Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC.
Restricted accessResearch articleFirst published online March, 2020
Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC.
Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts’ opinions, for all emergency medical services’ health providers involved in the pre-hospital management of acute cardiovascular care.
PittetVBurnandBYersinB, et al. Trends of pre-hospital emergency medical services activity over 10 years: A population-based registry analysis. BMC Health Serv Res2014; 14: 380.
2.
ErhardtLHerlitzJBossaertL, et al. Task force on the management of chest pain. Eur Heart J2002; 23: 1153–1176.
3.
NolanJPHazinskiMFBilliJE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation2010; 81(Suppl. 1): e1–e25.
4.
TubaroMVranckxPPriceS, et al. (eds). The ESC textbook of intensive and acute cardiovascular care. 2nd ed.The European Society of Cardiology, Sophia Antipolis, France, 2015.
5.
RyynänenO-PIirolaTReitalaJ, et al. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med2010; 18: 62.
6.
Rosell-OrtizFMellado-VergelFJFernández-ValleP, et al. Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation. Emerg Med J2015; 32: 559–563.
7.
WelshRCTraversASenaratneM, et al. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J2006; 152: 1007–1014.
8.
DucasRAWassefAWJassalDS, et al. To transmit or not to transmit: How good are emergency medical personnel in detecting STEMI in patients with chest pain?Can J Cardiol2012; 28: 432–437.
9.
StegPGJamesSKAtarD, 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). Eur Heart J2012; 33: 2569–2619.
10.
TubaroMDanchinNGoldsteinP, et al. Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology. Acute Card Care2011; 13: 56–67.
11.
BingisserRCairnsCChristM, et al. Cardiac troponin: A critical review of the case for point-of-care testing in the ED. Am J Emerg Med2012; 30: 1639–1649.
12.
WongC-KWhiteHD.The HERO-2 ECG sub-studies in patients with ST elevation myocardial infarction: Implications for clinical practice. Int J Cardiol2013; 170: 17–23.
13.
WongC-KFrenchJKAylwardPEG, et al. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes. J Am Coll Cardiol2005; 46: 29–38.
14.
SinghSMFitzGeraldGYanAT, et al. High-grade atrioventricular block in acute coronary syndromes: Insights from the Global Registry of Acute Coronary Events. Eur Heart J2015; 36: 976–983.
15.
de WinterRJVeroudenNJWWellensHJJ, et al. A new ECG sign of proximal LAD occlusion. N Engl J Med2008; 359: 2071–2073.
16.
PistersRLaneDANieuwlaatR, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest2010; 138: 1093–1100.
17.
MoscucciMFoxKACannonCP, et al. Predictors of major bleeding in acute coronary syndromes: The Global Registry of Acute Coronary Events (GRACE). Eur Heart J2003; 24: 1815–1823.
18.
WindeckerSKolhPAlfonsoF, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J2014; 35: 2541–2619.
19.
BoersmaEMaasACDeckersJW, et al. Early thrombolytic treatment in acute myocardial infarction: Reappraisal of the golden hour. Lancet1996; 348: 771–775.
20.
PintoDSKirtaneAJNallamothuBK, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: Implications when selecting a reperfusion strategy. Circulation2006; 114: 2019–2025.
21.
ChenZMJiangLXChenYP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: Randomised placebo-controlled trial. Lancet2005; 366: 1607–1621.
22.
StubDSmithKBernardS, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation2015; 131: 2143–2150.
23.
ZijlstraFErnstNde BoerM-J, et al. Influence of prehospital administration of aspirin and heparin on initial patency of the infarct-related artery in patients with acute ST elevation myocardial infarction. J Am Coll Cardiol2002; 39: 1733–1737.
24.
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet1988; 2: 349–360.
25.
ZeymerUArntzH-RMarkB, et al. Efficacy and safety of a high loading dose of clopidogrel administered prehospitally to improve primary percutaneous coronary intervention in acute myocardial infarction: The randomized CIPAMI trial. Clin Res Cardiol2012; 101: 305–312.
