The Living Guidelines: UA/NSTEMI Recommendations for Initial Evaluation, Clinical Assessment and Management Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines
1. Patients with symptoms that may represent ACS should not be evaluated solely over the telephone but should be referred to a facility that allows evaluation by a physician and the recording of a 12-lead ECG and biomarker determination (e.g., an ED or other acute care facility). (Level of Evidence: C)

2. Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s], back, neck, jaw or epigastrium; shortness of breath; weakness;diaphoresis; nausea; lightheadedness) should be instructed to call emergency service providers (e.g. 112 for most Asian and European countries, 911 for US, 108 for India, 110 and 120 for China) and should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B)

3. Health care providers should actively address the following issues regarding ACS with patients with or at risk for coronary heart disease and their families or other responsible caregivers:

a. The patient’s heart attack risk; (Level of Evidence: C)

b. How to recognize symptoms of ACS; (Level of Evidence: C)

c. The advisability of calling emergency service if symptoms are unimproved or worsening after 5 min, despite feelings of uncertainty about the symptoms and fear of potential embarrassment; (Level of Evidence: C)

d. A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access emergency medical services (EMS). (Level of Evidence: C)

4. Prehospital EMS providers should administer 162 to 325 mg of ASA (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric coated ASA for initial dosing, more rapid buccal absorption occurs with non enteric coated formulations. (Level of Evidence: C)

5. Health care providers should instruct patients with suspected ACS for whom nitroglycerin (NTG) has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 911 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 911 if symptoms have not resolved completely. (Level of Evidence: C)

6. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for >20 min, hemodynamic instability, or recent syncope or pre syncope should be referred immediately to an Emergency Department. Other patients with suspected acute coronary syndromes (ACS) who are experiencing less severe symptoms and who have none of the above high risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (Level of Evidence: C)