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Acute coronary syndromes

About

What is covered

This pathway covers the assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin, and the early management of unstable angina and NSTEMI.
Fast and accurate diagnosis of chest pain or discomfort caused by an 'acute coronary syndrome' (that is, myocardial infarction or unstable angina) is essential so that treatment can be offered quickly.
NICE has also produced a pathway on stable angina for people presenting with stable chest pain.
In this pathway, chest pain is used to mean both chest pain and discomfort.
The pathway addresses assessment and diagnosis irrespective of setting, because people present in different ways.
This pathway also addresses the early management of unstable angina and NSTEMI once a firm diagnosis has been made and before discharge from hospital. If untreated, the prognosis is poor and mortality high, particularly in people who have had myocardial damage. Appropriate triage, risk assessment and timely use of acute pharmacological or invasive interventions are critical for the prevention of future adverse cardiovascular events (myocardial infarction, stroke, repeat revascularisation or death).

Updates

Updates to this pathway

28 July 2016 Endoaortic balloon occlusion for cardiac surgery (NICE interventional procedure guidance 261) added to coronary artery bypass grafting.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to coronary artery bypass grafting.
21 July 2015 Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti-platelet therapy (terminated appraisal) (NICE technology appraisal 351) added to percutaneous coronary intervention.
10 June 2015
  • CardioQ-ODM oesophageal doppler monitor (NICE medical technology guidance 3) and an extract from Detecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems) (NICE diagnostics guidance 13) added to coronary artery bypass grafting.
  • Thrombin injections for pseudoaneurysms (NICE interventional procedure guidance 60) added to coronary angiography and percutaneous coronary intervention.
30 September 2014 Myocardial infarction (acute): Early rule out using high-sensitivity troponin tests (Elecsys Troponin T high-sensitive, ARCHITECT STAT High Sensitive Troponin-I and AccuTnI+3 assays) (NICE diagnostics guidance 15) added to initial assessment.
4 September 2014 Acute coronary syndromes (including myocardial infarction) (NICE quality standard 68) added.
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to percutaneous coronary intervention.
24 June 2014 Endoscopic saphenous vein harvest for coronary artery bypass grafting (NICE interventional procedure guidance 494) added to coronary artery bypass grafting in the early management of unstable angina and NSTEMI path.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to percutaneous coronary intervention
13 November 2013 A recommendation on clopidogrel was updated for the early management of stable angina and NSTEMI, for a 'person at low risk, and a 'person at intermediate, high or highest risk', and a minor update was made to a recommendation in 'Rehabilitation and discharge planning'. Links to NICE clinical guideline 48 were replaced with the updated guideline on MI − secondary prevention, CG172.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin, and the early management of unstable angina and non-ST-segment-elevation myocardial infarction

What is covered

This pathway covers the assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin, and the early management of unstable angina and NSTEMI.
Fast and accurate diagnosis of chest pain or discomfort caused by an 'acute coronary syndrome' (that is, myocardial infarction or unstable angina) is essential so that treatment can be offered quickly.
NICE has also produced a pathway on stable angina for people presenting with stable chest pain.
In this pathway, chest pain is used to mean both chest pain and discomfort.
The pathway addresses assessment and diagnosis irrespective of setting, because people present in different ways.
This pathway also addresses the early management of unstable angina and NSTEMI once a firm diagnosis has been made and before discharge from hospital. If untreated, the prognosis is poor and mortality high, particularly in people who have had myocardial damage. Appropriate triage, risk assessment and timely use of acute pharmacological or invasive interventions are critical for the prevention of future adverse cardiovascular events (myocardial infarction, stroke, repeat revascularisation or death).

