The 2014 AHA NSTE-ACS Guidelines

One of the best things about Emergency Medicine is the preponderance of guidelines imposed upon our management of patients by non-Emergency Medicine clinicians.  One of the most glorious offenders is the American Heart Association, dictating our care of Stroke and Acute Coronary Syndrome.

But, actually, this most recent update – despite the continued absence of Emergency Medicine from the Writing Committee – contains some interesting subtle shifts.  Out of its 150-odd pages of content and evidence, most of the Emergency Medicine-relevant content is in Section 3: Initial Evaluation and Management.  Many of the guidelines are not controversial – send patients with suspected ACS to the Emergency Department, give aspirin, obtain an ECG, etc.

But, as a Class I recommendation, they note patients with suspected ACS can be risk-stratified based on likelihood of ACS to decide on the need for hospitalization.  They also now include an expanded discussion of tools beyond the old stalwarts TIMI and GRACE, incorporating ED-centric tools such as the Vancouver Rule, the HEART score, and the HEARTS3 score.  This greatly expands guideline-based backing of these rules for shared decision-making with patients, and, frankly, makes the previously “mandatory” observation of patients with chest pain less so.

The next interesting bit relevant to the ED lay in subsection 3.4.1 – the use of biomarkers.  I’ll just reproduce my favorite bit here:

Class III: No Benefit
1. With contemporary troponin assays, creatine kinase myocardial isoenzyme (CK-MB) and myoglobin are not useful for diagnosis of ACS (158-164). (Level of Evidence: A)

The guidelines also imply, if symptom onset can be reliably determined, a single troponin measurement is reasonable 6+ hours after onset, or, for shorter onset timeframes, a troponin on arrival and a second as few as 3 hours after onset is reasonable to detect rising or falling levels.  And, beautifully, in subsection 3.5.1, all recommendations regarding discharge from the ED are Class IIa, only make weak recommendations for the reasonableness of observation, and acknowledge most patients with chest pain do not have ACS, and most are not at risk of ACS.

There is ample further fodder for the interested reader to pick apart recommendations and conflicts of interest – particularly with regards to the incorporation of newer antiplatelet agents – but, I’m generally pleased with the general direction of this guideline, as it applies to our practice.  However, this does not preclude the need for ACEP to develop its own Clinical Policy, to further guide and protect both patients and Emergency Physicians.

“2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines”
http://circ.ahajournals.org/content/early/2014/09/22/CIR.0000000000000134.full.pdf+html