Evidence-based guideline for evaluation, risk stratification, and management of STEMI, NSTEMI, and unstable angina in the emergency department.
A comprehensive, evidence-based clinical guideline for the evaluation, risk stratification, and emergency management of acute coronary syndromes (ACS) in adult patients, encompassing ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA). This resource synthesizes recommendations from the major international cardiology professional societies, emergency medicine expert consensus panels, and cardiovascular disease guidelines committees into a single integrated reference for emergency physicians, cardiologists, hospitalists, intensivists, and advanced practice providers who manage patients presenting with acute chest pain and suspected ACS.1 2 3 4 5 6 7
Acute coronary syndromes represent a spectrum of clinical presentations caused by acute myocardial ischemia, ranging from unstable angina to transmural myocardial infarction. Coronary artery disease remains the leading cause of death globally, with an estimated 17.9 million cardiovascular deaths per year. In the United States alone, approximately 605,000 new and 200,000 recurrent myocardial infarctions occur annually. STEMI accounts for approximately 25-40% of MI presentations, with in-hospital mortality of 5-6% in contemporary registries; NSTEMI accounts for 60-75%, with in-hospital mortality of 3-5% but higher long-term mortality due to greater comorbidity burden. Time-dependent reperfusion for STEMI and risk-stratified invasive management for NSTEMI/UA form the cornerstones of evidence-based ACS care.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Definitions, Pathophysiology & Initial Evaluation | ACS spectrum definitions; Fourth Universal Definition of MI (Types 1-5); pathophysiology of plaque rupture and erosion; initial ED evaluation (focused history, physical examination, differential diagnosis); 12-lead ECG acquisition and interpretation; STEMI criteria by coronary territory; STEMI equivalents (de Winter, Wellens, posterior MI, Sgarbossa criteria); right ventricular MI |
| Part 2 | Cardiac Biomarkers & Risk Stratification | Troponin biology (conventional vs high-sensitivity); hs-cTn 0/1-hour and 0/3-hour rapid rule-out/rule-in algorithms with assay-specific cutoffs; other biomarkers (CK-MB, BNP, CRP); HEART score (complete table and pathway); TIMI risk scores (STEMI and NSTEMI); GRACE score; HEART Pathway protocol; chest pain unit and observation pathways |
| Part 3 | STEMI Management — Reperfusion, Pharmacotherapy & Complications | Systems of care (door-to-balloon, door-to-needle targets); primary PCI strategy; fibrinolytic therapy (tenecteplase, alteplase, reteplase — weight-based dosing, contraindications, rescue PCI); pharmacoinvasive strategy; dual antiplatelet therapy (aspirin, clopidogrel, ticagrelor, prasugrel — dosing and comparison); anticoagulation for PCI and fibrinolysis (UFH, enoxaparin, bivalirudin, fondaparinux); adjunctive therapy (nitroglycerin, beta-blockers, oxygen, morphine caution, ACE inhibitors, statins); cardiogenic shock management; mechanical complications |
| Part 4 | NSTEMI/UA Management, Special Populations & Disposition | Early invasive vs initially conservative strategy; timing of angiography by risk category; antiplatelet and anticoagulation nuances for NSTEMI; glycoprotein IIb/IIIa inhibitors; arrhythmia management; special populations (women, elderly, diabetes, CKD, cocaine-associated chest pain, prior CABG); post-ACS care and secondary prevention; DAPT duration; chest pain disposition algorithms |
| Part 5 | Post-ACS Care, Secondary Prevention & Quality Metrics | Long-term antiplatelet therapy; statin therapy; ACE inhibitor/ARB therapy; beta-blocker therapy; aldosterone antagonists; cardiac rehabilitation; lifestyle modification; quality metrics and performance measures; systems of care optimization |
O’Gara PT, Kushner FG, Ascheim DD, et al. “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.” Circulation. 2013;127(4):e362-e425. DOI: 10.1161/CIR.0b013e3182742cf6 ↩︎
Amsterdam EA, Wenger NK, Brindis RG, et al. “2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.” Circulation. 2014;130(25):e344-e426. DOI: 10.1161/CIR.0000000000000134 ↩︎
Byrne RA, Rossello X, Coughlan JJ, et al. “2023 ESC Guidelines for the management of acute coronary syndromes.” Eur Heart J. 2023;44(38):3720-3826. DOI: 10.1093/eurheartj/ehad191 ↩︎
Gulati M, Levy PD, Mukherjee D, et al. “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.” Circulation. 2021;144(22):e588-e637. DOI: 10.1161/CIR.0000000000001029 ↩︎
Thygesen K, Alpert JS, Jaffe AS, et al. “Fourth Universal Definition of Myocardial Infarction (2018).” Circulation. 2018;138(20):e618-e651. DOI: 10.1161/CIR.0000000000000617 ↩︎
Lawton JS, Tamis-Holland JE, Bangalore S, et al. “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.” Circulation. 2022;145(2):e18-e114. DOI: 10.1161/CIR.0000000000001038 ↩︎
Ibanez B, James S, Agewall S, et al. “2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.” Eur Heart J. 2018;39(2):119-177. DOI: 10.1093/eurheartj/ehx393 ↩︎
Long-term antiplatelet therapy and DAPT duration, statin therapy, ACE inhibitor/ARB, beta-blocker, aldosterone antagonists, cardiac rehabilitation, lifestyle modification, and quality metrics.
Early invasive vs conservative strategy, timing of angiography, antiplatelet and anticoagulation for NSTEMI, special populations (women, elderly, diabetes, CKD, cocaine), arrhythmias, and chest pain disposition.
Systems of care, primary PCI, fibrinolytic therapy with dosing, pharmacoinvasive strategy, dual antiplatelet therapy, anticoagulation, adjunctive therapy, cardiogenic shock, and mechanical complications.
Troponin biology, high-sensitivity troponin algorithms (0/1h and 0/3h), HEART score, TIMI risk scores, GRACE score, HEART Pathway, and chest pain observation pathways.
ACS spectrum definitions, Fourth Universal Definition of MI (Types 1-5), pathophysiology, initial ED evaluation, 12-lead ECG interpretation, STEMI criteria by territory, STEMI equivalents, and right ventricular MI.