26.
DucciKGrottiSFalsiniG, et al. Comparison of pre-hospital 600 mg or 900 mg vs. peri-interventional 300 mg clopidogrel in patients with ST-elevation myocardial infarction undergoing primary coronary angioplasty. The Load&Go randomized trial. Int J Cardiol2013; 168: 4814–4816.
27.
Bellemain-AppaixAO’ConnorSASilvainJ, et al. Association of clopidogrel pretreatment with mortality, cardiovascular events, and major bleeding among patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis. JAMA2012; 308: 2507–2516.
28.
ZeymerUMochmannH-CMarkB, et al. Double-blind, randomized, prospective comparison of loading doses of 600 mg clopidogrel versus 60 mg prasugrel in patients with acute ST-segment elevation myocardial infarction scheduled for primary percutaneous intervention: The ETAMI trial (early thienopyridine treatment to improve primary PCI in patients with acute myocardial infarction). JACC Cardiovasc Interv2015; 8: 147–154.
29.
MontalescotGWiviottSDBraunwaldE, et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): Double-blind, randomised controlled trial. Lancet2009; 373: 723–731.
30.
StegPGJamesSHarringtonRA, et al. Ticagrelor versus clopidogrel in patients with ST-elevation acute coronary syndromes intended for reperfusion with primary percutaneous coronary intervention: A Platelet Inhibition and Patient Outcomes (PLATO) trial subgroup analysis. Circulation2010; 122: 2131–2141.
31.
MontalescotGvan’tHofAWLapostolleF, et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction.N Engl J Med2014; 371: 1016–1027.
32.
ParodiGXanthopoulouIBellandiB, et al. Ticagrelor crushed tablets administration in STEMI patients: The MOJITO study. J Am Coll Cardiol2015; 65: 511–512.
33.
ParodiGValentiRBellandiB, et al. Comparison of prasugrel and ticagrelor loading doses in ST-segment elevation myocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study. J Am Coll Cardiol2013; 61: 1601–1606.
34.
EllisSGTenderaMde BelderMA, et al. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med2008; 358: 2205–2217.
35.
DE LucaGBellandiFHuberK, et al. Early glycoprotein IIb-IIIa inhibitors in primary angioplasty-abciximab long-term results (EGYPT-ALT) cooperation: Individual patient’s data meta-analysis. J Thromb Haemost2011; 9: 2361–2370.
36.
BergJMten van’tHofAWJDillT, et al. Effect of early, pre-hospital initiation of high bolus dose tirofiban in patients with ST-segment elevation myocardial infarction on short- and long-term clinical outcome. J Am Coll Cardiol2010; 55: 2446–2455.
37.
HuberKHolmesDRvan ’t HofAW, et al. Use of glycoprotein IIb/IIIa inhibitors in primary percutaneous coronary intervention: Insights from the APEX-AMI trial. Eur Heart J2010; 31: 1708–1716.
38.
EllisSGTenderaMde BelderMA, et al. 1-year survival in a randomized trial of facilitated reperfusion: Results from the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial. JACC Cardiovasc Interv2009; 2: 909–916.
39.
ValgimigliMTebaldiMCampoG, et al. Prasugrel versus tirofiban bolus with or without short post-bolus infusion with or without concomitant prasugrel administration in patients with myocardial infarction undergoing coronary stenting: The FABOLUS PRO (Facilitation through Aggrastat By drOpping or shortening Infusion Line in patients with ST-segment elevation myocardial infarction compared to or on top of PRasugrel given at loading dOse) trial. JACC Cardiovasc Interv2012; 5: 268–277.
40.
BhattDLStoneGWMahaffeyKW, et al. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med2013; 368: 1303–1313.
41.
VerheugtFWLiemAZijlstraF, et al. High dose bolus heparin as initial therapy before primary angioplasty for acute myocardial infarction: Results of the Heparin in Early Patency (HEAP) pilot study. J Am Coll Cardiol1998; 31: 289–293.
