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• W2883586349 abstract "Dear Colleagues, In this EMCREG-International Monograph, Continuum of Care for Acute Coronary Syndrome: Optimizing Treatment for STEMI and NSTE-ACS, you will find a detailed discussion regarding the treatment of this important disease entity, acute coronary syndrome (ACS), which impacts millions of patients across the United States each year. This is a “state-of-the-art” Monograph for emergency physicians, cardiologists, and hospitalists, which provides the evidence basis for the optimal approach to treating non–ST-elevation acute coronary syndrome (NSTE-ACS) and ST-elevation myocardial infarction (STEMI). This Monograph is divided into 4 sections, which starts with the patient at home having symptoms of ACS interacting with the prehospital care system and finishing with the patient being discharged from the hospital to home with follow-up and treatment, which have a duration of more than 12 months. The first section carefully examines the prehospital evaluation and treatment of patients with symptoms consistent with ACS. The prehospital care system, using ambulances staffed by paramedics with Advanced Cardiac Life Support capabilities, is responsible for obtaining a 12-lead electrocardiogram, providing monitoring for cardiac dysrhythmias and initiation of treatment for ACS including aspirin and nitroglycerin. For patients with confirmed STEMI, P2Y12 platelet receptor antagonists such as ticagrelor can be administered in the ambulance. In the second section of this Monograph, the treatment of NSTE-ACS and STEMI is defined for patients with ACS entering the Emergency Department (ED) by private vehicle or ambulance. The importance of early identification of these patients with the 12-lead electrocardiogram and aggressive assessment by nurses suspecting serious disease promptly places patients on care pathways that include appropriate anticoagulation and treatment with dual antiplatelet therapy. For patients with STEMI presenting to the ED, the goal is to have the patient undergo percutaneous coronary intervention (PCI) in the cardiac catheterization laboratory with a resulting open coronary artery within 90 minutes from first medical contact in the prehospital environment or 60 minutes after presentation to the ED. The third section of this Monograph focuses on therapy in the cardiac catheterization laboratory and coronary care unit. The continuation of anticoagulation and antiplatelet therapy from the prehospital environment and the ED is supplemented by a detailed discussion of PCI and other therapies necessary to optimize the outcome for these often critically-ill patients. The final section of this Monograph discusses the discharge of patients from the hospital and the appropriate treatment and follow-up care pathways for these individuals. With publication in 2016 of the ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease, the prolonged treatment of patients with ACS for 12 months after their initial presentation has become standard practice for these patients to decrease the potential for recurrence. It is our sincere hope that you will find this EMCREG-International Monograph useful to you in your daily practice as an emergency physician, cardiologist, and hospitalist. This Monograph, reflecting dual input from experts in Emergency Medicine and Cardiology, is a state-of-the-art compilation of data on the treatment of NSTE-ACS and STEMI. The Emergency Medicine Cardiac Research and Education Group (EMCREG)-International was established in 1989 as an emergency medicine cardiovascular and neurovascular organization led by experts from the United States, Canada, and across the globe. We now have Steering Committee members from the United States, Canada, Australia, Belgium, Brazil, France, the Netherlands, New Zealand, Japan, Singapore, Sweden, and the United Kingdom. Now in our 29th year, we remain committed to providing you with the best educational programs and enduring material pieces possible. In addition to our usual Emergency Physician audience, we now reach out to our colleagues in cardiology, internal medicine, family medicine, hospital medicine, and emergency medicine with our EMCREG-International University of Cincinnati Office of CME accredited symposia and enduring materials. Instructions for obtaining CME from the University of Cincinnati College of Medicine, Office of Continuing Medical Education, are available at the conclusion of this February 2018 EMCREG-International Monograph. Thank you very much for your interest in EMCREG-International educational initiatives, and we hope you visit our website (www.emcreg.org) for future educational events and publications. W. Brian Gibler, MD, President, EMCREG-International Professor of Emergency Medicine, University of Cincinnati College of Medicine.W. Brian