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Optimising acute care and secondary prevention for patients with acute coronary syndrome

Patients who experience an acute coronary syndrome (ACS) present with heterogeneous clinical manifestations. In the emergency department, risk assessment should immediately identify patients with ST-segment elevation myocardial infarction (STEMI) who are in need of emergency reperfusion. In patients with non-ST-segment elevation acute coronary syndrome (NSTEACS), the focus is on identifying those at higher risk of recurrent infarction or death. This then guides the application of evidence-based therapies such as angiography and appropriate revascularisation, powerful antithrombotic therapy and comprehensive secondary prevention.

Evaluations of clinical practice have consistently shown underuse of risk stratification and consequent inappropriate application of evidence-based practice. This is particularly true for patients at higher risk of adverse events, who are often undertreated yet have the most to gain from evidence-based therapy.

Optimising systems of care for STEMI

The acute occlusion of a major epicardial coronary vessel usually occurs in the context of poor collateral supply, and results in the rapid onset of myocardial necrosis accompanied by an increased likelihood of lethal arrhythmia. These patients have the highest inhospital mortality rates, but these can be improved by prompt institution of reperfusion therapy. There is a clear relationship between longer time from symptom onset to reperfusion and increasing…