Original Article
Adherence to NSTEMI Guidelines in the
Emergency Department
Regression to Reality
Harel Gilutz, MD, ESCF,* Sevatlana Shindel, RN,† and Ilana Shoham-Vardi, PhD†
Background: Adherence to guidelines for the initial treatment of ST-Segment
Elevation Myocardial Infarction has been thoroughly studied, whereas the
study of emergency department (ED) adherence to guidelines for Non–ST-
Segment Elevation Myocardial Infarction-Acute Coronary Syndrome
(NSTEMI-ACS) has been much scarcer. The recommended guidelines for the
Downloaded from http://journals.lww.com/critpathcardio by BhDMf5ePHKbH4TTImqenVHXBtH07/PgUIJCyDbnlCpClSvhYkb/xau9/8jzhfeyaH9SQI54bVG0= on 02/16/2019
initial prompt workup and treatment of NSTEMI-ACS remains a challenge.
Aim: We studied adherence to guidelines for NSTEMI in the ED.
Methods: A single-center, retrospective study of consecutive patients with
NSTEMI admitted to a tertiary hospital and discharged alive between March
2013 and March 2014. ED records were manually reviewed for adherence to
prespecified parameters. Cases with sudden death, shock, or type-II NSTEMI
were excluded. Canadian Triage and Acuity Scale score system was used for
triage in the ED.
Results: Adherence rates were 33.3%/24.6% of 240 patients for ECG/troponin
obtained within 10/60 minutes receptively and 31.3% for anticoagulation
within 15 minutes from diagnosis of ACS. Females were less likely to undergo
electrocardiography (P = 0.009) or troponin-level tests within the specified
timeframe (P = 0.043). Many cardiovascular risk markers were missed. Global
Registry of Acute Coronary Events score was not used to risk stratify patients.
Conclusions: Prompt identification and early medical treatment of NSTEMI
in the ED is lacking. Better computerized medical history assembly, attention
to typical and atypical clinical presentation, and the employment of an
appropriate cardiologic risk stratification method may unblind the treating
teams at the point of care and improve adherence to NSTEMI guidelines.
Key Words: non–ST-elevation myocardial infarction, emergency department,
gender, guidelines adherence, triage.
(Crit Pathways in Cardiol 2019;18: 40–46)
A dherence to guidelines for the initial treatment of ST-Segment
Elevation Myocardial Infarction (STEMI) has been thoroughly
studied, whereas the study of emergency department (ED) adherence
to guidelines for Non–ST-segment Elevation Myocardial Infarction-
Acute Coronary Syndrome (NSTEMI-ACS) has been much scarcer.
The recommended guidelines for the initial treatment of both con-
ditions are nearly identical regarding prompt work up and medica-
tions.1,2 Nonetheless, timely management of emergency treatment of
NSTEMI-ACS remains a challenge.3
The overall in-hospital adherence to guideline-based medi-
cal therapy was shown to be significantly lower in the treatment of
NSTEMI—compared with the treatment of STEMI—patients.3 In a
Received for publication June 26, 2018; accepted August 18, 2018.
From the *Department of Cardiology, Goldman School of Medicine, Faculty of
Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel; and
†Department of Public Health, Faculty of Health Sciences, Ben-Gurion University
of the Negev, Beersheba, Israel.
