Management of Acute Coronary Syndromes (ACS)

Management of acute coronary syndromes (ACS)This presentation reflects the recommendations in the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealands Guidelines for the Management of Acute Coronary Syndromes (ACS) (2006), updated in the 2007 and 2011 addenda.The presentation is designed for use in health professional development and training on acute ACS care.2012 National Heart Foundation of AustraliaThis presentation should be viewed in the context of similar material on Warning Signs and Reducing risk in heart disease. By way of introduction speakers should brief the audience that this presentation is intended to summarise recent changes contained in the 2011 addendum to the Guidelines for the Management of Acute Coronary Syndromes (ACS) (2006) developed jointly by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.

1OutlineCardiovascular disease (CVD) the facts and risk factorsAcute coronary syndromes (ACS) Presentation of ACSACS management: summary of updates in the 2011 addendum11. Systems of care2. Investigations3. Management of patients with ST-segment elevation myocardial infarction (STEMI)4. Management of patients with non-ST-segment elevation ACS (NSTEACS)5. Long-term management

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.

2012 National Heart Foundation of AustraliaThis presentation provides a background to ACS, and the incidence of ACS in Australia. It includes a summary of the key updates outlined in the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand 2011 addendum to the 2006 Guidelines. The addendum is a summary of clinical trial evidence published between 2007 and the end of 2010 that is relevant to the recommendations in the 2006 Guidelines and subsequent 2007 addendum. The updates span systems of care, diagnosis and work-up of suspect ACS cases, discharge arrangements and long-term management.

2CVD the factsHeart disease is the single leading cause of death.

In 2009, 28 Australians died from a heart attack each day. Thats one life claimed every 51 minutes.1

CVD is expected to affect 1 in 4 Australians by 2051.2References1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.

2012 National Heart Foundation of AustraliaCVD is the single leading cause of death in Australia. The Heart Foundations strategic purpose is: to reduce premature death and suffering from heart, stroke and blood vessel disease in Australia. This is based on the expectation that, despite advances in medicine, CVD is still expected to affect 25% of the Australian public by 2051. 3Modifiable risk factors:smokingpoor diethigh cholesterolphysical inactivityhigh blood pressurebeing overweightdepression, social isolation andlack of social support.Non-modifiable risk factors:gender agefamily history of CVDdiabeteshuman immunodeficiency virus (HIV).Risk factors for CVD2012 National Heart Foundation of AustraliaThis slide is an introduction to modifiable and non-modifiable risk factors. The speaker may wish to outline that modifiable risk factors are those that an individual can change.

4Acute coronary syndromes (ACS)ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack) through an accelerated pattern of angina without evidence of myonecrosis1/infarction (muscle death). Myocardial infarction (MI) occurs when the blood supply to the heart muscle is interrupted due to partial or complete occlusion (thrombus) of the coronary artery. As a result, some of the heart muscle becomes infarcted (dies). A heart attack can be confirmed by an electrocardiogram (ECG) test. Reference1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1S14.2012 National Heart Foundation of AustraliaThis slide presents an introduction to ACS and heart attacks, and how they occur. This presentation could be set within the context of other initiatives by the National Heart Foundation of Australia namely Warning Signs (a public awareness campaign about the warning signs of a potential heart attack) and Reducing risk in heart disease a guide to clinical practice for secondary prevention of coronary heart disease for health professionals.

5Thrombus formation in the arterial lumen

2012 National Heart Foundation of AustraliaThese diagrams illustrate thrombus formation in the arterial lumen. They illustrate the trans-section of an artery, showing how the narrowing of an artery due to thrombus formation can block the flow of blood. This blockage restricts the blood supply to the heart, and can lead to a heart attack.

6Acute presentation of ACSCritical factors to timely treatment:recognition time People experiencing ACS symptoms should seek help promptly and activate emergency services.

Heart attack

2012 National Heart Foundation of AustraliaThis diagram shows the effect of a blood clot in a coronary artery. Speakers should highlight the point that anyone experiencing ACS symptoms should seek help promptly by calling Triple Zero (000) to activate emergency services.

7Signs and symptoms of ACS presentation

Symptoms may include: chest discomfort (tightness, pressure, heaviness) at rest or for a prolonged period (> 10 minutes, not relieved by sublingual nitrates)recurrent chest discomfortdiscomfort associated with syncope/acute heart failure.

