Semin Vasc Med 2003; 03(4): 425-432
DOI: 10.1055/s-2004-817692

Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Treatment Algorithms and Critical Pathways for Acute Coronary Syndromes

Christopher P. Cannon
  • Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, and Harvard Medical School, Boston, MA
Weitere Informationen


03. Februar 2004 (online)


Although numerous clinical trials have identified many advances in the treatment of patients with acute coronary syndromes (ACS), registries of clinical practice have identified that in clinical practice a large proportion of patients do not receive guideline-recommended therapies. In addition to development and dissemination of national guidelines, there is a need for specific tools to ensure that the guideline recommendations are implemented on a patient-by-patient basis. Better adherence to practice guidelines has been found to be associated with improved outcomes. Critical pathways and/or the process of Continuous Quality Improvement (CQI) are means of trying to improve care. Critical pathways are standardized protocols that aim to optimize and streamline patient care, which usually involve standardized order sets, (or computerized ones), and/or simple pocket cards, reminders, or checklists of the appropriate therapies. Another key part of an overall CQI effort is to monitor data on performance-i.e. utilization of guideline recommended therapies. Several well-conducted studies, showing that particular use of critical pathways, can lead to improve quality of care.


  • 1 Braunwald E, Antman E M, Beasley J W. et al . ACC/AHA Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction-2002; Summary Article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina).  Circulation . 2002;  106 1893-1900
  • 2 Van de Werf F, Ardissino D, Betriu A. et al . Management of acute myocardial infarction in patients presenting with ST-segment elevation.  Eur Heart J . 2003;  24 28-66
  • 3 Ryan T J, Antman E M, Brooks N H. et al . 1999 Update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations.  Circulation . 1999;  100 1016-1030
  • 4 Cannon C P, O'Gara P T. Critical pathways in acute coronary syndromes. In: Cannon CP, ed. Management of Acute Coronary Syndromes Totowa, NJ: Humana Press 1999: 611-627
  • 5 Every N R, Hochman J, Becker R, Kopecky S, Cannon C P, for the Committee on Acute Cardiac Care. Council of Clinical Cardiology; American Heart Association. Critical pathways: a review. An AHA Scientific Statement.  Circulation . 2000;  101 461-465
  • 6 National Heart Attack Alert Program Coordinating Committee-60 Minutes to Treatment Working Group. Emergency department: rapid identification and treatment of patients with acute myocardial infarction.  Ann Emerg Med . 1994;  23 311-329
  • 7 Pearson S D, Goulart-Fisher D, Lee T H. Critical pathways as a strategy for improving care: problems and potential.  Ann Intern Med . 1995;  123 941-948
  • 8 Cannon C P. Critical pathways in cardiology: a journal of evidence-based medicine. Translating evidence into practice.  Crit Path Cardiol . 2002;  1 1-2
  • 9 Cannon C P. Critical pathway for unstable angina and non-ST elevation myocardial infarction.  Crit Path Cardiol . 2002;  1 12-21
  • 10 Braunwald E, Mark D B, Jones R H. et al .Unstable Angina: Diagnosis and Management. Clinical Practice Guideline Number 10. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, U.S. Department of Health and Human Services; 1994
  • 11 Braunwald E, Antman E M, Beasley J W. et al . ACC/AHA guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Unstable Angina and Non-ST Segment Elevation Myocardial Infarction).  J Am Coll Cardiol . 2000;  36 970-1056
  • 12 Rogers W J, Bowlby L J, Chandra N C. et al . Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction.  Circulation . 1994;  90 2103-2114
  • 13 Ellerbeck E F, Jencks S F, Radford M J. et al . Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project.  JAMA . 1995;  273 1509-1514
