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Acute Coronary Syndromes –
the Case for Improvement
© Commonwealth of Australia 2015
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Suggested citation
Australian Commission on Safety and Quality in Health Care (2015). Acute Coronary Syndromes – the Case for
Improvement. ACSQHC, Sydney.
Acknowledgements
Many individuals and organisations have freely given their time and expertise in the development of this paper. In
particular, the Commission wishes to thank Professor Derek Chew, other members of the Acute Coronary Syndromes
Topic Working Group and other key experts who have given their time and advice. The involvement and willingness of
all concerned to share their experience and expertise is greatly appreciated.
Disclaimer
The Australian Commission on Safety and Quality in Health Care has produced this Case for Improvement to support
the implementation of the corresponding Clinical Care Standard. The Case for Improvement and the Clinical Care
Standard support the delivery of appropriate care for a defined clinical condition and are based on the best evidence
available at the time of development. Healthcare professionals are advised to use clinical discretion and consideration of
the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian when applying
information contained within the Clinical Care Standard. Consumers should use the information in the Clinical Care
Standard as a guide to inform discussions with their healthcare professional about the applicability of the Clinical Care
Standard to their individual condition.
Contents
Acute Coronary Syndromes Clinical Care Standards
2
Purpose
3
Acute coronary syndromes – the case for improvement
4
Quality statement 1 – Immediate management
6
Quality statement 2 – Early assessment
7
Quality statement 3 – Timely reperfusion
9
Quality statement 4 – Risk stratification
10
Quality statement 5 – Coronary angiography
12
Quality statement 6 – Individualised care plan
13
Glossary
14
References
16
Acute Coronary Syndromes – the Case for Improvement
1
Acute Coronary Syndromes Clinical Care Standard
1
A patient presenting with acute chest pain or other symptoms suggestive of
an acute coronary syndrome receives care guided by a documented chest
pain assessment pathway.
2
A patient with acute chest pain or other symptoms suggestive of an acute
coronary syndrome receives a 12-lead electrocardiogram (ECG) and the
results are analysed by a clinician experienced in interpreting an ECG within
10 minutes of the first emergency clinical contact.
3
A patient with an acute ST-segment-elevation myocardial infarction (STEMI),
for whom emergency reperfusion is clinically appropriate, is offered timely
percutaneous coronary intervention (PCI) or fibrinolysis in accordance with
in interpreting an ECG within 10 minutes of the first emergency
the time frames recommended in the current National Heart Foundation of
Australia/Cardiac
Society of Australia and New Zealand Guidelines for the
clinical
contact.
Management of Acute Coronary Syndromes.1
In general, primary PCI is recommended if the time from first medical contact
to balloon inflation is anticipated to be less than 90 minutes, otherwise the
patient is offered fibrinolysis.
2
4
A patient with a non-ST-segment-elevation acute coronary syndrome
(NSTEACS) is managed based on a documented, evidence-based
assessment of their risk of an adverse event.
5
The role of coronary angiography, with a view to timely and appropriate
coronary revascularisation, is discussed with a patient with a non-STsegment-elevation acute coronary syndrome (NSTEACS) who is assessed to
be at intermediate or high risk of an adverse cardiac event.
6
Before a patient with an acute coronary syndrome leaves the hospital, they
are involved in the development of an individualised care plan. This plan
identifies the lifestyle modifications and medicines needed to manage their
risk factors, addresses their psychosocial needs and includes a referral to an
appropriate cardiac rehabilitation or another secondary prevention program.
This plan is provided to the patient and their general practitioner or ongoing
clinical provider within 48 hours of discharge.
Acute Coronary Syndromes – the Case for Improvement
Purpose
This document supports the implementation of the Acute Coronary Syndromes
Clinical Care Standard by highlighting what is known about the evidence, best
practice and current practice – and the opportunities to bring these closer together.
A Clinical Care Standard is a small number of
quality statements that describe the clinical care that
a patient should be offered for a specific clinical
condition. A Clinical Care Standard supports:

people to know what care may be offered by
their healthcare system and to make informed
treatment decisions in partnership with
their clinician

clinicians to make decisions about
appropriate care

health services to examine the performance of
their organisation and make improvements in
the care they provide.