42.
MontalescotGZeymerUSilvainJ, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: The international randomised open-label ATOLL trial. Lancet2011; 378: 693–703.
43.
SilvainJBeyguiFBarthélémyO, et al. Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: Systematic review and meta-analysis. BMJ2012; 344: e553.
44.
StegPGvan’tHofAHammCW, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med2013; 369: 2207–2217.
45.
BangaloreSTokluBKotwalA, et al. Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: A meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors. BMJ2014; 349: g6419.
46.
CavenderMASabatineMS.Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: A meta-analysis of randomised controlled trials. Lancet2014; 384: 599–606.
47.
ShahzadAKempIMarsC, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): An open-label, single centre, randomised controlled trial. Lancet2014; 384: 1849–1858.
48.
ZeymerUvan’tHofAAdgeyJ, et al. Bivalirudin is superior to heparins alone with bailout GP IIb/IIIa inhibitors in patients with ST-segment elevation myocardial infarction transported emergently for primary percutaneous coronary intervention: A pre-specified analysis from the EUROMAX trial. Eur Heart J2014; 35: 2460–2467.
49.
HanYGuoJZhengY, et al. Bivalirudin vs heparin with or without tirofiban during primary percutaneous coronary intervention in acute myocardial infarction: The BRIGHT randomized clinical trial. JAMA2015; 313: 1336–1346.
50.
YusufSMehtaSRChrolaviciusS, et al. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: The OASIS-6 randomized trial. JAMA2006; 295: 1519–1530.
51.
DanchinNPuymiratEStegPG, et al. Five-year survival in patients with ST-segment-elevation myocardial infarction according to modalities of reperfusion therapy: The French Registry on Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) 2005 cohort. Circulation2014; 129: 1629–1636.
52.
MorrisonLJVerbeekPRMcDonaldAC, et al. Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA2000; 283: 2686–2692.
53.
SabatineMSCannonCPGibsonCM, et al. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: The PCI-CLARITY study. JAMA2005; 294: 1224–1232.
54.
WhiteHDBraunwaldEMurphySA, et al. Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: Results from ExTRACT-TIMI 25. Eur Heart J2007; 28: 1066–1071.
55.
WhiteH; Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: The HERO-2 randomised trial. Lancet2001; 358: 1855–1863.
56.
ArmstrongPWGershlickAHGoldsteinP, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med2013; 368: 1379–1387.
57.
BøhmerEHoffmannPAbdelnoorM, et al. Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction). J Am Coll Cardiol2010; 55: 102–110.
58.
CantorWJFitchettDBorgundvaagB, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med2009; 360: 2705–2718.
59.
HuberKGershBJGoldsteinP, et al. The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: Current state, unmet needs and future directions. Eur Heart J2014; 35: 1526–1532.
60.
SørensenJTTerkelsenCJSteengaardC, et al. Prehospital troponin T testing in the diagnosis and triage of patients with suspected acute myocardial infarction. Am J Cardiol2011; 107: 1436–1440.
61.
StengaardCSørensenJTLadefogedSA, et al. Quantitative point-of-care troponin T measurement for diagnosis and prognosis in patients with a suspected acute myocardial infarction. Am J Cardiol2013; 112: 1361–1366.
62.
AmsterdamEAWengerNKBrindisRG, et al. 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol2014; 64: e139–e228.
63.
HammCWBassandJ-PAgewallS, 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). Eur Heart J2011; 32: 2999–3054.
64.
WallentinLBeckerRCBudajA, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl J Med2009; 361: 1045–1057.
65.
Bellemain-AppaixA.Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: A systematic review and meta-analysis. BMJ2014; 349: g6269.
66.
Almendro-DeliaMGonzalez-TorresLGarcia-AlcantaraÁ, et al. Prognostic impact of clopidogrel pretreatment in patients with acute coronary syndrome managed invasively. Am J Cardiol2015; 115: 1019–1026.
67.
