Version 1.3 November 2007.

Review date April 2009

Compiled by the CHD MCN. Version 1.3 November 2007. Review Date April 2009

Contents Page
Section 1 - ICP Pre-Hospital 2008
Pre Hospital
Patients Suitable for Thrombolysis

Page No.
3

Section 2 ICP Initial Assessment

Chest Pain/Acute Coronary Syndrome Initial Assessment

Section 3 ICP STEMI Thrombolysis 2008

Administration of thrombolysis using Tenectaplase
Patients not suitable for Thrombolysis

Section 4 ICP UA-NSTEMI 2008

ACS NSTEMI

12

Section 5 ICP Insulin/Glucose

ICP Insulin/Glucose Therapy

14

Section 6 ICP Day to Day Sheet

ACS Coronary Syndrome ICP: Ward Sheet

16

Section 7 ICP Discharge Sheet

ICP Discharge Recommendations

17

Version 1.3 November 2007. Review date April 2009

ACUTE CORONARY SYNDROME INTEGRATED CARE PATHWAY:

PRE-HOSPITAL.
ELEGIBILITY:
All patients presenting with chest pain or associated symptoms consistent with a
diagnosis of cardiac ischemia/MI of >15 minutes duration
Surname
First Name
DOB
CHI
Address

Action

Date
Time of Symptom
Onset
Time of Arrival

Time

Value

12 lead ECG

Attach
Continuous
Cardiac
Monitoring
Aspirin 300mg
orally (soluble
or crushed)
Clopidogrel
300mg orally

GTN spray s/l

Version 1.3 November 2007. Review date April 2009

Reason if Not
Done

Notes
Essential to
plan
appropriate
further
treatment
VT/VF are
common in
the initial
phase of an
ACS
Reduces the
risk of events
by one third
to one half
Only in the
presence of
an ischemic
ECG
(LBBB/ST
elevation or
depression)
Give at 5
minute
intervals as
required for
the relief of

chest pain
Attach Pulse
oximetry
Administer Hi
Flow (10l) O2
via a non
rebreathing
mask
IV Access
Anti-emetic:
metoclopramide
10mg IV or
cyclizine 50mg
IV

___%

Analgesia:
Diamorphine
2.5 5 mg (rpt
if necessary).
OR
Morphine 510mg (rpt if
necessary)

Caution if
evidence of
Type 2
respiratory
failure.
Avoid
cyclizine if
any signs of
Left
Ventricular
Failure
Note clearly
which drug
used

ECG INTERPRETATION:
ST elevation 1mm in two or more adjacent limb leads?
ST elevation2mm in two or more contiguous chest leads?
Presumed new onset Left Bundle Branch Block?
Posterior Infarction?
If Yes to any of the above then administer thrombolysis according to the
protocol. If No to all arrange immediate transfer to hospital for further
assessment.

Version 1.3 November 2007. Review date April 2009

Version 1.3 November 2007. Review date April 2009

1.PATIENTS SUITABLE FOR THROMBOLYSIS

CHECKLIST OF CONTRAINDICATIONS FOR THROMBOLYSIS
Symptom onset > 6hours prior to presentation
Recent haemorrhage, trauma or surgery
Ischemic Stroke in the last 3/12
Aortic Dissection
Coma
Previous intracerebral haemorrhage or known intracerebral lesion including neoplasms.
Uncontrolled hypertension (SBP >180)
Pregnancy
Prolonged CPR
Active peptic ulceration
Bleeding Diathesis
Acute pancreatitis
Oesophageal varices
Current oral anticoagulant therapy (INR > 1.3)
ADMINISTRATION OF THROMBOLYSIS

STEP 1
STEP 2
STEP 3
STEP 4

Patient Weight
Calculate dose of tenectaplase
from table below
Administer tenectaplase as an IV
bolus and flush line with 0.9%
NaCl
Administer IV Bolus dose of
LMWH ( 3000U Dalteparin)

STEP 5

Calculate and administer dose of

LMWH (Enoxaparin) for SC
injection.
(Dose = 1mg/kg)

STEP 6

Arrange immediate transfer to

hospital.

