Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital

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1 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital Pitha Promlikitchai, MD Cardiovascular Unit, Department of Medicine, Saraburi Hospital, Saraburi, Thailand Abstract Objective: to study the efficacy of diagnosis, management, outcome and epidemiology of acute coronary syndrome (ACS) patients who were admitted into Saraburi Hospital. Methods: The data was collected from a prospective registry of chest discomfort patients who were admitted by fast track ACS to Saraburi Hospital between 1 January 2008 and 31 December Results: There were 1026 chest discomfort cases admitted to Saraburi Hospital during the study period. Of these patients, 635 were finally diagnosed with ACS; 78 cases had ST-segment elevation acute coronary syndrome (STE-ACS) and 557 cases had no ST-segment elevation acute coronary syndrome (Non STE-ACS). Agreement of the ACS diagnosis between the emergency room and final diagnosis was moderately reliable in STE-ACS cases (Kappa value = 0.622, p <0.001). Mean age of ACS patients was ± years. Thrombolytic therapy was used in 55.1% of STE-ACS cases; mean door to needle time was ± 64.50; mean total ischemic time was ± In-hospital mortality was 8.3% overall and 19.2% for STE-ACS which was significantly higher than the 6.8% for the Non STE-ACS group, p < Factors associated with increased mortality were cardiogenic shock, malignant arrhythmia (ventricular tachycardia, ventricular fibrillation, heart block more than 2 degree AV block Mobits II) and an initial systolic blood pressure < 100 mmhg. Conclusion: The results of this study provide additional data concerning ACS in the rural population where there are restricted access to invasive treatment strategies and drug limitations. There were high in-hospital mortality, heart failure and readmission rates. These findings suggest that there should be further development of guidelines for ACS that improves efficacy of diagnosis, management, creates a cardiac network for appropriate early referral for high risk ACS patients. Key words: Acute coronary syndrome, ST-elevated acute coronary syndrome, Non ST-elevated acute coronary syndrome Thai Heart J 2009; 22 : E-Journal : Introduction Acute coronary syndrome (ACS) is currently the second cause of death, following motor vehicle accidents. It also is a leading cause of death in developing countries (1). If the diagnosis and treatment were delayed, the mortality rate would be high due to cardiac arrhythmia or heart failure (2). Guidelines describing up to date management of the ACS are readily available in western countries (3-5) which suggest that routine fast track guidelines should be used in these patients. There have Correspondence: Pitha promlikitchai, MD Cardiovascular Unit, Department of Medicine, Saraburi Hospital, Saraburi, Thailand E mail address: pitha8133@hotmail.com been several studies published concerning ACS in the Thai population (6-8) and Thai acute coronary syndrome data (Thai ACS registry) has been collected by The Heart Association of Thailand under The Royal Patronage (9). However this data analysis has been based on urban populations in tertiary medical care facilities or teaching hospitals but data in rural areas or primary medical care hospitals is limited. The purpose of this article is to study the efficacy of diagnosis, management, outcome and epidemiology of ACS patients who were admitted into Saraburi Hospital. Methods This study was approved by the director of Saraburi hospital. The data were collected from a prospective registry of patients who had chest discomfort and were