Gibler, MD President, EMCREG-International Professor of Emergency Medicine University of Cincinnati College of Medicine Cincinnati, OHTABLE OF CONTENTS: CONTINUUM OF CARE FOR ACUTE CORONARY SYNDROME PREHOSPITAL SYSTEMS OF CARE FOR ST-ELEVATION MYOCARDIAL INFARCTION Jeffrey Luk, MD, Director, Prehospital and Disaster Medicine, UH Cleveland Medical Center Assistant Professor, Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Ankur Kalra, MD, Assistant Professor, Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Sri Madan Mohan, MD, Assistant Professor, Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Marco Costa, MD, PhD, President, Harrington Heart and Vascular Institute, UH Institutes; Professor, Medicine, Case Western Reserve, University School of Medicine; Chief Innovation Officer, Director, Interventional Cardiovascular Center, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH Christopher J. Miller, MD, Chairman, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Clinical Professor, Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, OH APPROPRIATE EVALUATION AND TREATMENT OF ST-ELEVATION MYOCARDIAL INFARCTION AND NON–ST-ELEVATION ACUTE CORONARY SYNDROME James W. Hoekstra, MD, Professor, Department of Emergency Medicine; Senior Vice President and Associate Dean for Clinical and Academic Network Development, Wake Forest Baptist Health, Winston-Salem, NC OPTIMAL CARE FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION AND NON–ST-ELEVATION ACUTE CORONARY SYNDROME IN THE CARDIAC CATHETERIZATION LABORATORY AND CORONARY CARE UNIT Jennifer Rymer, MD, Cardiology Fellow, Department of Internal Medicine, Duke University School of Medicine, Durham, NC Christopher B. Granger, MD, Professor of Medicine, Division of Cardiology, Department of Medicine; Director, Cardiac Care Unit, Duke University Medical Center, Durham, NC DEVELOPING OUTSTANDING POSTDISCHARGE CARE PROGRAMS FOR ACUTE CORONARY SYNDROME Tracy E. Macaulay, PharmD, Associate Professor of Pharmacy, University of Kentucky College of Medicine, Gill Heart & Vascular Institute, University of Kentucky Healthcare, Lexington, KY Khaled M. Ziada, MD, Gill Foundation Professor of Interventional Cardiology; Director - Cardiac Catheterization Laboratories and Interventional Fellowship Program; Clinical Chief of Cardiology, Division of Cardiovascular Medicine, University of Kentucky Healthcare, Lexington, KY PREHOSPITAL SYSTEMS OF CARE FOR ST-ELEVATION MYOCARDIAL INFARCTION Jeffrey Luk, MD Director, Prehospital and Disaster Medicine, UH Cleveland Medical Center Assistant Professor, Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Ankur Kalra, MD Assistant Professor, Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Sri Madan Mohan, MD Assistant Professor, Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Marco Costa, MD, PhD President, Harrington Heart and Vascular Institute, UH Institutes; Professor, Medicine, Case Western Reserve; University School of Medicine; Chief Innovation Officer, Director, Interventional Cardiovascular Center, University Hospitals; Case Western Reserve University School of Medicine, Cleveland, OH Christopher N. Miller, MD Chairman, Department of Emergency Medicine, University Hospitals Cleveland Medical Center; Clinical Professor, Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, OH Introduction: Approximately 250,000 patients suffer from an ST-elevation myocardial infarction (STEMI) each year in the United States.1 In 2013, the American College of Cardiology Foundation and the American Heart Association updated guidelines for the management of STEMI.2 A Class I recommendation for regional systems of STEMI care proposed “all communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities.”2 To achieve this goal, prehospital agencies have multiple responsibilities that include performing a 12-lead electrocardiogram (ECG) at the site of first medical contact (FMC), transporting a STEMI patient directly to a primary percutaneous coronary intervention (PCI)–capable hospital for primary PCI and coordinating early activation of the cardiac catheterization laboratory (CCL). Together, these interventions facilitate an ideal FMC-to-device time goal of 90 minutes or less. Heterogeneity exists in organizational architecture and clinical practice protocols across systems. Such heterogeneity is complicated by variability in “(1) paramedic training, (2) availability of prehospital ECGs, (3) ability to transmit ECGs to receiving hospitals, (4) catheterization lab activation processes, (5) protocols for bypassing non–PCI-capable hospitals with direct transport to PCI-capable hospitals, (6) reperfusion strategy at non-PCI centers, (7) data registry participants, and (8) consistent process for feedback.”3 Accordingly, a single universal design is neither practical nor achievable given variations in prehospital and hospital