While there are well-developed guidelines for
managing acute coronary syndromes, not all
patients are treated consistently, suggesting that
there is a gap between knowledge and practice. 2
The causes for this variation may be as diverse as
the possible solutions – and depend on the local
and individual circumstances.
This document outlines the following for each
quality statement:



Why is it important?
What is known about current practice?
What could be achieved with more consistent
application of the aspects of care described?
When possible, examples are provided showing
how specific approaches or systems for
implementing best practice have demonstrated
measurable change.
This document will be of interest to a wide audience,
including clinicians and health services, policy
makers, health system managers, researchers and
the general public, and all those with an interest in
the implementation of the Acute Coronary
Syndromes Clinical Care Standard.
Acute Coronary Syndromes – the Case for Improvement
3
Acute coronary syndromes – the case
for improvement
Acute coronary syndromes (ACS), including heart attacks, affect thousands
of Australians. An estimated 69,900 people aged 25 and over had an acute coronary
event in 2011, which equates to around 190 events per day.* Coronary heart disease
(CHD) – the underlying condition in ACS – contributed to 15 per cent of all deaths in
Australia in 2011.3
The Acute Coronary Syndromes Clinical Care
Standard aims to ensure that a person with a
potential ACS receives optimal treatment from
the onset of symptoms through to discharge
from hospital.
Coronary heart disease is still
a major health burden
Hospitalisation rates and CHD deaths have
declined over the past two to three decades,
probably as a result of improvements in treatment
and prevention.3 Despite these gains, CHD is the
most common chronic disease cause of death
and accounts for the greatest burden of disease in
Australia.3 With the ageing of the population, one
estimate suggests that the number of people living
with CHD could double, along with a 73 per cent
increase in new CHD by 2045. Correspondingly,
42 per cent of men and 30 per cent of women aged
25 in 2005 are predicted to develop CHD in their
lifetime.4 As more people survive heart attacks,
preventing further events and related disability is
critical for reducing the health burden associated
with coronary heart disease in Australia.
*
4
This figure includes both myocardial infarctions and unstable
angina as per the relevant national indicator; the latter uses
the term ‘heart attack’ when reporting this data for ease of
understanding. 2,9
Acute Coronary Syndromes – the Case for Improvement
Treatment and outcomes for
acute coronary events differ for
different groups
People in remote and rural locations still have
a higher rate of CHD mortality than their
urban counterparts.5
Despite well-developed guidelines for managing
ACS, not all people receive appropriate treatment.
Variation exists between the rates of invasive
treatment (angiography and percutaneous coronary
intervention [PCI]) received by people in
metropolitan compared to non-metropolitan areas,
and between treatment of people in low and
high-risk groups.2
Aboriginal and Torres Strait Islander peoples
experience coronary events, such as heart attacks,
at rates three times those of other Australians.6
Compared with other patients, Aboriginal and Torres
Strait Islander peoples admitted to hospital with
ACS are twice as likely to die in hospital from CHD,
while also experiencing lower levels of angiography
and invasive procedures.7
Preventing recurrence needs to start
at the first admission for an acute
coronary syndrome
Hospitalisations for ACS have increased since the
1990s but the average length of stay in hospital
has decreased. While most hospital stays are
for three days or more, stays of one day or less are
more frequent in all age groups than they
were in the late 1990s, due in part to advances in
medical procedures.8
Nonetheless, one-third of patients admitted for CHD
are readmitted within 24 months, with readmissions
accounting for up to a third of the total costs of
atherothrombotic disease.9 It is likely that at least
some of these readmissions (and associated costs)
could be prevented by reducing the gaps between
recommended and current care.
Systems of care can
improve outcomes
Clinical pathways and clinical care networks that
cross hospital and health service boundaries have
been shown to improve outcomes for people with an
ACS.11,12 The need for coordinated systems of care
to manage acute events and prevent future
recurrences is vital.