Reprints: Harel Gilutz, MD, ESCF, Goldman School of Medicine, Faculty of
Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
E-mail: gilutz@bgu.ac.il.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1003-0117/19/1801-0040
DOI: 10.1097/HPC.0000000000000165
40  |  www.critpathcardio.com Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019
chest pain unit, for instance, the NSTEMI adherence rate was only
38.2%.4 In a recent study, on in-hospital adherence to 13 individual
American College of Cardiology/American Heart Association Class
IA guideline-recommended interventions for NSTEMI, the overall
adherence score was 77.4%.5
A substudy from the CRUSADE (Can Rapid Risk Stratification
of Unstable Angina Patients Suppress Adverse Outcomes with Early
Implementation of the American College of Cardiology/American
Heart Association Guidelines) conducted in the ED showed that only
33% of high-risk patients with NSTEMI-ACS underwent an initial
electrocardiogram within 10 minutes of arrival.6 A similar result was
obtained regarding timely ECG, as documented by a study evaluating
guidelines adherence for NSTEMI.7
In contrast, a recent study reported an outstandingly excellent
adherence rate of >95% in the ED to the recommended medication
guideline (Aspirin, Clopidogrel, and anticoagulation).8
Patients presenting with NSTEMI present a clinical challenge,
as they are typically old, have higher comorbidity rates, ischemic heart
disease, more cardiovascular risk factors, and atherosclerotic vascular
disease.9,10 The clinical presentation of NSTEMI may be ambiguous, as
roughly only 40% of elderly patients experience some chest discomfort.11
Guidelines for the initial evaluation of NSTEMI-ACS recom-
mend using either the “Global Registry of Acute Coronary Events”
(GRACE) for suspected ACS1 or the “Thrombolysis In Myocardial
Infarction (TIMI) score.”12 However, some EDs apply the Canadian
Triage and Acuity Scale (CTAS) to evaluate all ED comers. CTAS
has 5 acuity levels consisting of resuscitation, emergent, urgent, less
urgent, and nonurgent; by that assists ED personnel to assess patients’
acuity better, department resources need, and structured performance.13
The latter evaluation protocol refers to complaints and clinical
presentation but does not include initial ECG; symptoms suggestive
of NSTEMI are highly prioritized. We sought to measure adherence
to guidelines for NSTEMI evaluation in the ED.
METHODS
Study Hypotheses
We hypothesized that NSTEMI patients at high risk (GRACE
score ≥140) would be treated within 60 minutes of arrival, whereas
patients at a lower risk treatment time would exceed 80 minutes.
Study Design
This was a single-center, retrospective chart-review study of
patients who had been admitted to a tertiary (~1200 beds), univer-
sity medical center and were discharged with a primary diagnosis
of NSTEMI. The term ACS is used to describe actions taken during
the time interval between the initial presentation with ACS and the
confirmation of myocardial damage by troponin elevation.
The ED is being driven by emergency medicine specialists
with interns of the ED and forms the internal division. Cardiologists
are being called for consultations when needed by the ED team.
High-quality adherence was defined as meeting all of the fol-
lowing NSTEMI guidelines: ECGs performed within 10 minutes
Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019
of arrival, troponin levels determined within 60 minutes of arrival,
accurate diagnosis of NSTEMI in the ED, and initial administration
of unfractionated heparin or low molecular weight heparin within 15
minutes after ACS diagnosis. Aspirin is being delivered to patients dur-
ing the first medical contact (30% in our study). The standard practice
in the institute where the research was done was to consider adding a
second antiplatelet agent by the treating team in the ward; thus, these 2
medications could not be regarded as an adherence marker in the ED.
The studied ED had applied the CTAS to evaluate all ED comers
including patients suspected to have NSTEMI.13 As the GRACE score
was not used in the ED for risk stratification of the current cohort, it is
likely that the patient’s clinical profile would have been the alternative
way to intuitively stratify patients’ risk level. Hence, in an attempt to
approximate the presumed method of risk stratification, we reviewed
documentation of the following clinical medical history items: chronic
ischemic heart disease, prior invasive intervention, previous stroke,
congestive heart failure, carotid stenosis, peripheral vascular dis-
ease, hypertension, dyslipidemia, diabetes mellitus, smoking, chronic
obstructive pulmonary disease, and chronic renal failure. Patients were
retrospectively assigned a GRACE score by the investigators.
The institutional ethics committee approved the study proto-
col. The databases contain exclusively anonymous information; thus,
there was no need for approval from included patients for this study.
Study Population
Inclusion Criterion
Live patients discharged from the hospital with a diagnosis of
NSTEMI.
Exclusion Criteria
Patients presenting with sudden death, shock or type-II
NSTEMI diagnosis, and patients with ACS not having a final dis-
charge diagnosis of NSTEMI.
The patient’s cohort represent a mixed population living in
cities and rural areas of native Israeli’s who speak Hebrew, native
Bedouins (Muslims) most would speak Hebrew but some, the partic-
ular elder woman would speak Arabic and immigrants mainly from
former USSR who would speak Russian.
Data Collection
A list of live consecutive patients discharged with a diag-
nosis of NSTEMI (International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) 410.72 or 410.71) from
March 1 2013 to March 1, 2014 was obtained from the hospital elec-
tronic information systems that include data from the community
EMR Data included demographic and clinical characteristics, car-
diovascular risk factors, prior cardiovascular disease and interven-
tions, comorbidities, and laboratory tests. ED records were manually
evaluated for adherence to prespecified parameters.