resources, geography, population density, and transport distances. To optimize clinical outcomes and overcome barriers that may hinder coordinated, efficient STEMI system care, regional leaders must unify to address such constraints and apply best practices. Competition in areas with multiple hospitals and physician groups can prevent a coordinated effort to achieve reperfusion in the most regionally efficient manner; this may force emergency medical system (EMS) providers to navigate complex referral networks. Development of a robust STEMI system of care requires investment in equipment and personnel for both prehospital agencies and hospitals. Prehospital agencies are challenged by escalating demand; this requires ongoing equipment maintenance and consistent education and training programs. Because EMS reimbursement is currently fixed regardless of the level of care, hospitals that agree to serve as PCI centers typically incur the burden of funding STEMI systems. In addition, although STEMI systems improve care processes, their effect on population-wide outcomes remains an active debate. Comprehensive data collection into a single warehouse is needed to assess community-wide outcomes and understand optimal system configurations. Participation in national registries and quality improvement programs is critical to continuous quality improvement. The aforementioned heterogeneity among EMS systems across the country requires that STEMI systems adapt to the local community with regard to referral patterns, interfacility transfers, and transport distances.3 Nevertheless, it has been shown that when a STEMI system of care is established in a region, both door-to-balloon (DTB) time and symptom onset-to-balloon time significantly decrease.4 In the mid-1990s, University Hospitals Health System (UHHS) in Cleveland, Ohio, integrated the mechanism for prehospital agencies to perform and transmit prehospital ECGs. In 2005, the University Hospitals EMS Training and Disaster Preparedness Institute was established as a regional leader in prehospital medicine; around the same time, heparin and clopidogrel were incorporated into the EMS Institute’s protocols for prehospital STEMI care. In 2015, clopidogrel was transitioned to ticagrelor for the prehospital setting to remain consistent with the latest guidelines and recommendations. Currently, UHHS consists of 15 hospitals, and the UH EMS Institute has over 150 prehospital agencies under its medical command in northeast Ohio. All the prehospital agencies adhere to system-wide prehospital protocols, which include that for STEMI care (Fig. 1).FIGURE 1.: University Hospitals Emergency Medical Services Training and Disaster Preparedness Institute Prehospital Protocol for Acute Coronary Syndrome.Prehospital ECG Transmission: Prehospital ECG transmission is a critical component of any regional STEMI system. Patients with anterior wall STEMI who received emergent PCI have been retrospectively evaluated and categorized based on the mode of transport and prearrival STEMI notification.5 Individuals who were transported by EMS with STEMI notification had the shortest DTB time and also had smaller infarct size compared with those who were transported without STEMI notification. The relationship between patient home distance from a PCI center, prehospital ECG use, and FMC-to-balloon time among STEMI patients using the ACTION-Get With the Guidelines Registry has been studied.1 In this evaluation, prehospital ECGs were associated with a statistically significant 10-minute reduction in FMC-to-balloon time. Moreover, the association between prehospital ECGs and shorter FMC-to-balloon times was attenuated by 0.8 minute for every 10-mile increase in distance from a PCI center. The effect that wireless transmission of prehospital ECGs has on STEMI recognition and reperfusion times has also been evaluated.6 Patients with prehospital ECGs had a mean transport time to the angioplasty suite of 43 minutes and a mean DTB time of 66 minutes compared with 49 minutes and 79 minutes, respectively, for those STEMI patients who did not receive prehospital ECGs. The patients in this study with prehospital STEMI identification and concomitant CCL activation had statistically significant reductions in mean transport time to the angioplasty suite and DTB time (33 and 58 minutes, respectively). FMC-to-balloon times have been shown to decrease significantly with prehospital ECGs (140 vs. 106 minutes; P = 0.01) or prehospital CCL activations (125 vs. 98 minutes; P = 0.04).7 Those individuals who received both prehospital ECGs and prehospital CCL activations had significantly reduced FMC-to-balloon times compared with those who did not (125 vs. 91 minutes; P = 0.02). The authors concluded that the “time-saving benefits of prehospital ECGs may not be fully realized unless prehospital CCL activations