Acute coronary syndromes: consensus recommendations for translating knowledge into action

Current guidelines recommend early reperfusion for patients with STEMI.4 The earlier the delivery of reperfusion, the better the outcomes.9 If delivered promptly (within 90 minutes of presentation in most settings), percutaneous coronary intervention (PCI) achieves superior outcomes to those achieved with fibrinolysis.10 Where PCI is not available, fibrinolysis is the best option, and should be delivered within 30 minutes of presentation to hospital, or in the prehospital setting if feasible.4,11

Current management gaps. Recent Australian registry data12 show that:

• median presentation-to-PCI interval is 102 minutes, with the benchmark of 90 minutes exceeded in 65.7% of patients;

• among patients treated with a fibrinolytic agent, the median presentation-to-needle time is 45–68 minutes, with the benchmark of 30 minutes exceeded in most patients; and

• up to 30% of patients with STEMI do not receive reperfusion therapy; this is comparable with observations in other developed countries.13

Strategies for closing these gaps. Effective strategies to reduce delay between presentation and reperfusion include systems to:

• enable the catheterisation laboratory to be activated by a single call by the first health care professional qualified to recognise STEMI, bypassing traditional hospital hierarchical decision-making systems;14,15

• activate the catheterisation laboratory before the patient arrives at the hospital,15 either through an ambulance-based 12-lead electrocardiogram (ECG) or a voice call;16

• transfer patients directly to a reperfusion-capable facility in preference to a closer non-reperfusion centre;16 and

• enable initiation of fibrinolytic therapy by health care workers other than doctors, including in a prehospital setting in some circumstances.11

No single system will improve reperfusion rates and times in all Australian regions. Modelling studies are needed to ensure patients in all geographical locations have timely access to reperfusion-capable facilities, either through more efficient use of existing resources or by setting up additional centres. Collaboration between local agencies is recommended so that the optimal system for each region can be developed based on case loads, resources, workforce, geographical considerations and referral patterns.

Once ST-elevation has been excluded, guidelines recommend formal risk stratification of patients with suspected NSTEACS to identify those at high risk of an adverse cardiac outcome. This process involves a detailed history, physical examination, and interpretation of electrocardiograms and blood tests, including troponin assays.4 Decision-making tools, such as clinical pathways and ACS protocols, have been shown to improve the accuracy of risk stratification and referral to appropriate evidence-based therapies.17,18 Clinical pathways are agreed procedures for applying protocols in the local setting, including prehospital, intra- and interhospital transfer of patients. Components may include risk stratification tools for identifying patients who belong to low-, moderate- or high-risk categories to guide clinical management. ACS protocols are standardised procedures for applying evidence-based guidelines at the state, network or institution levels, to guide the “rules of business” for ACS management.

Current management gaps. Evidence of discordance between assessed risk and intensity of management19 suggests that risk stratification for patients with ACS is often not performed appropriately. Furthermore, resistance to the use of clinical algorithms has been observed in some Australian hospitals.20

Strategies for closing these gaps. The process of risk stratification can be improved by:

• implementing clinical pathways that incorporate triage, risk assessment and referral, taking into account local context. This would require clinical leadership, education, and acceptance of the agreed clinical pathway by medical staff, on the understanding that it is not intended to replace clinical judgement;

• a system-wide approach to staff training to overcome barriers encountered due to mobility of the medical workforce; and

• including risk stratification measurement and feedback in key performance indicators (KPIs) (see priority area 6).

Guidelines recommend access to coronary angiography and PCI for patients with high-risk NSTEACS,4 based on evidence that the use of these interventions improves outcomes.21-24

Current management gaps. Available Australian data indicate that the probability of patients with high-risk NSTEACS receiving angiography and PCI or coronary artery bypass graft (CABG) surgery is significantly reduced when they present to a hospital without angiographic facilities, and that the incidence of this situation has increased since the early 1990s.23,25,26 Although some regions face a significant lack of resources, existing resources and facilities are not being fully utilised in others. For instance, recent New South Wales health data indicate that revascularisation rates can vary by up to 30% between area health care services with comparable numbers of catheterisation facilities.27

Strategies for closing these gaps. Increased access to invasive management for patients with high-risk NSTEACS will require a combination of decentralisation of invasive facilities3 and system-based approaches to overcome other barriers to access. Further feasibility modelling will be required to determine the population needed to support a catheterisation laboratory in each region. A hub-and-spoke model of hospital networks is an effective mechanism for improving access. This requires attention to:

• triage systems (see priority area 2);

• systems of communication between clinical staff, departments and institutions; and

• patient transport between facilities.

