Adherence with Guidelines for NSTEMI-ACS in the Emergency Department

Background: While the adherence with guidelines for the initial treatment of STEMI was intensively studied, there are scarce data on adherence with guidelines for Non ST Evaluation Myocardial Infarction-Acute Coronary Syndrome (NSTEMI-ASC).

Aim: to study guideline adherence with initial NSTEMI-ACS in the emergency department (ED).

Methods: A retrospective study of 240 consecutive patients diagnosed as NSTEMI excluding patients with sudden death, shock or having secondary NSTEMI. Data were collected from electronic medical records and ED files were manually evaluated for three quality measures: prompt ECG and biomarker results (within 10 and 60 minutes receptively), diagnosis of NSTEMI and treatment with antiplatelets and anticoagulation in the ED.

Results: Prompt ECG and one hour biomarker results were performed in 40% of patients. Initiation of anticoagulation and antiplatelets medication occurred in 31% of patients and initial diagnosis of NSTEMI was documented in 77% of cases. Composite adherence score (all three) was achieved in 10% of NSTEMI patients. Males more than females had prompt ECG (47% vs. 29% p<0.018). Factors that attenuated medications adherence were older age (70.6‎±‎12.5y vs. 65.0‎±‎12.6 p< 0.002), renal failure (18% vs. 35% p<0.029) and higher "Global Registry of Acute Coronary Events" (GRACE) score, (25% vs. 41% p<0.008). A factors that enhanced adherence was consulting with a cardiologist (41% vs. 19% p<0.001).

Comment: The overall low adherences with NSTEMI-ACS guidelines calls for action. Expediting ECG and biomarkers performance are required. An initial triage by trained and cardiology trained nurse would facilitate prompt triage. Troponin elevation was probably the only diagnostic factor in 23% of patients. The cardiologic consultation impact illuminates `gaps of knowledge` of the ED team, demanding further clinical education.