The quality of medical information recorded in the ED was
compared with administrative data recorded before admission, which
for our purposes constituted the “gold standard.” We calculated the
gap between the 2 records and called it “missed existing diagnoses.”
Data Analysis
We hypothesized that most of the patients with a GRACE
score ≥140 would be treated within 60 minutes of arrival, whereas
for patients with a GRACE score <140, the time between arrival
and treatment would exceed 80 minutes. Based on the literature, we
assumed that approximately 25% of patients would have a GRACE
score above 140.14 If that would have been the case, then 240 (60 vs.
180) patients would suffice sample size to show a P value of 0.05
with 90% power.
We compared the selected groups using a χ2 test for categori-
cal variables and Student t test or Mann-Whitney for continuous
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Regression to Reality
variables where appropriate. A P value of <0.05 with 2-sided testing
was considered statistically significant. Multivariable logistic regres-
sion models were used to determine the independent contribution of
patient’s demographic and clinical characteristics to associated with
adherence. Factors that were included in the models were: sex, age,
being an immigrant from former USSR, family status, diabetes mel-
litus, stroke, and chronic kidney disease (CKD).
Statistical analysis was performed using Predictive Analytics
Software software, version 18.0.
RESULTS
Baseline Analysis of the Study Cohorts
Patients’ mean age was 68.8  ± 
8.2; 65.4% were males.
Calculated GRACE score ≥140 was established in 148 patients (61.7
%), and a GRACE score ≤140 was determined in 92 patients (38.3%).
Demographic characteristics of the patient cohort distributed accord-
ing to GRACE score groups are outlined in Table 1. Patients in the
GRACE score ≥140 group were significantly older; the majority
were males, married, and born in Israel. Clinical characteristics of
the patient cohort distributed according to GRACE score groups are
outlined in Table 2. The prevalence of previous diagnoses and risk fac-
tors were based on preadmission electronic medical records. Patients
in the GRACE score ≥140 group had significantly higher rates of
chronic ischemic heart disease, congestive heart failure, peripheral
vascular disease, hypertension, diabetes mellitus, smoking, chronic
obstructive pulmonary disease, and chronic kidney disease, compared
with the rates found in the group with the lower GRACE scores.
Triage
The triage in the ED applied the CTAS system, which is suit-
able for assessing “all comers.” When the triage does not include a
“cardiological risk score” (such as GRACE), medical history plays
a crucial role in risk stratification. Although assessment of medical
information documentation in the ED was not a prespecified aim of
our study, we noted information gaps, whereby the ED documenta-
tion failed to record previous diagnoses.
The percentage of missed diagnosis was 5.0% for chronic
ischemic heart disease, 7.9% for prior revascularization, 7.6% for
prior stroke, 13.3% for diabetes mellitus, 24.7% for hypertension,
34.7% for dyslipidemia, 13.9% for smoking, and 10.8% chronic kid-
ney disease.
Adherence Performance
Overall adherence (meeting all prespecified parameters) per-
centages and adherence percentages for each prespecified endpoint
[ie, ECG performed within 10 minutes, troponin levels obtained
within 60 minutes, written diagnosis of ACS, and anticoagulation
(enoxaparin or unfractionated heparin) administered within 15 min-
utes of the ACS diagnosis] are presented in Table 3. Overall adher-
ence was poor and occurred in 9.6% of patients. The demographic
factors that had a significantly negative effect on overall adherence
were age, single status, and being an immigrant from the former
USSR (Table 3). None of the clinical factors had a significant effect
on overall adherence.
In general, the levels of adherence to each of the prespeci-
fied parameters was low: ECG was performed within 10 minutes of
arrival in 33.3% of the patients (mean 29.7 ± 43.9, median 17 min-
utes). Troponin levels were obtained within 60 minutes of arrival in
23.8% of the entire cohort (mean 184.4 ± 229.3, median 100.5 min-
utes). Unlike our hypothesis, a lower percentage of patients with high
GRACE score had timely ECG while having troponin levels within
60 minutes was the same for the 2 groups.