2 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital admitted to Saraburi Hospital by a fast track guideline between 1 January 2008 and 31 December 2008 with a diagnosis of acute myocardial infarction (both ST segment elevation and Non-ST-segment elevation myocardial infarction) or unstable angina and possible ACS. Operational Definitions ACS ranged from ST segment elevation myocardial infarction (STEMI) to non ST-segment elevation MI (NSTEMI) and unstable angina (UA). ST elevated acute coronary syndromes (STE-ACS) includes ST- segment elevation myocardial infarction (STE-ACS) or new LBBB. Non ST elevated acute coronary syndromes (Non STE- ACS) includes NSTEMI and UA. The diagnosis of acute myocardial infarction (AMI) based on the recommendation by the Universal Definition of Myocardial Infarction (10-11). The detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99 th percentile of the upper reference limit (URL). Optimal precision (coefficient of variation (CV)) at the 99th percentile URL for each assay should be defined as 10%. The current practical threshold is the lowest serum level that is reliably detectable based on assay performance Troponin T level 0.03 ug/l (12-13) together with evidence of myocardial ischemia with at least one of the following: Symptoms of ischemia; ECG changes indicative of new ischemia (new ST- T changes or new left bundle branch block (LBBB)); Development of pathological Q waves in the ECG; Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. ECG manifestations of AMI (in absence of left ventricle (LVH) and LBBB) ST elevation : New ST elevation at the J-point in two contiguous leads with the cut-off points: 0.2 mv in men or 0.15 mv in women in leads V2-V3 and/or 0.1 mv in other leads ST depression and T-wave changes: New horizontal or downsloping ST depression 0.05 mv in two contiguous leads; and/or T inversion 0.1 mv in two contiguous leads with prominent R-wave or R/S ratio >1. UA: one of the following criteria is necessary (14): 1. Angina that occurred at rest and was prolonged, usually lasting more than 20 minutes 2. New-onset angina of at least severity III by the Canadian Cardiovascular Society (CCS) classification 3. Recent acceleration of angina reflected by an increase in severity of at least 1 CCS class to at least CCS class III History of stroke (14): Documented history of cerebrovascular accident (CVA), loss of neurological function caused by an ischemic event with residual symptoms at least 24 hours after onset. Diabetes (14): History of diabetes, regardless of duration of disease, need for antidiabetic agents, or a fasting blood sugar greater than 126 mg/dl. Hypertension (14): 1. History of hypertension diagnosed and treated with medication, diet, and/or exercise 2. Blood pressure greater than 140 mmhg systolic or 90 mmhg diastolic on at least 2 occasions 3. Current use of antihypertensive pharmacological therapy Current Smoking (14): History of confirmed cigarette smoking in the past within 1 month of this admission Dyslipidemia (14): History of dyslipidemia diagnosed and/or treated by a physician. National Cholesterol Education Program criteria include documentation of the following: Total cholesterol greater than 200 mg/dl; Low-density lipoprotein (LDL) greater than or equal to 130 mg/dl; or High-density lipoprotein (HDL) less than 40 mg/dl. Killip class: (14) Class 1: Absence of rales over the lung fields and absence of S3 Class 2: Rales over 50% or less of the lung fields or the presence of an S3 Class 3: Rales over more than 50% of the lung fields Class 4: Shock Cardiogenic shock (14): Clinical criteria for cardiogenic shock are hypotension (a systolic blood pressure of less than 90 mmhg for at least 30 minutes or the need for supportive measures to maintain a systolic blood pressure of greater than or equal to 90 mmhg), end-organ hypoperfusion (cool extremities or a urine output of less than 30 ml/h, and a heart rate of greater than or equal to 60 beats per minute).