Updates

Updates to this pathway

28 July 2016 Endoaortic balloon occlusion for cardiac surgery (NICE interventional procedure guidance 261) added to coronary artery bypass grafting.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to coronary artery bypass grafting.
21 July 2015 Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti-platelet therapy (terminated appraisal) (NICE technology appraisal 351) added to percutaneous coronary intervention.
10 June 2015
  • CardioQ-ODM oesophageal doppler monitor (NICE medical technology guidance 3) and an extract from Detecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems) (NICE diagnostics guidance 13) added to coronary artery bypass grafting.
  • Thrombin injections for pseudoaneurysms (NICE interventional procedure guidance 60) added to coronary angiography and percutaneous coronary intervention.
30 September 2014 Myocardial infarction (acute): Early rule out using high-sensitivity troponin tests (Elecsys Troponin T high-sensitive, ARCHITECT STAT High Sensitive Troponin-I and AccuTnI+3 assays) (NICE diagnostics guidance 15) added to initial assessment.
4 September 2014 Acute coronary syndromes (including myocardial infarction) (NICE quality standard 68) added.
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to percutaneous coronary intervention.
24 June 2014 Endoscopic saphenous vein harvest for coronary artery bypass grafting (NICE interventional procedure guidance 494) added to coronary artery bypass grafting in the early management of unstable angina and NSTEMI path.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to percutaneous coronary intervention
13 November 2013 A recommendation on clopidogrel was updated for the early management of stable angina and NSTEMI, for a 'person at low risk, and a 'person at intermediate, high or highest risk', and a minor update was made to a recommendation in 'Rehabilitation and discharge planning'. Links to NICE clinical guideline 48 were replaced with the updated guideline on MI − secondary prevention, CG172.

Sources

NICE guidance and other sources used to create this pathway.
Drug-eluting stents for the treatment of coronary artery disease (2008) NICE technology appraisal guidance 152
Guidance on the use of coronary artery stents (2003) NICE technology appraisal guidance 71
Endoscopic saphenous vein harvest for coronary artery bypass grafting (2014) NICE interventional procedure guidance 494
Bioresorbable stent implantation for treating coronary artery disease (2014) NICE interventional procedure guidance 492
Optical coherence tomography to guide percutaneous coronary intervention (2014) NICE interventional procedure guidance 481
Percutaneous laser coronary angioplasty (2011) NICE interventional procedure guidance 378
Off-pump coronary artery bypass grafting (2011) NICE interventional procedure guidance 377
Percutaneous laser revascularisation for refractory angina pectoris (2009) NICE interventional procedure guidance 302
Transmyocardial laser revascularisation for refractory angina pectoris (2009) NICE interventional procedure guidance 301
Endoaortic balloon occlusion for cardiac surgery. NICE interventional procedure guidance 261 (2008)
Totally endoscopic robotically assisted coronary artery bypass grafting (2005) NICE interventional procedure guidance 128
Thrombin injections for pseudoaneurysms (2004) interventional procedure guidance 60
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technology guidance 3
SeQuent Please balloon catheter for in-stent coronary restenosis (2010) NICE medical technology guidance 1
Acute coronary syndromes in adults (2014) NICE quality standard 68

Quality standards

Quality statements

Diagnosis of acute myocardial infarction

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with a suspected acute coronary syndrome are assessed for acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Rationale

Acute myocardial infarction can have a poor prognosis so prompt and accurate diagnosis is important to ensure that appropriate treatment and care is offered as soon as possible. Treatment for adults with suspected acute coronary syndrome is often started before a diagnosis is confirmed. Confirming the diagnosis using the criteria in the universal definition of myocardial infarction is important to ensure that any ongoing treatment is appropriate and any inappropriate treatment is stopped.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Data source: Local data collection.
Process
Proportion of adults with a diagnosis of acute myocardial infarction who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Numerator – the number in the denominator who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Denominator – the number of adults with a diagnosis of acute myocardial infarction.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Healthcare professionals ensure that they are aware of the universal definition of myocardial infarction and assess adults with a suspected acute coronary syndrome for the presence of acute myocardial infarction using the criteria in the universal definition.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with expertise in using the criteria in the universal definition of myocardial infarction to diagnose acute myocardial infarction in adults with a suspected acute coronary syndrome.

What the quality statement means for patients, service users and carers

Adults with severe pain in the chest and/or in other areas (for example, the arms, back or jaw) that might be a heart attack (a suspected acute coronary syndrome) are only given a diagnosis of heart attack if their signs and symptoms meet an agreed definition.

Source guidance

Definitions of terms used in this quality statement

Universal definition of myocardial infarction
A rise in cardiac biomarkers (preferably cardiac troponin) with at least 1 value above the 99th percentile of the upper reference limit and/or a fall in cardiac biomarkers, together with at least 1 of the following:
  • symptoms of ischaemia
  • ECG changes indicating new ischaemia (new ST-segment-T wave changes or new left bundle branch block)
  • pathological Q wave changes in the ECG
  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
[NICE clinical guideline 95, recommendation 1.2.6.1]

Equality and diversity considerations

Symptoms of acute coronary syndromes should be assessed in the same way in men and women and among people from different ethnic groups.

