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## Complete Summary

#### GUIDELINE TITLE

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS).

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
treatment of chest pain and acute coronary syndrome (ACS). Bloomington
(MN): Institute for Clinical Systems Improvement (ICSI); 2006 Oct. 76 p.
\[121 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical
Systems Improvement (ICSI). Diagnosis and treatment of chest pain and
acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Oct. 78 p.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s)/intervention(s) for which important revised
regulatory information has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [June 8, 2007, Troponin-I
    Immunoassay](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Architect):
    Class I Recall of all lots of the Architect Stat Troponin-I
    Immunoassay. The assay may report falsely elevated or falsely
    decreased results at and near a low level, which may impact patient
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Chest pain/discomfort, including coronary artery disease (CAD) and
    non-cardiac causes

-   Acute myocardial infarction

-   ST-elevation myocardial infarction

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Rehabilitation\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Emergency Medicine\
Family Practice\
Internal Medicine\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Health Care Providers\
Health Plans\
Hospitals\
Managed Care Organizations\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To increase the success of emergency intervention for patients with
    high-risk chest pain

-   To minimize the delay in administering thrombolytics or angioplasty
    to patients with acute myocardial infarction (AMI)

-   To increase the timely initiation of treatment to reduce
    postinfarction mortality in patients with AMI

-   To increase the percentage of patients with AMI, who have used
    tobacco products within the past year, who receive tobacco use
    assessment and cessation counseling and treatment within 24 hours of
    admission

-   To improve the diagnostic value of stress tests through their
    appropriate use in patients with chest pain symptoms

-   To increase the percentage of patients with AMI using appropriate
    cardiac rehabilitation post-discharge

-   To increase the percentage of patients with AMI whose course of
    treatment has followed the recommended critical pathway

-   To increase the use of risk stratifying procedures in patients with
    AMI

#### TARGET POPULATION

Adults greater than age 18 years presenting with past or present
symptoms of chest pain, discomfort, and/or indications of acute coronary
syndrome (ACS)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening/Evaluation/Diagnosis/Risk Assessment**

1.  Initial evaluation by triage

2.  Medical history, physical examination, and risk assessment

3.  Clinic evaluation depending on symptoms and risk factors

4.  Vital signs assessment

5.  Electrocardiogram (ECG)

6.  Cardiac markers (troponin T or I, creatine kinase MB)

7.  Diagnostic coronary angiography

8.  Treadmill stress test

9.  Computed tomography (CT) angiogram, echocardiogram/transesophageal
    echocardiography (Echo/TEE), magnetic resonance imaging (MRI),
    arterial blood gases, chest x-ray if indicated

**Management/Treatment/Rehabilitation**

1.  Emergency interventions including ambulance transport to Emergency
    Department, immediate assessment with cardiac monitoring, initial
    management according to the American Heart Association Advanced
    Cardiac Support guideline

2.  Early therapy including an intravenous line, oxygen, aspirin (ASA),
    heparin/low-molecular weight heparin (LMWH), beta-blockers (esmolol)
    in eligible patients, clopidogrel, nitroglycerin, morphine,
    glycoprotein IIb-IIIa inhibitors (Tirofiban HCL, abciximab,
    Eptifibatide)

3.  Percutaneous coronary intervention (PCI) or coronary artery bypass
    graft (CABG) if indicated

4.  Thrombolytics including tissue plasminogen activator (tPA) TNK, rPA

5.  Treatment of acute myocardial infarction (AMI) complications

6.  Phase 1 cardiac rehabilitation including ASA, clopidogrel,
    beta-blockers, angiotensin-converting enzyme (ACE) inhibitors
    (angiotensin receptor blockers \[ARBs\] if ACE inhibitors not
    tolerated), calcium channel blockers, oral nitrates, LMWH, warfarin,
    antiarrhythmic agents, statins, tobacco cessation, glycemic control,
    healthy diet, and manageable exercises

7.  Phase 2 cardiac rehabilitation (outpatient management) including
    medically supervised exercise with ECG monitoring, health education,
    risk factor modifications, and exercise prescription

8.  Phase 3 and 4 cardiac rehabilitation (maintenance)

9.  Follow-up

#### MAJOR OUTCOMES CONSIDERED

-   Diagnostic value of tests

-   Prognostic value of risk assessment interventions

-   Effectiveness of secondary prevention, treatment, and rehabilitation
    interventions on reducing mortality and morbidity rates

-   Positive predictive value of new ST elevation

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

Clinical Validation-Pilot Testing\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

**Institute Partners: System-Wide Review**

The guideline draft, discussion, and measurement specification documents
undergo thorough review. Written comments are solicited from clinical,
measurement, and management experts from within the member medical
groups during an eight-week period of review period.

Each of the Institute\'s participating medical groups determines its own
process for distributing the guideline and obtaining feedback.
Clinicians are asked to suggest modifications based on their
understanding of the clinical literature coupled with their clinical
expertise. Representatives from all departments involved in
implementation and measurement review the guideline to determine its
operational impact. Measurement specifications for selected measures are
developed by the Institute for Clinical Systems Improvement (ICSI) in
collaboration with participating medical groups following general
implementation of the guideline. The specifications suggest approaches
to operationalizing the measure.

**Guideline Work Group**

Following the completion of the review period, the guideline work group
meets 1 to 2 times to review the input received. The original guideline
is revised as necessary and a written response is prepared to address
each of the responses received from member groups. Two members of the
Cardiovascular Steering Committee carefully review the input, the work
group responses, and the revised draft of the guideline. They report to
the entire committee their assessment of four questions: (1) Is there
consensus among all ICSI member groups and hospitals on the content of
the guideline document? (2) Has the drafting work group answered all
criticisms reasonably from the member groups? (3) Within the knowledge
of the appointed reviewer, is the evidence cited in the document current
and not out-of-date? (4) Is the document sufficiently similar to the
prior edition that a more thorough review (critical review) is not
needed by the member group? The committee then either approves the
guideline for release as submitted or negotiates changes with the work
group representative present at the meeting.

**Pilot Test**

Member groups may introduce the guideline at pilot sites, providing
training to the clinical staff and incorporating it into the
organization\'s scheduling, computer, and other practice systems.
Evaluation and assessment occur throughout the pilot test phase, which
usually lasts for three-six months. At the end of the pilot test phase,
ICSI staff and the leader of the work group conduct an interview with
the member groups participating in the pilot test phase to review their
experience and gather comments, suggestions, and implementation tools.

The guideline work group meets to review the pilot sites\' experiences
and makes the necessary revisions to the guideline, and the
Cardiovascular Steering Committee reviews the revised guideline and
approves it for release.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC) and the Institute
for Clinical Systems Improvement (ICSI)**: For a description of what has
changed since the previous version of this guidance, refer to \"[Summary
of Changes \-- October
2006](http://www.icsi.org/acs_acute_coronary_syndrome/acute_coronary_syndrome_and_chest_pain__diagnosis_and_treatment_of__summary_of_changes_.html).\"

The recommendations for diagnosis and treatment of chest pain and acute
coronary syndrome (ACS) are presented in the form of 7 algorithms with
127 components, accompanied by detailed annotations. Algorithms are
provided for: [Chest Pain
Screening](http://www.guideline.gov/algorithm/5390/NGC-5390_1.html);
[Emergency
Intervention](http://www.guideline.gov/algorithm/5390/NGC-5390_2.html);
[ST-Segment Elevation Myocardial Infarction
(STEMI)](http://www.guideline.gov/algorithm/5390/NGC-5390_3.html);
[Acute Myocardial Infarction (AMI)
Complications](http://www.guideline.gov/algorithm/5390/NGC-5390_4.html);
[Special
Work-Up](http://www.guideline.gov/algorithm/5390/NGC-5390_5.html);
[Non-Cardiac
Causes](http://www.guideline.gov/algorithm/5390/NGC-5390_6.html); and
[Clinic
Evaluation](http://www.guideline.gov/algorithm/5390/NGC-5390_7.html).
Clinical highlights and selected annotations (numbered to correspond
with the algorithm) follow.

Class of evidence (A-D, M, R, X) definitions are provided at the end of
the \"Major Recommendations\" field.

**Clinical Highlights**

-   On initial contact with the health care system, high-risk patients
    need to be identified quickly and referred to an emergency room (ER)
    via the 9-1-1 system. (*Annotations #1-7*).

-   Patients whose chest pain symptoms are suggestive of serious illness
    need immediate assessment in a monitored area of the emergency
    department (ED) and early therapy to include an intravenous (IV)
    line, oxygen, aspirin, nitroglycerin, and morphine. (*Annotations
    #20 and 25*)

-   Triage and management of patients with chest pain and unstable
    angina must be based on a validated risk assessment system (i.e.,
    American College of Cardiology/American Heart Association
    \[ACC/AHA\] criteria). (*Annotation #27*)

-   Patients with high-risk features need to be identified quickly and
    treatment instituted in a timely fashion (*Annotations #27-31*)

-   Patients with low-risk symptoms should be evaluated as outpatients
    in a timely fashion. (*Annotations #27, 36, 37* )

-   Treadmill test results should be reported using the Duke treadmill
    score, based on the Bruce protocol (*Annotations #97-103, 107, 111,
    115*).

-   Thrombolysis should be instituted within 30 to 60 minutes of
    arrival, or angiogram/primary percutaneous coronary intervention
    (PCI) should be performed within 90 minutes of arrival with a target
    of less than 60 minutes. (*Annotations #43, 45*)

-   Use of medication: aspirin and clopidogrel (Plavix®) (or clopidogrel
    alone if aspirin allergic) at admission. (Avoid clopidogrel if
    cardiac surgery is anticipated.) Beta-blockers whenever possible
    and/or angiotensin-converting enzyme (ACE) inhibitors at 24 hours if
    stable, nitrates (when indicated), and statins whenever possible.
    Once the issue of surgery is clarified, consider the early use of
    clopidogrel for those in whom PCI is planned (*Annotations #25, 48,
    and 65*)

-   Recommend appropriate use of cardiac rehabilitation post-discharge.
    (*Annotations #63 and 64*)

[**Chest Pain Screening Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_1.html)

1.  **Initial Contact with Complaint of \"Chest Pain/Discomfort\" in
    Person or Via Telephone**

> Initial presentation may be in person or on the phone, etc.
>
> Definitions:
>
> Chest: Upper abdomen, chest, upper back, throat, jaw, shoulders, upper
> arms.
>
> Pain: \"Discomfort\" or other abnormal sensation such as \"gas,\"
> \"indigestion,\" \"fullness,\" \"pressure,\" \"tightness,\" or
> \"heaviness.\"
>
> ***Evidence supporting this recommendation is of class: R***

2.  **Initial Evaluation by Triage Indicates Elevated Risk?**

> **Key Points**:

-   The purpose of triage is to avoid delay in the identification of
    acute coronary syndromes, not to diagnose common, non-emergent
    causes of chest pain.

> Triage should move patients with suspicious symptoms forward
> (especially diabetic and middle-aged or older) to immediate
> electrocardiogram (ECG) and prompt clinician assessment (with
> expedited cardiac enzymes if appropriate). Triage staff should be
> systematically trained to recognize chest pain and cardiovascular risk
> indicators. Reception and other staff should bring all complaints of
> chest pain and breathlessness to medical personnel for further
> evaluation, especially when:

-   The patient is currently having symptoms.

-   The interviewer senses distress.

-   Symptoms have been present for less than 8 weeks (or are getting
    worse).

-   The patient feels the pain was at least moderate.

-   There are other symptoms of ill health (e.g., shortness of breath,
    weakness, sweating, nausea).

-   The patient requests an immediate opportunity to discuss the
    symptoms with medical personnel.

> ***Evidence supporting this recommendation is of class: D***

4.  **Brief Screening History by Medical Personnel**

> **Key Points**:

-   Teach medical triage personnel to appropriately conduct the brief
    screening history, paying particular attention to presence of
    high-risk symptoms.