3 Statistical Analysis Continuous variables are expressed as mean ± standard deviation (SD) or median when appropriate and discrete variables are expressed as percentages. Differences in the distribution of selected characteristics between patient groups were examined using the Chi-square test for categorical variables. Differences in continuous variables between study groups were analyzed using either analysis of variance or t tests. The diagnosis of ACS at the emergency room (ER) and the final diagnosis of ACS at the ward were analyzed by Kappa analysis. A p-value less than 0.05 was considered statistically significant. All statistical data were analyzed by SPSS program for windows version Results There were a total of 1026 consecutive patients who were presented with chest discomfort and admitted by the fast track guideline. 120 had a diagnosis of STE-ACS at the ER, while 806 had Non STE-ACS in the ER, 100 had possible ACS. All of these patients after admission had serial EKGs, followed by cardiac enzyme especially cardiac Pitha Promlikitchai, MD Troponin T. As shown in Figure 1 we concluded the final diagnosis to be 78 with STE-ACS, 557 with Non STE- ACS, 72 with Possible ACS and 319 with no ACS. In chest discomfort patients agreement between the ER diagnosis and final diagnosis was moderately reliable only in the STE-ACS group but not the Non STE-ACS and possible ACS groups (Kappa value = 0.622, 0.170, and p value < 0.001, 0.04, < respectively). Finally the total ACS patients at summery discharge were 635 which were composed of 78 STE-ACS and 557 Non STE- ACS. Characteristics and risk factors of ACS patients are shown in Table 1. Mean age was ± and it ranged from 27 to 95 years. As shown in Table 2 serum creatinine was slightly higher in the Non STE-ACS group 1.89 ± 1.70 vs 1.47 ± 0.79 (p = 0.034). The wall distribution of MI is shown in Figure 2 with the majority of STE-ACS being anterior wall MI 33 (42%). Door to needle time mean was ± 64.50, median 70 minutes; total ischemic time mean ± ; median 205 minutes (shown in Figure 3 and 4). Half of the ACS patients in both groups developed HF in the hospital (Killip II - IV). The mean hospital stay was 5.67 ± 6.62 days which was slightly Figure 1. discharge. All chest discomfort patients who were admitted by fast track guideline ACS at ER and final diagnosis at

4 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital Table 1. Baseline characteristics of ACS patients. Characteristic ACS Total ACS (N = 635) STE ACS (N = 78) Non STE ACS (N = 557) P value Mean age (± SD, yrs) ± (27-95) ± (27-88) ± (36-95) <0.001* < (3.1%) 8 (10.3%) 12 (2.2%) <0.001* (9.3%) 19 (24.4%) 40 (7.2%) (21.7%) 22 (28.2%) 116 (20.8%) (36.4%) 19 (24.4%) 212 (38.1%) (29.4%) 10 (12.8%) 177 (31.8%) Male 280 (44.1%) 64 (82.1%) 216 (38.8%) <0.001* SBP/DBP (mmhg) ± ± ± ± ± ± * HR (beat/min) ± ± ± * O2 saturation (%) 97.3 ± ± ± Risk factor Age > 45 male, > 55 in woman 589 (92.8%) 63 (80.8%) 526 (94.4%) <0.001* DM 207 (32.6%) 21 (26.9%) 186 (33.4%) HT 513 (80.8%) 57 (73.1%) 456 (81.9%) 0.09 Dyslipidemia 455(71.7%) 55 (70.5%) 400 (71.8%) Current smoking 110 (17.3%) 41 (52.6%) 69 (12.4%) <0.001* Numbers of risk factors (8.2%) 10 (12.8%) 42 (7.5%) (20.6%) 9 (11.5%) 122 (21.9%) (41.1%) 32 (41.0%) 229 (41.1%) (30.1%) 27 (34.6%) 164 (29.4%) Prior diseases History of stroke 108 (17%) 6 (7.7%) 102 (18.3%) 0.016* History of IHD 384 (60.5%) 16 (20.5%) 368 (66.1% ) <0.001* Chest pain to door time (min) ± ± ± Door to EKG and ASA (min) ± ± ± Admission time (min) ± ± ± * statistically significant.