These systems must be tailored for local conditions, particularly in rural and remote settings (see priority area 5).

Current guidelines recommend that all patients with ACS be referred to a cardiac rehabilitation program following an acute event.4 Recent data from the United States and the United Kingdom suggest that secondary prevention therapies have been as significant as acute therapies in achieving the reduction in age-adjusted CHD mortality seen over the past two decades.28,29

Current management gaps. Only about 30% of eligible Australian patients access cardiac rehabilitation programs, comparable with findings overseas,30,31 and this has not improved significantly over the past 10 years.26 Failure to educate patients about the importance of secondary prevention strategies probably contributes to the 10%–15% medication drop-off rates observed in the 12 months following hospital discharge.23,26

Strategies for closing these gaps. Participation in cardiac rehabilitation or secondary prevention programs after ACS can be improved by:

• implementing protocols for referral to cardiac rehabilitation programs for all ACS patients, including those who had NSTEACS or have undergone CABG surgery;

• offering cardiac rehabilitation program sessions on evenings and weekends or through health professional home visits; and

• expanding effective alternative secondary prevention programs such as Choice of Health Options In prevention of Cardiovascular Events (CHOICE)32,33 and Coaching patients On Achieving Cardiovascular Health (COACH), which have been shown to be effective in reducing risk in the Australian setting.34,35

Although most Australians live in urban centres, 10%–30% (depending on definition) live in rural and remote areas. Where the nearest PCI centre is over 90 minutes away, thrombolysis becomes the choice for reperfusion therapy. All centres currently treating ACS need access to third-generation single-dose fibrin-specific fibrinolytic agents (tenecteplase or reteplase).

Current management gaps. The yearly CHD-related death rate increases with remoteness, from 71.1 per 100 000 population in metropolitan areas to 85.5 in remote Australia.36 Aboriginal and Torres Strait Islander peoples experience higher mortality rates from CHD than other Australians.1 Health system issues differ between urban, rural and remote Aboriginal and Torres Strait Islander communities.

Despite guideline recommendations against the use of streptokinase, it is still used in some centres, particularly regions with Indigenous populations. The greatest efficiencies in remote settings are achieved where local health care workers are able to deliver fibrinolysis. However, staff in remote areas may lack appropriate training and access to expert support for decision making. There is some evidence that Aboriginal and Torres Strait Islander peoples may not receive ideal care once hospitalised.37 A shortage of culturally appropriate health care workers in these facilities probably contributes to this problem. Failure to provide secondary prevention for patients presenting to rural and remote locations has also been reported.38

Strategies for closing these gaps. ACS care for geographically isolated or vulnerable communities can be improved by:

• ensuring that hospitals, community health centres and medical centres have access to point-of-care pathology and electrocardiography, and technology for electronic transfer of ECG images;

• developing transparent and culturally appropriate regional systems for prompt and appropriate patient transfer of high-risk patients;23,26 and

• developing local networks that are identifiable to local communities.

A nationally standardised collection of clinical data, with feedback on patient characteristics, processes of care and clinical outcomes, would enable comparisons within and between health care facilities, and inform improvements in clinical effectiveness.39

Current management gaps. There is a lack of standardised information on the care of patients with ACS across the continuum of ACS management in Australia. Available evidence indicates that ACS management in Australia is suboptimal, consistent with findings from other developed nations.40

Strategies for closing these gaps. Systems for optimal data collection and governance should be established, with:

• standards for a minimum dataset including patient characteristics, investigations, management and clinical outcomes;

• development of KPIs;

• mandated audit of data veracity for 10%–15% of clinical presentations;

• reporting of KPIs through standard health department processes, and aggregation of data at state and national levels; and

• communication of performance outcomes to hospitals and clinical networks, with appropriate peer group comparisons.

Local health facilities should be responsible for collection of data, and retain ownership. Incentives to participate in this process may be facilitated by the development of multisite quality improvement collaboratives. State and federal governments should be responsible for aggregating data at state and national levels, respectively.