Elsevier

Resuscitation

Volume 95, October 2015, Pages e121-e146
Resuscitation

Part 5: Acute coronary syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

https://doi.org/10.1016/j.resuscitation.2015.07.043Get rights and content

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:

  • Prehospital electrocardiography (ECG) (ACS 336).

  • Computer-assisted ECG STEMI interpretation (ACS 559).

  • Nonphysician ECG STEMI interpretation (ACS 884).

  • Prehospital STEMI activation of the catheterization laboratory (ACS 873).

  • Biomarkers to rule out

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:

  • 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:

  • 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

First page preview

First page preview
Click to open first page preview

References (126)

  • D.R. Young et al.

    Paramedics as decision makers on the activation of the catheterization laboratory in the presence of acute ST-elevation myocardial infarction

    J Electrocardiol

    (2011)
  • M.F. Dorsch et al.

    Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention

    Am Heart J

    (2008)
  • D.G. Strauss et al.

    Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction

    J Electrocardiol

    (2007)
  • M.R. Le May et al.

    Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital

    Am J Cardiol

    (2006)
  • L. Cullen et al.

    Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome

    J Am Coll Cardiol

    (2013)
  • F. Xavier Scheuermeyer et al.

    Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

    CJEM

    (2014)
  • E.P. Hess et al.

    Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome

    Ann Emerg Med

    (2012)
  • G. Montalescot et al.

    Prehospital ticagrelor in ST-segment elevation myocardial infarction

    N Engl J Med

    (2014)
  • P.G. Steg et al.

    Bivalirudin started during emergency transport for primary PCI

    N Engl J Med

    (2013)
  • M.M. Hirschl et al.

    Prehospital treatment of patients with acute myocardial infarction with bivalirudin

    Am J Emerg Med

    (2012)
  • G. Montalescot et al.

    Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial

    Lancet

    (2011)
  • S. Bangalore et al.

    Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors

    BMJ

    (2014)
  • J.M. Rawles et al.

    Controlled trial of oxygen in uncomplicated myocardial infarction

    Br Med J

    (1976)
  • D. Stub et al.

    Air versus oxygen in ST-segment-elevation myocardial infarction

    Circulation

    (2015)
  • W.D. Weaver et al.

    Prehospital-initiated vs hospital-initiated thrombolytic therapy. The myocardial infarction triage and intervention trial

    JAMA

    (1993)
  • E. Bonnefoy et al.

    Comparison of angioplasty and prehospital thromboysis in acute myocardial infarction study group. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study

    Lancet

    (2002)
  • H. Thiele et al.

    Randomized comparison of pre-hospital-initiated facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention in acute myocardial infarction very early after symptom onset: the LIPSIA-STEMI trial (Leipzig immediate prehospital facilitated angioplasty in ST-segment myocardial infarction)

    JACC Cardiovasc Interv

    (2011)
  • P.W. Armstrong et al.

    Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction

    N Engl J Med

    (2013)
  • Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial

    Lancet

    (2006)
  • E. Bonnefoy et al.

    Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up

    Eur Heart J

    (2009)
  • L. Svensson et al.

    Comparison of very early treatment with either fibrinolysis or percutaneous coronary intervention facilitated with abciximab with respect to ST recovery and infarct-related artery epicardial flow in patients with acute ST-segment elevation myocardial infarction: the Swedish Early Decision (SWEDES) reperfusion trial

    Am Heart J

    (2006)
  • F. Vermeer et al.

    Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study

    Heart

    (1999)
  • Institute of Medicine. Standards for systematic reviews....
  • Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE handbook. 〈http://www.guidelinedevelopment.org/handbook/〉; 2013....
  • O’Connor D, Green S, Higgins JPT, editors. Chapter 5: Defining the review questions and developing criteria for...
  • Higgins J, Altman D, Sterne J, editors. Chapter 8.5 The Cochrane Collaboration's tool for assessing risk of bias. In:...
  • P.F. Whiting et al.

    QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies

    Ann Intern Med

    (2011)
  • Schünemann H, Brożek J, Guyatt G, Oxman A. 5.2.1 Study limitations (risk of bias). In: GRADE handbook....
  • Evidence Prime Inc. GRADEpro guideline development tool. 〈http://www.guidelinedevelopment.org/〉. [accessed...
  • Schünemann H, Brożek J, Guyatt G, Oxman A. 5. Quality of evidence. In: GRADE handbook....
  • Schünemann H, Brożek J, Guyatt G, Oxman A. 5.1 Factors determining the quality of evidence. In: GRADE handbook....
  • S. Mendis et al.

    Writing group on behalf of the participating experts of the WHO consultation for revision of WHO definition of myocardial infarction. World Health Organization definition of myocardial infarction: 2008–09 revision

    Int J Epidemiol

    (2011)
  • C.J. Terkelsen et al.

    Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention

    Eur Heart J

    (2005)
  • S. Carstensen et al.

    Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome

    Eur Heart J

    (2007)
  • A. Martinoni et al.

    Importance and limits of pre-hospital electrocardiogram in patients with ST elevation myocardial infarction undergoing percutaneous coronary angioplasty

    Eur J Cardiovasc Prev Rehabil

    (2011)
  • J.T. Sørensen et al.

    Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction

    Eur Heart J

    (2011)
  • T. Quinn et al.

    Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project

    Heart

    (2014)
  • A. van de Loo et al.

    Primary percutaneous coronary intervention in acute myocardial infarction: direct transportation to catheterization laboratory by emergency teams reduces door-to-balloon time

    Clin Cardiol

    (2006)
  • J.M. Caudle et al.

    Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction

    CJEM

    (2009)
  • D.M. Nestler et al.

    Impact of prehospital electrocardiogram protocol and immediate catheterization team activation for patients with ST-elevation-myocardial infarction

    Circ Cardiovasc Qual Outcomes

    (2011)
  • Cited by (54)

    • European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

      2021, Resuscitation
      Citation 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, Resuscitation
      Citation 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

    View all citing articles on Scopus

    This article has been copublished in Circulation.

    1

    Co-Chair

    2

    The members of the Acute Coronary Syndrome Chapter Collaborators are listed in the Acknowledgments section.

    View full text