An integrated, systems-based approach supported
by health services and networks of services is
therefore central to the delivery of patient-centred
care identified in this Clinical Care Standard.
Key elements of this approach include:

an understanding of the capacity and limitations
of each component of the system across
metropolitan, regional and remote settings,
including pre-hospital care, within and across
hospitals, through to community and other
support services

clear lines of communication across
components of the system

appropriate coordination so that patients receive
timely access to optimal care regardless of how
or where they enter the system.
Acute Coronary Syndromes – the Case for Improvement
5
Quality statement 1 – Immediate management
A patient presenting with acute chest pain or other symptoms suggestive of
an acute coronary syndrome receives care guided by a documented chest
pain assessment pathway.
Why is this important?
What is current practice?
Acute chest pain is a common symptom of acute
coronary syndromes (ACS). However, not all
patients with an ACS have chest pain and not all
chest pain is due to an ACS.
Published data are not available about the rate
of missed MI in Australia, or the proportion of
hospitals that use chest pain assessment
pathways. However, there is considerable
variation in procedures and treatments for how
chest-pain patients are managed across the
country2, suggesting that treatment is not always
evidence based. Research has demonstrated that
different protocols for assessing chest pain,
including the specific tests used, are associated
with different rates of MI and other serious
outcomes after the patient is discharged from
the ED. This research suggests there is value in
a more standardised approach.16,17
Non-standardised or inconsistent approaches to
assessment expose patients to the risk of missed
diagnosis, with the greatest risk being that patients
may be discharged to home, and subsequently
suffer a fatal heart attack. Patients sent home with
undiagnosed myocardial infarction (MI) or unstable
angina have a 30-day mortality rate almost double
that of those who are hospitalised (5.5 per cent
compared with 9.8 per cent).13
Chest pain assessment pathways could help to
reduce emergency department (ED) over-crowding
by streamlining processes. ED over-crowding
reduces the effectiveness of care to those in
highest need.14
While patients with an ST-segment-elevation
myocardial infarction (STEMI) are usually identified,
diagnosing other patients with chest pain who are at
the highest risk of a myocardial infarction is
challenging, particularly for those presenting with
less typical signs and symptoms. Of patients who
present with undifferentiated chest pain in Australia,
it is estimated that only 10 –15 per cent are finally
diagnosed with an ACS.15,16
Evidence-based pathways can help differentiate
between low-risk patients who can be safely
discharged from the ED for outpatient follow up, and
high-risk patients who need immediate investigation
and treatment.15,16
6
Acute Coronary Syndromes – the Case for Improvement
What could be achieved?
Using a standardised chest pain assessment
pathway, it is possible to streamline the investigation
and management of patients with chest pain, with
very low rates of major adverse cardiac outcomes –
less than one per cent.15 –17
As well as reducing adverse consequences of
misdiagnosis, total ED length of stay can be
significantly reduced.15 This can contribute to
achieving national emergency access targets
(NEAT) that aim to ensure patients are either
admitted, discharged, or referred on within four
hours of presenting to the ED, which will improve
access and reduce waiting times for all ED patients.
Quality statement 2 – Early assessment
A patient with acute chest pain or other symptoms suggestive of an acute coronary
syndrome receives a 12-lead electrocardiogram (ECG), and the results are analysed
by a clinician experienced in interpreting an ECG, within 10 minutes of the first
emergency clinical contact.
Why is this important?
What is current practice?
Establishing ECG changes is the key diagnostic
step for identifying the most lethal and time-critical
type of heart attack – STEMI. The earlier the ECG
can be carried out and correctly interpreted, the
more likely it is the patient will receive prompt
reperfusion treatment, restoring blood flow to the
heart and reducing the risk of heart tissue damage
or death. The closer to symptom onset that
reperfusion occurs, the better.