5 Figure 2. Wall distribution in STE-ACS Figure 3. Door to needle time (minutes) Figure 4. Total ischemic time in STE-ACS who received thrombolytic drug (hours) Pitha Promlikitchai, MD significantly longer in the STE-ACS group 7.49 ± vs 5.42 ± 5.27 days, p = 0.01 (shown in Table 3). Overall hospital mortality of ACS patients was 53 (8.3%). Patients with the STE-ACS had a 3-time higher mortality than those with Non STE-ACS patients, 15 (19.2%) vs 38 (6.8%) p < Factors associated with mortality in the hospital were cardiogenic shock (Killip IV), malignant arrhythmia, initial systolic blood pressure < 100 mmhg, STE-ACS, serum creatinine or Troponin T level at admission and peak cardiac enzyme as shown in Tables 4. Nearly all fatal cases (51, 96.2%) developed cardiogenic shock (Killip IV). A shorter door to needle time or total ischemic time demonstrated a trend toward decreased mortality rate in STE-ACS patients in this study but was not statistically significant due to the small number of patients (Table 5). Pharmacological treatment in the hospital and discharge is show in Table 6. The reason that some did not receive antiplatelets (1.4%) were an active gastrointestinal bleeding or they received anticoagulant therapy or rejected treatment, while 30 patients (4.72%) did not receive ACEI or ARB because of renal failure (Cr >3) and 63 patients (9.92%) due to renal insufficiency (Cr 2-3). 20 patients (3.14%) could not tolerate medication due to hypotension. 215 patients (33.85%) did not receive Beta blockers due to heart failure (HF), 6 patients (0.94%) developed heart block, 22 patients (3.46%) had sinus bradycardia, 6 (0.94%) had asthma or COPD,13 patients (2.04%) could not tolerate medication due to hypotension. 92 patients (14.48%) did not get statins due to LDL<100 mg/dl, 4 patients (0.62%) received fibric group first due to TG > 500 mg/dl. 3 patients (0.47%) did not get streptokinase (SK) due to age > 75 year, 9 patients (1.41%) with an onset more than 12 hours and did not have chest pain at presentation, and 5 patients (0.78%) had prolong CPR more than 10 minutes. However there were 3 patients (0.5%) of the Non STE-ACS group that received thrombolytic drugs due to a misdiagnosis. The overall bleeding complication was 6% with major bleeding requiring a blood transfusion a 1.4% significant increase in the STE-ACS group 5.1% vs 0.9%, p There was one case that had an intracranial hemorrhage in STE-ACS who recieved thrombolytic drugs.

6 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital Table 2. Blood chemistry at admission in ACS patients. Blood chemistry Total ACS (N; mean ± SD) STE ACS (N; mean ± SD) Non STE ACS (N; mean ± SD) P value Hct (%) 625; ± ; ± ; ± 5.96 <0.001* BS (mg/dl) 456; ± ; ± ; ± Total CHOL (mg/dl) 488; ± ; ± ; ± HDL (mg/dl) 473; ± ; ± ; ± TG (mg/dl) 473; ± ; ± ; ± LDL (mg/dl) 470; ± ; ± ; ± BUN (mg/dl) 629; ± ; ± ; ± * Serum Cr (mg/dl) 628; 1.84 ± ; 1.47 ± ; 1.89 ± * * statistically significant. Table 3. Hospital outcomes. Characteristic ACS Total ACS (N = 635) STE ACS (N = 78) Non STE ACS (N = 557) P value Death 53 (8.3%) 15 (19.2%) 38 (6.8%) <0.001* Heart failure (Killip II, III) 218 (34.3%) 8 (10.3%) 210 (37.7%) <0.001* Cardiogenic shock (Killip IV) 116 (18.3%) 34 (43.6%) 82 (14.7%) <0.001* Cardiac arrhythmia (Total) 140 (22%) 23 (29.5%) 117 (21.0%) Non malignant arrhythmia** 105 (16.5%) 8 (10.3%) 97 (17.4%) < 0.001* Malignant arrhythmia*** 35 (5.5%) 15 (19.2%) 20 (3.6%) < 0.001* All bleeding 38 (6.0%) 10 (12.8%) 28 (5%) 0.017* Major bleeding # 9 (1.4%) 4 (5.1%) 5 (0.9%) 0.016* Minor bleeding # # 29 (4.6%) 6 (7.7%) 23 (4.1%) Hospital stay (mean ± SD; days) 5.67 ± ± ± * Readmission (within 28 days) 136 (21.4%) 2 (1.5%) 134 (24.1%) <0.001* Discharge 550 (86.6%) 58 (74.4%) 492 (88.3%) 0.002* Refer to tertiary care hospital 24 (3.8%) 4 (5.1%) 20 (3.6%) Bad outcome 8 (1.3%) 1 (1.3%) 7 (1.3%) * statistically significant. Heart failure = heart failure at index of hospitalization (killip II-IV within 48 hour or heart failure after 48 hour); Bad outcome = non ACS death, not improved and rejected treatment; ** PAC, PVC, AF, Flutter, SVT, heart block less than second degree AV block mobitz I; *** VT/VF, Heart block more than 2 degree AV mobitz II; # ICH, UPGI bleeding required blood transfusion; # # Hematuria, hematoma, UGIB did not require blood transfusion