The demographic factors that had a significantly negative
effect on adherence to prespecified parameters were sex (adherence
www.critpathcardio.com  |  41
Gilutz et al Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019

TABLE 1.  Demographic Characteristics of the Patient Cohort Distributed According to GRACE Score Groups
All GRACE ≥ 140 GRACE < 140
Characteristic N = 240 n = 148 (61.7 %) n = 92 (38.3%) P
Age (mean ± SD) 68.8 ± 8.2 74.6 ± 10.2 59.6 ± 11.1 0.001
Sex: male 157 (65.4%) 90 (60.8%) 67 (72.8%) 0.057
Married 162 (67.5%) 91 (61.5%) 71 (77.2%) 0.014
Ethnicity
 Jews 198 (82.5%) 122 (82.4%) 76 (82.6%)
 Muslims 38 (15.8%) 24 (16.2%) 14 (15.2%)
 Other 4 (1.7%) 2 (1.4%) 2 (2.2%) NS
Jews: country of origin
 Israel 76 (31.7%) 34 (23.0%) 42 (45.7%)
 Former USSR 89 (37.1%) 60 (40.5%) 29 (31.5%)
 Oriental 75 (31.3%) 54 (36.5%) 21 (22.8%) 0.01
Socioeconomic status
 Low 97 (40.4%) 56 (37.8%) 41 (44.6%) NS
 High 143 (59.6%) 92 (62.2%) 51 (55.4%)
Clinical background
 CIHD 146 (60.8%) 103 (69.6%) 43 (46.7%) 0.001
 Prior reVas 94 (39.3%) 63 (42.6%) 31 (33.7%) NS
 CHF 26 (10.8%) 22 (14.9%) 4 (4.3%) 0.01
 Stroke 45 (18.9%) 32 (21.6%) 13 (14.1%) NS
 PVD 25 (10.5%) 21 (14.2%) 4 (4.3%) 0.01
 Hypertension 173 (72.4%) 113 (76.4%) 60 (65.2%) 0.01
 Dyslipidemia 165 (69.0%) 98 (66.2%) 67 (72.8%) NS
 Diabetes mellitus 126 (52.5%) 85 (57.4%) 41 (44.6%) 0.01
 Smoking 82 (34.5%) 41 (27.7%) 41 (44.6%) 0.02
 COPD 27 (11.2%) 23 (15.5%) 4 (4.3%) 0.004
 CKD 75 (31.2%) 61 (41.2%) 14 (15.2%) 0.001
CIHD indicates chronic ischemic heart disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; PVD, peripheral vascular disease; reVas,
revascularization.

TABLE 2.  Gaps in Medical History Documentation in the ED

CIHD Prior reVas PVD Stroke CHF
%Diagnoses documented in ED* 55.8 31.4 6.3 11.3 9.6
Missed existing diagnoses† (%) 5.0 7.9 4.2 7.6 1.2
Diabetes Mellitus Hypertension Dyslipidemia Smoking COPD CKD
Diagnoses documented in ED (%) 39.2 47.7 34.3 20.6 8.3 20.4
Missed existing diagnoses (%) 13.3 24.7 34.7 13.9 2.9 10.8
*% diagnoses documented in ED: The % of patients with a specific diagnosis that was documented in the ED record.
†% Missed existing diagnoses: a diagnosis that existed in the preadmission electronic medical records and was not recorded in the ED.
CIHD indicates chronic ischemic heart disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; PVD, peripheral vascular disease; reVas,
revascularization

to ECG: female patients-16.9% vs. male patients-29.9%; P = 0.027).
Patients with a history of stroke were less likely to be diagnosed
with NSTEMI in the ED (79.6%) than were patients without a his-
tory of stroke (59.3%; P = 0.017). Significantly lower adherence to
the parameter of anticoagulation treatment was recorded for older
age (P = 0.002), having CKD (34.6% vs. 18.4%; P = 0.029) and
GRACE SCORE ≥140 (41.3% vs. 25.0%; P = 0.008). We found that
the following demographic and clinical factors had no impact either
on a single parameter or overall composite adherence: ethnicity,
socioeconomic status, congestive heart failure, peripheral vascular
disease, hypertension, dyslipidemia, smoking, and chronic obstruc-
tive pulmonary disease.