> Angina, typical angina, atypical angina, atypical chest pain, and
> non-cardiac chest pain are not consistently defined and used in
> medical practice. Sometimes they are used to describe a symptom
> complex; at other times they are used to describe an etiology. For the
> purposes of this guideline, the following definitions will be used to
> categorize the patient\'s chest pain or discomfort as a symptom
> complex and not an etiology:
>
> **Typical angina** - pain or discomfort that is 1) substernal, 2)
> provoked by exercise and/or emotion, and 3) relieved by rest and/or
> nitroglycerine.
>
> **Atypical angina** - pain or discomfort that has two of the three
> features listed for typical angina.
>
> **Nonanginal chest pain** - pain or discomfort that has one or none of
> the three features listed for typical angina.
>
> It should be emphasized that patients with non-anginal chest pain may
> still be at risk for AMI or acute coronary syndrome. Several serious
> illnesses are included in the differential diagnosis of chest pain.
> Assessment of these illnesses requires office or ED evaluation. The
> initial phone interview is limited to determining the timing and
> location of the initial office or ED evaluation.
>
> The risk of immediate adverse outcome is a function of the time course
> of the chest pain. If the symptoms have been stable for more than 2
> weeks, the risk of an immediate adverse outcome is low. The phone
> history should stress symptoms suggestive of life-threatening
> illnesses and the time course of the symptoms.
>
> **High-Risk Symptoms**
>
> Symptoms suggestive of a high risk of immediate adverse outcome
> include, but are not limited to:

-   Severe or ongoing pain

-   Pain lasting 20 minutes or more

-   New pain at rest or with minimal activity

-   Severe dyspnea

-   Loss of consciousness

> **The interviewer may use his/her discretion with respect to the need
> to obtain further history for such symptoms or refer to a physician.**
>
> All patients with high-risk chest pain symptoms should be instructed
> on the proper use of 911.
>
> The interviewer must use his or her judgment. This guideline focuses
> on serious complaints that the interviewer feels may signify a serious
> illness. Chest pain that is not high risk in the judgment of the
> interviewer (e.g., a young person with chest wall pain) may be
> evaluated in the office.
>
> A suggested shingle outlining the necessary documentation for this
> encounter is available from Institute for Clinical Systems Improvement
> (ICSI). See the Support for Implementation section in the original
> guideline document.
>
> Teach medical triage personnel to appropriately conduct the brief
> screening history.
>
> ***Evidence supporting this recommendation is of class: R***

5.  **High-Risk Symptom(s) Present at Time of Call**

> Call 911

6.  **High-Risk Symptom(s) Present Within Last 2 Days**

> Patients who have had high-risk symptom(s) within the previous two
> days are at the highest risk and should enter the 911 system. The
> interviewer may judge the need for ambulance transport and office or
> ED evaluation for patients who call hours or days after transient
> symptoms resolve.

8.  **High-Risk Symptom(s) Present Between 3 Days and Last 2 Weeks**

> Patients who have had high-risk symptom(s) within the previous two
> weeks but not the previous two days may be safely evaluated in either
> a properly equipped office or the ED.

10. **High-Risk Symptom(s) Present Between 2 Weeks and 2 Months**

> High-risk symptom(s) within two months of the initial evaluation but
> not within two weeks identify a group of patients at lower risk for
> immediate adverse outcome. These patients can be evaluated in the
> office within three days.

11. **Clinic Evaluation Within 72 Hours**

> Patient education directed toward use of 911 and recognition of signs
> and symptoms of an advancing coronary event should occur at this
> point.

12. **High-Risk Symptom(s) Present More than Two Months Ago**

> Patients who have been stable without high-risk symptoms for the
> previous two months can be seen as a routine appointment.

13. **Elective Clinic Evaluation (Within 2 Weeks)**

> Patient education directed toward use of 911 and recognition of signs
> and symptoms of an advancing coronary event should occur at this
> point.

14. **Urgency Uncertain**

> If the severity and/or duration of the chest pain symptoms cannot be
> determined in the phone interview, the patient should be seen on the
> same day in the office or the ED.

[**Emergency Intervention Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_2.html)

19. **Ambulance Transport to Emergency Department**

> A patient complaining of chest pain suggestive of serious etiology
> should be transported via ambulance with advanced cardiac life support
> (ACLS) capabilities whether he/she is being transported from home or
> outpatient clinic to the ED.
>
> Patients who are critically ill or unstable should be taken to a
> hospital capable of performing cardiac catheterization and cardiac
> surgery unless this would lead to excessive transport time. Plans for
> triage of a critically ill patient to a tertiary care institution
> should be part of every community hospital plan.
>
> If a patient is seen in a clinic or physician\'s office complaining of
> chest pain suggesting a serious condition, the patient must be
> transported to the ED as soon as possible. Attempts should be made to
> stabilize the patient as well as possible prior to transport. The
> referring physician must call the receiving physician and send copies
> of all medical records pertaining to the current illness.
>
> ***Evidence supporting this recommendation is of classes: B, R***

20. **Immediate Assessment with Cardiac Monitoring**

> On arrival in the ED, a patient complaining of chest pain should
> immediately receive oxygen via nasal cannula, and a 324 mg loading
> dose of aspirin, preferably chewed (for patient palatability, use four
> 81 mg baby aspirin tablets). An immediate electrocardiogram (ECG)
> should be done and the physician called for as the patient is placed
> on a cardiac monitor. An IV should be started as soon as possible and
> cardiac markers drawn. Troponin I or T has been proven to be very
> sensitive and specific for myocardial injury as well as predictive of
> short-term risk for myocardial infarction or death. Creatine kinase MB
> band (CKMB) should no longer be used as the **primary** marker for
> myocardial infarction, but can be useful in assessing the timing of
> the event. It may also be useful in patients with renal failure who
> also have an elevated troponin. Interpretation of an abnormal serum
> troponin (or CKMB) is dependent upon the clinical setting in which the
> myocardial injury occurred. Initial brain natriuretic peptide (BNP)
> may be of value in assessing cardiac function. A portable chest x-ray
> may be performed if indicated. The ED physician should also be called
> to the patient\'s bedside immediately.
>
> On arrival, the physician should perform a brief initial assessment
> based on vitals, brief historical information, and physical
> examination. Institution of stabilizing therapy (including chewable
> aspirin, nitroglycerin, and morphine for suspect anginal pain) prior
> to completing history or physical is appropriate and often necessary
> at this level.
>
> ***Evidence supporting this recommendation is of classes: B, R***

21. **Vital Signs Compromised?**

> In the critically ill patient whose vitals are compromised (i.e.,
> cardiac arrest, tachyarrhythmias, severe bradycardia, shock, or
> hypotension); the Advanced Cardiac Life Support guideline developed by
> the American Heart Association should be followed.

22. **Initiate Advanced Cardiac Life Support (ACLS) Protocols**

> The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1987,
> 1989, and 1990 places strict requirements and restrictions on initial
> assessment and transfer of patients with emergency medical conditions
> and women in labor.
>
> The American Heart Association Advanced Cardiac Life Support guideline
> provides the most recent protocols for initial management of patients
> whose vital signs are compromised.

23. **Symptoms Suggest Possibility of an Acute Coronary Syndrome Disease
    (ACS)?**

> The symptoms that suggest ACS are, in order of importance:

1.  Chest pain description (See Annotation #4 above, \"Brief Screening
    History by Medical Personnel\")

2.  History or evidence of ischemic heart disease

3.  Age, gender, comorbidities (atypical presentation in female,
    elderly, and diabetic)

4.  Presence of cardiac risk factors

> The description of the patient\'s chest pain or discomfort is the most
> critical part of the history. Although multiple other features of the
> chest pain may be incorporated into an experienced clinician\'s
> judgment, the clinician should ultimately attempt to classify the
> patient as having typical angina, atypical angina, or nonanginal chest
> pain as described in Annotation #4, \"Brief Screening History by
> Medical Personnel\" of the Chest Pain Screening algorithm.
>
> ***Evidence supporting this recommendation is of classes: C, M***

24. **ECG Positive for ST-Segment Elevation?**

> **Key Points**:

-   An ECG should be obtained immediately upon arrival in the ED.

> The recognition of coronary artery disease and evaluation of its
> severity cannot be adequately carried out without an ECG. The early
> performance of an ECG following arrival at the emergency department is
> therefore critical. When patients have new or presumably new ST
> elevation of greater than 1 mm in two contiguous limb leads, or equal
> to two mm or more in precordial leads, they should be considered to
> have acute myocardial infarction. Patients with new or presumably new
> left bundle branch block (LBBB) should be treated similarly to those
> with ST segment elevation. Although some patients with LBBB will prove
> not to have acute myocardial infarction, thrombolytic therapy of
> patients with LBBB is nevertheless associated with a reduction in
> patient mortality.
>
> Regardless of ST elevation, consider cardiology consultation early.
>
> ***Evidence supporting this recommendation is of classes: A, C, R***

25. **Early Therapy**

> **Key Points**:

-   Patients whose chest pain symptoms are suggestive of serious illness
    need immediate assessment in a monitored area of the ER and early
    therapy to include an IV, oxygen, aspirin, nitroglycerin, and
    morphine.

-   Early therapy may consist of: aspirin, heparin or low molecular
    weight heparin, nitrates, beta blockers, and clopidogrel.

> Aspirin (ASA) reduces mortality, reinfarction, and stroke. Although
> the incremental value of heparin/low-molecular weight heparin (LMWH)
> in conjunction with aspirin and reperfusion therapy is controversial,
> it does appear to enhance patency, and was included in the GUSTO
> protocol. In eligible patients, beta-blockers reduce mortality,
> reinfarction, and stroke. Although long-acting nitrates (oral and
> intravenous) appeared to reduce mortality in trials that did not
> include thrombolysis, more recent studies that did include
> thrombolysis found no incremental benefit from nitrate therapy.
> Nitrate therapy is still appropriate for ischemic pain relief.
>
> All patients should receive aspirin (chewable) as soon as possible and
> continued indefinitely. In those patients who are unable to take
> aspirin, clopidogrel should be considered in hospitalized patients. If
> the probability of urgent coronary artery bypass graft (CABG) is low,
> consider early use of clopidogrel. The benefits of beta-blockers,
> nitroglycerin, and heparin are well established. There is data to
> support the use of LMWH as an alternative to intravenous heparin.
>
> In high-risk patients, early administration of subcutaneous LMWH
> (enoxaparin 1mg/kg subcutaneous every 12 hours) or IV unfractionated
> heparin (UFH) (70 units/kg load then 12 to 15 units/kg/hr to achieve
> activated partial thromboplastin time \[aPTT\] levels of 1.5 to 2.5
> times the control), with aspirin and/or clopidogrel is associated with
> a decrease in the incidence of AMI and ischemia.
>
> LMWH, specifically enoxaparin, has been shown to have a moderate
> benefit over IV heparin in decreasing the rate of death, myocardial
> infarction (MI), and recurrent ischemia. A meta-analysis of the 2
> trials showed a statistically significant reduction by 20% in the rate
> of death and MI.
>
> LMWH should be used with caution in patients with renal insufficiency.
>
> The recently completed SYNERGY study found increased adverse events in
> patients that were switched from unfractionated heparin to
> low-molecular weight heparin or vice-versa at the time of referral to
> tertiary care institutions. Therefore, the suggestion is that the
> patient be started and maintained on one drug or the other during
> transfer and treatment at referring and referral institutions.
>
> Beta-blockers should be initiated early in the absence of any
> contraindications. In high-risk patients, they should be given
> initially IV, then followed by the oral route with a goal target
> resting heart rate of 50 to 60 beats per minute (bpm). Patients with
> low to intermediate risk may start out with oral therapy. The duration
> of benefit is uncertain. A meta-analysis of double blinded randomized
> trials in patients with evolving MI showed a 13% reduction in risk
> progression to AMI. Other multiple randomized trails in coronary
> artery disease (CAD) patients have shown a decrease in mortality
> and/or morbidity rates.
>
> Beta-blockers should be used in most patients with STEMI. They remain
> underutilized in patients with chronic obstructive pulmonary disease
> (COPD) and diabetes mellitus where definite benefit has been
> demonstrated. Beta-blockers are relatively contraindicated in patients
> with asthma and hypotension, less so with first degree
> atrioventricular (AV) block, heart rate less than 60/min, or
> decompensated congestive heart failure (CHF). They should be used
> cautiously, if at all in these conditions. They should be completely
> avoided in STEMI due to cocaine use because of the risk of
> exacerbating coronary spasm, and in patients with cardiogenic shock.
>
> Nitroglycerin should be given sublingually (0.4 mg every five minutes)
> to relieve ischemic symptoms. If symptoms are ongoing or recurrent
> despite the administration of IV beta-blockers, IV nitroglycerin can
> be initiated at 10 mcg/min and titrated every 3 to 5 minutes by 10
> mcg/min until symptom response is noted or blood pressure decreases to
> less than 110 mmHg in patients previously normotensive or by 25% in
> patients who were hypertensive on presentation, or to a maximum dose
> of 200 mcg/min. Patients can be converted to topical or oral nitrates
> once stabilized (no manifestations of ischemia and pain free for 12 to
> 24 hours).
>
> ISIS-4 and GISSI-3 failed to show a benefit of nitroglycerin on
> reduction of mortality in AMI.
>
> Nitroglycerin is contraindicated in patients who are hypotensive, have
> documented severe aortic stenosis, have hypertrophic cardiomyopathy,
> or who have received sildenafil, vardenafil, or ordenafil within the
> previous 24 hours or tadalafil in the previous 48 hours.
>
> **GPIIb/IIIa Inhibitors**
>
> Patients with high risk or patients with intermediate risks and
> diabetes as defined in Annotation #27 \"Risk Assessment (ACC/AHA
> Criteria),\" benefit from receiving GP IIb-IIIa inhibitor (Tirofiban
> HCl, abciximab, or Eptifibatide) as part of initial treatment.
>
> Early invasive strategy involves diagnostic catheterization within 24
> to 48 hours, followed by PCI or CABG if warranted.
>
> Contraindications to IIb-IIIa inhibitors include bleeding less than
> six weeks, intracranial hemorrhage (ever), recent stroke less than 2
> years, uncontrolled hypertension greater than 200/100 mm Hg, surgery
> less than six weeks, aortic dissection, acute pericarditis, and
> platelets less than 100,000 mm^3^.
>
> ***Evidence supporting this recommendation is of classes: A, C, M,
> R***

27. **Risk Assessment (ACC/AHA Criteria)**

> **Key Points**:

-   Medical groups and hospitals should implement a validated risk
    assessment criteria set systemwide.

