MJA
MJA

Guidelines for the management of acute coronary syndromes 2006

Acute Coronary Syndrome Guidelines Working Group
Med J Aust 2006; 184 (8): S1-S32. || doi: 10.5694/j.1326-5377.2006.tb00304.x
Published online: 17 April 2006
Summary of key recommendations
Management of patients with ST-segment-elevation myocardial infarction
Introduction

Acute coronary syndromes (ACS) include “a broad spectrum of clinical presentations, spanning ST-segment-elevation myocardial infarction, through to an accelerated pattern of angina without evidence of myonecrosis”.1 Collectively, they represent one of the most common causes of acute medical admissions to Australian hospitals.

The current guidelines for the management of both ST-segment-elevation ACS and non-ST-segment-elevation ACS have been developed by a joint working party of the National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ).

The aim of these guidelines is to incorporate contemporary information on the diagnosis and management of ACS into a set of recommendations that defines the boundaries of highest quality care. The guidelines expand on previous guidelines2,3 by consolidating recommendations for the management of ST-segment-elevation myocardial infarction (STEMI), non-ST-segment-elevation myocardial infarction and unstable angina, as well as incorporating the newer developments that have arisen since the previous guidelines, Management of unstable angina — 20003 (and addenda, available at: http://www.heartfoundation.com.au) and Reperfusion therapy for acute myocardial infarction (2002).2

These new guidelines provide a general framework for appropriate practice, to be followed subject to clinical judgement in each individual patient. They are primarily for doctors in a hospital environment (emergency physicians, general physicians, rural doctors and cardiologists) who manage patients with ACS, but they also contain information relevant to general practitioners and others, including ambulance personnel. The guidelines are designed to provide information to assist decision making, and are based on the best information available up to September 2005. It should be understood that the context in which clinical trials are performed and the local environment in which practice is undertaken must always be considered when assessing the evidence base for guidelines and, at times, their local implementation.

These new guidelines represent a local synthesis of the most recent evidence including recent international guidelines. Where relevant, the evidence has been interpreted with regard to the Australian context in which the guidelines will be implemented.

Key recommendations are summarised at the beginning of these guidelines.

Systems of care for patients with acute coronary syndromes

The ability to implement best-practice guidelines for the management of ACS will depend on local resources and systems of care. The following guidance is offered to assist practitioners and organisations in facilitating the most effective systems of care for the communities they serve.

Effective management of ACS requires collaborative systems of care to ensure that patients have access to the services that they need in a timeframe commensurate with their clinical condition and the potential benefit of treatments available in larger or specialised centres. The guiding principles for developing these systems are equity of access, equity of care and evidence-based care, taking into account patients’ preferences.

The systems of care should be regionally based, formal rather than ad-hoc, and should cover the continuum of care from the first point of presentation to a health professional to definitive care and rehabilitation. Responsibility for establishing these systems should be at board or executive level within health services.

The systems of care should address:

The structure of these systems will vary depending on the features of the region in which they are placed. In a metropolitan setting, a hospital without percutaneous coronary intervention (PCI) capabilities may have arrangements with a local PCI-capable facility for timely transfer of selected patients. In a rural or remote setting, the system is usually considerably more complex and involves general practitioners or community health centres, prehospital care providers, retrieval services (such as Careflight, Victorian Adult Emergency Retrieval and Coordination Service, Royal Flying Doctor Service), and regional and metropolitan referral hospitals. The systems should be tailored to a region’s needs.

The key elements of successful systems include:

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