Chest pain is the most common presentation of NSTEMI;
however, elderly patients frequently present with atypical symp-
toms in the absence of chest pain including dyspnea, diaphoresis,
nausea and vomiting, and syncope.15,16 Acute dyspnea on exertion
alone is also referred as an angina equivalent.17 In our study unex-
pectedly, the following presenting symptoms likewise had no impact

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Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019 Regression to Reality

TABLE 3.  Level of Adherence (in Terms of Patient Percentages) by Sociodemographic and Clinical Characteristics
Anticoagulation
n ECG (10 min) Troponin (60 min) ACS Diagnosis Administered* Coagulation
Overall adherence 240 33.3% 24.6% 77.5% 31.3% 9.6%
Adherence by
 Age (y) [n]
  Good 69.0 ± 14.2 [61] 66.9 ± 12.7 [56] 69.0 ± 12.5 [186] 65.0 ± 12.6 [75] 62.6 ± 12.4[23]
  Poor 68.8 ± 12.4 [179] 69.7± 12.8 [184] 68.3 ± 13.8 [54] 70.6 ± 12.5 [165] 69.6 ± 12.7 [217]
  P NS NS NS 0.002 0.004
 Sex
  Male 157 47 (29.9%) 44 (28.0%) 124 (79.0%) 52 (33.1%) 18 (11.5%)
  Female 83 14 (16.9%) 12 (14.5%) 62 (74.7%) 23 (27.7 %) 6 (7.2%)
  P 0.027 NS NS NS NS
 Family status
  Married 162 36 (22.2%) 39 (24.1%) 122 (75.3%) 55 (34.0%) 19 (11.7%)
  Single 77 25 (32.5%) 17 (22.1%) 63 (81.8%) 20 (26.0%) 5 (6.5%)
  P NS NS NS NS 0.031
 Being an immigrant from 89 18 (20.2%) 16 (18.0%) 69 (77.5%) 22 (24.7%) 5 (6.7%)
former USSR
 Other 151 43 (28.5%) 40 (26.5%) 117 (77.5%) 53 (35.1%) 18 (11.9%)
NS NS NS NS 0.033
 CIHD
  With† 146 34 (25.4%) 28 (19.1%) 105 (78.4%) 41 (30.6%) 9 (6.7%)
  Without† 94 27 (25.5%) 28 (29.8%) 81 (76.4%) 34 (32.1%) 14 (13.2%)
  P NS NS NS NS NS
 Prior reVas
  With 75 18 (24.0%) 13 (17.3%) 61 (81.3%) 26 (34.7%) 5 (6.7%)
  Without 164 43 (26.2%) 43 (26.2%) 124 (75.6%) 49 (29.9%) 11 (6.7%)
  P NS NS NS NS NS
 Stroke
  With 27 4 (14.8%) 7 (25.9%) 16 (59.3%) 10 (37.0%) 3 (11.1%)
  Without 213 56 (26.5%) 47 (22.3%) 168 (79.6%) 64 (30.3%) 19 (9.0%)
  P NS NS 0.017 NS NS
 Diabetes mellitus
  With 94 18 (18.4%) 19 (20.2%) 74 (78.7%) 36 (38.3%) 10 (10.6%)
  Without 146 39 (31.2%) 37 (25.3%) 112 (76.7%) 39 (26.7%) 13 (8.9%)
  P NS NS NS 0.059 NS
 CKD
  With 49 9 (18.4%) 9 (18.4%) 41 (83.7%) 9 (18.4%) 2 (4.1%)
  Without 191 57 (25.9%) 47 (24.6%) 145 (75.9%) 66 (34.6%) 21 (11.0%)
  P NS NS NS 0.029 NS
 GRACE
  <140 92 25 (27.2%) 24 (26.1%) 69 (75.0%) 38 (41.3%) 9 (9.7%)
  ≥140 148 31 (20.9%) 37 (25.0%) 117 (79.1%) 37 (25.0%) 14 (9.5%)
  P NS NS NS 0.008 NS
*Unfractionated heparin or low molecular weight heparin.
†With/without: the number represents documentation of diagnoses in the ED and not the absolute true prevalence.
CIHD indicates chronic ischemic heart disease; reVas, revascularization, retrospectively GRACE calculation.

on adherence: typical angina, which presented in 39.6% of patients;
atypical angina, in 20% of the patients; and anginal equivalents, in
14.6% of patients. In 25.4% of the total cohort, no CVD symptoms
were reported.
Results of the multivariate analysis of factors that affect adher-
ence to prespecified parameters are presented in Table 4. Female
patients as compared with male were less likely to have ECG per-
formed within 10 minutes (P = 0.009) and receive troponin levels
within 60 minutes (P = 0.043). Also, single patients were less likely to
have ECG performed within 10 minutes (P = 0.015). Unfortunately,
the multivariable analysis could not identify independent factors
affecting adherence to the parameter of medication treatment or

© 2018 Wolters Kluwer Health, Inc. All rights reserved. www.critpathcardio.com  |  43

Gilutz et al Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019

TABLE 4.  Multivariable Analysis Results conceivable that administrating anticoagulation medications within
15 minutes of the diagnosis is an unrealistic proposition in the real-
95% Confidence world setting of the ED.