Risk assessment for adults with NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Rationale

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment (for example, using the GRACE scoring system) in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment related adverse events. Failure to categorise future risk can lead to people being given inappropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Data source: Local data collection.
Process
Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Numerator – the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Denominator – the number of presentations because of NSTEMI or unstable angina.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 1.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.
Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for risk of future adverse cardiovascular events
Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
The formal risk assessment should include:
  • a full clinical history (including age, previous myocardial infarction and previous percutaneous coronary intervention or coronary artery bypass grafting)
  • a physical examination (including measurement of blood pressure and heart rate)
  • resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
[NICE clinical guideline 94, recommendations 1.2.1 and 1.2.2]
Categories for risk of future adverse cardiovascular events
Using 6-month mortality, the categories for the risk of future adverse cardiovascular events are:
Predicted 6-month mortality
Risk of future adverse cardiovascular events
1.5% or below
Lowest
>1.5 to 3.0%
Low
>3.0 to 6.0%
Intermediate
>6.0 to 9.0%
High
Over 9.0%
Highest
[NICE clinical guideline 94, recommendation 1.2.5]

Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) within 72 hours of first admission to hospital.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. In people with an intermediate or higher risk of future adverse cardiovascular events, coronary angiography within 72 hours of admission to hospital offers advantages over an initial conservative strategy, provided there are no contraindications to angiography (such as active bleeding or comorbidity). Services should provide coronary angiography (with follow-on PCI if indicated) as soon as it offers net clinical benefits; they should not wait until 72 hours if this is sooner.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Data source: Local data collection.
Process
Length of time taken for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to receive coronary angiography (with follow-on PCI if indicated).
Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.
Proportion of adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who receive coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Numerator – the number of people in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 72 hours of admission.
Denominator – the number of adults with NSTEMI or unstable angina with an intermediate or higher risk of future adverse cardiovascular events on admission to hospital.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 9.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to be seen by cardiac specialists and offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise to offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina who have a medium or higher risk of another heart attack are offered a test called coronary angiography, and treatment to improve blood flow to the heart if needed, within 72 hours of first being admitted to hospital.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 72 hours, rather than 96 hours as stated in the recommendation, is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Intermediate or higher risk of future adverse cardiovascular events
A predicted 6-month mortality above 3.0%. [NICE clinical guideline 94, recommendation 1.5.1]

Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who are clinically unstable have coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. The benefits of an early invasive strategy appear to be greatest in people at higher risk of future adverse cardiovascular events. In people with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) should be done as soon as possible so that appropriate treatment can be given. It may reduce lengthy hospital stays and prevent further cardiovascular events in both the short and long term. The timing of coronary angiography will be different for each person, but should be within 24 hours of becoming clinically unstable.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who are clinically unstable have coronary angiography (with follow-on PCI if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.
Data source: Local data collection.
Process
Length of time taken for adults with NSTEMI or unstable angina who are clinically unstable (on admission or during their hospital stay) to receive coronary angiography (with follow-on PCI if indicated).
Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.
Data source: Local data collection.
Proportion of adults with NSTEMI or unstable angina who are clinically unstable who receive coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Numerator – the number in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Denominator – the number of adults with NSTEMI or unstable angina who are clinically unstable.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (secondary care and cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina and whose condition is unstable are offered a test called coronary angiography and treatment to improve blood flow to the heart if needed, as soon as possible but within 24 hours of their condition becoming unstable.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 24 hours is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Clinically unstable
People who are clinically unstable are defined as those with:
  • ongoing or recurring pain despite treatment
  • haemodynamic instability (low blood pressure, shock)
  • dynamic ECG changes
  • left ventricular failure.
[Expert opinion]
As soon as possible
Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. [Expert opinion]

Level of consciousness and eligibility for coronary angiography and primary PCI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial infarction (STEMI) are not excluded from having coronary angiography (with follow–on primary percutaneous coronary intervention [PCI] if indicated).