also occur.”7 When prehospital ECGs were combined with prehospital CCL activation, prehospital providers achieved further reductions in the median FMC-to-balloon time of approximately 24 minutes. In summary, prehospital ECGs facilitate prompt STEMI identification. The resultant temporal benefits optimize reperfusion strategies and may be complemented by prehospital CCL activation as discussed in the next section. Prehospital CCL Activation: Prehospital CCL activation has been shown to reduce DTB time, but its effect on mortality for STEMI patients is uncertain. A retrospective cohort study to compare the effects of CCL activation before patient arrival versus activation after arrival in the Emergency Department (ED) has been performed.8 Prehospital CCL activation was associated with a 14-minute shorter mean DTB time compared with ED CCL activation. In this analysis, 93% of prehospital CCL activations met the 90-minute target; ED-based activations had 85% compliance. Patients with prehospital CCL activations in this study, however, had a 1.5% higher in-hospital mortality and a 7.8% higher false-positive activation rate than patients who had an ED-based CCL activation. The DTB times and compliance with the national 90-minute DTB standard (at the time of the study) among 3 categories of STEMI patients has been studied: (1) EMS field activations, (2) patients transported by EMS without EMS CCL activation, and (3) walk-in STEMI patients.9 The mean DTB time was shorter for the EMS field activations when compared with the other 2 categories. Compliance with the 90-minute benchmark was 100% for the EMS CCL activation group, 72% for prehospital transports without CCL activation, and 68% for walk-in STEMI patients. Although prehospital CCL activation has been shown to provide process improvements, further refinements can be made. The clinical and ECG characteristics of STEMI patients who do not undergo PCI after prehospital CCL activation have also been evaluated.10 Increased age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and nonwhite race were all independently associated with an increased likelihood of not undergoing PCI. Out of these 5 variables, the 3 with the most significance were any type of bundle branch block [adjusted odds ratio (aOR) 5.66], left ventricular hypertrophy (aOR 4.63), and nonwhite race (aOR 3.53). The only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (aOR 2.94). These findings may lead to improvement of prehospital protocols by optimizing system-based clinical risk stratification protocols while minimizing false positive, or clinically inappropriate, prehospital CCL activations. False positive, or clinically inappropriate, CCL activation is a quality concern to any STEMI center. One study found a total positive and inappropriate CCL activation rate of 14%.11 The authors of the study found that unwanted CCL activations were more likely to occur in men older than 65 years and patients with a history of coronary artery disease. Overall, prehospital CCL activation improves DTB metrics. The reperfusion benefits of processes that improve patient progression to the CCL are well established. Prehospital P2Y12 Receptor Antagonists: Pretreatment with P2Y12 receptor antagonists while en route to the CCL for emergent/urgent PCI in acute coronary syndromes (ACS) has potential advantages: lower incidence of intra- and postprocedural stent thrombosis, decreased periprocedural myocardial infarction, and less ancillary use of glycoprotein IIb/IIIa antagonists as a bailout strategy. These potential advantages must be weighed against the potential disadvantages associated with potent antiplatelet agent pretreatment before invasive coronary angiography. These include (1) increased risk of bleeding events [both coronary artery bypass graft (CABG) and non–CABG-related bleeding], (2) higher risk of procedural bleeding (if access for coronary angiography is femoral), and (3) increased length of stay if patients require CABG (for the effects of potent antiplatelet agents to wear off).12 Pretreatment with P2Y12 receptor antagonists can occur in the prehospital environment, the ED, the cardiac intensive care unit, or the CCL before PCI.13 Clopidogrel, prasugrel, or ticagrelor are the most commonly used P2Y12 receptor antagonists. Clopidogrel is an irreversible P2Y12 receptor antagonist. The onset of action is dose dependent (600 mg loading dose vs. 300 mg loading dose) and delayed with onset in 2–6 hours.14 These kinetics render clopidogrel less effective if the pretreatment loading dose is administered after a diagnostic coronary angiogram immediately before PCI. There is paucity of high-fidelity, randomized controlled data to support the strategy of pretreatment of ACS patients with clopidogrel. The Clopidogrel for the Reduction of Events During Observation (CREDO) trial evaluated the use of a 