7 Pitha Promlikitchai, MD Table 4. Characteristics of fatal outcome. Factor Total ACS (N = 635) N (%) Fatal (N = 53) N (%) Non fatal (N = 582) N (%) P value Age > (29.4 %) 19 (35.8%) 168 (28.9%) Male 280 (44.1%) 25 (47.2%) 255 (43.8%) Risk factors DM 207 (32.6%) 10 (18.9%) 197 (33.8%) 0.031* Hypertension 513 (80.8%) 21 (39.6%) 492 (84.5%) <0.001* Dyslipidemia 455 (71.7%) 22 (41.5%) 433 (74.4%) <0.001* Current smoking 110 (17.3%) 13 (24.5%) 97 (16.7%) Male age > 45, Female > 55 year 589 (92.8%) 49 (92.5%) 540 (92.8%) Number of risk factor (8.2%) 22 (41.5%) 30 (5.2%) <0.001* (20.6%) 10 (18.9%) 121 (20.8%) (41.1%) 12 (22.6%) 249 (42.8%) > (30.1%) 9 (17.0%) 182 (31.3%) Prior diseases History of IHD 384 (60.5%) 27 (50.9%) 357 (61.3%) History of stroke 108 (17%) 8 (15.1%) 100 (17.2%) Heart failure Killip (II, III) 219 (34.5%) 2 (3.8%) 217 (37.3%) < 0.001* Cardiogenic shock (Killip IV) 123 (19.4%) 51 (96.2%) 72 (12.4%) <0.001* Malignant arrhythmia*** 35 (5.5%) 14 (26.4%) 21 (3.6%) <0.001* Initial SBP < 100 mmhg 66 (10.4%) 18 (34%) 48 (8.2%) <0.001* Chest pain to door time (min) ± ± ± Time to EKG and ASA (min) ± ± ± Time to admission (min) ± ± ± STE ACS 78 (12.3%) 15 (28.3%) 63 (10.8%) 0.001* Door to needle time (min) # ± ± ± Total ischemic time (min)# ± ± ± Hospital stay (mean ± SD; days) 5.67 ± ± ± Readmission within 28 days 136 (21.4%) 7 (13.2%) 129 (22.2%) * statistically significant; *** VT/VF, Heart block more than 2 degree AV mobitz II; # only STE-ACS who got thrombolytic drug

8 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital Table 5. Golden period in patients with thrombolytic therapy who had a fatal outcome Total (43) Fatal ( 6 ) Nonfatal ( 37 ) P value Door to needle time (min) (23.3%) 1 (16.7%) 9 (24.3%) (39.5%) 2 (33.3%) 15 (40.5%) > (37.2%) 3 (50%) 13 (35.1%) Total ischemic time (hour) < (37.2%) 15 (34.9%) 2 (33.3%) 1 (16.7%) 14 (37.8%) 14 (37.8%) > 5 12 (27.9%) 3 (50%) 9 (24.3%) Table 6. Pharmacologic treatment during hospital stay and discharge Total ACS; STE-ACS; Non STE-ACS; P value N (%) N (%) N (%) Antiplatelet 627 (98.7%) 78 (100 %) 549 (98.6%) Streptokinase 46 (7.2%) 43 (55.1%) 3 (0.5%) <0.001* LMWH or heparin 505 (79.5%) 50 (64.1%) 455 (81.7%) 0.001* SK ± LMWH 22 (3.5%) 22 (28.2%) 0 (0%) <0.001* Beta blocker 174 (27.4%) 23 (29.5%) 151 (27.1%) ACEI or ARB 301 (47.4%) 45 (57.7%) 256 (46%) Statin 395 (62.2%) 48 (61.5%) 347 (62.3%) Fibric group 27 (4.3%) 4 (5.1%) 23 (4.1%) Nondihydropyridine Ca blocker 8 (1.3%) 1 (1.3%) 7 (1.3%) Nitrate 488 (76.9%) 58 (74.4%) 430 (77.2%) * show statistically significant. Discussion The management of ACS had been well defined by clinical trials and summarized in guidelines (3-4,15). However, general practice sometimes differ markedly from guidelines, especially in a rural population that receives treatment in a primary care unit such as Saraburi Hospital that has two cardiologists and four medicine internists, with no invasive strategies for revascularization, no intra-aortic balloon pump and only a two bed coronary care unit. Baseline characteristics and risk factors of the patients in our study are comparable with other studies. Nearly all the patients were more than 65 years, trended to be more elderly in the Non STE-ACS group, were male and smoked predominantly more