_____kg
_____units
____Time Given
____Time Given
____Mg
____Time Given

TENECTEPLASE/DALTEPARIN
DOSE CALCULATOR
Tenecteplase Tenecteplase
Patients' body weight
category (kg)

(U)

(mg)

< 60

6,000

30

Version 1.3 November 2007. Review date April 2009

Corresponding
volume of
reconstituted
Tenectaplase
solution (ml)
6

60 to < 70

7,000

35

70 to < 80

8,000

40

80 to < 90

9,000

45

90

10,000

50

10

Version 1.3 November 2007. Review date April 2009

CHEST PAIN/ACUTE CORONORY SYNDROME INITIAL ASSESSMENT

(In Hospital: all areas)
ELEGIBILITY
All patients presenting with chest pain or associated symptoms consistent with a diagnosis of
cardiac ischemia/MI of > 15 minutes duration
Surname
First Name
DOB
CHI
Address

Actions

Date
Time of Symptom
Onset
Time of Arrival

Time

Value

12 lead ECG
Aspirin 300mg p.o.
GTN spray given
Pulse oximetry attached (state if on air or %
O2)
Administer Hi Flow O2 (10litres)
Attach CONTINUOUS Cardiac Monitoring
IV Access
Check Troponin T level
Take blood also for
FBC/U+E/LFT/TSH/Cholesterol/HDL/Glucose

Anti emetic: metoclopramide 10mg IV or

cyclizine 50mg IV

Analgesia:
Diamorphine 2.5-5mg IV (can be repeated if
necessary)
Clopidogrel 300mg p.o.

Version 1.3 November 2007. Review date April 2009

Reason if
not done
(e.g. prehospital)

Information

Soluble or
crushed.
Give x3 doses
at 5 minute
intervals

Check on
admission in
all cases.
Chol level
may be
misleadingly
low due to
acute current
illness.
Avoid
cyclizine if
any signs of
Left
Ventricular
Failure

If ischemic
ECG or
Elevated
Cardiac
Markers

ECG INTERPRETATION:
ST elevation 1mm in two or more adjacent limb leads?
ST elevation 2mm in two or more contiguous chest leads?
Presumed new onset of Left Bundle Branch Block?
Posterior Infarction?

Yes to any

Signed:

Go to ACS STEMI Pathway

No to all

Date:

Time:

Go to ACS NSTEMI/UA Pathway

Version 1.3 November 2007. Review date April 2009

ACUTE MYOCARDIAL INFARCTION

(Acute Coronary Syndrome ST Segment Elevation Myocardial Infarction (STEMI))
ELEGIBILITY
All patients with diagnostic ECG changes of an acute MI and one or both of an appropriate
clinical history or raised cardiac enzyme markers
Surname
First Name
DOB
CHI
Address

Date
Time of Symptom
onset

Confirm STEMI from 12 lead ECG

ST elevation 1mm in two or more adjacent limb leads
ST elevation 2mm in two or more contiguous chest leads
Presumed new onset LBBB
Posterior Infarction

Check Aspirin 300mg administered

Check Clopidogrel 300mg
administered

Yes?
Yes?

No?
No?

Version 1.3 November 2007. Review date April 2009

Reason if not given:

Reason if not given:

10

1.PATIENTS SUITABLE FOR THROMBOLYSIS

THROMBOLYSIS POLICY USING TENECTAPLASE
CHECKLIST OF CONTRAINDICATIONS FOR THROMBOLYSIS
Symptom onset > 6hours prior to presentation (may be considered in certain cases. d/w consultant on
call)
Recent haemorrhage, trauma or surgery
Ischemic Stroke in the last 3/12
Aortic Dissection
Coma
Previous intracerebral haemorrhage or known intracerebral lesion including neoplasms.
Uncontrolled hypertension (SBP >180)
Pregnancy
Prolonged CPR
Active peptic ulceration
Bleeding Diathesis
Acute pancreatitis
Oesophageal varices
Current oral anticoagulant therapy (INR > 1.3)