The pain may spread to other parts of the upper body, including: back, neck, jaw, arm(s), shoulder(s) or epigastric pain.

The person may also experience:dyspnoea (shortness of breath), diaphoresis (profuse perspiration), dizziness, nausea or vomitingrecent research shows that women, the elderly and people with diabetes are less likely to experience chest pain as a symptom.

2012 National Heart Foundation of AustraliaIt is important to understand that warning signs can vary from person to person and they may not always be sudden or severe. Although chest pain or discomfort is the most common symptom of a heart attack, some people will not experience chest pain at all, while others will experience only mild chest pain or discomfort. Others may experience one symptom, while some experience a combination.

This slide outlines the range of signs and symptoms associated with the presentation of ACS. The one thing all suspected heart attacks have in common is that the sooner the patient receives treatment, the less damage will be done.

Note to speakers: epigastric pain is also known as upper abdominal pain.

82011 addendum to 2006 GuidelinesThe 2011 addendum to the 2006 Guidelines provides updates to:1. Systems of care to support delivery of ACS services 2. Early response3. Management of patients with STEMI4. Management of patients with NSTEACS5. Long-term management (after control of myocardial ischaemia).1

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.

2012 National Heart Foundation of AustraliaThe National Heart Foundation of Australia, in partnership with the Cardiac Society of Australia and New Zealand, released an update to the 2006 Guidelines for the management of acute coronary syndromes.

The update (2011 addendum) provides a summary of updated clinical trial evidence (published between 2007 and 2010) that is relevant to the recommendations contained within the guidelines.

These are summarised (on this slide) into five key areas. The remainder of the presentation provides further detail on each of these key areas.

Speakers, please highlight that the recommendations contained in the 2011 addendum are graded according to the level of evidence supporting that recommendation. The grade of recommendation is provided in brackets ( ) after each recommendation. Grades of recommendations are based upon the NHMRC additional levels of evidence and grades of recommendations for developers of guidelines.

9Formal systems of care:defined continuum of care from presentation to long-term management system-based approaches to deliver timely reperfusion at a local level (Grade B)routine audit integrated into all clinical ACS services (Grade B)training GPs/health workers to initiate fibrinolysis (if primary percutaneous coronary intervention [PCI] services are not readily accessible) practitioners are supported by ready access to expert cardiology consultation (Consensus)cardiac clinical networks established with appropriate protocols (Grade B).1. Systems of care to support delivery of ACS servicesFor example: iCCnet CHSA network links > 70 hospitals, health centres and general practitioner [GP] surgeries across SA, aligned to the Health Reform Agenda principles.2012 National Heart Foundation of AustraliaThis slide gives an overview of the key recommendations for systems supporting the delivery of ACS care across Australia.

It advocates for defined care along the patients entire pathway (i.e. from a patients initial presentation through to their long-term care (secondary prevention)).

System-based approaches would include:universal response across Australia to Triple Zero (000) calls describing the warning signsroutine audit of ACS servicescountry-wide training of GPs and health workers to thrombolyse a patient diagnosed as having a heart attack particularly where PCI services are unavailable.

State-based cardiac clinical networks have been successful in establishing protocols of care relevant to the infrastructure available in their state. Some cardiac clinical networks have implemented ready-access support mechanisms to assist health practitioners to link with an expert for patients with suspected or diagnosed ACS.

102. Early response: treatment is time critical Time from symptom onset and likely outcome< 1 hourAborted heart attack or only little heart muscle damage12 hoursMinor heart muscle damage only24 hoursSome heart muscle damage with moderate heart muscle salvage46 hoursSignificant heart muscle damage with only minor heart muscle salvage612 hoursNo heart muscle salvage (permanent loss) with potential infarcthealing benefit> 12 hoursReperfusion is not routinely recommended if the patient is asymptomatic and haemodynamically stableIn cases of major delay to hospitalisation (> 30 minutes) ambulancecrews should consider pre-hospital fibrinolysis.2012 National Heart Foundation of AustraliaHeart Foundation research shows that the current median delay time to treatment is around four hours that is two and a half hours too long! Even scarier, one in three patients will delay longer than eight hours, and one in eight longer than 24 hours.

Early recognition of the warning signs of heart attack can reduce the potential damage to the heart muscle.

