Scope and Target Population:

Adults greater than age 18 years presenting with past or present symptoms of chest pain/discomfort and/or indications of acute coronary syndrome (ACS).

Clinical Highlights and Recommendations:

• On initial contact with the health care system, high-risk patients need to be identified quickly and referred to an ER via the 911 system.
  
• Patients whose chest pain symptoms are suggestive of serious illness need immediate assessment in a monitored area of the ED and early therapy to include an IV, oxygen, aspirin, nitroglycerin and morphine.
  
• Triage and management of patients with chest pain and unstable angina must be based on a validated risk assessment system (i.e., ACC/AHA criteria).
  
• Patients with high-risk features need to be identified quickly and treatment instituted in a timely fashion.
  
• Patients with low-risk symptoms should be evaluated as outpatients in a timely fashion.
  
• Treadmill test results should be reported using the Duke treadmill score, based on the Bruce protocol.
  
• Thrombolysis should be instituted within 30-60 minutes of arrival, or angiogram/primary PCI should be performed within 90 minutes of arrival with a target of less than 60 minutes.
  
• Use of medication: Aspirin and clopidogrel (Plavix®) (or clopidogrel alone if aspirin allergic) at admission. (Avoid clopidogrel if cardiac surgery is anticipated.) Beta-blockers whenever possible and/or ACE inhibitors at 24 hours if stable, nitrates (when indicated), and statins whenever possible. Once the issue of surgery is clarified, consider the early use of clopidogrel for those in whom PCI is planned.
  
• Recommend appropriate use of cardiac rehabilitation postdischarge.
  

Priority Aims:

1. Increase the success of emergency intervention for patients with high-risk chest pain.
   
2. Minimize the delay in administering thrombolytics or angioplasty to patients with acute myocardial infarction (AMI).
   
3. Increase the timely initiation of treatment to reduce postinfarction mortality in patients with AMI.
   
4. Increase the percentage of patients with AMI who have used tobacco products within the past year, who receive tobacco use assessment and cessation counseling and treatment within 24 hours of admission (JCAHO).
   
5. Improve the diagnostic value of stress tests through their appropriate use in patients with chest pain symptoms.
   
6. Increase the percentage of patients with AMI using appropriate cardiac rehabilitation postdischarge.
   
7. Increase the percentage of patients with AMI whose course of treatment has followed the recommended critical pathway.
   
8. Increase the use of risk stratifying procedures in patients with AMI.