NB: If raised SBP only contraindication try to lower with an infusion of IV nitrate to
SBP<180
NB: consider referral for PCI if any contraindications exist
( Patients relevant co morbidities may affect this decision)

Version 1.3 November 2007. Review date April 2009

11

ADMINISTRATION OF THROMBOLYSIS USING TENECTAPLASE

STEP 1
STEP 2

Patient Weight
Calculate dose of tenectaplase from table below

_____kg
_____units

STEP 3

Administer tenectaplase as an IV bolus and flush line with 0.9% NaCl

____Time Given

STEP 4

Administer IV Bolus dose of LMWH (3000U Dalteparin)

Preferably through a separate line. If unavailable flush the
thrombolysis line before administration.
Calculate dose of LMWH (Enoxaparin) for SC injection.
(Dose = 1mg/kg)

STEP 5
STEP 6

Administer LMWH (Enoxaparin) SC Injection.

____Time Given

____Mg
____Time Given

TENECTEPLASE DOSE
CALCULATOR
Tenecteplase Tenecteplase
Patients' body weight
category (kg)

(U)

(mg)

Corresponding volume of
Tenectaplase reconstituted
solution (ml)

< 60

6,000

30

60 to < 70

7,000

35

70 to < 80

8,000

40

80 to < 90

9,000

45

90

10,000

50

10

Version 1.3 November 2007. Review date April 2009

12

2.PATIENTS NOT SUITABLE FOR THROMBOLYSIS

NB: If thrombolysis is contraindicated for any reason then consideration should be given to contact tertiary
centre for transfer for Primary PCI. For Greatest benefit, PCI should be performed within 12 hours. PCI has
significant benefits over thrombolysis in terms of death, stroke, recurrent MI etc. and the increased survival in
those who cannot receive thrombolysis must not be ignored. The suitability for transfer will however depend
on the individual patients co morbidities.
STEP 1:
Patients Suitable for Transfer

Contact tertiary Centre as a

priority. Immediate transfer
for PCI is the preferred
therapy.
For transfer check:

?further dose of
Clopidogrel advised

? Bolus LMWH/UFH
advised

? Infusion of UFH
recommended
?S/C dose LMWH
recommended

STEP 2:
Patients Unsuitable for transfer
STEP 3:

STEP 4:

?Gp IIb/IIIa Inhibitor

advised

Weight
Administer Fondaparinux
2.5mg s/c
(CI: Not to be used if serum
creatinine >265)
If Fondaparinux CI use
LMWH (Enoxaparin 1mg/kg
s/c twice a day)
N.B. In severe renal
impairment (creatinine
clearance <30 ml/min) the
product literature
recommends 1mg/kg s/c once
daily

Version 1.3 November 2007. Review date April 2009

Contact Glasgow Royal

Infirmary (GRI) on 0141 211
4000 and bleep the
Cardiologist on call.
____Dose
____Time Given
____Name
____Dose
____Time Given
____Dose
____Time Commenced
____Name
____Dose
____Time Given
____Name
____Dose
____Time Given

____Kg
____Time Given

____Dose
____Time Given

13

3.ALL PATIENTS
INTRAVENOUS BETA BLOCKER THERAPY (Patients must be haemodynamically stable to
allow the use of IV beta blockers):
If patients have P>65 and SBP >105mm/Hg and no clinical evidence of heart failure then
consider IV metoprolol 5-15mg IV (Give 5mg at 2 minute intervals if tolerated).
If tolerated, give a stat oral dose of metoprolol 50mg 15 minutes later. Oral metoprolol 50mg
should be given qid for the first 24 hrs. A long acting beta blocker (atenolol, bisoprolol) can be
substituted on day 2 if the above is tolerated.
INSULIN/GLUCOSE INFUSION:
All patients with a prior diagnosis of diabetes (Type 1 or 2) as well as those in whom their
admission random glucose is >11 mmol/l should have immediate intensive glucose control with an
insulin/dextrose infusion for a minimum of 24 hrs. ( See separate ICP for insulin/dextrose
infusion)

IV Beta blocker given?