This table illustrates the impact of ongoing delay (by not responding quickly to the warning signs). The table shows the benefit of early response to the warning signs, and calling for help or presenting in the emergency department (ED). For example: four hours after symptom onset, there is significant damage to your heart muscle, with only limited ability for treatment to reduce this damageafter six hours the damage to your heart will be permanent and cannot be reversedafter 12 hours there is unlikely to be any benefit from treatment.

11STEMI what is it? An ST-segment elevation myocardial infarction (STEMI) can be confirmed by an ECG.

STEMI is defined as presentation with clinical symptoms consistent with an ACS with ECG features including any of:persistent ST-segment elevation 1 mm in two contiguous limb leadsST-segment elevation 2 mm in two contiguous chest leadsnew left bundle branch block (LBBB) pattern.

2012 National Heart Foundation of AustraliaA STEMI is a strong indication of a heart attack. The name STEMI comes from the elevated S-T segment reading of the ECG.

For patients presenting with symptoms consistent with an ACS, an ECG reading is taken to assess whether the indications (listed) for reperfusion therapy are met. An ECG is a recording of the hearts electrical activity.

A trigger of the reperfusion strategy is an ECG reading, in patients presenting with symptoms consistent with ACS, where any of the features outlined on the slide are found. 12

3. Management of patients with STEMI

2012 National Heart Foundation of AustraliaThis slide presents an overview of the recommended care pathway for patients presenting with symptoms that are consistent with STEMI.

This algorithm is published by the Heart Foundation. It is intended for use in a clinical setting.

The upper section of the algorithm is designed to assist clinicians, such as in an ED, in the examination of patients presenting with symptoms that are consistent with ACS. The initial steps focus on physical examination and monitoring of symptoms, pain relief and tests to aid diagnosis. (The next slide provides more detail on this section.)

The next steps outline the doctors assessment of the patient (Australasian Triage Category 2). If the patient meets the indications for reperfusion therapy, based on the ECG readings, an assessment of the time duration from symptom onset is taken.

Reperfusion therapy should be considered 12 hours from symptom onset.

13Early responseImplement reperfusion strategy for patients presenting within 12 hours of onset of ischaemic symptoms consistent with ACS (determined by physical examination): immediate 12-lead ECG insert cannulae pain relief blood tests.Give aspirin 150300 mg (unless already given, or contraindicated).Doctor sees patient within 10 minutes of arrival (Australasian Triage ScaleCategory 2).Oxygen therapy indicated only for patients with hypoxia (oxygen saturation < 93%) and those with evidence of shock (Consensus).

2012 National Heart Foundation of AustraliaThis slide details the initial examination of a patient presenting with symptoms consistent with ACS. It is intended for use in a clinical setting (e.g. within an ED).

Within an ED, patients with suspected ACS are categorised as Australasian Triage Category 2 (i.e. a doctor sees the patient within 10 minutes of arrival).

Speakers, please note the change to the recommendations regarding oxygen therapy (this is consistent with Australian Resuscitation Council guidelines).

14Choice of reperfusion therapyIn general, PCI is the treatment of choice, providing it can be performed promptly by a qualified interventional cardiologist in an appropriate facility.1All PCI facilities should be able to perform primary angioplasty within 90 minutes of patient presentation.Fibrinolysis should be considered early if PCI is not readily available.In cases of major delay to hospitalisation (> 30 minutes) consider pre-hospital fibrinolysis.Reference1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S929.2012 National Heart Foundation of AustraliaThe choice of reperfusion therapy is dependant largely on the distance to hospital and/or infrastructure available.

Pre-hospital fibrinolysis should be considered for patients who experience a major delay in reaching hospital (> 30 minutes).

PCI is recommended as the treatment of choice, providing there is a qualified team present to perform PCI, in appropriate facilities, within 90 minutes of presentation.

Fibrinolysis is recommended early where PCI is not readily available, unless contraindicated. We will revisit the absolute and relative contraindications for fibrinolysis later in the presentation.

Note 1: Reperfusion is not routinely recommended after 12 hours from symptom onset if the patient is asymptomatic and haemodynamically stable.

Note 2: Patients for whom fibrinolysis is contraindicated, or who have ongoing symptoms or instability after fibrinolysis, should be transferred for PCI.