In Australia, around 50 per cent of patients with
chest pain arrive at hospital by ambulance.18
In some parts of Australia, the ECG is now
performed in an ambulance by a trained paramedic,
allowing much faster diagnosis and streamlining of
treatment, including transfer to the most appropriate
treatment location.11,18
In Australia, guidelines recommend a PCI should
be performed within 90 minutes of first medical
contact and fibrinolysis within 30 minutes, for
patients with a STEMI.1 When a pre-hospital
ECG can be performed in the ambulance,
treatment can often start earlier – either through
paramedic-administered fibrinolysis or by facilitated
transfer to a PCI-capable hospital. Delays imposed
by distance (particularly in rural areas) and the fact
that patients often present several hours after their
first symptoms make rapid ECG assessment even
more crucial.18
For those who come to ED independently, it may
take longer for the first ECG to be conducted.
By specifying a time frame of 10 minutes, the
Clinical Care Standard indicates the importance of
achieving fast diagnosis – whether the patient is first
seen in hospital or by paramedics. The time frame
of 10 minutes is consistent with an Australasian
Triage Category score of 2.19
Acute Coronary Syndromes – the Case for Improvement
7
What could be achieved?
Obtaining an ECG result within 10 minutes of first
emergency clinical contact will enable the early
diagnosis of more patients with STEMI, allowing
faster activation of emergency processes required to
provide timely reperfusion. A pre-hospital diagnosis
of STEMI can help the hospital prepare for
reperfusion or direct the patient to a hospital
equipped to perform PCI. In rural and remote areas,
fibrinolysis may start before hospital arrival.18
Acquiring an ECG before arrival with advance
hospital notification has been shown to reduce the
8
Acute Coronary Syndromes – the Case for Improvement
relative risk of short-term mortality by 30–40 per
cent compared to standard care, according to
pooled international studies.20
Time to treatment was nearly halved by one hospital
network using an ambulance-based pre-hospital 12lead ECG to facilitate transfer to the cardiac
catheterisation lab when needed. ‘Door-to-balloon’
time was reduced from a median of 100 minutes to
54 minutes compared with patients who came by
ambulance without an ECG or came themselves to
the ED.11
Quality statement 3 – Timely reperfusion
A patient with an acute ST-segment-elevation myocardial infarction (STEMI),
for whom emergency reperfusion is clinically appropriate, is offered timely
percutaneous coronary intervention (PCI) or fibrinolysis in accordance with the time
frames recommended in the current National Heart Foundation of Australia/Cardiac
Society of Australia and New Zealand Guidelines for the Management of Acute
Coronary Syndromes.1
In general, primary PCI is recommended if the time from first medical contact to balloon
inflation is anticipated to be less than 90 minutes, otherwise the patient is offered fibrinolysis.
Why is this important
Treatment of STEMI is time critical. Reducing the
time between symptom onset and restoration of
blood flow to cardiac muscle has a direct impact on
the extent of permanent damage to the heart, longterm disability and death in these patients.18
The appropriate choice of therapy depends on a
number of factors, including how soon PCI can be
performed and the time since symptom onset. While
distance and access to PCI-capable facilities can
affect the choice of reperfusion, the timeliness of
reperfusion is crucial.
What is current practice?
An Australian national audit of STEMI
patients 21 found:

90 per cent of patients presented within a time
from symptom onset that allowed for reperfusion
(less than 12 hours)

67 per cent of patients received any reperfusion
therapy – either primary PCI or fibrinolysis

23 per cent of patients received the reperfusion
therapy within the optimal time frame.
Australian patients with STEMI 21:

90 per cent presented in time for reperfusion
(< 12 hours)


67 per cent received any reperfusion
23 per cent received timely reperfusion.
What could be achieved?
Extending timely reperfusion to all patients with
STEMI could prevent an estimated 23
deaths and 213 recurrent MIs or strokes
per 10,000 presentations.22
One Australian cardiac network was able to double
the number of PCIs performed within recommended
time frames from 42 per cent to 90 per cent. The
service model included paramedic field triage and
pre-hospital notification in a metropolitan healthcare
network including three hospitals, only one of which
had a PCI facility.11
Approximately eight per cent of patients who had a
STEMI died within 12 months of hospital admission,
regardless of their treatment. However, STEMI
patients who received timely reperfusion therapy
were much more likely to be alive after 12 months
than those who received late reperfusion therapy or
none at all. 21
Acute Coronary Syndromes – the Case for Improvement
9
Quality statement 4 – Risk stratification
A patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS)
is managed based on a documented, evidence-based assessment of their risk of an
adverse event.