in the STE-ACS group. Moreover, the decreased frequency of STE-ACS presentation with advanced age and number of risk factors are compatible with the GRACE registry (16) and the Thai ACS registry 2007 (9). Hypertension and dyslipidemia were the most common risk factors. The proportion of Non STE-ACS compared with STE-ACS patients in our study was higher than the GRACE registry (16) and the Thai ACS registry 2007 (9). This is because we incorporated inclusion criteria by the new universal definition of MI 2007 (10) in this study that increased the frequency of AMI diagnosis by

9 50-100% (17-18) compared with the old definition of MI by World Health Organization criteria (19). Thus, the number of Non STE-ACS patients who were readmitted was high 134 (24.1%), so the proportion in the Non STE- ACS group was higher than other studies. The overall mortality in ACS patients were lower than the Thai ACS registry 2007 (9) (8.3% vs 12.6%) or the GRACE registry (16) (8.3% vs 16%) especially in Non STE-ACS patients (6.8% vs 16.1%) and (6.8% vs 9%). This is because the criteria for the diagnosis of AMI were much more sensitive and thus the number of patients who were enrolled in this study had a much lower severity of disease. However, the mortality in STE-ACS was higher than the Thai ACS registry 2007 (9) (19.2% vs 17%) or the GRACE registry (19.2% vs 7%) (16). The reason may be because 1) mean chest pain to door time was very long ( ± minutes). 2) only 55.1% in STE-ACS had received reperfusion therapy that was not different from the Thai ACS registry 2007 (52.4%) but lower than the GRACE registry (62%). Both of those studies had both primary PCI or fibrin specific and non fibrin specific thrombolytic drugs but in our study we had only Streptokinase. 3) more than half of STE-ACS patients who received thrombolytic drugs (62.8%) had a total ischemic time longer than the best effective period of thrombolytic drugs (3 hours ) 3) may be the result of the patient s education to recognize symptoms, financial problems, referral system from home to hospital or hospital to hospital. 4) Mean or median door to needle time in STE-ACS patients who received thrombolytic drugs was longer than recommended by the standard guideline (30 minutes) (15). This was due to the waiting time to start SK at the ward, however shorter than the Thai ACS registry 2007 (9) (81.12 ± vs 114 ± 96 min; 70 vs 85 min respectively). 5) 60% of STEMI in our study were anterior and anterolateral wall MI. None of risk factors seemed to be involved because the number of risk factors associated with an increase in mortality was in an opposite direction; that is the mortality rate was significantly higher in ACS patients who had lower numbers of risk factors. The severity of disease was the main factor associated with increased mortality especially Killip IV, malignant arrhythmia, initial systolic blood pressure < 100 mmhg had mortality percentages of Pitha Promlikitchai, MD 96.2%,26.4%,34% respectively. These patients should be preferentially treated by an invasive strategy than a conservative strategy but our hospital did not have a Catheterization Laboratory and the number of patients who were referred to tertiary care hospitals in the same hospitalization was only 3.8%. So the only way to improve mortality rate outcome in STE-ACS or readmission rate in Non STE-ACS was to have a good referral system. The incidence of HF was high in both the STE-ACS and Non STE-ACS groups and slightly higher than the Thai ACS registry 2007 (9) and the GRACE registry (16) (52.6% vs 45.5%; 52.6% vs 46 % respectively). Killip IV was much more in the STE-ACS group. A shorter door to needle time or total ischemic time demonstrated a trend toward decreased mortality rate in STE-ACS patients in this study but was not statistically