15PCI cardiac catheterThe catheter can be inserted via the radial or femoral artery (insertion via the femoral arteryillustrated below).

2012 National Heart Foundation of AustraliaPCI is undertaken using a cardiac catheter. This slide illustrates how a cardiac catheter can be inserted. The image on the right is an angiogram (angiography is essential to PCI procedures).

16PCI how it works

2012 National Heart Foundation of AustraliaThis slide illustrates in three steps how reperfusion by PCI is performed, as follows:1. The artery or vessel narrows, restricting blood flow to the heart muscle. A catheter carrying a stent (spring-like), in which is enclosed a small balloon, is inserted.2. Once in the correct position the narrow part of the vessel the balloon is inflated, expanding the stent. The balloon is deflated and the catheter with the balloon is removed.3. The stent creates a passage through the vessel, restoring the blood flow to the heart muscle.

17Primary PCI technique and antithrombotic therapy

Among patients with STEMI undergoing primary PCI the use of bivalirudin can be considered as an alternative to heparin and GP IIb/IIIa inhibitors (Grade B).1Among patients undergoing primary PCI for reperfusion, consider antiplatelet therapy with either:high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75 mg/day for at least 12 months) (Grade B)prasugrel (60 mg oral bolus + 10 mg daily) (Grade B)ticagrelor (180 mg oral bolus + 90 mg twice daily) (Grade B).1Careful assessment of bleeding risk should be undertaken before using antithrombotic agents (Grade B).1Consider use of mechanical thrombectomy techniques to reduce thrombus burden during primary PCI (Grade A).1

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.

2012 National Heart Foundation of AustraliaThis slide provides a summary of recommendations when performing primary PCI.

Mechanical thrombectomy is a technique used to remove thrombus for the vessel prior to the insertion of a stent.

Careful assessment of bleeding risk is recommended before use of an antithrombotic agent. Alternative antithrombotic agents may be considered.

The slide outlines a selection of antiplatelet therapies, together with the recommended dosage. 18Bleeding risk

age > 75 years femalehistory of bleedinghistory of stroke or transient ischaemic attack (TIA) creatinine clearance rate < 60 mL/min diabetesheart failure tachycardiablood pressure < 120 mmHg or 180 mmHg peripheral vascular disease (PVD) anaemia concomitant use of GP IIb/IIIa inhibitor enoxaparin 48 hours prior switching between unfractionated heparin and enoxaparin procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart catheterisation).The following risk factors should be considered when assessing bleeding risk and choosing antithrombotic therapies in patients with ACS (Grade B):

2012 National Heart Foundation of AustraliaThere is a bleeding risk associated with PCI procedures, and with the use of antithrombotic therapies.

Careful assessment of bleeding risk is recommended (further details are provided on the next slide).

The slide sets out the risk factors to consider when assessing bleeding risk, and choice of antithrombotic therapy.19Fibrinolysis

Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the coronary vessels to restore blood flow to the heart muscle.1 Consider early routine revascularisation of patients receiving fibrinolysis, regardless of success of pharmacologic reperfusion (Grade A). Absolute contraindicationsActive bleeding or bleeding diathesis (excluding menses).Significant closed head or facial trauma within 3 months.Suspected aortic dissection.Any prior intracranial haemorrhage.Ischaemic stroke within 3 months.Known structural cerebral vascular lesion.Known malignant intracranial neoplasm.

Reference1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis primary or secondary fibrinolysis.Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm. Accessed 7 August 2011. 2012 National Heart Foundation of AustraliaEarly fibrinolysis is recommended where PCI is not readily available, unless contraindicated. Fibrinolysis is sometimes referred to as a clot busting therapy. Note the absolute (and relative) contraindications for fibrinolysis (relative contraindications are shown on the following slide).

Note 1: Reperfusion is not routinely recommended after 12 hours from symptom onset if the patient is asymptomatic and haemodynamically stable.

Note 2: Patients for whom fibrinolysis is contraindicated, or who have ongoing symptoms or instability after fibrinolysis, should be transferred for PCI.

