Part 9: Acute Coronary Syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Introduction Clinicians often struggle with uncertainty and complexity in deciding which course of treatment will likely lead to an optimal outcome for an individual patient. Scientific research provides information on how patient populations have responded to treatment regimens, and this information, combined with a knowledge of the individual patient, can help guide the clinician’s decisions. The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the ILCOR 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and was completed in February 2015. In this in-depth evidence review process, ILCOR examined topics and then generated a prioritized list of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format, and then a search for relevant articles was performed. The evidence was evaluated by the ILCOR task forces by using the standardized methodologic approach proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. The quality of the evidence was categorized based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). Then, where possible, consensus-based treatment recommendations were created. To create this 2015 AHA Guidelines Update for CPR and ECC, the AHA formed 15 writing groups, with careful attention to avoid conflicts of interest, to assess the ILCOR treatment recommendations, and to write AHA treatment recommendations by using the AHA Class of Recommendation and Level of Evidence (LOE) system. The recommendations made in the 2015 Guidelines Update for CPR and ECC are informed by the ILCOR recommendations and GRADE classification, in the context of the delivery of medical care in North America. In the online version of this publication, live links are provided so the reader can connect directly to the systematic reviews on the Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a superscript combination of letters and numbers (eg, ACS 873). This 2015 Guidelines Update offers recommendations for the care of patients with acute coronary syndromes (ACS). The recommendations made here update those made in the 2010 Guidelines and address only those issues that were reviewed in 2015. The ILCOR ACS Task Force did not review areas in which it found a paucity of new evidence between 2010 and 2015; therefore, the 2010 Guidelines for these unreviewed areas remain current. For example, acetylsalicylic acid administration has been shown to be of benefit in ACS and was recommended by the 2010 Guidelines. Acetylsalicylic acid was not reviewed by the ACS Task Force in 2015, so the recommendations from 2010 should be used. (Note: The First Aid section of this 2015 Guidelines Update makes recommendations on acetylsalicylic acid administration by nonmedical personnel—see “Part 15: First Aid”). The recommendations that were not reviewed in 2015 will either be reviewed and included in future AHA Guidelines for CPR and ECC or will be in the most recent ACC/AHA Guidelines. A table of recommendations made in this update, as well as the recommendations made in “Part 10: Acute Coronary Syndromes” of the 2010 Guidelines, can be found in the Appendix. The 2015 Guidelines for ACS are directed toward practitioners who provide care for patients with suspected ACS from the time of first medical contact until disposition from the emergency department (ED). Care providers during this time may include emergency medical service (EMS) dispatchers, first responders, EMT-Bs, paramedics, nurses, physicians, and other independent practitioners.