients, the of management the diagnosis with an ECG if and immediate to cardiac where For this patients should not to the ED and by emergency medical is to ED should not on troponin Care should be where possible and includes aspirin and