Acute coronary syndrome (ACS) accounts for more than 1.4 million hospital admissions per year, and as many as 1 in 5 ACS patients die in the first six months after diagnosis, according to the American Academy of Family Physicians. With that in mind, Bruce Darrow, MD, PhD, presented the seminar “Acute Coronary Syndrome (ACS): Keys to Treatment and New Advances” for more than 150 hospitalists at the seventh annual Mid-Atlantic Hospital Medicine Symposium in October at Mount Sinai Medical Center in New York City.
“ACS patients are being admitted to a hospitalist’s care, although these physicians are not coronary service-line providers,” said Dr. Darrow, Mount Sinai’s director of telemetry services. “Often they work with cardiologists, but there are things hospitalists should be comfortable doing without consulting a specialist.”
Dr. Darrow spent the majority of his presentation reviewing the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2012 update of the 2007 guidelines for managing patients with myocardial infarction (MI).
Three Phases of Treatment
To achieve the comfort level he believes hospitalists require, Dr. Darrow explained three phases of ACS care: initial medical treatment, reperfusion therapy, and transitional management.1,2 Hospitalists who see patients within the first 24 hours of their hospital stay are providing
Once the physician determines that the patient is experiencing an acute myocardial infarction, treatment should begin with:
- Low-molecular-weight heparin (or heparin if the patient will be heading to the cath lab); and
- Antiplatelet agents (clopidogrel or ticagrelor for this “upstream” portion of therapy).
There are things hospitalists should be comfortable doing without consulting a specialist.
—Bruce Darrow, MD, PhD, director of telemetry services, Mount Sinai Medical Center, New York
Other medications to consider are intravenous IIb/IIIa inhibitors, such as abciximab, that often were used for patients going to the cath lab. Beta-blockers, although no longer required, can be included in the arsenal. Similarly, anti-ischemics may be employed, despite a lack of evidence to support their use (e.g. oxygen can be a good idea, and morphine will certainly benefit someone in pain).
In cases with ST elevation, after initial treatment, the patient is generally sent to reperfusion therapy, unless it is contraindicated. Primary percutaneous coronary intervention (PCI) is recommended in facilities with a 24/7 cath lab, or in cases for which the patient can be transferred to a hospital with an available cath lab within three hours. Otherwise, thrombolysis is the route to take, and all hospitals should be capable of that procedure, Dr. Darrow said.
After reperfusion or conservative management measures are taken, the patient is transitioned to post-MI care, which includes:
- Aspirin (except where contraindicated);
- Antiplatelet agents (clopidogrel, ticagrelor, and prasugruel, depending on patient risk factors; see Figure 1, right);
- ACE inhibitors (for patients with systolic dysfunction); and
- Eplerenone/spironolactone (for patients with systolic dysfunction and respiratory conditions).
Dr. Darrow also addressed the ACS Core Measures, performance measurement, and improvement initiatives set by The Joint Commission and the Centers for Medicare & Medicaid Services (CMS).3
Upon arrival, patients should be given:
- Aspirin (Joint Commission-required; voluntary according to CMS);
- Thrombolyis within 30 minutes (if applicable); and
- Primary PCI within 90 minutes (if applicable).