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THE breadth of the clinical evidence base informing the modern care of heart attacks and threatened heart attacks is unrivalled.
Acute coronary syndrome (ACS) is a common, high-risk and often time-critical condition treated in hospitals throughout Australia with varying degrees of local clinical expertise, and investigative and treatment capacities. As a consequence, variations in both care and outcomes remain evident within audits of local clinical practice.
The need for strategies and interventions that extend beyond simply improving the knowledge of clinicians has long been appreciated. Modern ACS care relies on a combination of integrated and well practised systems for early risk-based decision making and seamless provision of non-invasive and invasive investigation, with pharmacologic and procedural interventions informed by the knowledge of risk.
Continually improving access and provision to these services requires a coordinated effort from clinicians, health service providers and heath policymakers.
The Australian Commission on Safety and Quality in Health Care’s Acute Coronary Syndromes Clinical Care Standard was launched last week, representing a big step forward in focusing national, state and local efforts on improving ACS care. It places the patient at the very heart of these efforts.
By translating key aspects of the ACS evidence base into nationally agreed standards of practice, this Clinical Care Standard will help form the foundation of how Australian ACS care is practised and evaluated in years to come.
The Clinical Care Standards have been designed by consumers and clinicians involving several acute care disciplines. Through an extensive consultation process, feedback was received from state health departments, professional societies and the National Heart Foundation of Australia. This Clinical Care Standard is now endorsed by the Australian Health Ministers’ Advisory Council.
It focuses on:
1. The establishment of chest pain pathways to reduce the risk of missed myocardial infarction (MI)
2. The timely identification of patients with ST-elevation MI (STEMI) through the early conduct of electrocardiographs (ECGs)
3. The rapid provision of lifesaving reperfusion therapy for patients with STEMI
4. The use of evidence-based methods to evaluate patient risk to inform treatment decisions
5. Ensuring decisions about invasive investigation and management clearly involve the patients’ priorities and preferences
6. Developing individualised ongoing management plans that meet the patients’ medical needs in a psychosocially and culturally appropriate manner.
The standards aim to ensure that care providers meet the needs and wishes of ACS patients with greater fidelity. They can be integrated into the design and provision of clinical services in both rural and metropolitan hospitals, taking account of the diversity of clinical expertise, and will assist in adopting evolving evidence that informs current ACS care.
Measures of hospital and health service performance will be built around these standards to provide a more robust and comprehensive evaluation of how well ACS care is provided, highlighting where care may be improved. Evaluating regional and rural differences by how well these standards are achieved enables a focus for service redesign, such as the extension of networked clinical cooperation between rural and metropolitan centres.
These clinical networks help to facilitate the delivery of the right clinical expertise to the remote patient while at the same time bringing the right remote patient to technology-dependent investigations, and management that has become integral to modern ACS care.
The ACS Clinical Care Standard will assist all levels of our health system in coordinated efforts to meet the needs of the nearly 70 000 Australians experiencing heart attacks every year.
Professor Derek Chew is a clinical and interventional cardiologist, clinical trialist and an outcomes researcher in cardiovascular medicine.
The other drawback of the emphasis on reducing missed myocardial infarctions is the mandatory (in NSW, at least) triage category 2 applied to any patient with chest pain. This has been applied even when the cause of chest pain is clearly not cardiac; the most obvious example I’ve seen is a category 2 applied when the triage nurse correctly diagnosed shingles as the cause of a patient’s chest wall pain, but felt obliged to categorise the patient as a 2 nevertheless. This can divert resources from other patients triaged as lower categories but who are clearly sicker and in need of more urgent care.
Thanks for the article. The flip-side of the push to minimise the so-called ”missed ACS” is also risky but seldom identified – it is the risk associated with over-diagnosis. Over-diagnosis occurs through mis-application of a “Chest pain pathway” to a low-prevalence population, as well as misinterpretation of the pathophysiology reflected in raised High-sensitivisty Troponins. “Non-STEMI” used to be evidence of myocardial infarction with ST-depression rather than elevation. Now “Non-STEMI” can be an asymptomatic person with raised HS tropinin. Most people with chest pain do not have ACS. A large proportion people with coronary disease (almost all the elderly) do not have chest pain.
We have applied a model of acute coronary artery occlusion to a population of people who may have no coronary disease, diffuse coronary disease, or, in a tiny minority, acute coronary occlusion. Vessel-opening therapies only apply to the latter, and can cause harm in themselves (artery stripping, occlusion, no-flow). We also know that stenting may not be superior to medical therapy in the treatment of non-occlusive coronary artery disease.
Once the risk of having acute coronary occlusion is minimised below 1%, more harm is created by over-diagnosis than is spared by invasive investigation and treatment. We are already straying into this area. We need more information on the harms of over-diagnosis, and discussion from clinicians without a vested interest in doing invasive procedures.