Name:

Oral Beta blocker given

Name:

Admission plasma glucose

level?

____mmol/l

____Dose
____Time Given
____Dose
____Time Given

4. POST THROMBOLYSIS ASSESSMENT

ALL PATIENTS ADMITTED FOR STEMI WHO HAVE BEEN THROMBOLYSED SHOULD BE
CONSIDERED FOR EARLY TRANSFER TO TERTIARY CENTRE FOR WHICHEVER OF THE
FOLLOWING MAY APPLY:

RESCUE PCI FOR FAILED THROMBOLYSIS (This is said to be the case when there is <50%
resolution of ST segment elevation after thrombolysis)

Consideration should also be given to transfer after successful thrombolysis to allow assessment
for revascularisation to be performed

Has tertiary care centre been contacted to

discuss suitability of rescue PCI

Version 1.3 November 2007. Review date April 2009

____Yes ____No
(Give reason if not done)

14

ACS NSTEMI
(Acute Coronary Syndrome Non ST Segment Elevation Myocardial Infarction)
ELEGIBILITY
All patients presenting with chest pain or associated symptoms of cardiac ischemia in whom
STEMI has been excluded on the basis of ECG/ Clinical History and/or biochemical markers

Surname
First Name
DOB
CHI
Address

Date
Time of
Symptom Onset
Time of Arrival

Check Aspirin 300mg

administered
Check Clopidogrel 300mg
administered
(for all with ischemic ECG or
elevated cardiac markers)

Yes?

No?

Reason if not given:

Yes?

No?

Reason if not given:

RISK STRATIFICATION (DO THIS FIRST (AS PER SIGN 93))

The optimal therapeutic intervention for patients with an ACS depends upon their relative risk of
MI/ Death. All patients should have their risk assessed by the use of the GRACE Risk Calculator.
(GRACE is an electronic risk calculator- use website or download calculator to laptop/PALM etc to
calculate risk)
http://www.outcomes-umassmed.org/grace/
Patients are then classified as being at High, Medium or Low risk as follows:
High >9% risk of in-hospital death
Medium 1-9% risk of in-hospital death
Low <1% risk of in-hospital death
Discuss with tertiary centre about the possibility of early transfer for angiography/intervention
for all patients at medium to high risk. Remember to take account of patients co morbidities
prior to referral.

Calculated GRACE Risk

Version 1.3 November 2007. Review date April 2009

____%

15

Step 1:
Patient Suitable for Transfer
(Medium or High Risk Score)

Contact tertiary centre as a matter of priority.

Immediate transfer for invasive assessment
may be warranted.
For transfer check:

?further dose of Clopidogrel advised

? Bolus LMWH/UFH advised

? Infusion of UFH recommended

? S/C dose of LMWH recommended

? Gp IIb/IIIa Inhibitor advised

Step 2:
Patients unsuitable for
transfer or low risk on TIMI
score
Step 3:

? Beta Blocker

____Dose
____Time Given
____Dose
____Time Given
____Dose
____Time
Commenced
____Dose
____Time Given
____Name
____Dose
____Time Given
____ Name
____Dose
____Time Given

Weight

Kg
____Time Given

IV Beta blocker given?