> Low-risk patients may be safely evaluated as outpatients. These will
> include some patients with slight progression of their symptoms, which
> may reflect non-compliance with medications, increasing activity,
> emotional stress, or other exacerbating factors. Patients with a low
> likelihood of CAD on the basis of chest pain description, age, gender,
> and risk factor assessment, and patients at intermediate likelihood
> who have not had at-rest symptoms that are prolonged or accompanied by
> shortness of breath or other worrisome features, should also be
> considered stable.
>
> For patients whose angina does not seem stable, it is important to use
> objective risk assessment criteria for purposes of triage (Critical
> Care Unit \[CCU\]), monitored bed, or dismissal with follow-up). This
> guideline endorses the criteria published by the ACC/AHA in 2002
> \"ACC/AHA 2002 Guideline Update for the Management of Patients with
> Unstable Angina and Non-ST-segment Elevation Myocardial Infarction.\"
> These consist of a simple set of clinical variables to classify
> patients as high-, intermediate-, or low-risk of death of MI. The work
> group acknowledges that many other risk assessment criteria sets exist
> (e.g., TIMI), and recommends that medical groups and hospitals choose
> one that is validated and implement its use systemwide.
>
> Complete certainty of the etiology of a patient\'s chest pain can
> commonly not be attained in the ED. It is therefore vitally important
> to assess risk in order to safely and yet cost-effectively triage
> chest pain patients. Further, it is important to recognize the
> difference between risk assessment and likelihood assessment in that
> likelihood assessment merely serves to communicate just that, while
> risk assessments may be used as a tool for clinical management.
>
> ***Evidence supporting this recommendation is of classes: B, C, R***

28. **High Risk**

> High-risk unstable angina patients require a high level of care with
> close monitoring and IV therapy, including heparin, beta-blockade, and
> nitroglycerin. This needs to be started in the ED setting.
> Hospitalization usually requires an intensive care unit (ICU) setting
> or competent nursing in a monitored bed setting.

29. **Early Therapy**

> See Annotation #25, \"Early Therapy\", above.

31. **Perform Catheterization Within 24 to 48 Hours**

> An early invasive strategy is beneficial in many patients with
> non-STEMI and ACS, especially when coupled with aggressive adjunctive
> therapy such as unfractionated heparin with a glycoprotein IIb/IIIa
> antagonist or use of a low molecular weight heparin. Certainly the
> aggressive anticoagulation and antiplatelet agents should be utilized
> when there are recurrent symptoms and no ability to proceed to early
> angiography, such as a weather-related delay or the catheterization
> lab is not available. However, in patients who become unstable or have
> recurrent symptoms, one should minimize the delay for angiography and
> percutaneous coronary revascularization.
>
> Contraindications to IIb-IIIa inhibitors include bleeding less than
> six weeks, intracranial hemorrhage (ever), stroke less than two years,
> uncontrolled hypertension greater than 200/100 mm Hg, surgery less
> than six weeks, aortic dissection, acute pericarditis, platelets less
> than 100,000 mm^3^ and dialysis dependent renal failure.
>
> ***Evidence supporting this recommendation is of classes: A, C, M,
> R***

32. **Intermediate Risk**

> A patient of intermediate risk unstable angina (as defined by the
> ACC/AHA Guideline) is by far the most common presentation to the
> emergency department. Approximately 50% of these patients will turn
> out to have an end point diagnosis other than ACS. It is, however,
> impossible to predict which patients truly have an ACS after the
> initial evaluation in the emergency department. As the short-term risk
> of a significant cardiac event is between 5 and 20%, it is imperative
> to treat each patient according to protocol during the evaluation
> process. These patients should be considered as primary candidates for
> evaluation in a cardiac observation unit if available, or a critical
> pathway in a monitored bed setting.

33. **Early Therapy**

> See Annotation #25,\"Early Therapy\" above.

34. **Admit to Chest Pain Unit (CPU) or Monitored Bed**

> If the patient\'s risk assessment is not clearly in a high- or
> low-risk category, and the institution has an ED-based chest pain
> observation unit, admission to this unit would be appropriate.
> Otherwise, management using a critical pathway for unstable angina
> with a similar protocol on a monitored bed unit is recommended.
>
> A CPU/critical pathway provides monitoring capabilities, a dedicated
> nurse, serial cardiac markers (markers should be negative for at least
> six hours from the onset of symptoms), and a post-observation stress
> test prior to final triage decision. Generally, after successful
> completion of the evaluation, patients can be classified as low-risk
> and safely followed up as outpatients in the next 1 to 3 days. In the
> case of a positive or indeterminate lab test, ECG or stress/imaging
> test, or if there is recurrent chest pain during the observation
> period, a patient should be considered high risk and managed
> accordingly.
>
> It should be emphasized that a patient who requires repeated doses of
> nitroglycerin and/or IV nitroglycerin or paste, or requires
> beta-blockade for pain control should be considered high risk.
>
> Refer to Annotation #27, \"Risk Assessment (ACC/AHA Criteria)\" above
> for more information on risk stratification.
>
> ***Evidence supporting this recommendation is of class: R***

35. **Patient Has Positive: Markers? ECG Changes? Treadmill Stress Test?
    Unstable Dysrhythmias?**

> If a patient develops recurrent chest discomfort during the
> observation period, the patient should be considered having failed the
> observation unit intervention and should be considered high risk and
> admitted to a monitored bed or an ICU setting. If the cardiac markers,
> troponin T or I, and CKMB on the second blood draw are positive, or
> the patient develops new or dynamic ST-T wave changes, the patient
> should also be considered high risk. If a patient develops an unstable
> dysrhythmia (i.e., ventricular tachycardia \[VT\] or multifocal
> premature ventricular contractions \[PVCs\], etc.), he/she should also
> be considered high risk and admitted.
>
> Most patients in this category will have an uneventful observation
> period and should undergo an endpoint stress test. The choice of a
> treadmill exercise test utilizing the Bruce treadmill score should be
> preferred in all patients who can walk and have an interpretable ECG.
> In some instances additional imaging may be beneficial. Refer to the
> National Guideline Clearinghouse (NGC) summary of the Institute for
> Clinical Systems Improvement (ICSI) guideline [Cardiac Stress Test
> Supplement](http://www.guideline.gov/summary/summary.aspx?doc_id=10810&nbr=005635).
> If the patient is unable to walk, a pharmacologic stress test should
> be considered. Patients needing continued beta-blockade may be
> candidates for nuclear imaging instead of standard treadmill stress
> testing.
>
> ***Evidence supporting this recommendation is of classes: A, C***

36. **Low Risk**

> Patients with a history of brief episodes of chest pain (less than 20
> minutes) but suggestive of accelerating and/or class 3 or 4 angina
> should be considered low risk if indeed ECG can be obtained during the
> chest pain episodes. If, however, an ECG cannot be obtained during a
> chest pain episode or other atypical features are present, the patient
> may be managed as intermediate risk and be evaluated in a cardiac
> observation unit.

37. **Discharge to Outpatient Management**

> If the diagnosis is low-risk unstable angina, a follow-up appointment,
> preferably with a cardiologist, should be done. Otherwise, a follow-up
> with a primary care physician may also be appropriate. These
> appointments should occur within one to three days. If the chest pain
> is considered stable angina and non-anginal chest pain, an arrangement
> for follow-up with a primary care physician should be arranged in the
> near future. The primary care physician may want to follow the
> clinical evaluation algorithm provided within the original guideline
> document.

38. **Non-Cardiovascular Chest Pain**

> In elevating a patient with chest pain it is important to keep in mind
> the entire differential diagnosis, including non-cardiac causes.
> Missed or misdiagnosis may have serious implications, both in regards
> to medico-legal issues and resource utilization.

39. **Chest Pain Not Related to CAD, but Indicative of Other Serious
    Diagnosis?**

> Aortic dissection, pulmonary embolus, expanding pneumothorax,
> pericarditis with impending tamponade, or serious gastrointestinal
> pathology are all potentially life threatening and may closely mimic
> presentations of an acute coronary syndrome. Further, the presence or
> absence of reproducible chest wall pain does not preclude the
> possibility of a more serious underlying cause.

[**STEMI Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_3.html)

42. **ST-Segment Elevation on ECG**

> About 40% of patients with AMI present with ST-segment elevation. They
> can be treated with thrombolytics or with emergency coronary
> angiography and percutaneous coronary intervention. Patients
> presenting with chest pain but no ST-segment elevation may be triaged
> to the telemetry unit if they are hemodynamically stable and
> pain-free.
>
> Facilities without PCI capabilities should consider establishing
> processes and criteria for transfer for immediate PCI.

43. **Thrombolytics or PCI for Initial Therapy**

> **Indications for Thrombolytics**

-   ST segment elevation of 1 mm or more in two or more contiguous limb
    leads **or**

    -   ST segment elevation of 2 mm or more in precordial leads **or**

    -   New or presumably new LBBB; ST segment depression of 2 mm or
        more in V~1~V~2~ (true posterior infarction), **and**

-   Anginal chest pain between 30 minutes and 12 hours in duration that
    is unrelieved with nitroglycerin

> When immediately available, percutaneous transluminal coronary
> angioplasty (PTCA) is equal to and may be superior to thrombolysis.
>
> **Administration of Thrombolytics**
>
> Options include full dose lytic of choice (tissue plasminogen
> activator \[tPA\], TNK, rPA), half-dose lytic (transfer arrangements
> with the receiving institution should be worked out in advance; this
> is a IIb indication per the 2004 ACC/AHA guidelines), or transfer for
> primary PCI.
>
> Low patient weight has been identified as an ongoing risk factor for
> significant intracranial hemorrhage (ICH) when thrombolytics are
> administered. It is imperative to accurately estimate the weight of
> patients with acute myocardial infarction to determine the proper dose
> of thrombolytic to minimize the risk of ICH.
>
> Single-bolus agents, such as tenecteplase (TNKase®) simplify
> administration; however patient weight remains important in
> calculating dose.
>
> Refer to the original guideline document for additional information on
> lytic administration.
>
> **Contraindications to Thrombolytics**
>
> Refer to the \"Contraindications\" field for more information.
>
> Refer to the original guideline document for common causes of delay in
> initiation of thrombolytics.

45. **Emergency Coronary Angiography and Primary PCI**

> **Key Points**:

-   Primary PCI has been demonstrated to be more effective than
    thrombolysis in opening acutely occluded arteries in settings where
    it can be rapidly employed by experienced interventional
    cardiologists.

> Time to open artery is critical to effective primary PCI. Current
> ACC/AHA guidelines suggest that institutions wishing to apply primary
> PCI for STEMI should achieve a median door-to-balloon time of 90
> minutes or less. The ACC/AHA Consensus Panels have set a 60-minute
> median door-to-balloon time as the benchmark for top performing
> institutions.
>
> Institutions that cannot meet the recommended treatment times should
> consider preferential use of intravenous thrombolytic therapy. *These
> institutions should have a predetermined plan for treating patients
> who present with contraindication to thrombolytics*.
>
> Aspirin, heparin, nitrates, and beta-blockers should be administered
> early to these patients, unless contraindicated.
>
> Primary PCI may also play a role in the treatment of
> non-STEMI/refractory angina pectoris if angina symptoms fail to
> resolve within an hour of instituting aggressive anti-anginal therapy
> with aspirin, heparin, beta-blockers, and GP IIb-IIIa inhibitors; or
> serial ECG or echocardiogram suggest a large amount of myocardium at
> risk.
>
> For centers that have demonstrated high success rates and low
> complications rates, this strategy is at least equal in efficacy to
> that of initial thrombolytic therapy, especially for those patients at
> high risk of mortality, and may be considered in thrombolytic
> candidates, as well as in patients with thrombolytic
> contraindications. It is the preferred therapy for cardiogenic shock.
> Immediate transfer of salvageable patients to an institution capable
> of treating this condition is indicated for the presentation or
> development of cardiogenic shock.
>
> Rescue angioplasty involves the use of PCI to restore coronary flow
> after thrombolysis has failed. Guidelines for time from arrival to
> balloon inflation are not established for this complex subset of
> patients, but rescue PCI should be accomplished within 90 to 120
> minutes of thrombolytic failure if possible. Thrombolytic failure may
> be evident by failure of ST-elevation to resolve within 30 to 60
> minutes of thrombolytic therapy and usually includes persistent
> symptoms.
>
> Facilitated PCI is the use of additional agents to pretreat the
> patient awaiting primary PCI. No strategy employing full- or
> reduced-dose thrombolytic (with or without a glycoprotein IIb-IIIa
> receptor inhibitor) has been approved for facilitated PCI. GPIIb/IIIa
> inhibitors should be considered in patients with symptoms refractory
> (persistent chest pain or ECG changes consistent with ischemia) to
> standard therapy. Otherwise these agents may be given at the time of
> angiography. Based on REPLACE-2 study, a reasonable alternative to
> heparin is to use bivalirudin for patients who will be undergoing
> percutaneous coronary interventions.
>
> Current ACC guidelines recommend treating the culprit vessel when
> feasible and deferring surgical or PCI-based revascularization of
> other vessels until the patient has stabilized and the clinically most
> appropriate strategy determined.
>
> ***Evidence supporting this recommendation is of classes:  C, R***

48. **Cardiac Care Unit (CCU) Admission**

> Patients who present with acute ST-segment elevation, hemodynamic
> instability, or both should be admitted to the CCU. Early use of
> adjunctive medications can be reconsidered. Once the issue of surgery
> is clarified, consider the early use of clopidogrel (Plavix®) for
> those in whom PCI is planned. (See Emergency Interventions Algorithm
> Annotations #20 to #31.) A CCU admission order set template has been
> developed by the ICSI acute coronary syndrome work group and is
> available from ICSI \-- see the \"Support for Implementation\" section
> of the original guideline document.