20Fibrinolysis

Relative contraindicationsCurrent use of anticoagulants.Non-compressible vascular punctures.Recent major surgery (< 3 weeks).Traumatic or prolonged (> 10 mins) CPR.Recent internal bleeding (within 4 weeks).Active peptic ulcer.History of chronic, severe, poorly controlled hypertension.Severe uncontrolled hypertension on presentation (systolic 180 mmHg or diastolic 110 mmHg).Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.Pregnancy. 2012 National Heart Foundation of AustraliaThis slide outlines the relative contraindications for fibrinolysis.21NSTEACS what is it? Non-ST-elevation ACS (NSTEACS) applies to patients with suspected ACS in the absence of other plausible causes of troponin elevation (e.g. sepsis, pulmonary embolus).On physical examination, patients with NSTEACS may have a normal ECG reading, or show minor changes (occurs in up to 50% of patients).All patients with NSTEACS should have their risk stratified to direct management decisions.The management of patients with NSTEACS requires evolving risk stratification: clinical assessment, assessment of cardiac biomarkers and time.

2012 National Heart Foundation of AustraliaThe presentation of patients with suspected non-ST-elevated ACS is less clear cut. The physical examination and ECG reading may be normal.

The management of patients with NSTEACS requires evolving risk stratification: clinical assessment, assessment of cardiac biomarkers and time. 224. Management of patients with NSTEACS.Clinical assessment: careful clinical history, ECG, chest X-ray and investigations to diagnose other causes of chest pain and evaluate the likelihood of evolving ACS.Troponin assessment: to assess the likelihood of MI.Stratify risk.

2012 National Heart Foundation of AustraliaThis slide presents an overview of the recommended care pathway for patients with suspected ACS in the absence of other plausible causes of troponin elevation (e.g. sepsis, pulmonary embolus). Where other diagnoses are evident, management of these patients should be directed at these conditions.

This algorithm is published by the Heart Foundation. It is intended for use in a clinical setting.

It outlines the evolving risk stratification, which entails: ongoing clinical assessmentrepeated troponin assessment. Serum troponin measurement is an important tool in the evolving risk stratification of patients with suspected NSTEACS. The algorithm is based on high-sensitivity (HS) troponin testing new, improved assays of cardiac troponins T (TnT) and I (TnI) show acceptable analytical precision at levels 10- to 100-fold lower than conventional assays. The superior performance of these high sensitivity assays for early detection of MI has been confirmed in the following large clinical trials:Apple FS. A new season for cardiac troponin assays: its time to keep a scorecard. Clin Chem 2009; 55(7):13031306Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009; 361(9):868877ReichlinT, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009; 361(9):858867.However, HS troponin testing is not routinely used throughout Australia. If HS troponin testing is unavailable, assessment should be based on conventional assay tests at four-hour and eight-hour time points.

Risk stratification to high, intermediate, and low risk is based upon the National Heart Foundation of Australias risk stratification model (shown on the slide). The following slides provide further detail about the three levels of risk.

23Evolving risk stratification

Admit to coronary care unit or high dependency unit:estimate ischaemic risk, estimate bleeding risk, choose augmented antithrombotic therapyrefer for angiography to determine surgery/PCI, or medical therapy.2012 National Heart Foundation of AustraliaDetails of the high-risk NSTEACS. 24Evolving risk stratification

2012 National Heart Foundation of AustraliaThis slide outlines the clinical features consistent with ACS, without the high-risk features of the previous slide.

In the event of recurrent ischaemia or elevated troponins, it is recommended that these patients are admitted to a coronary care unit or other high-dependency care unit.

In the absence of recurrent ischaemia or elevated troponins, it is recommended that these patients undergo a stress test, which is also known as an exercise ECG, using a treadmill.

25Evolving risk stratification Intermediate-risk NSTEACSRecurrent ischaemia or elevated troponin?YESadmit to CCU or high dependency unit:estimate ischaemic risk, estimate bleeding risk, choose augmented antithrombotic therapyrefer for angiography to determine surgery/PCI, or medical therapy.NOundertake stress test (e.g. exercise ECG):positive refer for angiography to determine surgery/PCI, or medical therapynegative proceed to discharge patient with urgent cardiac follow-up (on upgraded medical therapy) according to long-term management after control of myocardial ischaemia.

2012 National Heart Foundation of AustraliaContinuing from the previous slide, if clinical features consistent with ACS are present, without the high-risk features:

in the event of recurrent ischaemia or elevated troponins, it is recommended that these patients are admitted to a coronary care unit or other high-dependency care unit

in the absence of recurrent ischaemia or elevated troponins, it is recommended that these patients undergo a stress test, which is also known as an exercise ECG, using a treadmill.

