title: A pilot study on the application of the current European guidelines for the management of acute coronary syndrome without elevation of ST segment (NSTEMI) in the Emergency Department setting in the Italian region Lazio.
abstract: BACKGROUND
  In 2011 the European Society of Cardiology published the new guidelines for the treatment and management of acute coronary syndrome without elevation of the ST segment (NSTEMI). For the treatment of the syndrome, the use of P2Y12 inhibitors in addition to aspirin was strongly recommended (evidence IA). We studied the application of this recommendation in the setting of the emergency department in the vast and uneven area of the Italian region Lazio, three years after the release of these drugs in Italy.
  
  
  METHODS
  121 consecutive patients (65% older than 65 years) affected by NSTEMI were recruited between May and July 2013. During the transition in the emergency department data was collected on patient's symptoms, syndrome severity and type & timing of treatments chosen. Adherence to the guidelines was evaluated considering the number of "good treated" patients: these being the patients that received at least 80% of the main five recommendations on percutaneous coronary intervention (PCI) timing, antiplatelet and anti-coagulant therapy suggested by the European Cardiology Task Force (ESC guidelines, 2011) for the very acute phase of NSTEMI.
  
  
  RESULTS
  Patients were treated with: 1) 35% of cases with double antiplatelet therapy and anticoagulation (DAPT+AC), 2) 22% of cases with single antiplatelet and anticoagulation (SAPT+AC), 3) 6% of cases with a single antiplatelet therapy (SAPT), 4) 6% of cases with a double antiplatelet therapy (DAPT) and 5) 24% of cases did not receive any therapy. Data on PCI was available for 95 patients and, of these, only 82% of the patients underwent the procedure. The percentage of "good treated" patients were among of 20-40%, depending on PCI timing--as guidelines suggested--was considered as mandatory (20,5%) or as the extreme time limit (40%). Significant differences were found between patients treated in a central hospital with a hemodynamic laboratory active 24/24hr (HUB) and patients treated in the other hospital (SPOKE). HUBs showed a higher percent of "good treated" patients, a higher percentage of early invasive treated and a better adherence to recommended pharmacological therapy.
  
  
  CONCLUSIONS
  A significant number of patients did not receive adequate treatment during the emergency department stay. The absence of hemodynamic services increases the risk of inadequate treatment.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Valli
authors.forename: Francesca
authors.initials: F
authors.lastname: De Marco
authors.forename: Maria Teresa
authors.initials: MT
authors.lastname: Spina
authors.forename: Valentina
authors.initials: V
authors.lastname: Valeriano
authors.forename: Antonello
authors.initials: A
authors.lastname: Rosa
authors.forename: Valentina
authors.initials: V
authors.lastname: Minerva
authors.forename: Enrico
authors.initials: E
authors.lastname: Mirante
authors.forename: Maria Pia
authors.initials: MP
authors.lastname: Ruggieri
authors.forename: Francesco Rocco
authors.initials: FR
authors.lastname: Pugliese
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000628:therapy; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use*; D002985:Clinical Protocols; D019468:Disease Management; D004562:Electrocardiography; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D007558:Italy; D008297:Male; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000706:statistics & numerical data; D010865:Pilot Projects; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D058921:Purinergic P2Y Receptor Antagonists / Q000627:therapeutic use*; D058996:Quality Improvement; D018570:Risk Assessment / Q000379:methods / Q000592:standards; D061665:Time-to-Treatment
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D001241:Aspirin