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The Clinical Care Standards in ACS: Towards an Integrated Approach to Evidence Translation in ACS Care

2015; Elsevier BV; Volume: 24; Issue: 3 Linguagem: Inglês

10.1016/j.hlc.2014.12.159

1444-2892

Derek P. Chew, Tom Briffa,

Cardiac Health and Mental Health

The evidence-base informing the management of acute coronary syndromes (ACS) is substantial and now encapsulated in numerous local and international clinical practice guidelines. These guidelines have sought to assimilate this evidence into carefully crafted and robustly debated practice recommendations representing the foundation of modern ACS care. [ 1 Authors/Task Force Members Steg P.G. James S.K. Atar D. Badano L.P. Lundqvist C.B. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). European Heart Journal. 2012; Google Scholar , 2 Authors/Task Force Members Hamm C.W. Bassand J.P. Agewall S. Bax J. Boersma E. et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal. 2011; 32: 2999-3054 Crossref PubMed Scopus (3047) Google Scholar , 3 Aroney C. Aylward P. Kelly A. Chew D. Clune E. National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia. 2006; 184: S1-S32 Google Scholar , 4 Chew D.P. Aroney C.N. Aylward P.E. Kelly A.-M. White H.D. Tideman P.A. et al. Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ. 2011; 20: 487-502 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar , 5 Amsterdam E.A. Wenger N.K. Brindis R.G. Casey D.E. Ganiats T.G. Holmes D.R. et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130: 2354-2394 Crossref PubMed Scopus (723) Google Scholar ] Yet, registries of Australian and New Zealand clinical practice continue to demonstrate evidence of incomplete clinical care and sub-optimal clinical outcomes among many patients presenting with ACS. [ 6 Chew D.P. Amerena J.V. Coverdale S.G. Rankin J.M. Astley C.M. Soman A. et al. Invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry. Med J Aust. 2008; 188: 691-697 PubMed Google Scholar , 7 Aliprandi-Costa B. Ranasinghe I. Chow V. Kapila S. Juergens C. Devlin G. et al. Management and outcomes of patients with acute coronary syndromes in Australia and New Zealand, 2000-2007. Med J Aust. 2011; 195: 116-121 PubMed Google Scholar , 8 Chew D.P. French J. Briffa T.G. Hammett C.J. Ellis C.J. Ranasinghe I. et al. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust. 2013; 199: 185-191 Crossref PubMed Scopus (126) Google Scholar , 9 Ellis C. Devlin G. Elliott J. Matsis P. Williams M. Gamble G. et al. ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients. N Z Med J. 2010; 123: 44-60 PubMed Google Scholar , 10 Ellis C. Devlin G. Matsis P. Elliott J. Williams M. Gamble G. et al. Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities. N Z Med J. 2004; 117: U954 PubMed Google Scholar ] Disappointingly, sequential registries spanning nearly a decade of clinical experience continue to show significant challenges in the provision of reperfusion for ST segment elevation MI, variation in rates of angiography in non-ST elevation ACS, incomplete utilisation of secondary prevention therapies and low rates of referral to cardiac rehabilitation. This inertia in the evolution of clinical practice suggests that elements beyond physician “knowledge of the evidence” are at play in compromising the optimal adherence to guideline recommended care. Such factors may include: •challenges in accessing the essential cardiac expertise required to optimise decisions regarding the use of modern ACS therapies; •the urban-centric geographic concentration of cardiac diagnostic and therapeutic technologies that are now critical to effective ACS care; •current health information systems which have evolved to effectively report health resource utilisation, but not the quality and outcomes associated with this care; •as well as health policy settings that reward hospital and clinician activity but not outcome.