Why is this important?
Underestimating a patient’s risk of a future major
adverse cardiac event can reduce the likelihood of
them receiving timely, intensive treatment.23
Objective risk assessment tools can help clinicians
to accurately predict risk.†
Clinical data from Australia and internationally
demonstrate that physician perceptions of risk are
quite varied and less accurate than risk prediction
undertaken through established risk scoring
methods. Underestimating clinical risk appears to be
associated with an increase in late mortality.24,25
What is current practice?
Retrospective studies have found a ‘treatment-risk’
paradox – suggesting that high-risk patients are less
likely to receive treatment using objective risk
prediction tools such as the Global Registry of Acute
Coronary Events score (GRACE) or the
Thrombolysis In Myocardial Infarction (TIMI)
score.2,23 In one Australian study, 19 per cent of
high-risk patients with NSTEACS received early
coronary angiography compared to 34 per cent of
low-risk patients. From the same data, 18 per cent
of high-risk patients received reperfusion compared
with 88 per cent of low-risk patients.23
While patient complexity (age, multiple morbidity)
can justifiably affect treatment decisions, the risk
conferred by such factors may sometimes be
†
Risk assessment tools for consideration include:
i. Global Registry of Acute Coronary Events score (GRACE)
ACS Risk Calculator27
ii. Thrombolysis In Myocardial Infarction (TIMI) Risk Score for
UA/NSTEMI28
iii. Acute Coronary Syndromes Treatment Algorithm 29
10
Acute Coronary Syndromes – the Case for Improvement
overestimated, so that high-risk patients who are
most likely to benefit do not receive treatment.21,24
Under-treatment of high-risk patients has been
shown even after compensating for age and other
factors that might increase the risks of therapy.23
While integrated into the recommendations of
national and international clinical practice
guidelines, no clinical trials have formally evaluated
a strategy of objective risk assessment versus
physician impression in guiding care among patients
with ACS.25,26
Data that describe how often patients are managed
using a documented, evidence-based assessment
of risk is not currently available.
What could be achieved?
Employing objective risk assessment may assist in
reducing the major adverse cardiac events that
result from the under-treatment of high-risk patients
across the spectrum of ACS.23,25
More consistent estimation of risk may help shared
decision making and communication with patients
and their carers26, making it easier to weigh up the
benefits and risks of different treatment options.
Treatment rates and risk in NSTEACS patients23
Note: Risk was categorised according to the TIMI score; reperfusion includes fibrinolytic therapy and angioplasty. 23
Acute Coronary Syndromes – the Case for Improvement
11
Quality statement 5 – Coronary angiography
The role of coronary angiography, with a view to timely and appropriate coronary
revascularisation, is discussed with a patient with a non-ST-segment-elevation acute
coronary syndrome (NSTEACS) who is assessed to be at intermediate or high risk
of an adverse cardiac event.
Why is this important?
While not every patient with a NSTEACS should have
an angiogram, the potential treatment benefits and
risks should be discussed with all patients at high or
intermediate risk.
Australian national audit data (ACACIA) show
considerable risk of adverse cardiac outcomes in the
first 12 months after hospital admission for
NSTEACS.30 Rates of death, MI, or stroke within 12
months were similar for patients with NSTEACS (16
per cent) and STEMI (17 per cent). For all ACS, 12month mortality was reduced for patients who had
coronary angiography during their acute admission
(adjusted hazard ratio of 0.53).30
International data from randomised trials show a three
per cent absolute risk reduction in cardiovascular
death or non-fatal MI for NSTEACS patients
randomised to routine coronary angiography (and
revascularisation as appropriate) compared to
intervention based on persistent or refractory
symptoms. For highest-risk patients, the absolute
difference was 11 per cent over five years.31
What is current practice?
