2014 AHA NSTEMI update

Another round of guidelines are now on the table. For practitioners across Canada this may lead to a possible change in practice. Fortunately it seems, that the changes will not be drastic.

Some interesting things to note:

  • In the absence of contraindications, it may be reasonable to administer morphine sulfate intravenously to patients with NSTE-ACS if there is continued ischemic chest pain despite treatment with maximally tolerated anti-ischemic medications (Class IIb LOE B)
  • Measure serial cardiac troponin I or T at presentation and 3-6 hours after symptom onset in all patients with ACS symptoms. Additional troponin levels should be obtained beyond 6 hours in patients with normal troponin levels on serial examination when ECG changes clinical presentation confer an intermediate or high suspicion for ACS. (Class I LOE A)
  • If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values (Class I LOE A).
    • Further reinforcing the need for a good history while on scene.
  • With contemporary troponin assays, CK-MB and myoglobin are not useful for diagnosis of ACS. (Class III LOE A)
  • A 12-lead ECG should be performed and interpreted within 10 minutes of the patient’s arrival at an emergency facility to assess for cardiac ischemia or injury
    • This protocol used to indicate an experienced physician to interpret the ECG. However that has been removed. This further reinforces the need for all practitioners to know their ECG’s!

Reference: Amsterdam A, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes Circulation, epub September 23, 2014.

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