300-mg loading dose of clopidogrel pretreatment versus placebo followed by a 75-mg maintenance dose for a duration of 12 months in the pretreatment group versus 1 month in the placebo group in 2116 patients with ACS.15 The 18% relative risk reduction in the primary end point of death, myocardial infarction, or urgent target vessel revascularization at 28 days was not statistically significantly different between the pretreatment and no pretreatment groups. In the patients who received benefit from pretreatment, a prespecified subgroup analysis showed a 6-hour time lapse between the administration of clopidogrel and performance of PCI. Also, a recent meta-analysis that included studies from the thrombolytic era showed no mortality benefit and a significantly higher bleeding risk with pretreatment using clopidogrel.16 Prasugrel is another oral, irreversible P2Y12 antagonist. Its onset of action is faster in comparison to clopidogrel (30 minutes–4 hours vs. 2–6 hours). The Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction (ACCOAST) trial randomized biomarker-positive ACS patients with non–STEMI to pretreatment with 30-mg prasugrel before diagnostic angiography and an additional 30 mg at the time of PCI versus placebo before angiography followed by a 60-mg dose before PCI.17 There were no between-group differences with regard to the composite end point of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or unplanned use of glycoprotein IIb/IIIa inhibitors through 7 days. However, patients in the pretreatment group had significantly higher major bleeding events (2.6% vs. 1.4%; hazard ratio, 1.90; 95% confidence interval, 1.19–3.02 for Thrombolysis in Myocardial Infarction [TIMI] major bleeding) that led to premature termination of the trial by the Data Safety Monitoring Board. Ticagrelor is a reversible oral P2Y12 antagonist that, unlike clopidogrel and prasugrel, does not require in vivo conversion to an active metabolite. Therefore, it has a significantly faster onset of action (30 minutes–2 hours). Ticagrelor was approved for use in ACS patients (both NSTEMI and STEMI) following data from the PLATelet inhibition and patient Outcomes (PLATO) trial that randomized 18,624 patients to upstream administration of either ticagrelor or clopidogrel (300–600 mg loading dose) before any procedure in the CCL.18 In patients who received ticagrelor, there was a significant reduction in the combined primary end point of death from any vascular cause, myocardial infarction, or stroke (9.8% vs. 11.7%; hazard ratio, 0.84; 95% confidence interval, 0.77–0.92), but there was not an increased incidence of major bleeding. Ticagrelor use was, however, associated with an increase in non–CABG-related bleeding events. Administration of upstream ticagrelor is a Class I indication in the current guidelines in patients at high risk of ischemic events.19 The Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST-Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial specifically addressed the question of pretreatment with ticagrelor in the prehospital environment or the ED versus its administration in the CCL. Because only 1862 patients were enrolled, the trial was not powered to determine superiority of pretreatment with regard to clinical end points. Surrogates were used to assess between-group differences: electrocardiographic resolution of ST-elevation greater than 70% before PCI and angiographic lack of TIMI III flow, respectively. There were no significant between-group differences in the co-primary surrogates of ST-segment resolution or TIMI III flow.20 A System-Based Approach: Effective regional STEMI care demands: (1) a sophisticated partnership between prehospital agencies, hospitals within the system, and providers across multiple disciplines; (2) continuous review of every echelon’s adherence to established guidelines through a robust, multidisciplinary quality assurance process; (3) frequent re-examination of the evidence to update guidelines accordingly; (4) a strategy to ensure continuing education; and (5) feedback for their prehospital providers. As systems seek to streamline patient movement from the field to the CCL, their leadership must develop detailed guidelines for prehospital CCL activation to minimize clinical overtriage. In the UHHS, the integration of the UH Center for Patient Flow Management (CPFM) provides 24/7 navigation support to ensure the right patient is transported to the right facility. The CPFM connects all providers in the patient’s care continuum to mitigate overtriage through visualization of the prehospital ECG and communication between all providers. As the “eyes in the sky,” the CPFM oversees patient movement throughout the system of 15 hospitals and optimizes the deployment of personnel resources and hospital capabilities to meet the needs of each patient. Coupled with