The care of ACS patients at deployed locations is limited by the fact that cardiac care is provided in austere locations without rapid access to higher levels of care. While medical therapies can stabilize patients for short periods of time, any complications that arise do not have the benefit of being treated urgent/emergently in a cardiac catheterization laboratory. A plan for urgent MEDEVAC/aeromedical evacuation to a PCI capable center should be initiated as soon as they are diagnosed with ACS and initiated medical therapy.

Telemedicine/Cardiology Consultant

The first cardiology consultant within the evacuation chain should be consulted immediately for patients diagnosed with a STEMI or UA/NSTEMI at deployed locations. Diagnosis and treatment of ACS should be guided by expert consultation, to include electronic transmission of ECGs (by whatever means available).

MEDEVAC

When possible, all patients diagnosed with or with high suspicion of ACS at Role 1 or 2 facilities should be moved to a Role 3 facility (preferably a facility with a cardiologist) as soon as possible.

Host Nation

At times host nations (HNs) have facilities that meet U.S. standards for medical care. If relationships with these facilities have been established and have been utilized for emergent care of U.S. personnel, then their use should be considered for emergent PCI in the following situations:

1. STEMI – PCI at a HN facility is preferred over fibrinolysis since this is the primary treatment for STEMI. If the facility or total transport time exceeds 120 minutes, then administer fibrinolysis (with cardiology teleconsultation) and continue coordinating transport to the HN PCI lab.
2. UA/NSTEMI – refractory angina, ischemic ECG changes, hemodynamic instability (with or without cardiogenic shock) or refractory arrhythmias after receiving medical therapy.

Aeromedical Evacuation

Aeromedical evacuation of all ACS patients should adhere to the following principles when possible due to the evolving nature of the disease and limited ability to fully handle the complications that come with this disease process.

1. All aeromedical evacuation of ACS patients should be evacuated by CCATT or equivalent level of care.
2. Missions should be requested as URGENT unless otherwise designated with cardiology consultation.
3. All in flight treatment should follow the recommendations put forth in the previous sections of the CPG.

In-Flight Considerations

1. Maintain O2 saturations > 90%.
2. Red blood cell transfusion should be avoided unless the hemoglobin level is < 8 g/dl in patients without active ischemia.13,36
3. In the event of an inflight STEMI (new vs. reinfarction), then thrombolytics should be given unless a contraindication exists (see Appendix A).
4. If the patient becomes unstable in-flight, consideration of diversion to the closest location with PCI capabilities should be strongly considered. An unstable patient is one who has ongoing ischemia and the presence of either:

a.Hypotension/shock primarily due to suspected cardiovascular causes.

b.Recurrent ventricular arrhythmias that are unable to be controlled with ACLS medications (e.g., beta blockers, amiodarone).