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NSTEMI – New ACEP Clinical Policy

December 10, 2018

So…I accidentally scheduled the Saturday summary to post at 10:00AM instead of 1:00AM, and it didn’t send out with the weekend email.


I hope you enjoy the (appropriately titled) Idiot’s Guide to Odds Ratios.

Now, on to the new ACEP NSTEMI Policy.

Written by Clay Smith

Spoon Feed
Be sure you know the formal word on the workup and treatment of NSTEMI for emergency physicians. We want to give patients a quick, safe workup and reduce the risk of short-term major adverse coronary events (MACE).

Why does this matter?
Chest pain leads to 10 million ED visits per year and costs billions. How we manage it in the ED could lead to better care with less expense and hassle for patients. A few definitions:

  • Level A – solid evidence, do it.

  • Level B – moderate quality evidence, recommended

  • Level C – lower quality evidence or expert consensus, meh…

NSTEMI in the ED
This policy was intended to answer these key questions.

  1. In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events?

    • The HEART score is recommended as Level B.

    • Other scores, such as TIMI are recommended as well. Level C.

  2. In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? All were Level C.

    • A HEART score of 0-3 and negative conventional troponin at zero and 3 hours predicts low rate of MACE.

    • “A single high-sensitivity troponin result below the level of detection on arrival to the ED, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of MACE.”

    • If, “low risk based on validated ADPs that include a nonischemic ECG result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day MACE allowing for an accelerated discharge pathway from the ED.”

  3. In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events?

    • They do not recommend further diagnostic testing in patients who have had MI ruled out (as above) in order to further lower 30-day MACE. Level B. Stress testing or coronary CTA doesn’t seem to impact 30-day MACE and likely leads to more downstream testing without reduction in the rate of MI.

    • Patients should follow up in 1-2 weeks after ED MI rule out. If no follow up is available, consider further ED testing. (Consensus recommendation). Level C

  4. Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events?

    • “P2Y12 inhibitors [i.e. clopidogrel] and glycoprotein IIb/IIIa inhibitors may be given in the ED or delayed until cardiac catheterization.” Level C

    • Personally, I prefer for cardiology to start whatever additional antiplatelet therapy they want and not start it myself in the ED.

Another Spoonful
Do not miss Sanity Returns to ACS, by EMLoN. ACEP now explicitly states that it’s acceptable to not expect a zero miss rate.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes. Ann Emerg Med. 2018 Nov;72(5):e65-e106. doi: 10.1016/j.annemergmed.2018.07.045.

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What are your thoughts?