significant due to the small number of patients. The association of lower hospital mortality (20) with better use of selected medical treatments to improve survival in ACS have been clearly defined in clinical trials and guidelines (3, 5, 15, 21). In our study ASA, Beta-blockers, ACEIs/ARBs and statins were used in 98.7%, 27.4%, 47.4% and 62.2% of patients respectively. ASA and statins were used with similar frequency to study ACS in other rural hospitals in Thailand, but beta blockers and ACEI or ARB were used with lower frequency due to heart failure and renal insufficiency or renal failure respectively. However the overall mortality rate was similar 8.3% vs 9.6% (6), so this was not associated with an increased mortality. Our results suggest that approaches to prevention of ACS and reduction of morbidity and mortality due to ACS were 1) educate ACS patients to early recognition of symptoms, improving care in currently known risk factors especially smoking 2) Improving the efficacy of ACS diagnosis and the guidelines for management of ACS in Saraburi Hospital to shorten the time of definite treatment, The TIMI risk score (20, 22) should be readily applied at the bedside at the time of hospital presentation, and poor prognostic patients should be recognized for close monitoring and management of complications by medical teams as well as the establishment of a coronary care unit 3) improve cardiac network systems to transfer high risk patients to centers with interventional cardiology facilities to decrease mortality, heart failure and readmission.

10 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital Our study has several potential limitations. STE-ACS and Non STE-ACS diagnoses were not strictly validated. ACS patients in Saraburi Hospital may not be reported especially death at the ER or out of the hospital. Lastly, in cardiogenic shock we used clinical diagnosis and did not use hemodynamic data and those with heart failure defined by Killip classification, both of the outcomes did not identify at initial presentation. Conclusion The results of this study provide additional data concerning ACS in the rural population where there are restricted access to invasive treatment strategies and drug limitations. There were high in-hospital mortality and heart failure. These findings suggest that there should be further development of guidelines for ACS to improve efficacy of diagnosis, management, and create cardiac networks for appropriate early referral of patients with ACS admitted to Saraburi Hospital. References 1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics-2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2006; 113: e Van de Werf F, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with STsegment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2003; 24: Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary. 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12 Fast Track Guideline for Patients with Acute Coronary Syndrome at Saraburi Hospital ก ก,. ก ก : ก ก ก ก ก ก ก ก : ก ก ก ก 1 ก ก ก : ก ก ก ก ก ก 1026 ก 635 ก ST-segment elevation acute coronary syndrome (STE-ACS) 78, no ST-segment elevation acute coronary syndrome (Non STE-ACS) 557 ก STE-ACS ก ก ก ก (Kappa value = 0.622, P <0.001) ± 11.12, Non STE-ACS กก ± vs ± 12.35; P <0.001, 44.1% ก (80.8%) (71.7%) ก ก ก STE-ACS (52.6%). ก STE-ACS 55.1%; door to needle time ± 64.50, 70 ; total ischemic time ± , 205 ก 8.3% STE-ACS ก ก Non STE-ACS 19.2% vs 6.8%, P <0.001 ก 28 Non STE-ACS ก STE-ACS 24.1% vs 1.5%; P < ก cardiogenic shock, malignant arrhythmia (VT/VF, Heart block more than 2 degree AV block Mobits II) initial systolic blood pressure < 100 mmhg % ก ก ACS Time delay from the onset of symptoms to admission door to needle time ก STE-ACS : ก ก ก ก ก ก ก ก 28 ก ก ก ก ก