Administer Fondaparinux 2.5mg s/c

(CI: Not to be used if serum creatinine >265)
If Fondaparinux CI use LMWH (Enoxaparin
at a dose of 1mg/kg s/c Twice Daily)
N.B. In severe renal impairment (creatinine
clearance <30 ml/min) the product literature
recommends 1mg/kg s/c once daily
Consider early use of beta blocker (IV then
oral) according to the protocol below.
Name:

Oral Beta blocker given

Name:

Step 4:

Step 5:

____Units
____Time Given

____Dose
____Time Given
____Dose
____Time Given

INTRAVENOUS BETA BLOCKER THERAPY (Patients must be haemodynamically stable to allow the
use of IV beta blockers):
If patients have P>65 and SBP >105mm/Hg and no clinical evidence of heart failure then consider IV
metoprolol 5-15mg IV (Give 5mg at 2 minute intervals if tolerated).
If tolerated, give a stat oral dose of metoprolol 50mg 15 minutes later. Oral metoprolol 50mg should
be given qid for the first 24 hrs. A long acting beta blocker (atenolol, bisoprolol) can be substituted on
day 2 if the above is tolerated.

Version 1.3 November 2007. Review date April 2009

16

Version 1.3 November 2007. Review date April 2009

17

INTEGRATED CARE PATHWAY-INSULIN/GLUCOSE THERAPY

(DIGAMI PROTOCOL)
ELEGIBILITY
All patients presenting with an ST-elevation MI whose admission plasma glucose level is
>11mmol/l regardless of prior diagnosis of diabetes.
The following regime should be continued for a minimum of 24hrs after admission.
Surname
First Name
DOB
CHI
Address

Value
Step 1:

Discontinue any oral hypoglycaemic medication

Step 2:

Prepare Infusion:
80u of Human Actrapid in 500mls of 5% Dextrose.

Step 3:

Measure finger prick blood glucose at start of infusion

Step 4:

Commence IV Insulin/Dextrose Infusion at 30mls/hr

Step 5:

Measure finger prick blood glucose one hour after

commencing the infusion

Step 7:

Use the guide below to decide on dosage adjustment

____mmol/l
____Time
____mmol/l
____Time

Measure blood glucose one hour after a change in infusion rate

Otherwise measure glucose every 2 hours
Aim for blood glucose in the range 7-10mmol/l
Halve the infusion rate between 10pm and 7am provided the blood glucose level has been stable for at
least two hours.
Blood Glucose level mmol/l
>15mmol/l
11-14.9mmol/l
7-10.9mmol/l
4-6.9mmol/l

Version 1.3 November 2007. Review date April 2009

Action
Give 8u IV insulin stat
Increase infusion by 6ml/hr
Increase infusion by 3mls/hr
Leave infusion rate unchanged
Decrease infusion rate by 6mls/hr

18

<4mmol/hr

Stop infusion for 15 mins. Then test glucose every 15mins

until glucose 7mmol/l and restart infusion at 6mls/hr.
If hypoglycaemic symptoms are present, administer an IV
bolus of 12mls of 50% dextrose.

Time
Blood
Glucose
mmol/l
Infusion
Rate
mls/hr
Time
Blood
Glucose
mmol/l
Infusion
Rate
mls/hr

Time
Blood
Glucose
mmol/l
Infusion
Rate
mls/hr
Time
Blood
Glucose
mmol/l
Infusion
Rate
mls/hr

Version 1.3 November 2007. Review date April 2009

19

This IV regime should be continued for a minimum of 24hrs or until the

patient is able to eat and drink normally.
For Type 2 Diabetics, insulin therapy is not indicated beyond 24hrs unless
clinically indicated for the management of their diabetes.