MontalescotGBologneseLDudekD, et al. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med2013; 369: 999–1010.
68.
Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators, YusufSMehtaSR, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med2006; 354: 1464–1476.
69.
StoneGWMcLaurinBTCoxDA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med2006; 355: 2203–2216.
70.
PapeLATsaiTTIsselbacherEM, et al. Aortic diameter >or = 5.5 cm is not a good predictor of type A aortic dissection: Observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation2007; 116: 1120–1127.
71.
NazerianPVanniSMorelloF, et al. Diagnostic performance of focused cardiac ultrasound performed by emergency physicians for the assessment of ascending aorta dilation and aneurysm. Acad Emerg Med2015; 22: 536–541.
72.
SobczykDNyczKAndruszkiewiczP.Validity of a 5-minute focused echocardiography with A-F mnemonic performed by non-echocardiographers in the management of patients with acute chest pain. Cardiovasc Ultrasound2015; 13: 16.
73.
RogersAMHermannLKBooherAM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: Results from the international registry of acute aortic dissection. Circulation2011; 123: 2213–2218.
74.
AgnelliGBecattiniC.Acute pulmonary embolism. N Engl J Med2010; 363: 266–274.
75.
Kennedy HallMCoffeyECHerbstM, et al. The ‘5Es’ of emergency physician-performed focused cardiac ultrasound: A protocol for rapid identification of effusion, ejection, equality, exit, and entrance. Acad Emerg Med2015; 22: 583–593.
76.
KonstantinidesSV.2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J2014; 35: 3145–3146.
77.
GoASMozaffarianDRogerVL, et al. Heart disease and stroke statistics – 2014 update: A report from the American Heart Association. Circulation2014; 129: e28–e292.
78.
FonarowGCAdamsKFAbrahamWT, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure: Classification and regression tree analysis. JAMA2005; 293: 572–580.
79.
McMurrayJJVAdamopoulosSAnkerSD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J2012; 33: 1787–1847.
80.
MebazaaAYilmazMBLevyP, et al. Recommendations on pre-hospital and early hospital management of acute heart failure: A consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine – short version. Eur Heart J2015.
81.
MuellerCChristMCowieM, et al. European Society of Cardiology – Acute Cardiovascular Care Association Position paper on acute heart failure: A call for interdisciplinary care. Eur Heart J Acute Cardiovasc Care2015.
82.
MaischBSeferovićPMRistićAD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Eur Heart J2004; 25: 587–610.
83.
ImazioMAdlerY.Management of pericardial effusion. Eur Heart J2013; 34: 1186–1197.
84.
ChandraratnaPAMoharDSSidarousPF.Role of echocardiography in the treatment of cardiac tamponade. Echocardiography2014; 31: 899–910.
85.
MarillKAdeSouzaISNishijimaDK, et al. Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Ann Emerg Med2006; 47: 217–224.
86.
TomlinsonDRCherianPBettsTR, et al. Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: Is bolus dose amiodarone an appropriate first-line treatment?Emerg Med J EMJ2008; 25: 15–18.
87.
CammAJLipGYHDe CaterinaR, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J2012; 33: 2719–2747.
88.
GauscheMPersseDESugarmanT, et al. Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med1994; 24: 183–189.
89.
FurlongRGerhardtRTFarberP, et al. Intravenous adenosine as first-line prehospital management of narrow-complex tachycardias by EMS personnel without direct physician control. Am J Emerg Med1995; 13: 383–388.
90.
BradyWJSwartGDeBehnkeDJ, et al. The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: Prehospital and emergency department considerations. Resuscitation1999; 41: 47–55.
91.
SherbinoJVerbeekPRMacDonaldRD, et al. Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: SA systematic review. Resuscitation2006; 70: 193–200.
92.
ChristMMuellerC.Call to action: Initiation of multidisciplinary care for acute heart failure begins in the Emergency Department. Eur Heart J Acute Cardiovasc Care. Epub ahead of print 22 April 2015. DOI: 10.1177/2048872615581501.
