About the Guideline

Comprehensive guideline

What’s new in this guideline?

New terminology and definitions

• The guideline adopts the new term acute coronary occlusion myocardial infarction (ACOMI) to acknowledge ECG patterns that have been found to reflect acute coronary occlusion without ST-segment elevation (STE) such as posterior MI and De Winters T waves. It also includes STE patterns often under recognised in acute settings such as right ventricular or high lateral infarction.
• Coronary occlusion can result from both atherosclerotic and non-atherosclerotic causes, referred to in the 2016 guideline as ‘type 1 MI’ and ‘type 2 MI’ respectively.
• Conditions such as SCAD, coronary embolism and coronary spasm or microvascular dysfunction can present identically to atherosclerotic causes of AMI and may require urgent angiography to diagnose and treat appropriately. For this reason, these conditions have been classified as MI with acute coronary occlusion.

Assessment and diagnosis

New guidance on the assessment and diagnosis of people with suspected or confirmed ACS:

• Description of multiple ECG patterns of ACOMI, beyond the traditional ST-segment elevation criteria, which should prompt consideration of emergency reperfusion.
• New clinical decision pathways incorporating high-sensitivity cardiac troponin assays to enable more efficient risk assessment compared with traditional (contemporary/conventional) troponin-based algorithms.
• For people classed as intermediate risk, invasive cardiac testing is now an option to further stratify and assess risk beyond 30 days.

Hospital care and reperfusion

New guidance on the acute management of people with STEMI or non-ST-segment elevation acute coronary syndromes:

• Stronger emphasis on the optimal timing of primary percutaneous coronary intervention (PCI) in people with STEMI:
• <60 minutes from first medical contact at PCI-capable centres
• <90 minutes from first medical contact at non-PCI capable centres/emergency services.
• New evidence for use of intravascular imaging-guided PCI in people with non-ST-segment elevation acute coronary syndromes.
• New recommendations for managing ACS with cardiac arrest and/or cardiogenic shock, including considerations for use of haemodynamic support devices and left ventricular assist devices.
• New recommendations on the treatment of multivessel disease, including specific timing of PCI of non-infarct related arteries and considerations for invasive physiology assessment.
• New recommendations for the management of ACS due to SCAD, including considerations for selective revascularisation.

Recovery and secondary prevention

New recommendations and guidance on non-pharmacological and pharmacological secondary prevention measures:

• More detailed advice on post-discharge care, including medicines and adherence strategies, vaccinations and screening for mental health conditions.
• Treatment algorithms to enable more tailored prescribing of antiplatelet and anticoagulation therapies.
• A new recommended treatment target for low density lipoprotein cholesterol (LDL-C) of <1.4 mmol/L and a reduction of at least 50% from baseline.
• New recommendations on select medicines including beta blockers and PCSK9 inhibitors.

Considerations for priority populations

• New practice points address the unique needs of priority populations with suspected or confirmed ACS, including women, older adults, First Nations peoples and people living in regional and remote areas.