coordinated oversight of a simplified “no-drips” STEMI protocol by prehospital agencies, UHHS patients have distributed access to PCI at community hospitals with continuous high quality as close to their home as possible (Fig. 2).FIGURE 2.: University Hospitals Health System ST-Elevation Myocardial Infarction (STEMI) Protocol.The UHHS STEMI protocol is one example of an integrated, multidisciplinary approach. It optimizes standardized prehospital clinical care as outlined in Figs. 1 and 2. Notably, given the broad geographic base, some clinical situations preclude a 90-minute FMC-to-device time. The UHHS STEMI protocol, therefore, also includes a simplified thrombolysis transport protocol (Fig. 3).FIGURE 3.: University Hospitals Health System ST-Elevation Myocardial Infarction (STEMI) Thrombolysis Protocol. APPROPRIATE EVALUATION AND TREATMENT OF ST-ELEVATION MYOCARDIAL INFARCTION AND NON–ST-ELEVATION ACUTE CORONARY SYNDROME James W. Hoekstra, MD Professor, Department of Emergency Medicine; Senior Vice President and Associate Dean for Clinical and Academic Network Development, Wake Forest Baptist Health, Winston-Salem, NC Introduction: ST-elevation myocardial infarction (STEMI) and non–ST-elevation acute coronary syndrome (NSTE-ACS) can cause significant morbidity and mortality if not treated aggressively and appropriately. Delay in the appropriate treatment of either entity can result in adverse outcomes for patients who present to the Emergency Department (ED) for care. The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guidelines for Management of STEMI1 and the 2014 American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for the Management of Patients with NSTE-ACS2 outline the recommended acute care therapies for these 2 patient populations. This article focuses on the early triage and treatment of STEMI and NSTE-ACS, especially as it relates to dual antiplatelet therapy in the ED and cardiac catheterization laboratory. The most recent 2016 ACC/AHA Guidelines for the Duration of Dual Anti-platelet Therapy3 clarifies the recommendations on the long-term therapy for STEMI and NSTE-ACS patients. The 3 guidelines were promulgated to standardize and optimize the evaluation, diagnosis, and management of patients with STEMI and NSTE-ACS and to provide physicians with a framework for clinical decision making. They have become the cornerstone of many ED protocols for the treatment of STEMI and NSTE-ACS and are crucial to providing efficient care in the ED and seamless transitions for patients to the cardiac catheterization laboratory or coronary care unit. In addition, the guidelines and new clinical trials data support changes in the dosing and application of antiplatelet therapy in the treatment of STEMI and NSTE-ACS. STEMI Versus NSTE-ACS: Initial Triage And Risk Stratification: The pathophysiology of acute coronary syndrome (ACS) is initiated by the endothelial rupture of an atherosclerotic coronary artery plaque. Plaque rupture leads to platelet aggregation, platelet activation, fibrin deposition, and downstream myocardial ischemia and necrosis. Especially in STEMI, downstream necrosis is time dependent, with tissue ischemia and localized infarction progressing to a wave front of necrosis developing from the subendocardium and extending transmurally outward with time. The longer the period of necrosis, the higher the chance of heart failure, patient morbidity, and death. As such, rapid diagnosis and treatment are important in patients with STEMI. In patients with chest pain and presumed coronary syndromes, the first step in triage is obtaining a 12-lead electrocardiogram (ECG) within 10 minutes after medical provider contact. This test can be performed in the field by trained emergency medical technicians or paramedics, in the ED triage area by hospital staff, or at the bedside in the ED by nursing. The initial choice of treatment pathways between STEMI and NSTEMI is based on the presence of ST-elevation or a new left bundle branch block on the 12-lead ECG. If these are present, the patient follows the STEMI pathway. If these findings are not present, the patient initially follows the NSTE-ACS pathway (Fig. 1). It is worth noting that the ECG is only a snapshot in time and that often serial ECGs are needed to detect evolving STEMI or evolving ST depression in patients with ACS. In patients with clinical instability, fluctuating or severe pain, or a high index of clinical suspicion, serial ECGs are indicated.2FIGURE 1.: Initial ECG as a triage tool in patients with chest pain.Treatment Of STEMI: Time is of the essence in the care of patients with STEMI. Care occurs across the continuum, from the patient’s bedside at home, to emergency medical systems (EMS) transport to the ED and finally to the cardiac catheterization laboratory. The care of a patient with STEMI is influenced by" @default.