Rationale

People who remain unconscious after cardiac arrest should not be treated differently from people who are conscious. They should be able to have the same treatments within the same timescales and should be admitted to centres capable of undertaking primary PCI. Carrying out immediate primary PCI, if successful, could stabilise the person’s heart and may reduce the risk of further complications.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated) because they are unconscious.
Data source: Local data collection.
Process
Proportion of adults who were unconscious after cardiac arrest caused by suspected acute STEMI who receive coronary angiography (with follow-on primary PCI if indicated).
Numerator – the number in the denominator receiving coronary angiography (with follow-on primary PCI if indicated).
Denominator – the number of adults who were unconscious after cardiac arrest caused by suspected acute STEMI.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (ambulance services and cardiac service providers) ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated). Providers should also raise awareness among healthcare professionals of the importance of not using level of consciousness to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Healthcare professionals ensure that they do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that can carry out coronary angiography (with follow–on primary PCI if indicated) in adults who are unconscious after cardiac arrest caused by suspected acute STEMI.

What the quality statement means for patients, service users and carers

Adults who are unconscious after a type of heart attack called STEMI can have a test called coronary angiography, and treatment to improve blood flow to the heart if needed, even though they are unconscious.

Source guidance

Primary PCI for acute STEMI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with acute ST-segment-elevation myocardial infarction (STEMI) who present within 12 hours of onset of symptoms have primary percutaneous coronary intervention (PCI), as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of the time when fibrinolysis could have been given.

Rationale

Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis. However, when performed early, primary PCI is more effective. To ensure the best outcomes for adults with STEMI, the ambulance service and hospitals delivering primary PCI should work together to minimise delays in treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with acute STEMI who present within 12 hours of onset of symptoms have primary PCI, as the preferred coronary reperfusion strategy, within 120 minutes of the time when fibrinolysis could have been given.
Data source: Local data collection.
Evidence of local arrangements to ensure that adults with acute STEMI have access to primary PCI 24 hours a day.
Data source: Local data collection.
Evidence that commissioners with their services providers have developed a single care pathway for coronary reperfusion.
Data source: Local data collection.
Process
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 120 minutes of when fibrinolysis could have been given.
Numerator – the number in the denominator receiving primary PCI within 120 minutes of when fibrinolysis could have been given.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Data source: Local data collection. Some fields on time to primary PCI collected in Myocardial Ischaemia National Audit Project (MINAP) and National audit of percutaneous coronary interventional procedures (BCIS).
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 150 minutes of the call for professional help.
Numerator – the number of people in the denominator receiving primary PCI within 150 minutes of the call for professional help.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (ambulance services, accident and emergency service provider and cardiac service providers) ensure that local pathways and transfer protocols are in place for adults with acute STEMI who present within 12 hours of the onset of symptoms to be offered primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given.
Healthcare professionals ensure that they offer primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given to adults with acute STEMI who present within 12 hours of the onset of symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have the capacity and expertise to provide primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given (and at any time of the day or night, including weekends) to adults with acute STEMI who present within 12 hours of onset of symptoms. Commissioners should work with their service providers to develop a single care pathway for coronary reperfusion.

What the quality statement means for patients, service users and carers

Adults with a type of heart attack called STEMI whose symptoms started no more than 12 hours before first contacting a healthcare professional are offered a procedure to improve blood flow to the heart (called percutaneous coronary intervention or PCI). They should be able to have this as soon as possible, but within 120 minutes of when they could have received fibrinolysis (a ‘clot-busting’ drug).

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

If an acute coronary syndrome has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example NICE's pathways on cardiovascular disease prevention or hypertension.
Monitor people with acute chest pain, using clinical judgement to decide how often this should be done, until a firm diagnosis is made. This should include:
  • exacerbations of pain and/or other symptoms
  • pulse and blood pressure
  • heart rhythm
  • oxygen saturation by pulse oximetry
  • repeated resting 12-lead ECGs
  • checking pain relief is effective.

Glossary

Bispectral Index
clopidogrel hydrogen sulphate
coronary artery bypass grafting
electrocardiography
electroencephalography
Global Registry of Acute Cardiac Events
glycoprotein IIb/IIIa inhibitor
glyceryl trinitrate
left bundle branch block
non-ST-segment-elevation myocardial infarction
percutaneous coronary intervention
ST-segment-elevation myocardial infarction

Paths in this pathway

Pathway created: July 2013 Last updated: July 2016

© NICE 2016

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