49. **CCU Care: Chronic Adjunctive Medications/Phase I Cardiac
    Rehabilitation**

> A protocol should be in place to guide routine orders for continuous
> monitoring, oxygen delivery, IV therapy, activity, laboratory and
> diagnostic tests, diet, and medications.
>
> Use of the following medications should be considered:

-   **ASA/aspirin\*** - should be continued as the clinical situation
    warrants. ASA/aspirin has been shown to reduce reinfarction and
    mortality long-term, and should be continued whenever possible. Use
    of non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2
    inhibitors may reduce the cardioprotective benefits of aspirin.

-   **Clopidogrel\*\*** - ASA/aspirin (dose should be 81 mg when given
    with clopidogrel) with clopidogrel in intermediate and high-risk ACS
    patients is beneficial. Anyone with an allergy to aspirin or NSAIDs
    should receive a bolus dose of clopidogrel (300 mg) with maintenance
    dosing indefinitely. For patients who present with unstable angina
    or non-ST elevation MI who are not at high risk for bleeding,
    clopidogrel should be continued for 9 to 12 months. For patients
    undergoing a non-coated stent, clopidogrel should be continued for
    at least one month. For patients who receive a sirolimus eluting
    stent, clopidogrel should be continued for at least three months,
    and at least six months for a paclitaxel eluting stent. For patients
    who have undergone brachytherapy, clopidogrel should be continued
    for 12 months. ASA/aspirin plus clopidogrel or clopidogrel alone can
    also be used with patients who have stents. If clopidogrel is given
    and coronary artery bypass surgery planned, clopidogrel should be
    held for five days prior to surgery due to increased risk of
    perioperative bleeding.

-   **Beta-Blockers\*** - Beta-blockers reduce mortality, readmission,
    and reinfarction for both CAD and CHF. They should be instituted
    and/or continued whenever possible. Intravenous esmolol should be
    considered if a clinician is concerned about potential adverse
    effects of beta-blockers. Patients who prove intolerant of a
    beta-blocker after a large infarction should be reconsidered for
    beta-blocker therapy after discharge.

-   **ACE inhibitors\*** - ACE inhibitors (ACEI) are indicated
    (angiotensin receptor blockers \[ARBs\] if ACEI aren\'t tolerated;
    in addition to beta-blockers, when possible) for most patients
    following AMI to reduce mortality and morbidity associated with
    large infarcts with significant left ventricular (LV) dysfunction,
    reduce adverse ventricular remodeling that may result in further
    reduction in ejection fraction (EF), and for potential reduction of
    future MI and stroke. Consider hydralazine/isosorbide dinitrate if
    intolerant to ACEIs or ARBs or either drug is contraindicated.

> \*Shown in large clinical trials to reduce infarction mortality in all
> MIs.
>
> \*\*Shown in large clinical trials to reduce infarction mortality in
> non-STEMIs.
>
> ***Evidence supporting this recommendation is of class: A***

-   **Calcium channel blockers** may be useful for control of blood
    pressure and ischemic pain when beta-blockers are contraindicated
    but should be avoided in patients with decreased LV function or
    heart failure. The short-acting dihydropyridine calcium channel
    blockers (e.g., nifedipine) may be associated with increased risk
    and should be avoided in acute ischemic syndromes.

-   **Oral nitrates** may benefit selected patients with postinfarction
    angina or CHF.

-   **Low-molecular-weight heparin** has been shown to be superior to
    unfractionated heparin in patients without ST-segment elevation and
    can preferentially be used in subcutaneous dosing (e.g., enoxaparin
    sodium \[Lovenox®\], 1 mg/kg every 12 hours). Heparin may be
    continued for 2 to 4 days or maintained until conversion to warfarin
    is completed. If unfractionated heparin is used, the dose should be
    regulated to maintain an activated partial thromboplastin time of 50
    to 75 seconds.

-   **Warfarin** therapy may be initiated in certain clinical situations
    (e.g., postinfarction CHF or anterior MI with high risk of LV
    thrombus) as soon as clinical stability is achieved and invasive
    diagnostic studies are completed. The usual target international
    normalized ratio is 2.0 to 3.0.

-   **Oral antiarrhythmics** are not recommended, especially when LV
    function is reduced. Flecainide acetate (Tambocor®) and sotalol
    hydrochloride (Betapace®) should be avoided in patients with
    significant structural heart disease unless clearly indicated on the
    basis of electrophysiologic study for the suppression of
    life-threatening ventricular arrhythmias. Beta-blockers are the
    current drug of choice when tolerated. Routine use of amiodarone
    hydrochloride (Cordarone®) in post-MI patients with nonsustained
    ventricular ectopy has not been shown to reduce mortality.

> ***Evidence supporting this recommendation is of classes: A, M***

-   **Statins**. The large majority of patients who have an AMI have
    high serum lipid levels. Lipid treatment, including administration
    of statins, should be addressed as soon as possible. A patient\'s
    lipid status should be determined within the first 24 hours. If the
    low-density lipoprotein (LDL) level is greater than 70 mg/dL, the
    patient should be started on a statin within the first 24 hours of
    the onset of MI.

-   **Tobacco cessation** should be addressed as soon as possible for
    patients who smoke or use tobacco products. Appropriate treatment
    may include administration of bupropion and/or a nicotine patch in
    the hospital.

-   **Glycemic control**. Tight control of blood glucose in patients
    with diabetes is recommended.

> Medication tables and dosing protocols are attached in Appendix B,
> \"AMI Acute Medications and Adjunctive Therapy\" in the original
> guideline document.
>
> **Phase 1 Cardiac Rehabilitation**
>
> With shortened length of stay, teachable moments may be limited. As a
> result, timely initiation of education on lifestyle modification is
> crucial. Phase 1 cardiac rehabilitation should begin as soon as the
> patient is stable and pain-free. Goals are to minimize harmful effects
> of immobilization, assess the hemodynamic response to exercise, manage
> the psychosocial issues of cardiac disease, and educate the patient
> and family about lifestyle modification including:

-   Tobacco cessation

-   Dietary instruction including a heart healthy diet

-   Manageable exercise regimen should be explained.

50. **Complications?**

> Arrhythmic complications include sinus bradycardia, Möbitz I block
> (Wenkebach), Möbitz II block, complete heart block or asystole,
> premature ventricular contractions (PVCs), ventricular tachycardia,
> ventricular fibrillation, accelerated idioventricular rhythm, and
> supraventricular arrhythmias (atrial flutter, atrial fibrillation, and
> supraventricular tachycardia). Ischemic complications include
> postinfarction angina. Mechanical complications include papillary
> muscle dysfunction, rupture with significant mitral regurgitation,
> ventricular septal rupture, myocardial rupture, right ventricular
> infarction, pericarditis with or without tamponade, LV dysfunction,
> and aneurysm formation.
>
> ***Evidence supporting this recommendation is of classes: C, M***

52. **Transfer to Post-CCU Care**

> Patients should be transferred from the CCU to the telemetry or
> step-down unit when they are pain-free, hemodynamically stable, and
> meet the institution\'s protocol for admission to the telemetry unit
> (usually 12 to 24 hours after MI). Discontinuation of cardiac
> monitoring should be considered for patients who attain electrical
> stability (usually within 3 days of infarction).

54. **Risk Stratification**

> Assessment of ejection fraction is important in predicting prognosis.
> Most patients should undergo echocardiography or other assessment of
> LV ejection fraction. A treadmill test is useful for assessing
> functional reserve but is not useful for predicting recurrence of AMI.
> If ST-segment depression or angina is present early in treatment,
> angiography should be considered. If the patient is unable to
> exercise, pharmacologic stress testing should be considered, and if
> the ECG is uninterpretable, stress imaging (nuclear or
> echocardiographic) should be considered.
>
> Patient with no high-risk indications following thrombolytics therapy
> may be stratified non-invasively into low, medium, and high risk.
>
> Some clinicians may elect to measure multiple cardiac biomarkers in
> patients with myocardial infarction. This may especially be helpful in
> those in whom risk stratification is not available by other clinical
> evidence. The work by Sabatine, Morrow et al demonstrated the utility
> of cardiac troponins, c-reactive protein and B type natriuretic
> peptide measurements (BNP). This work demonstrated that patients with
> elevations of all three cardiac biomarkers had significantly higher
> risks of recurrent MI and death than those with only two or one
> elevated. There was a progressive step-wise increase in risk going
> from one abnormality to two abnormalities to elevations of all three
> biomarkers. For patients with obvious clinical heart failure there is
> little utility in measuring BNP during hospitalization for AMI. At
> present, there is no clear consensus about what to do with an elevated
> BNP value during hospitalization for AMI. Some have suggested there is
> limited utility in measuring BNP in patients if one is planning an
> intentional invasive strategy as well. Some have suggested that a lack
> of BNP elevation may identify patients hospitalized for AMI who are
> eligible for early discharge strategies. Further studies are warranted
> to fully understand how to apply BNP values in these populations. The
> most prudent strategy may be to not measure BNP in the great majority
> of patients until further data are available.
>
> ***Evidence supporting this recommendation is of class: R***

55. **Patient at Increased Risk and Needs Intervention?**

> Patients who are at increased risk for adverse prognosis after AMI and
> who are also candidates for short-term intervention include those with
> a large amount of myocardial necrosis (ejection fraction less than
> 40%), residual ischemia (angina during hospitalization or exercise
> testing), electrical instability (greater than 10 PVC/hr), left main
> or three-vessel CAD, limited exercise tolerance, or rales/crackles in
> more than one-third of lung fields.
>
> The following factors increase long-term risk:

-   70 years of age or older

-   Previous infarction

-   Anterior-wall MI

-   Hypotension and sinus tachycardia

-   Diabetes

-   Female gender

-   Continued smoking

-   Atrial fibrillation

-   Heart failure

> Patients able to exercise more than four metabolic equivalents (METs)
> had less than a 2% subsequent incidence of death or myocardial
> infarction within one year compared with 18% for those in the
> high-risk group.
>
> ***Evidence supporting this recommendation is of class: B***

56. **Cardiac Catheterization**

> Angiography should be performed in patients at increased risk as
> defined in Emergency Intervention Algorithm Annotation #27, \"Risk
> Assessment (ACC/AHA Criteria).\"
>
> Recent trials (collectively FRISC II and TACTICS-TIMI 18) suggest an
> early aggressive/invasive approach (early diagnostic coronary
> angiography and appropriate PCI or CABG) within 48 hours of
> presentation, in non-ST ACS (with ST segment deviation, elevated
> cardiac markers or TIMI Risk Score greater than 3), significantly
> reduces the risk of major cardiac events. However, the majority of
> non-STEMI patients should undergo coronary angiography.

57. **Revascularization Candidate?**

> CABG should be considered in patients with left main, three-vessel or
> two-vessel disease with left anterior descending coronary artery
> involvement and demonstration of ischemia or in patients who would not
> receive the ideal benefit from PCI. Pharmacologic or stress test
> imaging may be helpful if myocardial viability is uncertain and
> revascularization is considered.
>
> PCI should be considered for patients with acceptable anatomy in whom
> its prognostic effect has been most clearly demonstrated: significant
> residual ischemia, CABG candidacy, and failure of maximal medical
> therapy (two of three medications) to control angina or
> contraindications to medications.

60. **Continue Adjunctive Medications**

> See STEMI Algorithm Annotation #49, \"CCU Care: Chronic Adjunctive
> Medications/Phase I Cardiac Rehabilitation\" above.

61. **Secondary Prevention and Risk Factor Modification**

> Modification of risk factors (e.g., high lipid levels, hypertension,
> smoking) significantly reduces subsequent cardiovascular mortality.
> Risk factor counseling must be documented in the medical record in a
> consistent manner. A \"care plan\" or \"critical pathway\" approach
> with flow sheets may be used. Ongoing patient monitoring and feedback
> are important. Adjunctive therapy (ASA or clopidogrel if ASA allergic,
> beta-blockers, warfarin for large anterior infarctions, ACE
> inhibitors, and statins) should be continued.
>
> Efforts targeted at exercise (as an adjunct, in the management of
> other risk factors), lipid management, hypertension control, and
> smoking cessation can reduce cardiovascular mortality, improve
> functional capacity, attenuate myocardial ischemia, retard the
> progression and foster the reversal of coronary atherosclerosis, and
> reduce the risk of further coronary events.
>
> The Cooperative Cardiovascular Project (CCP) has documented a
> discrepancy between risk factor counseling documentation and actual
> practice during hospital stays of patients with MI. Therefore,
> documentation of smoking cessation counseling has become one of 13
> indicators judged to be representative of quality care by the CCP
> steering committee.

