Acute Coronary Syndromes Clinical Care Standard

Evidence Sources

Acute Coronary Syndromes
Clinical Care Standard

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ISBN: 978-1-921983-96-2

Suggested citation

Australian Commission on Safety and Quality in Health Care. Evidence Sources: Acute Coronary Syndromes Clinical Care Standard. Sydney: ACSQHC, 2014.

Acknowledgements

Many individuals and organisations have freely given their time and expertise in the development of the Acute Coronary Syndromes Clinical Care Standard. The Commission gratefully acknowledges the contributions from members of the Acute Coronary Syndromes Clinical Care Standard Topic Working Group and other key experts who informed thisdocument.

Disclaimer

The Australian Commission on Safety and Quality in Health Care has produced the Clinical Care Standard to support the delivery of appropriate care for a defined condition and is based on the best evidence available at the time of development. Health care professionals are advised to use clinical discretion and consideration of the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian when applying information contained within the Clinical Care Standard. Consumers should use the information in the Clinical Care Standard as a guide to inform discussions with their health care professional about the applicability of the Clinical Care Standard to their individual condition.

Evidence sources: Acute Coronary Syndromes Clinical Care Standard

Evidence Sources – Acute Coronary Syndromes Clinical Care Standard

The quality statements for the Acute Coronary Syndromes ClinicalCare Standard were developed in collaboration with the Acute Coronary Syndromes Clinical Care Standard Topic Working Group and are based on best available evidence.

Literature searches were conducted by Commission staff at different stages of development of the Clinical Care Standard. The initial search took place between June 2013 and August 2013. A draft evidence summary was prepared which was reviewed for completeness by the Acute Coronary Syndromes Clinical Care Standard Topic Working Group. A further search took place between August 2014 andSeptember 2014 to identify any new evidence that may affect the relevance or validity of the final quality statements.

The initial search was aimed at reviewing the evidence-base for each potential quality statement. As set out below, several steps were involved. The first step was to locate national clinical practice guidelines; if relevant, current, based on available evidence developed using systematic methods and endorsed by organisations, they would be the key sources of evidence. The second step was to locate other Australian guidelines, standards, policies, protocols, and international guidelines and standards. The third step was to identify high-level evidence published after the release of the national clinical practice guidelines.

Australian clinical practice guidelines, standards and policies were identified by searching:

the clinical practice guideline portal of the National Health and Medical Research Council (NHMRC)
websites of professional colleges and organisations
websites of state and territory health departments and agencies
internet search using various search engines.

International clinical practice guidelines were identified by searching:

guideline clearing houses such as the Agency for Healthcare Research and Quality (AHRQ), and Guidelines International Network (GIN)
websites of guideline developers, such as the UK’s National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guideline Network (SIGN).

Other high-level evidence was identified by searching:

the Cochrane Collaboration for systematic literature reviews and meta analyses
medical literature databases (Medline, Embase) for systematic reviews and meta-analyses.

A summary of evidence sources for each final quality statement is attached.