Interval
Parameter Odds Ratio Upper Lower P
Clinical Presentation
In our study, the clinical presentation had no impact on guide-
ECG within 10 min line adherence, although it should be noted that patients presenting
 Sex: female 2.629 5.427 1.274 0.009 with anginal equivalents received extremely low attention. There are
 Age (increase for 1 yr) 1.005 1.031 0.98 0.68 a few patient-related factors that contribute to the ambiguity of the
 Former USSR 0.573 1.117 0.294 0.102 clinical presentation. Previous studies have shown that NSTEMI
 Status: single 2.327 4.61 1.175 0.015 compared with STEMI patients are older, have a higher rate of
comorbidities, previous ischemic heart disease, and exhibit more car-
Troponin within 60 min
diovascular risk factors.10,11,25 The clinical presentation of NSTEMI
 Sex: female 2.143 4.484 1.024 0.043 symptoms is ambiguous, as in less than 40% of elderly patients pres-
 Age (increase for 1 year) 0.984 1.01 0.96 0.229 ent with some sort of chest discomfort,11 which often leads to delayed
 Former USSR 0.684 1.353 0.346 0.275 diagnosis or a misdiagnosis of NSTEMI.25 In our retrospective study,
 Status: single 1.326 2.705 0.651 0.437 as a result of atypical presentation and the linguistic barrier, adher-
ence to the parameters of timely ECG and troponin-level tests was
Factors that were included in the models were: sex, age, being an immigrant from significantly lower regarding elderly immigrant patients.
former USSR, family status, diabetes mellitus, stroke, and CKD.
Multilinguistic Environment
The multilinguistic environment (Hebrew, Russian, Arabic,
overall adherence. Interestingly, in-hospital follow-up showed that and Amharic), in which some patients speak a language unfamiliar
the group of patients that had low adherence in the ED had later less to members of the ED team, undermines the quality of communica-
cardiological workup: catheterization (65.4% vs. 91.7%; P = 0.001) tion. Under such circumstances, the physician has to decide whether
and echocardiography (65.4% vs. 92.9%; P = 0.001). In addition, they to “get by” or “get help,” that is, wait for an interpreter to be sum-
less often received statins (89.1%, vs. 97.6%; P = 0.017) or angio- moned.26 This crucial fork in the road may result in the receipt of
tensin-converting enzyme inhibitor (75.6% vs. 89.3%; P = 0.025). misleading medical information, as has been described in similar set-
ups.27 It has been suggested that the presence of a trained “greeter”
DISCUSSION in the triage section of the ED could be very efficacious in the initial
Many studies have evaluated in-hospital NSTEMI-ACS triage, which would facilitate the performance of timely ECGs in
guideline adherence,18,19 and some have studied the first 24 hours suspected Acute Coronary Syndrome patients.28
of hospitalization.3,5 However, only a few studies have evaluated
Obtaining Medical Background
NSTEMI-ACS guideline adherence in the first hours at the ED8,20,21
Although not prespecified, we evaluated the documentation in
Overall Composite Adherence the ED files and found a considerable occurrence of missed diagno-
In this study, we found that the overall composite adherence to ses, which could create a distorted clinical impression, resulting in
NSTEMI guideline was poor, although similar to another reported.22 suboptimal treatment. Similar reports of in-hospital documentation
Troponin levels were obtained in a timely fashion in a quarter of that was missing essential elements of cardiac history and risk fac-
patients, whereby the delay with the remaining patients appears to tors noted that the tendency was more frequent concerning elderly
be related to the need to communicate with non-Hebrew speaking, and female patients.29,30 Poor medical documentation in patients hos-
elderly immigrant patients. Similarly, another study showed that the pitalized with cardiovascular disease has been associated with poor
time of obtaining troponin results was longer than 60 minutes (≈100 patient outcomes29 and higher mortality, particularly in NSTEMI
minutes) for most patients.21 In over 20% of patient ED files, initially, patients.31
there was no documented diagnosis of NSTEMI. In these cases, it is In the era of computerized medical records, one might assume
reasonable to assume that high troponin levels might have been the that the relevant data is at one’s fingertips; however, it appears that
clue to a diagnosis of an acute ischemic disease. typically this is not the case. Data resources often include hospital
medical records, primary care medical records, image data, some of
Adherence to the Medication Treatment which might be located on institution stand-alone computerized sys-
Medical treatment within 15 minutes of diagnosis was deliv- tems or outside the hospital, as in the case of data produced by insti-
ered in a third of patients and was significantly low among the elderly tution and clinics. Hence, it may be impossible for the ED team to
patients, among patients with CKD, and among high-risk patients detect relevant items in a short time frame. That may lead to incom-
with a GRACE score ≥140. This may be explained by the physi- plete medical information at the point of care. A “smart” computer
cian’s hesitation to administer anticoagulation medication to elderly program capable of detecting relevant medical data according to a
patients or those with CKD due to the hazard of bleeding. In this chosen clinical profile could likely enhance optimal care.