Currently, there is significant variation nationally in
the use of diagnostic coronary angiography. While
60 per cent of ACS patients in principal referral
hospitals receive angiography, only 40 per cent of
those in regional centres do so.2 This suggests that
not all patients are receiving the same opportunity
to access treatment.
Several studies show that patients at highest risk
(according to GRACE or TIMI) are least likely to
receive invasive management.2,23 In one study, only
19 per cent of NSTEACS patients categorised as high
risk according to their TIMI score had early coronary
angiography compared with 34 per cent of low-risk
patients.23
12
Acute Coronary Syndromes – the Case for Improvement
In the ACACIA audit, 71 per cent of non-STsegment-elevation myocardial infarction (NSTEMI)
and 45 per cent of unstable-angina patients had
angiography and/or PCI during the index admission,
compared with 90 per cent of STEMI patients.30
What could be achieved?
Patients receiving coronary angiography before
discharge from acute care, experience a 47 per cent
lower relative rate of late mortality.30 It has been
estimated that a further 16 lives could be saved
per 10,000 presentations of NSTEMI if coronary
angiography occurred within 72 hours of
admission.22 As 65 to 70 per cent of all MIs are
NSTEMIs, the impact of improved management
could be substantial.2,8
While rates of mortality from CHD have declined
across Australia since 2001, the highest rates are still
for men in remote and very remote areas (238 per
100,000 population) compared to men in major cities
(181 per 100,000).5
Greater rates of angiography among patients in
metropolitan centres demonstrate that rates
exceeding 60 per cent are achieved in clinical settings
where logistical access to this investigation is not
problematic.2 For example, rural patients in a
regionalised clinical cardiac network were 30 per cent
more likely to receive angiography, and had lower 30day-mortality rates than rural patients in hospitals
outside the network.12
Better patient involvement in decision making,
particularly about transfer from rural areas to
metropolitan centres, may improve access to care.
This may be particularly important for Aboriginal and
Torres Strait Islander peoples who may not wish to
transfer to a different location for cultural reasons.
Quality statement 6 – Individualised care plan
Before a patient with an acute coronary syndrome leaves the hospital, they are involved in
the development of an individualised care plan. This plan identifies the lifestyle modifications
and medicines needed to manage their risk factors, addresses their psychosocial needs and
includes a referral to an appropriate cardiac rehabilitation or another secondary prevention
program. This plan is provided to the patient and their general practitioner or ongoing clinical
provider within 48 hours of discharge.
Why is this important?
What could be achieved?
Patients who have previously experienced a
coronary heart event are at high risk of a
subsequent event. As patients generally spend less
time in hospital for the treatment of an ACS because
of treatment advances in recent years, in-hospital
management may tend to focus on acute treatment
with less time spent planning follow-up care.
Hospital-based cardiac rehabilitation services may
be less relevant to patients whose post-operative
recovery is faster after PCI than after bypass
surgery (coronary artery bypass graft [CABG]). Most
patients require education and support to adhere to
exercise, diet and medication regimes. In most
cases this will happen in the community, but
encouragement from the treating cardiologist or
physician can strongly influence adherence.32
Extending the use of and adherence to guidelinerecommended therapies for at least 12 months
could prevent 104 deaths and 191 recurrent heart
attacks or strokes within the first 12 months, per
10,000 ACS patients.22
The cost of treating recurrent events is substantial.
In one Australian hospital, re-hospitalisations
within 24 months accounted for almost a third
of the annual costs of atherothrombotic disease
admissions. CHD made up 74 per cent of
these admissions.9
What is current practice?
Whether patients receive guideline-recommended
medications on discharge or a referral to cardiac
rehabilitation varies greatly, according to data from
the Australian SNAPSHOT ACS study. Overall, 64
per cent of all ACS patients received four or more
guideline-recommended therapies on discharge.