Evidence Sources: Acute Coronary Syndromes Clinical Care Standard

Quality Statement 1 / A patient presenting with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives care guided by a documented chest pain assessment pathway.
EVIDENCE SOURCES
Consensus opinion:
The Acute Coronary Syndromes Clinical Care Standards Topic Working Group agreed by consensus that patients presenting with acute chest pain, or other symptoms suggestive of an acute coronary syndrome, receive care guided by a documented chest pain assessment pathway.
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
Australian Resuscitation Council and New Zealand Resuscitation Council. Acute coronary syndromes: presentation with ACS. ARC and NZRC Guideline 2011. Emergency Medicine Australasia2011;23(3):302-307 (cited September 2014); Available from:
International Guideline
National Institute for Health and Care Excellence. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE clinical guideline 95. United Kingdom: NICE; 2010 [cited September 2014]; Available from:
Additional Source
NSW Ministry of Health. Chest Pain Evaluation (NSW Chest Pain Pathway). North Sydney: NSW Health; 2010 [cited September 2014); Available from:
Quality Statement 2 / A patient with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives a 12-lead electrocardiogram (ECG) and the results are analysed by a clinician experienced in interpreting an ECG within 10 minutes of the first emergency clinical contact.
EVIDENCE SOURCES
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
Australian Resuscitation Council and New Zealand Resuscitation Council. Acute coronary syndromes: presentation with ACS. ARC and NZRC Guideline 2011. Emergency Medicine Australasia2011;23(3):302-307 (cited September 2014); Available from:
International Guidelines
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction): Developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116(7):e148-e304 [cited September 2014]; Available from
Hamm C, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal 2011;32:2999-3054 [cited September 2014); Available from:
Non-ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. New Zealand 2012 guidelines for the management of non ST-elevation acute coronary syndromes.The New Zealand Medical Journal 2012;125(1357):122-147 [cited September 2014]; Available from:
Scottish Intercollegiate Guidelines Network. Acute coronary syndromes: a national clinical guideline. Sign publication no. 93. Edinburgh: SIGN; 2013 [cited September 2014]; Available from:
Steg P, James SK, Atar D. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal 2012;33:2569- 2619 [cited September 2014]; Available from:
Additional Source
National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand. Acute coronary syndromes treatment algorithm. NHFA & CSANZ; 2011 [cited May 2014]; Available from:
Quality Statement 3 / A patient with an acute ST-segment-elevation myocardial infarction (STEMI), for whom emergency reperfusion is clinical appropriate, is offered timely percutaneous coronary intervention (PCI) or fibrinolysis in accordance with the time frames recommended in the current National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes.
In general, primary PCI is recommended if the time from first medical contact to balloon inflation is anticipated to be less than 90 minutes, otherwise the patient is offered fibrinolysis.
EVIDENCE SOURCES
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
Australian Resuscitation Council and New Zealand Resuscitation Council. Acute coronary syndromes: presentation with ACS. ARC and NZRC Guideline 2011. Emergency Medicine Australasia2011;23(3):302-307 (cited September 2014); Available from:
International Guidelines
O'Gara P, Kushner, FG, Ascheim, DD, et al. 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362 - e425 [cited September 2014]; Available from:
National Institute for Health and Care Excellence. Myocardial infarction with ST-segment elevation: The acute management of myocardial infarction with ST-segment elevation. Clinical guideline 167. United Kingdom: NICE; 2013 [updated September 2014 ]; Available from:
Scottish Intercollegiate Guidelines Network. Acute coronary syndromes: a national clinical guideline. Sign publication no. 93. Edinburgh: SIGN; 2013 [cited September 2014]; Available from:
Steg P, James SK, Atar D. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal 2012;33:2569- 2619 [cited September 2014]; Available from:
Additional Sources
National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand. Acute coronary syndromes treatment algorithm. NHFA & CSANZ; 2011 [cited May 2014]; Available from:
National Institute for Health and Care Excellence. Acute coronary syndromes (including myocardial infarction). NICE quality statement 68. United Kingdom: NICE; 2014 [cited September 2014]; Available from:
Quality Statement 4 / A patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) is managed based on a documented, evidence-based assessment of their risk of an adverse event.
EVIDENCE SOURCES
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
Australian Resuscitation Council and New Zealand Resuscitation Council. Acute coronary syndromes: presentation with ACS. ARC and NZRC Guideline 2011. Emergency Medicine Australasia2011;23(3):302-307 (cited September 2014); Available from:
International Guidelines
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction): Developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116(7):e148-e304 [cited September 2014]; Available from
Hamm C, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal 2011;32:2999-3054 [cited September 2014); Available from:
National Institute for Health and Clinical Excellence. Unstable angina and NSTEMI: The early management of unstable angina and non-ST-segment-elevation myocardial infarction. Clinical Guideline 94. United Kingdom: NICE; 2010 [cited September 2014]; Available from:
