Management of suspected STEMI: key principles

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ST elevation myocardial infarction (STEMI) is a time-critical emergency that requires reperfusion of the blocked artery as soon as possible to reduce damage to the heart muscle.

Reperfusion optimises patient outcomes and quality of life. Timely treatment relies on rapid and accurate electrocardiogram (ECG) interpretation and advice on clinical management.

Clinical practice principles

The following clinical principles apply to the management of all patients with suspected STEMI.

  • It is essential to record a 12-lead ECG and have it assessed for signs of STEMI by a clinician experienced in ECG interpretation within 10 minutes of the first clinical contact with a patient. This applies to patients who call an ambulance and those who self-present to hospital with acute chest pain or other signs of acute coronary syndrome.1
  • If paramedics or clinicians at small facilities identify a patient with STEMI, they must transmit the ECG for review by a cardiologist or emergency physician as soon as possible.1 If there is no response within an agreed timeframe, the ECG must be retransmitted.
  • Develop a local back-up process to use as a failsafe if the usual transmission process is unavailable or a response to a notification is not provided within 10 minutes.
  • Document the transmitted ECG, advice provided on interpretation of the ECG and ongoing management in the patient’s health-care record.
  • Clinicians must be trained to use their local ECG device if they work in transmitting facilities and provide care for patients with acute coronary syndrome. They must be able to transmit an ECG and understand the associated local and NSW Health protocols within their scope of practice.
  • Patients with a confirmed STEMI who present within 12 hours of symptom onset and meet clinical criteria should receive reperfusion therapy as soon as possible. Guidelines recommend percutaneous coronary intervention (PCI) as the gold standard treatment within 90 minutes from first clinical contact,1 or thrombolysis within 30 minutes where timely PCI is not achievable.
  • Local health districts (LHDs) should develop a process for timely ECG review, clinical communication and data management. This includes all ECGs transmitted to an ECG reading service for interpretation of other abnormalities, such as non-ST elevation acute coronary syndromes or arrhythmias. For additional guidance on STEMI and other acute coronary syndrome presentations, see the Pathway for Acute Coronary Syndrome Assessment (PACSA).2

Clinical governance principles

  • Data must be transmitted, received and stored in line with the NSW Health Privacy Manual for Health Information, the NSW Health Policy Directives on Electronic Information Security3 and Bring Your Own Device and NSW Health Smart Devices.4
  • Clinicians caring for people with a suspected STEMI should refer to local clinical governance processes for matters relating to the use and maintenance of the ECG transmission system.
  • When developing local governance processes for STEMI and ECG transmission, representatives from cardiology and emergency departments, information technology, biomedical engineering and NSW Ambulance should be included. This will support best practice clinical care and system security.

Methods

These clinical practice principles are based on evidence-based practice as outlined in the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes (2016).

The governance principles are aligned with the requirements of the eHealth NSW-led Clinical Device and Notification Platform implementation and the use of electronic clinical information systems.

Representatives from metropolitan and rural NSW health services, NSW Ambulance and eHealth collaborated in the development and review of the principles. These representatives reviewed the clinical and governance principles and the PACSA. Through the use of a virtual discussion with the representatives, a consensus was reached on the key principles for NSW Health.

References

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