1.  Smoking cessation is clearly linked to mortality and morbidity after
    MI.

2.  Aggressive treatment of dyslipidemia can reduce subsequent
    myocardial ischemia.

3.  Hypertension control will reduce recurrent cardiac events.

4.  Exercise alone is only modestly effective for secondary prevention.

5.  A case management system may be more effective than usual care in
    long-lasting risk factor modification.

> Teaching must be done when the patient is ready, and ideally is based
> on patient-\*derived learning priorities. Teaching moments may be best
> taken advantage of by a team approach involving physician and nursing
> staff during the hospital stay. Ongoing outpatient follow-up and
> progress feedback are important for patient adherence.
>
> ***Evidence supporting this recommendation is of classes: A, D, M,
> R***

62. **Discharge**

> Complete and document the following before discharge:

-   Patient education that includes discharge diagnosis, medical
    regimen, lifestyle modification issues, and functional limitation
    (including resumption of sexual activity and driving)

-   Scheduling of a follow-up appointment with the primary care
    physician

-   Targeting a return-to-work date. Patients with sedentary jobs often
    return to work in 2 to 3 weeks. More physically demanding jobs often
    can be resumed in 4 to 6 weeks unless significant ischemia is
    present.

> Patients are commonly discharged in less than three days following
> successful primary PCI with evidence of complete or near complete
> salvage of threatened myocardium. Though patients should avoid
> strenuous exertion for several weeks during the stent healing phase,
> many such patients may return to sedentary or only moderately active
> work activities within days of discharge.
>
> Most patients with uncomplicated MIs should be discharged within five
> days. Patients undergoing primary PCI who are at low risk with an
> uncomplicated course may be discharged on the third day. Early
> reperfusion and definitive angiography revealing little or no residual
> injury or disease has increasingly demonstrated improved myocardial
> salvage and enhanced patient stability. Discharge may be
> individualized according to the degree of salvage and stability. In
> many centers some patients are safely discharged within 24 hours when
> salvage is nearly complete.
>
> Information on discharge medication is attached in Appendix C,
> \"Medications to Consider on Discharge\" in the original guideline
> document.
>
> ***Evidence supporting this recommendation is of class: A***

63. **ECG-Monitored Exercise Needed?**

> Most patients do not require an ECG-monitored, hospital-based (phase
> 2; outpatient) exercise program, but those with any of the following
> characteristics may be at increased risk for infarction or sudden
> death with unmonitored exercise and should be considered for a phase 2
> program, usually lasting 1 to 4 weeks: very low functional capacity
> (less than 4 METs), severely depressed ventricular function (ejection
> fraction less than or equal to 35%), complex resting ventricular
> arrhythmias, exercise-induced hypotension, exertional angina or
> significant silent ischemia, or inability to initiate a self-directed
> exercise program.
>
> For certain patients, referral to a phase 2 program may facilitate
> earlier hospital discharge by providing emotional support in the
> outpatient hospital setting. The decision to refer a patient to a
> phase 2 program should be made on a case-by-case basis. The patient\'s
> current exercise capacity and the demands of expected occupational and
> recreational activities should be considered.
>
> Most patients with uncomplicated MIs achieve a return to their
> prehospital levels of activity without a formal monitored exercise
> program. Home exercise training programs have been shown to be
> beneficial in certain low-risk patient groups.
>
> Certain patients felt to be at higher risk of complications post
> discharge are more likely to require monitoring during exercise in the
> immediate post discharge period.
>
> ***Evidence supporting this recommendation is of classes: A, M, R***

64. **Phase 2 Cardiac Rehabilitation - Outpatient**

> Patients at increased risk for adverse events during exercise should
> be considered for phase 2 cardiac rehabilitation. The length of time
> spent in phase 2 should be dependent on improvement in functional
> capacity. Phase 2 (outpatient monitored) programs, if indicated,
> consist of medically supervised exercise with continuous ECG
> monitoring attended by trained personnel who have emergency equipment.
> Most phase 2 programs are hospital-based. Health education and risk
> factor modifications need to be included in these programs.
>
> More patients should be enrolled in a Phase 2, monitored exercise
> program. In the past, the main emphasis was exercise-based, but today
> the focus also includes risk factor modification, education, and
> counseling.
>
> Research shows that a cardiac rehabilitation program based on regular
> exercise and education focused on risk factor reduction is both
> efficient and effective in altering the course of coronary heart
> disease.
>
> Cardiac rehabilitation programs have been shown to decrease mortality
> but have no effect on nonfatal recurrent myocardial infarctions.
> Unless there is a long-term effort of encouragement, most patients
> will revert back to previous sedentary activities.
>
> This initial outpatient phase includes comprehensive evaluation,
> education, and treatment for outpatients who have experienced a
> cardiac-related event. Phase 2 patients are monitored with continuous
> ECG, blood pressure, heart rate and subjective RPE ratings.
>
> **Goals of Phase 2 Rehab**:

-   Assist with appropriate risk factor modification

    -   Smoking cessation

    -   Lipid management and low fat diet

    -   Stress management and relaxation techniques

    -   Weight loss and BMI measurement

    -   Safe exercise guidelines

    -   Blood pressure control

    -   Diabetes education and glucose monitoring

-   Increase exercise tolerance and endurance to enable patient to
    perform activities of daily living, and return to, or above previous
    level of function

-   Improve quality of life

-   Improve psychological well-being and provide emotional support

-   Provide educational support and resources

> **Education Topics**:

-   Anatomy and physiology of the heart

-   Nutrition

-   Heart disease risk factors and modification

-   Stress reduction

-   Emotional aspects of heart disease

-   Cardiac medications

-   Aerobic exercise and exercise progression

-   Cardiac signs and symptoms

> **Exercise Prescription**
>
> An exercise prescription consists of:

-   **Intensity of exercise**: In general, moderate intensity (to
    40--60% of functional capacity) is advisable during the first weeks
    of conditioning with a goal to reach 40 to 85%, or that of the
    functional capacity of the population at large.

-   **Monitoring rate of perceived exertion (RPE)** is very useful. This
    is advantageous for many reasons: it is unaffected by negative
    chronotropic medications unlike heart rate monitoring; it is quite
    reproducible across age, gender, and cultural origin; and lastly, it
    only requires patient attunement to symptoms

-   **Monitoring METs**: Monitoring is determined by the patient\'s
    post-MI exercise tolerance test and/or in rehab is highly
    individual. The table in Appendix D of the original guideline
    document can be used to compare the demands of certain activities to
    the patient\'s known capacity. However, its usefulness lies
    primarily in vocational counseling.

> Refer to the original guideline document for more information on
> exercise prescription including exercise heart rate, exercise
> tolerance, mode, frequency, intensity, duration, and progression.
>
> ***Evidence supporting this recommendation is of classes: A, R***

65. **Phase 3 Cardiac Rehabilitation**

> Phase 3 is a maintenance program based on the continuation of a heart
> healthy lifestyle. The program is designed for patients who have
> completed a Phase 2 cardiac rehabilitation program or for individuals
> with a cardiac history or significant cardiac risk factors. Patients
> are not continually monitored by ECG, but spot check ECGs and daily
> blood pressures and heart rates are recorded. Trained staff continues
> to provide support and education for risk factor modification and
> exercise progression. Warm up, aerobic exercise, stretching, and
> strength training (when appropriate) are included in Phase 3.
>
> ***Evidence supporting this recommendation is of classes: A, M, R***

66. **Short-Term Follow-Up: Chronic Adjunctive Medication/Outpatient
    Management**

> **Chronic Adjunctive Medications**
>
> Use of enteric-coated ASA/aspirin or ASA/aspirin plus clopidogrel
> should be continued. Use of beta-blockers following MI has been shown
> to reduce ischemia, prevent arrhythmias and reinfarction, and improve
> survival. Patients with large anterior infarctions may benefit from
> therapeutic warfarin therapy (INR 2-3), usually for 3 months to reduce
> risk of systemic emboli. ACE inhibitors provide long-term cardiac
> protection for patients (with or without symptoms) with left
> ventricular ejection fraction (EF) of less than 40%.
>
> Most patients should be receiving a statin or alternative
> lipid-lowering medication at discharge from the hospital.
> Lipid-lowering therapy should be considered for patients who have
> undergone PCI or CABG and patients whose low-density lipoprotein
> cholesterol level is 100 mg/dL or greater. Calcium channel blockers
> should be considered only for patients with NSTEMI who cannot take
> beta-blockers and patients without CHF or decreased LV ejection
> fraction. Oral nitrates should be considered for patients with ongoing
> ischemia.
>
> Clinicians should be measuring LDL cholesterol and C-reactive protein
> levels in patients following myocardial infarction. Recent evidence
> has revealed that use of statin therapy following hospitalization for
> AMI reduces long-term risks. A sub-study from the PROVE-IT trial has
> demonstrated that the achievement of an LDL less than 70 and
> C-reactive protein (CRP) less than 2 mg/l around 30 days following
> hospitalization was associated with the lowest risk of recurrent
> clinical events by two years of follow-up. The achievement of these
> goals was more important than the selection of an individual statin
> agent. This evidence supports the measurement of LDL cholesterol and
> C-reactive protein levels about one month following hospital discharge
> and the aggressive use of statin therapy to achieve an LDL less than
> 70 mg/dl and a CRP of less than 2 mg/l by that time frame. Some
> patients may achieve these values through moderate statin doses, most
> will require higher doses of potent statins, and some patients will
> require combination therapy with a statin plus ezetimibe. Of interest,
> achievement of either goal alone (LDL less than 70 or CRP less than 2)
> but not both was associated with significantly higher recurrence
> risks.
>
> **Follow-Up Visits**
>
> Usually, patients should return for a follow-up visit with their
> cardiologist or primary care physician within 2 to 3 weeks so the
> physician can monitor progress, answer questions, and consider further
> risk stratification (i.e., stress testing). Risk factor modification
> should be continued.
>
> **Phase 4 Cardiac Rehabilitation**
>
> Phase 4 cardiac rehabilitation begins after the desired functional
> capacity has been attained (usually greater than or equal to 8 METs)
> and/or VO~2~max has reached a plateau. Maintenance is the principal
> goal. The exercise prescription should continue as at the end of phase
> 3 unless angina or exercise intolerance develops, either of which
> requires cessation of exercise and urgent medical attention. Refer to
> METs table in Appendix D and \"Nomogram of the prognostic Relations
> Embodied in the Treadmill Score\" in Appendix E of the original
> guideline document for guidance on setting exercise goals.

[**AMI Complications Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_4.html)

68. **Arrhythmic Complication(s)?**

> Arrhythmic complications including sinus bradycardia, Möbitz I
> (Wenkebach), PVCs, accelerated idioventricular rhythm, and
> supraventricular arrhythmias (transient atrial flutter, atrial
> fibrillation, supraventricular tachycardia, and hemodynamic stability)
> are generally benign and will usually require symptomatic therapy.
> Transient Mobitz II block with MI may be treated symptomatically.
> Permanent pacing is indicated for persistent and symptomatic second
> and third degree AV block.
>
> Six Centers for Medicare and Medicaid Services (CMS) covered
> indications for defibrillators:

1.  Documented episode of cardiac arrest due to ventricular fibrillation
    (VF), not due to transient or reversible cause

2.  Documented sustained ventricular tachyarrhythmia (VT) either
    spontaneous or induced by an electrophysiologic (EP) study, not
    associated with an AMI and not due to transient or reversible cause

3.  Documented familial or inherited conditions with a high risk of life
    threatening VT such as long QT syndrome or hypertrophic
    cardiomyopathy

4.  Coronary artery disease with documented prior MI, ejection fraction
    (EF) less than 35%, an inducible sustained VT, or VT at EP study

5.  Documented prior MI, EF less than or equal to 30%, QRS duration of
    greater than 120 msec (patient must not have Class IV heart failure,
    shock, CABG, PCI, MI within three months or a need for coronary
    revascularization or predicted survival less than one year).

6.  Patients with dilated cardiomyopathy, documented prior MI, heart
    failure, and left ventricular EF less than or equal to 35% for
    longer than nine months.

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69. **Treat Arrhythmic Complication(s)**

> **Key Points**:

-   ACLS guidelines provide in-depth descriptions of short-term
    treatment.

> Refer to the original guideline document for more information on
> treatment of arrhythmic complications, including
> atrioventricular/bundle branch blocks, ventricular arrhythmias,
> accelerated idioventricular rhythm, and supraventricular arrhythmias.
>
> ***Evidence supporting this recommendation is of classes: B, C***

70. **Ischemic Complication(s)?**

> Ischemic complications include postinfarction angina.

71. **Treat Ischemic Complication(s)**

> Treatment of postinfarction angina should be correlated with ECG
> changes, if possible. Optimal therapy consists of beta-blockers and
> long-acting nitrates. If beta-blockers are not tolerated or are
> ineffective and LV function is not significantly depressed, a calcium
> channel blocker may be used. Early coronary angiography should be
> considered. Angina after MI may be confused with pericarditis.
> Aneurysm formation should be a consideration.