26Evolving risk stratification Appropriate period of observation. Consider if stress test (e.g. exercise ECG) needed? Stress test (e.g. exercise ECG) using treadmill.

YESProceed to discharge patient with urgent cardiac follow-up (on upgraded medical therapy) according to long-term management after control of myocardial ischaemia.NO

2012 National Heart Foundation of AustraliaContinuing, this slide outlines the clinical features consistent with ACS, without intermediate-risk, or high-risk features from the previous slides.

Following a recommended period of observation, consideration should be given to the need for further investigation of these patients consider a stress test, which is also known as an exercise ECG, using a treadmill.

In the absence of further investigation, arrange discharge with urgent cardiac follow-up.

27Antithrombotic therapy for NSTEACSFor high-risk patients with NSTEACS, assess bleeding risk individually according to the number and severity of bleeding risk factors (Grade A).Assign a management strategy according to bleeding risk.For patients at high risk of bleeding, use a priority low-bleedingstrategy.Antithrombotic agents with lower bleeding risk include:clopidogrel in preference to prasugrel (Grade B)fondaparinux in preference to enoxaparin (Grade B)bivalirudin in preference to enoxaparin (Grade B).For patients at low risk of bleeding, use a standard effective antiplatelet regimen (prasugrel and ticagrelor) (Grade A). (cont.)2012 National Heart Foundation of AustraliaAgain, the bleeding risk in patients with NSTEACS requires careful assessment.

This slide provides a summary of recommendations on antithrombotic and antiplatelet therapy (management strategy) according to bleeding risk for patients with NSTEACS. Highlight the assessment of bleeding risk.

Continues on following slide.

28Antithrombotic therapy for NSTEACSMinimise the number of agents used (Grade B).When additional agents are needed, substitute rather than add (Grade B).Consider shorter-acting or reversible agents (Grade B).Avoid using GP IIb/IIIa inhibitors, where possible (Grade B).2012 National Heart Foundation of Australia5. Long-term management Before discharging a patient: discharge medication regimenprovide tailored lifestyle advice to reduce risk of further events, including: smoking cessationgood nutrition and moderate alcohol intakephysically active lifestyle and weight management as relevant managing depressionwarning signs of a heart attack.Refer all patients to comprehensive cardiac rehabilitation programs.Provide all patients with a written action plan for chest pain, which can be downloaded from www.heartfoundation.org.au

2012 National Heart Foundation of AustraliaAll patients with ACS (STEMI or NSTEACS) should receive a written chest pain action plan before they leave hospital.

Upon discharge, all patients with ACS should be referred to comprehensive ongoing prevention and cardiac rehabilitation services (i.e. continued management tailored to their condition, adherence to their medication [see next slide for more details] and lifestyle advice relevant to their CVD risk factors). 30Medication regimenContinued antiplatelet therapies for 12 months for all patients with stents (Grade A).In addition:aspirinbeta-blockersACE inhibitorsstatinswarfarinnitratesinsulin/oral hypoglycaemicsaldosterone antagonists.2012 National Heart Foundation of Australia31Concluding remarks This presentation is designed to ensure consistency of information regarding best practice ACS management, based upon the 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006.Understandings of the pathophysiology of ACS have improved, together with increasingly accurate diagnostic tools, better risk stratification and improved medical and invasive treatments. However, these advances have led to an increase in the complexity of possible treatment strategies. This is evolving.For more information please visit www.heartfoundation.org.au.

2012 National Heart Foundation of Australia ABN 98 008 419 761

Disclaimer: This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The statements and recommendations it contains are, unless labelled as expert opinion, based on independent review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the Heart Foundation and its employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness. The information is obtained and developed from a variety of sources including, but not limited to, collaborations with third parties and information provided by third parties under licence. It is not an endorsement of any organisation, product or service. This material may be found in third parties programs or materials (including, but not limited to, show bags or advertising kits). This does not imply an endorsement or recommendation by the National Heart Foundation of Australia for such third parties organisations, products or services, including their materials or information. Any use of National Heart Foundation of Australia materials or information by another person or organisation is at the user's own risk. The entire contents of this material are subject to copyright protection.2012 National Heart Foundation of AustraliaFor further information, guide participants to the Heart Foundation website.

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