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• W2883586349 title "Continuum of Care for Acute Coronary Syndrome" @default.
• W2883586349 cites W1608285098 @default.
• W2883586349 cites W1963686730 @default.
• W2883586349 cites W1966242613 @default.
• W2883586349 cites W1971528890 @default.
• W2883586349 cites W1980884073 @default.
• W2883586349 cites W1990435138 @default.
• W2883586349 cites W1992551461 @default.
• W2883586349 cites W1993893954 @default.
• W2883586349 cites W1995734689 @default.
• W2883586349 cites W2000511799 @default.
• W2883586349 cites W2031756259 @default.
• W2883586349 cites W2040450138 @default.
• W2883586349 cites W2040810648 @default.
• W2883586349 cites W2043964965 @default.
• W2883586349 cites W2053379248 @default.
• W2883586349 cites W2060607835 @default.
• W2883586349 cites W2061466162 @default.
• W2883586349 cites W2076350004 @default.
• W2883586349 cites W2077204822 @default.
• W2883586349 cites W2082149672 @default.
• W2883586349 cites W2092834790 @default.
• W2883586349 cites W2093665268 @default.
• W2883586349 cites W2095875710 @default.
• W2883586349 cites W2095901832 @default.
• W2883586349 cites W2096069261 @default.
• W2883586349 cites W2096429890 @default.
• W2883586349 cites W2097523487 @default.
• W2883586349 cites W2104806055 @default.
• W2883586349 cites W2110108344 @default.
• W2883586349 cites W2110166542 @default.
• W2883586349 cites W2114879453 @default.
• W2883586349 cites W2115824015 @default.
• W2883586349 cites W2119529881 @default.
• W2883586349 cites W2121908294 @default.
• W2883586349 cites W2122833169 @default.
• W2883586349 cites W2125043491 @default.
• W2883586349 cites W2125173296 @default.
• W2883586349 cites W2126800506 @default.
• W2883586349 cites W2128969306 @default.
• W2883586349 cites W2132861593 @default.
• W2883586349 cites W2140501627 @default.
• W2883586349 cites W2149011208 @default.
• W2883586349 cites W2151343477 @default.
• W2883586349 cites W2153107785 @default.
• W2883586349 cites W2156255513 @default.
• W2883586349 cites W2159865010 @default.
• W2883586349 cites W2161336471 @default.
• W2883586349 cites W2168812439 @default.
• W2883586349 cites W2169387542 @default.
• W2883586349 cites W2170949977 @default.
• W2883586349 cites W2171082437 @default.
• W2883586349 cites W2211414126 @default.
• W2883586349 cites W2272486312 @default.
• W2883586349 cites W2295175909 @default.
• W2883586349 cites W2312246162 @default.
• W2883586349 cites W2395993059 @default.
• W2883586349 cites W2409470239 @default.
• W2883586349 cites W2409932873 @default.
• W2883586349 cites W2546429006 @default.
• W2883586349 cites W2547562499 @default.
• W2883586349 cites W2555254911 @default.
• W2883586349 cites W2595429001 @default.
• W2883586349 cites W2744105079 @default.
• W2883586349 cites W2754054868 @default.
• W2883586349 cites W2755584350 @default.
• W2883586349 cites W2766152280 @default.
• W2883586349 cites W2990222218 @default.
• W2883586349 cites W3183915260 @default.
• W2883586349 cites W4211143229 @default.
• W2883586349 cites W4236531408 @default.
• W2883586349 cites W53719006 @default.
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