72. **Mechanical Complication(s)?**

> Mechanical complications may include papillary muscle dysfunction or
> rupture with significant mitral regurgitation, ventricular septal
> rupture, myocardial rupture, right ventricular infarction,
> pericarditis with or without tamponade, LV dysfunction, and aneurysm
> formation.

73. **Treat Mechanical Complication(s)**

> Papillary muscle dysfunction is evidenced by the murmur of mitral
> regurgitation, typically within five days of infarction.
>
> Papillary muscle rupture may occur within 10 days of the event.
> Findings include development of sudden CHF or pulmonary edema, often
> but not always accompanied by a new holosystolic apical murmur.
> Diagnosis is verified by echocardiography. Stabilization is achieved
> by one or more of the following: aggressive use of diuretics and
> vasodilators, insertion of a Swan-Ganz catheter, insertion of an
> intraaortic balloon pump (IABP). Because of the high mortality rate
> with this complication, urgent surgical repair is indicated.
>
> Ventricular septal rupture (VSR) occurs within 1 week of infarction
> and results in left-to-right shunting and subsequent hemodynamic
> deterioration. VSR is suggested by the presence of a new, harsh,
> holosystolic murmur that is loudest along the lower left sternal
> border; this may be accompanied by a thrill. Patients may also have
> symptoms of right-sided heart failure with right ventricular (RV)
> PO~2~ step-up and may have less pulmonary congestion than patients
> with papillary muscle rupture. The diagnosis is confirmed by
> two-dimensional echocardiography. Patients are best stabilized by
> vasodilator therapy, insertion of a Swan-Ganz catheter or an IABP, or
> all of these. Because of the high mortality rate, urgent surgical
> repair is indicated.
>
> Myocardial rupture is a common cause of sudden death after AMI.
> Symptoms or findings include emesis, persistent restlessness, anxiety,
> and persistent ST-wave elevation on ECG. Rupture usually occurs within
> 5--7 days of MI. LV free-wall rupture leads to hemopericardium and
> subsequent death from tamponade. Contained rupture may result in
> formation of a pseudoaneurysm. Surgical resection is recommended.
>
> Right ventricular (RV) infarction is suspected in patients with
> inferior infarction complicated by low cardiac output, hypotension,
> oliguria, jugular venous distention, and clear lung fields without
> radiographic evidence of pulmonary venous congestion. Infarction can
> be confirmed by ECG findings (ST-segment elevation in right precordial
> leads V~4~R through V~6~R in the presence of inferior ST elevation),
> two-dimensional echocardiography, or pulmonary artery catheter
> demonstrating a disproportionate elevation of right atrial pressure
> compared with pulmonary capillary wedge pressure. Treatment consists
> of intravascular volume expansion and use of inotropic agents; if the
> patient loses sinus rhythm, temporary pacing to re-establish AV
> synchrony should be considered. Agents that reduce RV preload, such as
> nitroglycerin, diuretics, and large doses of morphine, should be
> avoided. ACE inhibitors and beta-blockers may require dose reduction
> or discontinuation with milder presentation of RV dysfunction post-MI.
>
> Post-MI pericarditis can be early (occurring within 72 to 96 hours
> after AMI) or occasionally delayed (typically occurring weeks after
> MI); the latter is called Dressler\'s Syndrome. Early pericarditis is
> suspected in patients with pericardial friction rub, usually heard on
> the second or third day after AMI, and chest pain that may extend to
> the back, neck, or shoulders that is intensified by movement and
> respiration and relieved by sitting up or leaning forward. Treatment
> consists of anti-inflammatory agents and reassurance. Echocardiography
> to assess for possible incomplete myocardial rupture should be
> considered. It is important to emphasize to the patient that the
> recurrent pain is not the result of recurrent infarction. Risk of
> hemopericardium is increased in patients receiving anticoagulants;
> development of a pericardial effusion can be detected by close
> clinical observation and echocardiography.
>
> Dressler\'s Syndrome is characterized by an increase in erythrocyte
> sedimentation rate, leukocytosis, and more frequent pleural and
> pericardial effusions than in early pericarditis. The Incidence of
> Dressler\'s Syndrome is roughly 1 to 3 % of AMI patients. Because of
> the increased incidence of pericardial effusion, anticoagulation
> should be used with caution. Treatment for pericardial effusion with
> impending tamponade is pericardiocentesis, preferably guided by
> echocardiography.
>
> Risk of developing LV dysfunction and subsequent HF is greatly
> increased in patients with more extensive MI. Restricted diastolic
> filling patterns on echocardiography may predict subsequent clinical
> HF.
>
> Refer to the original guideline document for more information.
>
> ***Evidence supporting this recommendation is of classes: A, B, C, D,
> R***

[**Special Work-Up Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_5.html)

77. **Clinical Features Suggest Dissecting or Symptomatic Aneurysm?**

    -   Clinical findings of ischemia involving several organ systems

    -   Pain typically \"tearing\" or \"ripping\"

    -   Pain radiation from chest to back, hips and lower extremities

    -   Common findings: hypertension, cardiac murmurs, systolic bruits,
        diminished or absent pulses

    -   Chest x-rays (CXR) - abnormalities around aortic knob, increased
        diameter of ascending aorta

    -   Blood pressure discrepancy between right and left arm

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78. **Diagnosis of Dissection, Immediate Computed Tomography (CT)
    Angiogram or Echo/Transesophageal Echocardiography (TEE); Magnetic
    Resonance Imaging (MRI) if Clinically Stable and Patient
    Asymptomatic**

    -   CT angiogram is generally the quickest and most readily
        available diagnostic test.

    -   TEE with a biplane probe is equally diagnostic and preferable in
        patients with renal insufficiency or allergy to contrast dye.

    -   MRI remains the most accurate test, but requires a stable
        patient. MRI should be avoided if a type A dissection is
        suspected.

> ***Evidence supporting this recommendation is of classes: C, R***

79. **Test Diagnostic of Type A Dissection or Symptomatic Aneurysm?**

> The imaging procedure should establish the presence or absence of an
> aneurysm and the presence or absence, and location, of a dissection.

80. **Arrange for Immediate Cardiovascular Surgery
    Consultation/Nitroprusside + Esmolol Drip**

    -   Surgical intervention for symptomatic thoracic aneurysms and
        proximal (type A; ascending aorta) dissections

    -   Control blood pressure (BP) with nitroprusside or esmolol drip

> ***Evidence supporting this recommendation is of class: R***

81. **Treatment of Distal Dissection**

    -   Distal (type B; distal to left subclavian artery) aortic
        dissections generally appropriate for pharmacologic therapy

        -   Nitroprusside or esmolol drip to control BP and heart rate
            (eliminate pain and stabilize dissection)

        -   Consider surgery if therapy not effective

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82. **Symptoms, ABGs (Arterial Blood Gases), CXR (Chest X-Ray) Suggest
    Pulmonary Embolus?**

    -   Symptoms may include dyspnea, tachypnea, pleuritic chest pain

    -   Physical findings extremely variable, may include fever,
        wheezing

    -   ECG - non-specific ST-T changes

    -   CXR - normal, pleural effusion, wedge-shaped infiltrate

    -   ABG - abnormal A-a gradient

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84. **Symptoms, ABGs, CXR Suggest Pneumothorax?**

    -   Idiopathic or spontaneous pneumothorax - sudden onset of
        pleuritic chest pain and dyspnea (pleuritic pain more prominent
        with small pneumothorax, dyspnea with large)

    -   ABGs may be abnormal

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85. **Consider Chest Tube and Hospitalization**

    -   Pneumothorax greater than 10 to 20% usually require chest tube

        -   Primary pneumothorax - occurs in otherwise healthy people
            (idiopathic most frequently in tall young males, catamenial
            associated with endometriosis and menses)

        -   Secondary pneumothorax - chronic obstructive pulmonary
            disease (COPD), asthma, pneumonia, cystic fibrosis

    -   Outpatient treatment possible if progression unlikely and
        patient reliable

        -   Catheter aspiration followed by several hours of observation

        -   Indwelling catheter attached to Heimlich valve

    -   Inpatient treatment if pneumothorax is secondary or significant
        symptoms

    -   Reabsorption slow - 1.25% per day

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86. **Symptoms, Signs Suggest Pericardial Disease?**

    -   Chest pain worsened with inspiration, coughing, position changes
        or swallowing

    -   Pericardial friction rub

    -   ECG - ST-T changes

    -   Etiology - infectious, neoplastic, metabolic, inflammatory
        autoimmune disorders, post-MI (Dressler\'s syndrome)

    -   Drug related - hydralazine, procainamide, isoniazid, phenytoin,
        doxorubicin

    -   Consider blunt trauma, post-op

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87. **Tamponade?**

    -   Chest pressure and shortness of breath

    -   Exam - elevated jugular venous pressure, hypotension, tachypnea,
        narrow pulse pressure, pulsus paradoxus greater than 20 mmHg

    -   ECG may reveal electrical alternans

    -   CXR - normal or enlarged cardiac silhouette

    -   Echocardiogram diagnostic test of choice

    -   Pericardial space typically contains 50cc of fluid, with chronic
        accumulation may contain up to 2,000cc

    -   With acute, rapid accumulation, overt tamponade may develop with
        as little as 150cc

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88. **Pericardiocentesis - Prefer Echocardiography (ECHO) Directed**

    -   Echo-directed apical pericardiocentesis procedure of choice

    -   Subxyphoid approach if echo not available and patient unstable

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89. **Admit to CCU/Monitored Bed**

> The patient should be observed in a CCU/monitored bed setting.

90. **Echo; Discharge?/Consider Treatment**

    -   Pericarditis without tamponade \-- obtain echocardiogram

    -   Nonsteroidal anti-inflammatory drugs (NSAIDs) or ASA and close
        follow-up for viral or idiopathic

[**Non-Cardiac Causes Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_6.html)

92. **Symptoms, Signs, CXR Suggest Pleural or Parenchymal Pulmonary
    Disease?**

> Patients with pulmonary or pleural disease frequently have a
> presenting complaint of chest pain with or without shortness of
> breath. A detailed history, physical examination, ECG, chest x-ray and
> laboratory evaluation typically will often suggest the diagnosis.
> Differential diagnoses include chronic obstructive pulmonary disease
> (COPD), asthma, infectious processes, and malignancies. Specific
> management of these diagnoses is beyond the scope of this guideline.

93. **Evaluate for Observation or Admission**

> Disposition decisions are largely dependent on the patient\'s
> stability. The initial treatment must be directed toward treating any
> instability and searching for the etiology of the symptoms. Pulse,
> blood pressure, respirations, and level of consciousness must be
> assessed. Other factors that need to be considered are age, general
> state of health and immunocompetency, and reliability. If a patient is
> labile or unstable, or at risk of becoming unstable, admit the
> patient.

94. **Symptoms and Signs Suggest Chest Wall/Costochondritis?**

> Costochondritis and intercostal strain frequently presents with chest
> pain. Typically, the patient is able to localize the discomfort to a
> fairly limited area. Physical examination should reveal reproducible
> pain at the site of the discomfort.

95. **NSAIDs/Thermal Application/Follow-Up as needed (PRN)**

> Once the clinician has determined that the chest discomfort is limited
> to the chest wall, treatment with nonsteroidal anti-inflammatory
> medication should be started and the patient should be advised on
> local application. Follow-up may be arranged as needed. For expanded
> discussion, refer to the National Guideline Clearinghouse (NGC)
> summary of the Institute for Clinical Systems Improvement (ICSI)
> guideline [Assessment and Management of Acute
> Pain](http://www.guideline.gov/summary/summary.aspx?doc_id=12302&nbr=6371).
>
> ***Evidence supporting this recommendation is of classes: C, R***

96. **Consider Gastrointestinal (GI) Diagnosis?**

> GI disorders are sometimes perceived by the patient as chest pain.
> Once the clinician is confident that no intra-thoracic processes are
> the cause of the discomfort, a GI diagnosis should be considered.

97. **Gastrointestinal Evaluation**

> Commonly history, physical examination, and a laboratory evaluation
> will suggest a GI diagnosis. Further evaluation of this is beyond the
> scope of this guideline.

98. **Reconsider Differential Diagnosis**

> If the clinician, after initial evaluation and work-up, does not
> arrive at a likely working diagnosis, he/she may have to go back and
> reconsider the entire differential diagnosis a second time in order to
> make certain that no serious condition has been missed. The clinician
> may then have to redirect his/her search for a diagnosis to conditions
> of the thoracic spine and thoracic nerves. Other considerations are
> somatization and anxiety disorders. These may be more or less obvious
> after careful consideration. For anxiety diagnoses, refer to the NGC
> summary of the ICSI guideline [Major Depression in Adults in Primary
> Care](http://www.guideline.gov/summary/summary.aspx?doc_id=12617&nbr=6525).
>
> Differential diagnoses of thoracic spine and thoracic neuralgias
> include metastatic malignancy, multiple myeloma, arthritic processes,
> ankylosing spondylitis, osteomyelitis, kyphoscoliosis, and herpes
> zoster.
>
> Atypical chest pain associated with mitral valve prolapse is a poorly
> understood symptom.

[**Clinic Evaluation Algorithm
Annotations**](http://www.guideline.gov/algorithm/5390/NGC-5390_7.html)

100. **Initial Focused Assessment for High-Risk History, Physical Exam,
     and Other Findings**

> History should include characterization of pain, exacerbating or
> relieving factors, associated symptoms, and risk factors for coronary
> disease. Physical exam should include careful cardiovascular and
> pulmonary exam, peripheral vascular exam, and evaluation for
> hypertension and hypercholesterolemia. Lab studies may include resting
> ECG, chest x-ray, hemoglobin, and others if clinically indicated.
>
> The patient\'s description of pain and the history of previous
> coronary disease are by far the most important parts of the history.
>
> Carotid bruits, peripheral vascular disease, and xanthomas on physical
> exam suggest a higher likelihood of coronary disease. The resting ECG
> may show evidence of previous infarction.
>
> Direct provider education toward completing the history evaluation.
>
> High-risk symptoms on initial presentation include:
>
> History

-   Severe or ongoing pain

-   Pain lasting 20 minutes or more

-   New pain at rest or with minimal activity

-   Severe dyspnea

-   Loss of consciousness

> Physical Findings

-   Hypotension or other signs of underperfusion

-   Tachycardia or bradycardia

-   Pulmonary edema, cyanosis

> ECG Findings

-   ST elevation greater than 1 mm on two contiguous leads suggesting
    AMI

-   New ST or T wave changes

-   ST depression greater than 1 mm at rest

-   New LBBB

> ***Evidence supporting this recommendation is of class: C***

102. **Initiate Emergency Interventions and Transfer to ED as
     Appropriate**

> Initiate emergency intervention as appropriate and transfer the
> patient as soon as possible for further emergency intervention.
>
> A patient complaining of chest pain should immediately be placed on a
> cardiac monitor. Vital signs should be taken, IV started, oxygen
> administered, and immediate ECG taken. Institution of stabilizing
> therapy (including nitroglycerin (NTG) and chewable aspirin for
> suspect anginal pain) prior to the completion of the history or
> physical is appropriate and often necessary at this level.

103. **CAD Diagnosis Secure?**

> When the clinical setting and history suggest typical angina pectoris
> (substernal pain provoked by exertion and relieved by nitroglycerin or
> rest), the physician is very likely correct in assuming an ischemic
> coronary syndrome. Treatment and prognostic evaluation may proceed as
> outlined in the NGC summary of the ICSI guideline [Stable Coronary
> Artery
> Disease](http://www.guideline.gov/summary/summary.aspx?doc_id=10843&nbr=5658).

104. **Refer to the NGC summary of the ICSI guideline [Stable Coronary
     Artery
     Disease](http://www.guideline.gov/summary/summary.aspx?doc_id=10843&nbr=5658)**

> Typical angina pectoris, if stable for 60 days and without evidence of
> recent myocardial infarction, may be treated under the NGC summary of
> the ICSI guideline [Stable Coronary Artery
> Disease](http://www.guideline.gov/summary/summary.aspx?doc_id=10843&nbr=5658).

105. **Ischemic Heart Pain Possible?**

> When coronary disease is of intermediate probability, a stress test
> may contribute supplemental information. When coronary disease is
> unlikely based on highly atypical symptoms and low prevalence of
> coronary disease among the population to which the patient belongs,
> stress testing may be misleading.

106. **Choose Stress Test/Cardiology Referral Optional**

> Choose the best type of cardiac stress test based on:

-   The resting cardiogram

-   The patient\'s ability to walk

-   Local expertise

107. **Can Patient Walk?**

> In patients who cannot exercise, consider pharmacologic stress and
> imaging test (with adenosine, dipyridamole, or dobutamine). Physical
> exercise is the most physiologic form of cardiovascular stress. If one
> doubts how far a patient will be able to walk, it might still be
> worthwhile to attempt treadmill exercise. The occasional patient with
> orthopedic restriction may be able to perform bicycle ergometry.

109. **Resting ECG Interpretable?**

> Marked resting ECG abnormalities, such as LBBB, LVH with
> repolarization abnormality, ventricular pre-excitation, or ventricular
> paced rhythm, render the exercise ECG uninterpretable for ischemic
> changes. Patients on digoxin and those with less than 1 mm resting ST
> depression may undergo standard ECG stress testing, provided the
> clinician realizes that further ST depression with exercise has
> minimal diagnostic significance. A stable abnormality with exercise is
> reassuring.
>
> ***Evidence supporting this recommendation is of classes: C, R***

110. **Do Exercise Imaging Study**

> When the resting ECG is markedly abnormal, use an exercise imaging
> test (stress echo, stress radionuclear perfusion, stress radionuclear
> ventriculogram).

111. **Do Regular Treadmill Stress Test**

> Use the Bruce protocol, modified if need be for debilitated patients.
> Adequacy of exercise and myocardial challenge is generally accepted as
> achieving greater than or equal to 85% of age-predicted maximum heart
> rate. The Bruce protocol, because of extensive use and long-term
> follow-up, provides the most reliable prognostic information.

112. **Is Test Strongly Positive?**

> Stress testing may be strongly positive and suggest a moderate to high
> risk of cardiovascular events as indicated by the Duke treadmill
> score, which is based upon the Bruce protocol.
>
> A stress test predicts the patient\'s prognosis and provides evidence
> of the presence or absence of CAD. Of these two types of information,
> the first, establishing the patient\'s prognosis, is the more
> reliable.
>
> Treadmill findings which signify a poor prognosis are:

-   Poor exercise tolerance

-   Hypotension

-   Marked ST abnormality at a low work load

> Conversely, good exercise tolerance to a high heart rate and blood
> pressure signifies a good prognosis, even if the exercise ECG is
> somewhat abnormal. (For example, a patient who walks 9 minutes and has
> 1 mm of asymptomatic ST depression.)
>
> Mark et al (Duke treadmill score) validated an easy-to-use treadmill
> score which stratifies high-, intermediate-, and low-risk patients.
> Refer to the NGC summary of the ICSI [Cardiac Stress Test
> Supplement](http://www.guideline.gov/summary/summary.aspx?doc_id=10810&nbr=5635)
> for scoring methods and application.
>
> A Duke score of greater than or equal to five is generally accepted as
> a passing score, and such patients may be discharged to home with
> follow-up within 72 hours.
>
> Refer to Appendix E, \"Nomogram of the Prognostic Relations Embodied
> in the Treadmill Score\" in the original guideline document.
>
> The Duke treadmill score was developed from a retrospective study of
> 2,842 inpatients. It was prospectively tested on an outpatient
> population of 613 patients with an endpoint of patient mortality.
> Consequently it is the best well-validated measurement for the
> prognostic interpretation of treadmill tests.
>
> ***Evidence supporting this recommendation is of classes: A, B, C,
> R***

113. **Is Patient a Candidate for Revascularization?**

> Unless advanced age, comorbidity, or patient preference suggests
> medical treatment, high-risk patients should be considered for
> revascularization. Patients identified as high risk by treadmill
> testing often have left ventricular dysfunction, left main coronary
> stenosis, or other serious coronary disease. Revascularization may
> offer a better prognosis.
>
> ***Evidence supporting this recommendation is of classes: A, C***

116. **Is Test Positive but Low Risk?**

> A stress cardiogram may be positive but without features which signify
> a poor prognosis as noted above. For example, a 65-year-old man with
> atypical angina and 1.0 mm ST depression at 10 minutes has a good
> prognosis even though he has coronary disease.

117. **Is Diagnostic Certainty Adequate?**

> A positive test may confirm the clinical diagnosis of coronary disease
> and allow treatment as outlined under the NGC summary of the ICSI
> guideline [Stable Coronary Artery
> Disease](http://www.guideline.gov/summary/summary.aspx?doc_id=10843&nbr=5658).
>
> Refer to cardiology if diagnostic certainty is critical.
>
> ***Evidence supporting this recommendation is of classes: C, M***

120. **Is Test Equivocal?**

> Because of resting abnormality, limited exercise performance, limited
> heart rate, or minor exercise abnormalities, the test may not be
> clearly normal or abnormal, yet high-risk treadmill findings are
> absent.
>
> ***Evidence supporting this recommendation is of classes: C, M***

121. **Is Diagnostic Certainty Adequate?**

> Knowing that the patient is not at high risk may suggest empiric
> treatment or non-cardiac evaluation. Refer to cardiology if diagnostic
> certainty is important.
>
> ***Evidence supporting this recommendation is of classes: C, M***

124. **Test is Normal**

> A normal test may confirm the clinical impression of non-cardiac
> symptoms. Refer to cardiology if symptoms are worrisome despite a
> normal stress test.
>
> Compared with the prognostic information contained in a stress test,
> the diagnostic information is more variable. The physician must
> consider:

1.  How to estimate the pre-test likelihood of coronary disease based
    upon the patient\'s age, sex, and description of chest pain. If
    pretest likelihood is very high or very low, a test of intermediate
    predictive value, such as treadmill stress testing, may be
    misleading.

2.  How abnormal are the exercise findings?

> Greater than 1 mm flat or 1.5 mm upsloping ST depression measured 80
> msec. after the J point occurring with a normal resting ECG is
> considered a positive test. However, \"positive\" is not
> all-or-nothing. Downsloping ST depression, greater degrees of ST
> depression, persistent ST depression, and ST depression at a low work
> load are \"more positive.\" Conversely, upsloping ST depression, ST
> depression at a high work load, and rapidly-resolving ST depression
> are \"less positive.\"

3.  How good is the test itself? Is exercise challenge adequate, heart
    rate high enough? Resting abnormality present?

4.  The natural history of a coronary plaque. A non-obstructive plaque
    may become active, provoke unstable symptoms by platelet emboli or
    vasoconstriction, yet not impair exercise coronary flow. **A normal
    test isn\'t reassuring if the symptoms are worrisome.**

5.  What is the diagnostic goal? Absolute certainty for airline pilots?
    Reasonable reassurance?

> Despite the complexities of interpretation, stress testing is a
> valuable tool in the evaluation of a patient with chest pain. Clinical
> judgment is paramount.

**Definitions**:

**Classes of Research Reports**:

A.  Primary Reports of New Data Collection:

> Class A:

-   Randomized, controlled trial

> Class B:

-   Cohort study

> Class C:

-   Non-randomized trial with concurrent or historical controls

-   Case-control study

-   Study of sensitivity and specificity of a diagnostic test

-   Population-based descriptive study

> Class D:

-   Cross-sectional study

-   Case series

-   Case report

B.  Reports that Synthesize or Reflect upon Collections of Primary
    Reports:

> Class M:

-   Meta-analysis

-   Systematic review

-   Decision analysis

-   Cost-effectiveness analysis

> Class R:

-   Consensus statement

-   Consensus report

-   Narrative review

> Class X:

-   Medical opinion

#### CLINICAL ALGORITHM(S)

Detailed and annotated clinical algorithms are provided for:

-   [Chest Pain
    Screening](http://www.guideline.gov/algorithm/5390/NGC-5390_1.html)

-   [Emergency
    Intervention](http://www.guideline.gov/algorithm/5390/NGC-5390_2.html)

-   [ST-Segment Elevation Myocardial Infarction
    (STEMI)](http://www.guideline.gov/algorithm/5390/NGC-5390_3.html)

-   [Acute Myocardial Infarction (AMI)
    Complications](http://www.guideline.gov/algorithm/5390/NGC-5390_4.html)

-   [Special
    Work-Up](http://www.guideline.gov/algorithm/5390/NGC-5390_5.html)

-   [Non-Cardiac
    Causes](http://www.guideline.gov/algorithm/5390/NGC-5390_6.html)

-   [Clinic
    Evaluation](http://www.guideline.gov/algorithm/5390/NGC-5390_7.html)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is classified for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Successful emergency interventions for patients with high-risk chest
    pain

-   Improved diagnostic value of stress tests through their appropriate
    use in patients with chest pain symptoms

-   Minimized delay in administering thrombolytics or angioplasty to
    patients with acute myocardial infarction (AMI)

-   Appropriate tobacco use assessment and cessation counseling and
    treatment for patients with AMI

-   Appropriate course of treatment for patients with AMI that follows
    the recommended critical pathway

-   Timely initiation of treatment to reduce postinfarction mortality in
    patients with AMI

-   Increased use of risk stratifying procedures in patients with AMI

-   Appropriate use of cardiac rehabilitation post-discharge

#### POTENTIAL HARMS

**Adverse Effects of Medications and Precautions**

-   The recently completed SYNERGY study found increased adverse events
    in patients that were switched from *unfractionated heparin* to
    *low-molecular weight heparin* or vice-versa at the time of referral
    to tertiary care institutions. Therefore, the suggestion is that the
    patient be started and maintained on one drug or the other during
    transfer and treatment at referring and referral institutions.

-   *Low-molecular weight heparin (LMWH)* should be used with caution in
    patients with renal insufficiency.

-   *Calcium channel blockers* should be avoided in patients with
    decreased left ventricular (LV) function or heart failure. The
    short-acting dihydropyridine *calcium channel blockers* (e.g.,
    *nifedipine*) may be associated with increased risk and should be
    avoided in acute ischemic syndromes.