Non-ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. New Zealand 2012 guidelines for the management of non ST-elevation acute coronary syndromes.The New Zealand Medical Journal 2012;125(1357):122-147 [cited September 2014]; Available from:
Scottish Intercollegiate Guidelines Network. Acute coronary syndromes: a national clinical guideline. Sign publication no. 93. Edinburgh: SIGN; 2013 [cited September 2014]; Available from:
Additional Source
National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand. Acute coronary syndromes treatment algorithm. NHFA & CSANZ; 2011 [cited May 2014]; Available from:
National Institute for Health and Care Excellence. Acute coronary syndromes (including myocardial infarction). NICE quality statement 68. United Kingdom: NICE; 2014 [cited September 2014]; Available from:
Quality Statement 5 / The role of coronary angiography, with a view to timely and appropriate coronary revascularisation, is discussed with a patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) who is assessed to be at intermediate or high risk of and adverse cardiac event.
EVIDENCE SOURCES
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
International Guidelines
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction): Developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116(7):e148-e304 [cited September 2014]; Available from
Hamm C, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal 2011;32:2999-3054 [cited September 2014); Available from:
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA Focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012;126(7):875-910 [Cited September 2014]; Available from:
National Institute for Health and Clinical Excellence. Unstable angina and NSTEMI: The early management of unstable angina and non-ST-segment-elevation myocardial infarction. Clinical Guideline 94. United Kingdom: NICE; 2010 [cited September 2014]; Available from:
National Institute for Health and Clinical Excellence. Unstable angina and NSTEMI: The early management of unstable angina and non-ST-segment-elevation myocardial infarction. Clinical Guideline 94. United Kingdom: NICE; 2010 [cited September 2014]; Available from:
Non-ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. New Zealand 2012 guidelines for the management of non ST-elevation acute coronary syndromes.The New Zealand Medical Journal 2012;125(1357):122-147 [cited September 2014]; Available from:
Scottish Intercollegiate Guidelines Network. Acute coronary syndromes: a national clinical guideline. Sign publication no. 93. Edinburgh: SIGN; 2013 [cited September 2014]; Available from:
Additional Source
National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand. Acute coronary syndromes treatment algorithm. NHFA & CSANZ; 2011 [cited May 2014]; Available from:
Hoenig M, Aroney CN, Scott, IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era: Cochrane Database of Systematic Reviews 2010 [cited September 2014]; Available from:
National Institute for Health and Care Excellence. Acute coronary syndromes (including myocardial infarction). NICE quality statement 68. United Kingdom: NICE; 2014 [cited September 2014]; Available from:
Quality Statement 6 / Before a patient with an acute coronary syndrome leaves the hospital, they are involved in the development of an individualised care plan. This plan identifies the lifestyle modifications and medicines needed to manage their risk factors, addresses their psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or another secondary prevention program. This plan is provided to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.
EVIDENCE SOURCES
Australian Guidelines
Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia 2006;184(8):S1-S32 [cited September 2014); Available from:
International Guidelines
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction): Developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116(7):e148-e304 [cited September 2014]; Available from
Hamm C, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal 2011;32:2999-3054 [cited September 2014); Available from:
O'Gara P, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362 - e425 [cited September 2014]; Available from:
National Institute for Health and Clinical Excellence. Unstable angina and NSTEMI: The early management of unstable angina and non-ST-segment-elevation myocardial infarction. Clinical Guideline 94. United Kingdom: NICE; 2010 [cited September 2014]; Available from:
Non-ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. New Zealand 2012 guidelines for the management of non ST-elevation acute coronary syndromes.The New Zealand Medical Journal 2012;125(1357):122-147 [cited September 2014]; Available from:
Scottish Intercollegiate Guidelines Network. Acute coronary syndromes: a national clinical guideline. Sign publication no. 93. Edinburgh: SIGN; 2013 [cited September 2014]; Available from:
Smith CJ, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-73 [Cited September 2014]; Available from:
Steg P, James SK, Atar D. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal 2012;33:2569- 2619 [cited September 2014]; Available from:
Additional Sources
Australian Commission on Safety and Quality in Health Care. Australian Safety and Quality Framework for Health Care. Sydney: ACSQHC, 2010. [Cited September 2014]; Available from:
Briffa TG, Kinsman L, Maiorana AJ, et al. An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia. Policy statement from the Australian Cardiovascular Health and Rehabilitation Association. Medical Journal of Australia. 2009;190(12):683 – 6 [Cited September 2014]; Available from:
National Heart Foundation of Australia and Australian Cardiac Rehabilitation Association. Recommended framework for cardiac rehabilitation '04. NHFA and ACRA, 2004 [cited September 2014]; Available from: