The high prevalence of the morbidity and mortality associated with acute coronary syndrome is a cause for concern for patients and physicians in the United States. The prevalence of ACS in the U.S. in 2010 was approximately 625,000 patients. The condition is more prevalent among the elderly, with the average age of onset being 72 and 65 years in females and males respectively ( Switaj, Christensen, & Brewer, 2017). Early diagnosis and intervention is imperative in effective amelioration of patient symptoms and curtailing the prevalence of the condition. Primary caregivers have to understand and distinguish the clinical features of the condition, which often has two presentations: non-ST elevation acute coronary syndrome (NST-ACS) and ST-elevation myocardial infarction (STEMI). The American College of Cardiology Foundation provided guidelines for the management of STEMI in 2013 (Anderson, 2015). The guidelines provided approaches and recommendations for effective prevention and management of ACS, highlighting the important risk factors and indications. According to the guidelines, effective prevention relied on the identification of the symptoms and risk factors of ACS and initiating intervention strategies at individual and community levels. The AGREE II instrument provides an effective way of appraising clinical practice guidelines. The instrument contains 23 items organized into six domains that touch on all aspects of the guidelines (Hoffmann-Eßer et al., 2018). Adherence to the guidelines has been integral in the management of ACS and reduction of prevalence in the U.S.
STEMI Literature Review and History of Evolution
Clinical practice guidelines for coronary diseases was a joint initiative by the American Heart Association (AHA) and the American College of Cardiology (ACC). These guidelines were formulated on the premise of increased use of pacemakers, which the U.S. government raised concerns over potential overuse (Anderson, 2015). It was, therefore, important to develop guidelines and practice codes that would guide cardiovascular clinicians, incorporating clinical evidence to mitigate procedural or potentially harmful practices. The first guidelines for the management of patients with acute myocardial infarction were published in 1990.
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According to Jacobs, Anderson, & Halperin, (2014), the guidelines have subsequently been revised, making improvement and adding features aimed at improving the quality of patient care. The first revision was done in 1994, and subsequently in 1996, and subsequently every two years after that. The 1996 revision evaluated the implication of using the term coronary artery syndrome (ACS) in place acute myocardial infarction. This was on the premise of increasing findings that suggested that emerging episodes of ischemic discomfort among patients as a characteristic of the condition. The electrocardiogram (ECG) assay was used in clinical studies as the primary basis for classifying the patients into two broad categories: those with and without ST elevation. The category of patients without ST elevation was found to constitute of patients presenting with non-Q-wave myocardial infarction or unstable angina (Anderson, 2015). Both the 1996 and 1998 revision of the guidelines provided approaches for managing presentations of both ST and non-ST elevation among the coronary disease patients. The STEMI guidelines were thus formalized in the 1998 revision.
Twenty-three practice guidelines have since been developed, each guideline undergoing evolution to improve and incorporate newfound evidence (Anderson, 2015). Garnger et al. (2019) note that the AHA/ACC joint initiatives have aimed to improve cardiology clinical care and output by ensuring that clinicians closely adhere to the guidelines while conducting their clinical tests, procedures, treatment interventions, and management. Each version of the CPG has, however, always been subject to controversy based on why the guidelines are provided and how the evidence used to develop, the guidelines have been obtained (Jacobs, Anderson, & Halperin, 2014). Also, there has been an indication of the need for expert guidance for clinicians to understand the importance and applicability of the guidelines.
The increasing concerns on the quality, adoption, and the impact of the clinical practice guidelines prompted Congress to commission the Institute of Medicine (IOM). The IOM’s mandate was to evaluate and propose mechanisms and strategies for developing the existing CPGs. In 2011, the IOM issued two reports detailing its findings regarding the CPG. The reports compelled ACC/AHA to convene a methodology summit that comprised of the CPG Taskforce, experts, and other stakeholders (Jacobs, Anderson, & Halperin, 2014). The primary aim of the summit was to evaluate the ongoing improvement processes for the CPGs, as well as the impacts of the IOM reports on the guidelines. The conclusion of the summit was the CPGs were of high quality but needed some improvements and additional features to ensure high-quality care and optimal clinical outcomes (Jacobs, Anderson, & Halperin, 2014). Although considerable steps have been made in the management of STEMI patients following the revisions to the guidelines, there still exists room for further change and improvements. It is important to evaluate the guidelines based on the contemporary clinical evidence and changing healthcare needs of individual patients.
Appraisal of the STEMI Guideline
Scope and Purpose
The overall objectives of the STEMI guidelines are
To prevent long-term complications associated with acute myocardial infarction in patients.
To lower the prevalence of ACS in the United States
To implement effective risk assessment and mitigation strategies for acute myocardial infarction.
The health questions that may be raised by the guideline may include:
How frequently should patients be assessed for STEMI?
What are the criteria for initiating immediate ED general treatment for patients?
What is the effective aspirin dosage for specific patient groups?
Population to whom the guideline is meant for:
The STEMI guideline clearly defines its target population as patients with ST- elevated myocardial infarction.
Rating: 5
Stakeholder Involvement
Since its first publication, the STEMI guidelines have involved experts in its development processes. This includes members of specific Task Forces who have adequate knowledge of clinical cardiology practices as well as the involvement of patient representatives. The review and recommendation of improvements to the guideline involved extensive research and collaboration of the Task team in getting the views and clinical evidence. The views and experiences of the target population were, however, not overtly represented. Patient involvement in developing the guidelines was minimum. Information pertaining to the patients was obtained from a review of literature and evidence from clinical studies. The guideline clearly defines the target users of as cardiologist and primary caregivers in cardiology and coronary disease departments.
Rating: 6
Rigour of Development
The search for evidence used in developing the guidelines was primarily sourced from clinical studies. Other sources were online databases and publications. The need for revising the guidelines was based on concerns raised by the government or other stakeholders. The guidelines, however, do not explicitly mention the criteria used in selecting the appropriate evidence and the strengths and limitations of the evidence.
The methods used in the formulation of the recommendations were mainly forums and seminars in which the involved stakeholders discussed the implications of the evidence and its implementation. In these seminars, the health impacts of the recommendations were often explored in detail before deciding the best additions on the guidelines. The recommendations were based on the presented evidence. The procedure for subsequent revisions of the guidelines is not clearly defined.
Rating: 5
Clarity and Presentation
The recommendations provided by the guideline for managing STEMI patients are clear, consistent, and easy to understand. Different algorithms and approaches for different patient situations are provided. The procedures are sequential, from the EMS assessment before hospitalization of the patient, simple ED assessments that include checking Vital signs and cardiac marker levels to complex procedures. From the provided algorithms, it is easy to identify the key recommendations for different patient situations.
Rating: Strongly agree
Applicability in a hospital setting
Although the guideline mentions some factors that can facilitate or impede its application, these factors are not clearly defined. It is upon the cardiologist to identify and mitigate the barriers in their practice. It, however, provides recommendations on how the tool can be applied in different patient situations, highlighting all the procedures and algorithms that should be done before, during, and after hospitalization of the patient.
Rating 6
Conclusion
Acute coronary syndrome (ACS) has become a health concern in the United States in recent years. ACS is categorized as ST- elevated myocardial infarction and non- ST- elevated ACS. This prompted the development of clinical practice guidelines for managing patients with the condition. The STEMI guidelines have undergone several changes and improvements aimed at enhancing the quality of care and optimum output among the patients. Based on the evaluation on the AGREE II instrument, the overall score of the STEMI guidelines is 6.
References
Anderson, J. L. (2015). Evolution of the ACC/AHA clinical practice guidelines in perspective: guiding the guidelines.
Granger, C. B., Bates, E. R., Jollis, J. G., Antman, E. M., Nichol, G., O'Connor, R. E., ... & Henry, T. D. (2019). Improving the care of STEMI in the United States 2008 to 2012: a report from the American Heart Association Mission: Lifeline program. Journal of the American Heart Association , 8 (1), e008096.
Hoffmann-Eßer, W., Siering, U., Neugebauer, E. A., Brockhaus, A. C., McGauran, N., & Eikermann, M. (2018). Guideline appraisal with AGREE II: online survey of the potential influence of AGREE II items on overall assessment of guideline quality and recommendation for use. BMC health services research , 18 (1), 143.
Jacobs, A. K., Anderson, J. L., & Halperin, J. L. (2014). The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology , 64 (13), 1373-1384.
Switaj, T. L., Christensen, S. R., & Brewer, D. M. (2017). Acute Coronary Syndrome: Current Treatment. American family physician , 95 (4).