-   Low patient weight has been identified as an ongoing risk factor for
    significant intracranial hemorrhage when *thrombolytics* are
    administered.

-   Use of non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the
    cardioprotective benefits of aspirin.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Contraindications to IIb-IIIa Inhibitors**

-   Bleeding less than 6 weeks

-   Intracranial hemorrhage (ever)

-   Recent stroke less than two years

-   Uncontrolled hypertension greater than 200/100 mmHg

-   Surgery less than six weeks

-   Aortic dissection

-   Acute pericarditis

-   Platelets less than 100,000 mm^3^

-   Dialysis dependent renal failure

**Contraindications to Nitroglycerin**

-   Hypotension

-   Documented severe aortic stenosis

-   Hypertrophic cardiomyopathy

-   Sildenafil, vardenafil, or ordenafil within the previous 24 hours or
    tadalafil in the previous 48 hours

**Contraindications to Beta-blockers**

*Absolute Contraindication*

-   ST-elevation myocardial infarction due to cocaine use

-   Cardiogenic shock

*Relative Contraindications*

-   Asthma

-   First degree of atrioventricular block

-   Hypotension

-   Heart rate less than 60/min

-   Decompensated congested heart failure

**Contraindications to Thrombolytics\***

*Absolute Contraindications*

-   Previous hemorrhagic stroke at any time; other strokes or
    cerebrovascular events within one year

-   Known intracranial neoplasm

-   Active internal bleeding (does not include menses)

-   Suspected aortic dissection

*Cautions/Relative Contraindications*

-   Severe uncontrolled hypertension on presentation (greater than
    180/110 mm Hg)\*\*

-   History of prior cerebrovascular accident or known intracerebral
    pathology not covered in above absolute contraindications

-   Current use of anticoagulants in therapeutic doses (international
    normalized ration \[INR\] greater than or equal to 2.0 to 3.0);
    known bleeding diathesis

-   Recent trauma (including head trauma) within 2 to 4 weeks

-   Major surgery in past 3 to 6 months

-   Noncompressible vascular punctures

-   Recent internal bleeding

-   For streptokinase/anistreplase: prior exposure (especially within
    five days to two years) or prior allergic reaction

-   Pregnancy

-   Active peptic ulcer

-   History of chronic hypertension

\* Advisory only. May not be all inclusive or definitive. Patients with
relative contraindications should be evaluated on a case-by-case basis.
Percutaneous coronary intervention (PCI) may provide equal or increased
benefit at decreased risk.

\*\*Severe uncontrolled hypertension on presentation is a relative
contraindication. Even if hypertension is brought under control,
patients subsequently treated with thrombolytics experience increased
rates of ICH compared to patients who are normotensive on presentation.
Arrange for primary PCI in high-risk hypertensive patients if feasible.

**NOTE**: Cardiopulmonary resuscitation performed for less than 10
minutes is NOT a contraindication.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These clinical guidelines are designed to assist-clinicians by
    providing an analytical framework for the evaluation and treatment
    of patients, and are not intended either to replace a clinician\'s
    judgment or to establish a protocol for all patients with a
    particular condition. A guideline will rarely establish the only
    approach to a problem.

-   This medical guideline should not be construed as medical advice or
    medical opinion related to any specific facts or circumstances.
    Patients are urged to consult a health care professional regarding
    their own situation and any specific medical questions they may
    have.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Once a guideline is approved for general implementation, a medical group
can choose to concentrate on the implementation of that guideline. When
four or more groups choose the same guideline to implement and they wish
to collaborate with others, they may form an action group.

In the action group, each medical group sets specific goals they plan to
achieve in improving patient care based on the particular guideline(s).
Each medical group shares its experiences and supporting measurement
results within the action group. This sharing facilitates a
collaborative learning environment. Action group learnings are also
documented and shared with interested medical groups within the
collaborative.

Currently, action groups may focus on one guideline or a set of
guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented in the original guideline
document to help close the gap between clinical practice and the
guideline recommendations. Summaries of the measures are provided in the
National Quality Measures Clearinghouse (NQMC).

**Key Implementation Recommendations**

The following system changes were identified by the guideline work group
as key strategies for health care systems to incorporate in support of
the implementation of this guideline.

1.  Clinics should have a process in place for a patient to be referred
    for emergency intervention via 911, or be seen in the clinic the
    same day, within 72 hours, or as an elective clinic evaluation based
    upon the presence of high-risk symptoms and duration.

2.  Hospitals should develop and implement Emergency Department (ED)
    critical pathways and consider standard orders to accomplish rapid
    evaluation and treatment of acute coronary syndrome. Standard
    discharge orders/ instructions should also be considered.

3.  A process should be in place for the patient and family that will
    rapidly orient them to the suspected diagnosis, ED and Critical Care
    Unit (CCU) process and other treatment measures to be considered.
    This could include both caregiver face-to-face interactions with the
    patient and family as well as teaching tools in written form.

4.  Institutions that cannot meet the recommended treatment times for
    primary percutaneous coronary intervention (PCI) should consider the
    preferential use of intravenous thrombolytics therapy. These
    institutions should have a predetermined plan for treating patients
    who present with contraindications to thrombolytics. Such plans may
    employ delayed local primary PCI or transfer to another institution.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Pocket Guide/Reference Cards\
Quality Measures\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

#### RELATED NQMC MEASURES

-   [Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS): percentage of patients with chest pain symptoms in emergency
    department (ED) receiving early therapy including intravenous (IV)
    access, oxygen, nitroglycerin, morphine and a chewable aspirin on
    arrival.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10233)

-   [Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS): percentage of patients with acute myocardial infarction (AMI)
    receiving thrombolytics with a \"door-to-drug time\" (time from
    presentation to administration of drug) of less than 30
    minutes.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10234)

-   [Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS): percentage of patients with acute myocardial infarction (AMI)
    receiving beta-blockers within 24 hours of arrival and on
    discharge.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10235)

-   [Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS): percentage of patients with chest pain symptoms who have had
    treadmill tests with the Duke score present and aren\'t high
    risk.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10236)

-   [Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS): percentage of patients with acute myocardial infarction (AMI)
    receiving or scheduled for a risk stratifying procedure prior to
    discharge.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10237)

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
treatment of chest pain and acute coronary syndrome (ACS). Bloomington
(MN): Institute for Clinical Systems Improvement (ICSI); 2006 Oct. 76 p.
\[121 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Nov (revised 2006 Oct)

#### GUIDELINE DEVELOPER(S)

Institute for Clinical Systems Improvement - Private Nonprofit
Organization

#### GUIDELINE DEVELOPER COMMENT

Organizations participating in the Institute for Clinical Systems
Improvement (ICSI): Affiliated Community Medical Centers, Allina Medical
Clinic, Altru Health System, Aspen Medical Group, Avera Health,
CentraCare, Columbia Park Medical Group, Community-University Health
Care Center, Dakota Clinic, ENT Specialty Care, Fairview Health
Services, Family HealthServices Minnesota, Family Practice Medical
Center, Gateway Family Health Clinic, Gillette Children\'s Specialty
Healthcare, Grand Itasca Clinic and Hospital, HealthEast Care System,
HealthPartners Central Minnesota Clinics, HealthPartners Medical Group
and Clinics, Hutchinson Area Health Care, Hutchinson Medical Center,
Lakeview Clinic, Mayo Clinic, Mercy Hospital and Health Care Center,
MeritCare, Mille Lacs Health System, Minnesota Gastroenterology,
Montevideo Clinic, North Clinic, North Memorial Care System, North
Suburban Family Physicians, Northwest Family Physicians, Olmsted Medical
Center, Park Nicollet Health Services, Pilot City Health Center, Quello
Clinic, Ridgeview Medical Center, River Falls Medical Clinic, Saint
Mary\'s/Duluth Clinic Health System, St. Paul Heart Clinic, Sioux Valley
Hospitals and Health System, Southside Community Health Services,
Stillwater Medical Group, SuperiorHealth Medical Group, University of
Minnesota Physicians, Winona Clinic, Ltd., Winona Health

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425;
telephone, (952) 814-7060; fax, (952) 858-9675; e-mail:
<icsi.info@icsi.org>; Web site: [www.icsi.org](http://www.icsi.org/).

#### SOURCE(S) OF FUNDING

The following Minnesota health plans provide direct financial support:
Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica,
Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind
support is provided by the Institute for Clinical Systems Improvement\'s
(ICSI) members.

#### GUIDELINE COMMITTEE

Cardiovascular Steering Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Work Group Members*: Steve Mulder, MD (Work Group Leader) (Hutchinson)
(Family Medicine); Paul Spilde, PT (Park Nicollet Health Services)
(Cardiac Rehabilitation); James Morrison, MD (HealthPartners Medical
Group) (Cardiology); Jackson Thatcher, MD (Park Nicollet Health
Services) (Cardiology); R. Scott Wright, MD (Mayo Clinic) (Cardiology);
Harry D. Malcolm, MD (St. Mary\'s/Duluth Clinic Health System) (Family
Medicine); Jeffrey Garland, MD (St. Mary\'s/Duluth Clinic Health System)
(Hospitalist); Sai Haranath, MD (MeritCare) (Internal Medicine); Kathy
Melsha, PharmD (Park Nicollet Health Services) (Pharmacy); Teresa
Hunteman (Institute for Clinical Systems Improvement)
(Measurement/Implementation Advisor); Ann-Marie Evenson, BS, RHIT
(Institute for Clinical Systems Improvement) (Facilitator)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

In the interest of full disclosure, ICSI has adopted the policy of
revealing relationships work group members have with companies that sell
products or services that are relevant to this guideline topic. The
reader should not assume that these financial interests will have an
adverse impact on the content of the guideline, but they are noted here
to fully inform readers. Readers of the guideline may assume that only
work group members listed below have potential conflicts of interest to
disclose.

R. Scott Wright, M.D. is a consultant for Pfizer and Merck-Scherling
Plough.

No other work group members have potential conflicts of interest to
disclose.

ICSI\'s conflict of interest policy and procedures are available for
review on ICSI\'s website at [www.icsi.org](http://www.icsi.org/).

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical
Systems Improvement (ICSI). Diagnosis and treatment of chest pain and
acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Oct. 78 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Institute for Clinical Systems
Improvement (ICSI) Web
site](http://www.icsi.org//guidelines_and_more/guidelines__order_sets___protocols/).

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Diagnosis and treatment of chest pain and acute coronary syndrome
    (ACS). Executive summary. Bloomington (MN): Institute for Clinical
    Systems Improvement, 2006 Oct. 1 p. Electronic copies: Available
    from the [Institute for Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/cardiovascular/acs_acute_coronary_syndrome/acs__acute_coronary_syndrome_and_chest_pain__diagnosis_and_treatment_of__full_version_.html).

-   Health care order set: admission to CCU for acute coronary sydrome.
    Bloomington (MN): Institute for Clinical Systems Improvement, 2006
    Oct. 31 p. Electronic copies: Available from the [Institute for
    Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/cardiovascular/acs_acute_coronary_syndrome/acs__acute_coronary_syndrome_and_chest_pain__diagnosis_and_treatment_of__full_version_.html).

-   Nomogram of the prognostic relations embodied in the treadmill
    score. Appendix E in the original guideline document. Electronic
    copies: Available from the [ICSI Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/cardiovascular/acs_acute_coronary_syndrome/acs__acute_coronary_syndrome_and_chest_pain__diagnosis_and_treatment_of__full_version_.html).

-   Appendix E -- Nomogram of the prognostic relations embodied in the
    treadmill score.

-   ICSI pocket guidelines. April 2006 edition. Bloomington (MN):
    Institute for Clinical Systems Improvement, 2006. 298 p.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 16, 2005. This
summary was updated on May 3, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This NGC summary was updated by ECRI on January 12, 2006
and February 1, 2007. This summary was updated by ECRI on March 6, 2007
following the U.S. Food and Drug Administration (FDA) advisory on
Coumadin (warfarin sodium). This summary was updated by ECRI Institute
on June 22, 2007 following the U.S. Food and Drug Administration (FDA)
advisory on heparin sodium injection. This summary was updated by ECRI
Institute on July 12, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Troponin-1 Immunoassay. This summary
was updated by ECRI Institute on September 7, 2007 following the revised
U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin).
This summary was updated by ECRI Institute on November 9, 2007,
following the U.S. Food and Drug Administration advisory on
Antidepressant drugs. This summary was updated by ECRI Institute on
March 14, 2008 following the updated FDA advisory on heparin sodium
injection.

#### COPYRIGHT STATEMENT

This NGC summary (abstracted Institute for Clinical Systems Improvement
\[ICSI\] Guideline) is based on the original guideline, which is subject
to the guideline developer\'s copyright restrictions.

The abstracted ICSI Guidelines contained in this Web site may be
downloaded by any individual or organization. If the abstracted ICSI
Guidelines are downloaded by an individual, the individual may not
distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization,
copies may be distributed to the organization\'s employees but may not
be distributed outside of the organization without the prior written
consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are
reserved by the Institute for Clinical Systems Improvement, Inc. The
Institute for Clinical Systems Improvement, Inc. assumes no liability
for any adaptations or revisions or modifications made to the abstracts
of the ICSI Guidelines.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008