Only 46 per cent were formally referred to cardiac
rehabilitation. Variation between metropolitan and
rural centres was also observed.2
In an earlier study, of the 76 per cent of patients
discharged on four or more recommended
medicines, 22 per cent were no longer adherent
after six months.22
Acute Coronary Syndromes – the Case for Improvement
13
Glossary
Acute coronary syndromes (ACS ): The spectrum of
acute clinical presentations resulting from underlying
CHD, including myocardial infarction (heart attack) and
angina.18 These are further categorised on the basis of
ECG and other investigations as ST-segment-elevation
myocardial infarction (STEMI), non-ST-segment-elevation
myocardial infarction (NSTEMI) and unstable angina.
Acute myocardial infarction: A condition where there is
evidence of myocardial necrosis (cell death) consistent
with acute myocardial ischaemia.33 Acute myocardial
infarction is a type of acute coronary syndrome, typically
referred to as a ‘heart attack’, where the supply of blood to
the heart muscle is blocked. STEMI and NSTEMI are both
forms of myocardial infarction.
Angina: Chest pain due to obstruction or spasm of the
coronary artery. Unstable angina is part of the spectrum of
acute coronary syndromes and is a more severe form of
angina (see Unstable angina).
Atherosclerosis: A process in which fatty and fibre-like
deposits build up on the inner walls of arteries, often
forming plaques that can then cause blockages. It is the
main underlying condition in heart attack, angina, stroke
and peripheral vascular disease.
Atherothrombotic disease: Conditions with a similar
pathology (manifestations of disease) involving the
formation of a blood clot (thrombosis) in addition to
atherosclerosis. Generally this occurs in ischaemic stroke,
CHD and peripheral arterial disease.9
Cardiac event: Any severe or acute cardiovascular
condition including acute myocardial infarction, unstable
angina and cardiac death.34
Cardiac rehabilitation: The sum of activities required to
favourably influence the underlying cause of CHD, as well
as the best physical, mental and social conditions, so that
patients resume as normal a place as possible in the
community.35
Cardiac rehabilitation program: Describes all measures
used to help people with heart disease return to an active
and satisfying life and to prevent recurrence of cardiac
events.36
Care plan (individualised): A written agreement between a
consumer and health professional and/ or social services
to help manage day-to-day health.37 This information is
identified in a health record.
14
Acute Coronary Syndromes – the Case for Improvement
Carers: People who provide unpaid care and support to
family members and friends who have a disease,
disability, mental illness, chronic condition, terminal illness
or general frailty. Carers include parents and guardians
caring for children.38
Clinician: A healthcare provider, trained as a health
professional. Clinicians include registered and
nonregistered practitioners, or a team of health
professionals, who provide direct clinical care.38
Coronary angiography: A procedure in which a special
X-ray of the heart’s arteries (the coronary arteries) is
taken to see if they are narrowed or blocked. It involves
the insertion of a catheter (a long thin tube) into an artery
in the groin or arm, which is then moved up inside the
artery until it reaches the heart.39
Coronary heart disease: Caused by a slow build-up of
fatty deposits on the inner wall of the blood vessels that
supply the heart muscle with blood (the coronary arteries).
These fatty deposits gradually clog the arteries and
reduce the flow of blood to the heart.39
Coronary revascularisation: Procedures used to restore
good blood supply to the heart, for example, PCI or
coronary angioplasty (which involves inserting a catheter
with a balloon into a narrowed coronary artery, and
inflating the balloon to open up the artery and restore
blood flow).8
Door-to-balloon time: The duration of time from the point
of arrival at a PCI facility to the first inflation of a balloon
inside the blocked coronary artery during a PCI
procedure. A door-to-balloon time of 90 minutes or less is
recommended to expedite time to reperfusion.18
Electrocardiogram ( ECG ): A non-invasive test that
records the electrical activity of the heart. A 12-lead ECG
records 12 different electrical views of the heart
simultaneously.18
Fibrinolysis: Specialised drug treatment to dissolve a
blood clot blocking a coronary artery during a heart attack.
If given early enough, this treatment can reduce damage
to the heart muscle.18 May also be referred to as
thrombolysis.
First emergency clinical contact: The time when a
patient first encounters a clinician.
