Part 5: Acute coronary syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations☆
Introduction
Since 2000, the International Liaison Committee on Resuscitation (ILCOR) has published the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) every five years based on review of cardiopulmonary resuscitation (CPR) science. Seven task forces with representatives from the seven member resuscitation organizations create the CoSTR that enables regional resuscitation organizations to create their individual guidelines. The different guidelines are based on the scientific evidence and incorporate or adjust for regional considerations.
Section snippets
Why acute coronary syndromes?
Coronary heart disease remains among the leading causes of mortality globally. There is considerable research focus worldwide on improving outcomes in patients with acute coronary syndromes (ACS). Undoubtedly, this has led to improved health and dramatically improved morbidity and mortality in much of the world. Indeed, timely and appropriate care of ACS can reduce and prevent cardiac arrest. Some of the recommended interventions for ACS, however, are considered resource intensive and/or
Evidence evaluation and GRADE process
Each task force performed a detailed systematic review based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 After identification and prioritization of the questions to be addressed (using the PICO (population, intervention, comparator, outcome) format),3 with the assistance of information specialists, a detailed search
ACS task force abstract
The ACS Task Force ultimately completed 18 systematic reviews (14 based on meta-analyses) on more than 110 relevant studies spanning 40 years. The treatment recommendations were grouped by major topics as outlined below:
Diagnostic interventions in ACS:
Summary of new treatment recommendations
The following is a summary of the most important new reviews or changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2010:
Diagnostic interventions in ACS:
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The role of prehospital ECG was reemphasized. Newer evidence suggests that prehospital ECG may not only facilitate earlier diagnosis of STEMI and provide the opportunity for rapid prehospital and in-hospital reperfusion, but there is evidence of a substantial mortality benefit. This is relevant to
Diagnostic interventions in ACS
Acute coronary syndromes refers to a spectrum of clinical disorders that include acute myocardial infarction (AMI) with and without ST elevation and unstable angina pectoris. The term myocardial infarction, as defined by the World Health Organization, is used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia (no evidence of a cause other than ischemia). Criteria for diagnosis of AMI include10:
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Detection of increase and/or decrease of cardiac
Therapeutic interventions in ACS
Myocardial reperfusion therapy, by fibrinolysis or primary PCI, is the pivotal treatment of STEMI. The development of STEMI networks during the past decade has improved quick access to reperfusion therapy and led to a reduction of mortality in this setting.55
Reperfusion therapy benefits from adjunctive antithrombotic therapy, which, depending on the logistics and organization of emergency medical services, may be provided in the prehospital setting by physicians or in some regions by nurses and
Reperfusion decisions in STEMI
This section addresses the questions of which reperfusion strategy is best under specific circumstances. Which options are available for reperfusion will depend on the local prehospital system and availability of PCI centers. Some prehospital systems include physicians or highly trained personnel that can safely administer prehospital fibrinolysis. Some regions have short transport times to PCI, and STEMI patients can be triaged and transported directly to PCI. The questions in this section
Hospital reperfusion decisions after ROSC
There are widely accepted published guidelines surrounding the treatment of STEMI and NSTEMI in the general adult population that are endorsed by the ILCOR community. The evidence used to generate these guidelines did not specifically address patient populations who experienced OHCA and subsequently had ROSC. The management of this patient group, particularly patients having prolonged resuscitation and nonspecific ECG changes, has been controversial because of the lack of specific evidence and
Acknowledgments
We thank the following individuals (the Acute Coronary Syndrome Chapter Collaborators) for their collaborations on the systematic reviews contained in this section.
The task force members are grateful for the expertise and late-night assistance of the evidence evaluation experts and GRADE experts Eddy Lang and Peter Morley. In addition to our chapter collaborators, Anthony Camuglia and Julian Nam also assisted with insights from their previous work on related meta-analyses. Last, our final work
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Cited by (54)
European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care
2021, ResuscitationCitation Excerpt :In patients with ST segment elevation (STE) or left bundle branch block (LBBB) on the post-ROSC electrocardiogram (ECG) more than 80% will have an acute coronary lesion.111 A systematic review completed for the 2015 ILCOR CoSTR identified 15 observational studies enrolling 3800 patients showing a mortality benefit for emergent versus delayed or no cardiac catheterisation among patients with ROSC after cardiac arrest with evidence of STE on their ECG.112 The treatment recommendation from 2015 was to recommend emergency cardiac catheterisation laboratory evaluation in comparison with cardiac catheterisation later in the hospital stay or no catheterization in select adult patients with ROSC after OHCA of suspected cardiac origin with ST elevation on ECG (strong recommendation, low-quality evidence).
European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances
2021, ResuscitationCitation Excerpt :Primary percutaneous coronary intervention (PCI) is the strategy of choice and should be performed in ≤120 min from diagnosis.242,243,245,247 Pre-hospital fibrinolysis may be administered if a greater delay is expected, unless resuscitation efforts were prolonged or traumatic or other contraindications are present.242,243,245,247 Resuscitated STEMI patients who remain comatose after ROSC constitute a highly heterogeneous subgroup with a poorer prognosis, but there is no current evidence to discourage urgent coronary angiography.243
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This article has been copublished in Circulation.
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Co-Chair
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The members of the Acute Coronary Syndrome Chapter Collaborators are listed in the Acknowledgments section.