  • 14 Stone P H, Thompson B, Anderson H V. et al . Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III Registry.  JAMA . 1996;  275 1104-1112
  • 15 Scirica B M, Moliterno D J, Every N R. et al . Differences between men and women in the management of unstable angina pectoris (the GUARANTEE Registry).  Am J Cardiol . 1999;  84 1145-1150
  • 16 Cannon C P, Bahit M C, Haugland J M. et al . Underutilization of evidence-based medications in acute ST elevation myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry.  Crit Path Cardiol . 2002;  1 44-52
  • 17 European Action on Secondary Prevention by Intervention to Reduce Events. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. EUROASPIRE I and II Group.  Lancet . 2001;  357 995-1001
  • 18 Barron H V, Bowlby L J, Breen T. et al . Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2.  Circulation . 1998;  97 1150-1156
  • 19 FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Invasive compared with non-invasive treatment in unstable coronary- artery disease: FRISC II prospective randomised multicentre study.  Lancet . 1999;  354 708-715
  • 20 Cannon C P, Weintraub W S, Demopoulos L A. et al . Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.  N Engl J Med . 2001;  344 1879-1887
  • 21 Van de Werf F, Avezum A, Gulba D. et al . Interventional procedures and in-hospital outcomes in patients with acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE).  Eur Heart J . 2001;  22(abstr suppl) 617
  • 22 Cannon C P, Gibson C M, Lambrew C T. et al . Longer thrombolysis door-to-needle times are associated with increased mortality in acute myocardial infarction: An analysis of 85,589 patients in the National Registry of Myocardial Infarction 2+3.  J Am Coll Cardiol . 2000;  35 (suppl A) 376A
  • 23 Cannon C P, Gibson C M, Lambrew C T. et al . Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction.  JAMA . 2000;  283 2941-2947
  • 24 Topol E J, Bure K, O'Neill W W. et al . A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion.  N Engl J Med . 1988;  318 1083-1088
  • 25 Grines C L, Marsalese D L, Brodie B. et al . Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction.  J Am Coll Cardiol . 1998;  31 967-972
  • 26 Cannon C P, Johnson E B, Cermignani M, Scirica B M, Sagarin M J, Walls R M. Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction.  Clin Cardiol . 1999;  22 17-22
  • 27 Pell A CH, Miller H C, Robertson C E, Fox K AA. Effect of “fast track” admission for acute myocardial infarction on delay to thrombolysis.  BMJ . 1992;  304 83-87
  • 28 Caputo R P, Ho K K, Stoler R C. et al . Effect of continuous quality improvement analysis on the delivery of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.  Am J Cardiol . 1997;  79 1159-1164
  • 29 Ward M R, Lo S T, Herity N A, Lee D P, Yeung A C. Effect of audit on door-to-inflation times in primary angioplasty/stenting for acute myocardial infarction.  Am J Cardiol . 2001;  87 336-338
  • 30 Mehta R H, Montoye C K, Gallogly M. et al . Improving quality of care of acute myocardial infarction: the Guideline Applied in Practice (GAP) Initiative in Southeast Michigan.  JAMA . 2002;  287 1269-1276
  • 31 Fonarow G C, Gawlinski A, Moughrabi S, Tillisch J H. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP).  Am J Cardiol . 2001;  87 819-822
  • 32 Jha A K, Perlin J B, Kizer K W, Dudley R A. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.  N Engl J Med . 2003;  348 2218-2227
  • 33 Giugliano R P, Lloyd-Jones D M, Camargo Jr A C, Makary M A, O'Donnell C J. Association of unstable angina guideline care with improved survival.  Arch Intern Med . 2000;  160 1775-1780
  • 34 Cannon C P, Ornato J P. How to develop a critical pathway: the ACS ACTION program.  Crit Path Cardiol . 2002;  1 53-60
  • 35 Hoekstra J W, Pollack Jr V C, Roe M T. et al . Improving the care of patients with non-ST-elevation acute coronary syndromes in the emergency department: the CRUSADE initiative.  Acad Emerg Med . 2002;  9 1146-1155