regard, it is worth noting that a study of eyeball test to assess the
frailty of elderly patients before an invasive procedure matched Triage Protocol
poorly with data generated using objective measures: assessing the The triage protocol used for all comers to the ED studied here
patient’s presentation consistently overestimated frailty,23 stress- was the CTAS.13 Based on the findings, this triage protocol assigned
ing the need to use available risk scores. Following the same logic, a low priority to half of the patients with acute myocardial infarction
old age and indeed a high GRACE score is not a contraindication (AMI), which led to substantial delays in ECG acquisition. Thus, the
for administering anticoagulation medication. The paradoxical phe- CTAS may be an obstacle for guideline adherence in the ED as far
nomenon of low adherence in the context of NSTEMI particularly as NSTEMI management.32 It should be noted that the CTAS has
in high-risk patients is known.24 A delay of particularly anticoagula- not adopted any of the traditional cardiology risk stratification sys-
tion therapy has also been reported previously.21 However, it is also tems, such as GRACE33 or modified HEART.34 As a result, patient

44  |  www.critpathcardio.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Critical Pathways in Cardiology  •  Volume 18, Number 1, March 2019
evaluation was based on global diagnostic impressions (“gestalt”),
whereby troponin and ECG findings superior to chest pain history for
accepting a diagnosis of NTSEMI and chest pain history was supe-
rior for ruling out NSTEMI.24 That may explain why clinical presen-
tation received little attention in our study. Also, the aforementioned
communication barrier and the missing medical information may
have offset experience-based diagnostic impressions.
Screening With High-Sensitivity Troponin
Should high-sensitivity troponin (hs-TnT) be used to screen
in elderly patients with atypical complaints and limited medical
history in the absence of another diagnosis? It was shown that the
specificity of hs-TnT for AMI is very low and represents myo-
cardial damage but does not necessarily reflect the existence of a
flow-limiting coronary lesion; hence, hs-TnT elevation does not
substantiate an AMI diagnosis,35 as it could indicate several non-
ACS clinical conditions.36
LIMITATIONS
Our study has limitations. First, it is a single-center, retrospec-
tive ED file, chart-review analysis and it is possible that institutional
factors might have been overlooked. However, our ability to col-
lect details regarding the time from presentation to the initial ECG,
timely, time of first documented elevated troponin levels, and admin-
istration of medications—all considered in the context of adherence
to simple strict guidelines makes our study unique and provides non-
apologetic results.
Second, we did not consider the entire patient population that
is entering the ED or attempt to study how ACS was ruled out, as we
focused on patients with type 1 NSTEMI. Therefore, our findings
cannot be extrapolated to ED management of ACS patients.
Third, we did not exclude patients with contraindications to
guideline-directed therapies such as anticoagulation and antiplatelet
treatment; thus, it may be assumed that in some cases, the nonadher-
ence was appropriate.
Fourth, the low adherence to our prespecified parameters, both
overall and separately, yielded a very small variance, which limited
our ability to evaluate the effects of the different factors on adher-
ence. The use of more “liberal” criteria might have been better for the
methodology; however, it would have prohibited our ability to study
“real-world” absolute adherence.
CONCLUSIONS
Prompt identification and early medical treatment of NSTEMI
in the ED is lacking. Better computerized medical history assem-
bly, attention to typical and atypical clinical presentation, and the
employment of an appropriate cardiologic risk stratification method
may unblind the treating teams at the point of care and improve
adherence to NSTEMI guidelines.
DISCLOSURES
Nothing to declare.
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