Version 1.3 November 2007. Review date April 2009

20

ACUTE CORONARY SYNDROME ICP: WARD SHEET

Integrated Care Pathway:
Acute Coronary Syndromes
Date:
Value
Clinica
l
Assess
ment
Heart
Rate
Heart
Rhyth
m
Blood
Pressu
re
( Targ
et130
/85)
Auscu
ltation
?
murm
ur etc
Investi
gations
ECG
ECH
O
ETT
Tropo
nin T
Secon
dary
Preven
tion
Aspiri
n
75mg
Clopid
ogrel
75mg
Beta
blocke

Yes/N
o

Notes

Surname
First Name
DOB
CHI
Address

Reason if No

Version 1.3 November 2007. Review date April 2009

21

r
Statin
Omega-3*
ACEI
Fondaparinux/
LMWH
Other Medication:
Nitrate?
Ca channel blocker
Nicorandil etc
*Post MI only. Start within 3/12 of date of MI. Not required if patients diet contains 7g oily
fish/week (2-4 portions) (Taken from NICE 2007 Post MI guideline).

Clinical Notes:

Version 1.3 November 2007. Review date April 2009

22

INTEGRATED CARE PATHWAY ACS: DISCHARGE RECOMMENDATIONS

Y=YES
N=NO
Aspirin 75mg/day
Clopidogrel
75mg/day
Beta blocker

Statin

Angiotensin
Converting
Enzyme Inhibitor
(ACEI)
Angiotensin
Receptor Blocker
(ARB)
Eplerenone 25mg
(Increasing to
50mg/day after
4/52 if tolerated)
Omega 3-Fish Oils
(1g/day)

Reason if No

Notes/Duration of treatment
Long term treatment
One Month STEMI
Three months UA/NSTEMI
Twelve months after Drug Eluting Stent
One-Three months after Bare Metal Stent
Long Term Treatment for all.
Patients with clinical heart failure/evidence of LV
dysfunction need to be stable before commencing
a beta blocker. In these patients, carvedilol or
bisoprolol are the treatments of choice.
Commence at low dose and titrate slowly over
several weeks/months (Refer HF Nurse).
Long term treatment.
Total Cholesterol (TC) <5 as a minimum
standard
(JBS-2 recommends TC<4 and 25% reduction in
pre-treatment level)
Long Term Treatment.
SIGN 2007 recommends treatment for all
regardless of LV function
Long Term Treatment where indicated.
Patients with evidence of impaired LV function
who are intolerant of an ACEI should be
commenced on an ARB.
Long term Treatment where indicated.
(Patients Post-MI with reduced LVEF (<40%)
and either clinical heart failure or diabetes).
(Refer HF Nurse)
Recommended if commenced within 3/12 of MI.
Omacor only product with a post MI licence at
present (Oct 07).
Continue for up to 4 years
(From NICE 2007)

1.MEDICATION
a. Medication of prognostic Benefit

Version 1.3 November 2007. Review date April 2009

23

b. Medication of Symptomatic Benefit

The following medications have been shown to improve symptoms in patients with Angina but have no
known significant prognostic benefit.
Name if used
Nitrates
Calcium Channel Blockers
Nicorandil

2. SMOKING CESSATION
All patients admitted with ACS who are current smokers should receive advice and support to
quit smoking. This includes the use of Nicotine Replacement Therapy and referral to the smoking
cessation service as appropriate.

Yes/No

Reason if Not

Referred?

3.CARDIAC REHABILITATION
All patients admitted with ACS (and a raised Troponin T (> 0.01)) should be considered for
referral to the local Cardiac Rehabilitation service prior to discharge. In addition, all patients
referred should be seen by the cardiac rehabilitation nurse prior to discharge wherever possible.

Yes/No

Reason if Not

Referred?

4. BHF HEART FAILURE NURSE

All patients admitted with ACS should receive an ECHO as an inpatient whenever possible to
assess Left Ventricular function (This is in line with SIGN 93 (2007)). All with a diagnosis of heart
failure should be referred to the BHF Heart Failure nurse unless patient refuses.
Yes/No

Reason if Not

Referred

5. FOLLOW UP ARRANGEMENTS
Yes/No

Reason if Not

1.Referred for ETT at

Six Weeks post
discharge
2.MOPD Follow up
arranged

Version 1.3 November 2007. Review date April 2009

Notes
Consider for all
patients for risk
stratification.

24

Version 1.3 November 2007. Review date April 2009

25