Health record: Information about a patient held in paper
form or electronically. The health record may comprise
clinical records (such as medical history, treatment notes,
observations, correspondence, investigations, test results,
photographs, prescription records and medication charts),
administrative records (such as contact and demographic
information, and legal and occupational health and safety
records) and financial records (such as invoices,
payments and insurance information).40
Health service: A service responsible for the clinical
governance, administration and financial management of
unit(s) providing health care. A service unit involves a
grouping of clinicians and others working in a systematic
way to deliver health care to patients and can be in any
location or setting, including a pharmacy, clinic, outpatient
facility, hospital, patient’s home, community setting,
practice and clinicians’ rooms.38
Heart attack: Life-threatening emergency that occurs
when a vessel supplying blood to the heart muscle is
suddenly blocked completely by a blood clot.5 This term is
commonly used to refer to an acute myocardial infarction.
Hospital: A licensed facility providing healthcare
services to patients for short periods of acute illness,
injury or recovery.41
Individualised care plan: See Care plan.
Medicine: A chemical substance given with the intention
of preventing, curing, controlling or alleviating disease, or
otherwise improving the physical or mental welfare of
people. Prescription, non-prescription and complementary
medicines, irrespective of their administration route,
are included.38
Myocardial ischaemia: Reduced blood flow to
the muscle.
Non-ST-segment-elevation myocardial infarction
(NSTEMI ): A type of myocardial infarction identified by
what is seen on the electrocardiogram. In a NSTEMI, the
artery is only partly blocked, so only part of the heart
muscle being supplied by that artery is affected.42
Non-ST-segment-elevation acute coronary syndrome
(NSTEACS ): A condition where patients have acute
chest pain but do not have persistent ST segment
elevation in their electrocardiogram. NSTEACS is further
divided into unstable angina and non-ST-segmentelevation myocardial infarction.42
Percutaneous coronary intervention ( PCI ): An
invasive procedure that restores blood flow through a
blocked coronary artery. A special balloon is inserted to
open the blocked artery at the point of narrowing, without
the need for heart surgery. After PCI is performed, a stent
(an expandable metal tube such as a coil or wire mesh) is
delivered to the newly dilated site where it is expanded
and left in place to keep the artery open.18
Pre-hospital care: Emergency medical care provided in
the community and in transit to hospital.
Reperfusion: The restoration of blood flow (and therefore
oxygen supply) to an area of heart muscle that has been
deprived of circulation for a period of time (e.g. as a result
of a heart attack).18
Risk factor: Any variable (e.g. smoking, abnormal blood
lipids, elevated blood pressure, diabetes) that is
associated with a greater risk of a health disorder or other
unwanted condition or event.8
Secondary prevention: Health care designed to prevent
recurrence of cardiovascular events (e.g. heart attack) or
complications of cardiovascular disease in patients with
diagnosed cardiovascular disease. It involves medical
care, modification of behavioural risk factors, psychosocial
care, education and support for self-management
(including adherence to prescribed medicines), which
can be delivered in various settings. An example of an
evidence-based secondary prevention strategy is
cardiac rehabilitation.43
ST-segment-elevation myocardial infarction (STEMI ):
An acute heart attack for which the diagnosis has been
made by a 12-lead ECG test. A heart attack occurs when
an area of plaque within a coronary artery ruptures and
forms a blood clot, suddenly blocking the supply of blood
to a part of the heart muscle and depriving it of oxygen.18
Thrombosis: Clotting of blood; the term is usually applied
to clotting within a blood vessel due to disease, as in a
heart attack or a stroke.44
Unstable angina: A form of angina that is more
dangerous than normal angina but less so than a heart
attack. It can feature chest pain that occurs at rest; in
someone who already has angina it can be marked by
new patterns of onset with exertion or by pain that comes
on more easily, more often or for longer than previously,
and may be caused by a blockage in the blood vessel. 8
Unstable angina is a form of non-ST-segment-elevation
acute coronary syndrome (NSTEACS).
Acute Coronary Syndromes – the Case for Improvement
15
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Australian Commission on Safety and Quality in Health Care
Level 5, 255 Elizabeth Street, SYDNEY NSW 2000
GPO Box 5480, Sydney NSW 2001
Phone: (02) 9126 3600
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