What is the management of Acute Coronary Syndrome (ACS) at a healthcare center more than 2 hours away from a Percutaneous Coronary Intervention (PCI) center?

From the Guidelines

For management of Acute Coronary Syndrome (ACS) at a healthcare center more than 2 hours away from a PCI center, a fibrinolytic therapy strategy should be implemented if the patient presents within 12 hours of symptom onset with ST-elevation myocardial infarction (STEMI). According to the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1, immediate fibrinolysis rather than primary percutaneous coronary intervention (PPCI) may be considered when the expected delay to PPCI is more than 60 minutes. The guidelines also recommend that in STEMI patients presenting within 3 to 12 hours after symptom onset, performance of PPCI involving a possible delay of up to 120 minutes may be considered rather than initial fibrinolysis.

Key Considerations

• Begin with immediate administration of aspirin 325mg chewed, clopidogrel 300mg loading dose (75mg daily thereafter), and anticoagulation with unfractionated heparin (60 U/kg bolus, maximum 4000 U, followed by 12 U/kg/hr infusion, maximum 1000 U/hr) or enoxaparin (30mg IV bolus followed by 1mg/kg SC every 12 hours) 1.
• Administer fibrinolytic therapy such as tenecteplase (weight-based dosing: 30-50mg IV bolus) or alteplase (15mg IV bolus, then 0.75mg/kg over 30 minutes, then 0.5mg/kg over 60 minutes) 1.
• After fibrinolysis, arrange immediate transfer to a PCI-capable facility for rescue PCI if reperfusion fails (persistent chest pain, <50% resolution of ST elevation at 90 minutes) or routine early angiography within 24 hours 1.
• For non-ST elevation ACS, administer dual antiplatelet therapy (aspirin plus P2Y12 inhibitor), anticoagulation, and high-dose statin, then arrange transfer for early invasive strategy within 24 hours.

Recent Evidence

A 2017 study published in the Annals of Emergency Medicine 1 compared the outcomes of STEMI patients who presented to a PCI center versus patients who presented to a non-PCI center and were transferred to a PCI-capable hospital, finding that transfer for PCI had a mortality and MACE advantage over fibrinolytic administration alone, and that treatment is time-dependent. However, this study's findings are consistent with the 2015 guidelines, which prioritize timely reperfusion therapy.

Clinical Decision

Given the geographic distance and the need for timely reperfusion therapy, fibrinolytic therapy followed by transfer to a PCI-capable facility is the recommended approach. This approach balances the urgency of reperfusion therapy with the limitations of geographic distance, as timely reperfusion is critical to salvage myocardium and improve outcomes in ACS 1.

From the Research

Management of Acute Coronary Syndrome (ACS) at a Health Care Center

Overview of ACS Management

• Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina 2.
• The management of ACS involves immediate electrocardiography, administration of aspirin and other antiplatelet agents, and prompt reperfusion with primary percutaneous coronary intervention (PCI) or fibrinolytic therapy 2, 3.

Initial Management at a Health Care Center >2hrs away from PCI Centre

• For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) to distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS) 2.
• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated, and a second antiplatelet agent should also be administered 3.
• If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications, followed by transfer to a facility with the goal of PCI within the next 24 hours 2.
• Prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals is beneficial for patients with suspected ACS, although the certainty of evidence is very low 4.

Transfer to a PCI Centre

• Patients with STEMI should be transferred to a PCI centre as soon as possible, with a goal of PCI within 120 minutes of presentation 2, 3.
• For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death 2.
• The choice of antiplatelet therapy and duration of treatment should be individualized based on the patient's risk factors and clinical presentation 5.