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HUNTER NEW ENGLAND HEALTH

Emergency Department

MRN_________________________
Surname_____________________
Given Names_________________
Date of Birth__________________

ACUTE CORONARY SYNDROME (ACS)


CLINICAL PATHWAY

CHEST PAIN OR SYMPTOMS SUGGESTIVE OF MYOCARDIAL ISCHAEMIA

Triage 2, Oxygen, Cardiac monitor, ECG, cannula & baseline bloods


within 10 mins. Aspirin (if not already given) and Anginine (if appropriate).
Contact & fax ECG to either TRRH 67669302) or ARRH (67764630) if ECG interpretation uncertain.

ST elevation Myocardial
Infarction (STEMI) PATHWAY

YES

Aim for door to needle time: <30 mins

ST elevation
or presumed new left
yes
bundle branch block (LBBB)?

NO
CHEST PAIN ASSESSMENT
Using the table of signs & symptoms below, identify the risk group that your patient falls into and proceed
to the management principles on page 3.

HIGH RISK features- requires only one feature to be HIGH RISK NSTEACS
Repetitive or prolonged (>10 mins) ongoing chest pain or discomfort
Elevated level of at least one cardiac biomarker (troponin or creatinine kinase-MB isoenzyme CKMB)
Persistent or dynamic ECG changes of ST segment depression 0.5mm or new T wave inversion 2 mm
Transient ST segment elevation (0.5mm) in more than two contiguous leads
Haemodynamic compromise systolic BP <90mmHg, cool peripheries, diaphoresis, Killip Class > 1, and/or new onset
mitral regurgitation.
Sustained Ventricular Tachycardia (VT)
Syncope
Left ventricular systolic dysfunction (left ventricular ejection fraction < 0.40)
Prior Percutaneous Coronary Intervention (PCI) within 6 months or prior Coronary Artery Bypass Grafting (CABG).
Presence of known diabetes (with typical symptoms of ACS); or
kidney disease (estimated glomerular filtration rate < 60 mL/min) (with typical symptoms of ACS).

INTERMEDIATE RISK features- any of the following features AND DO NOT meet the criteria for HIGH
RISK NSTEACS
Chest pain or discomfort within the past 48 hours that occurred at rest, or was repetitive or prolonged (but currently
resolved)
Age > 65 years
Known coronary heart disease prior myocardial infarction with left ventricular ejection 0.40, or known coronary lesion
more than 50% stenosed.
No high-risk changes on ECG ( see above)
Two or more of the following risk factors- known hypertension, family history, active smoking or hyperlipidaemia.
Presence of known diabetes (with atypical symptoms of ACS)
Chronic kidney disease (estimated glomerular filtration rate < 60 mL/min) (with atypical symptoms of ACS); or
Prior aspirin use

LOW RISK features- Any clinical features consistent with ACS without ANY Intermediate risk or high
risk features. This includes;
Onset of anginal symptoms with the last month
Worsening in severity or frequency of angina
Lowering of anginal threshold.

NON CARDIAC
Continue ED management and find cause of symptom. Exit pathway. Complete Clinical management summary.

NB: Always consider differential diagnosis of chest pain such as pulmonary embolus or pericarditis

ACS HNE Nthn Developed March 2003 Revised July 2006 v 11

HUNTER NEW ENGLAND HEALTH


STEMI
MANAGEMENT PRINCIPLES
ACTION
Disposition
Transfer
Monitoring
Parameters
MEDICATIONS
Antiplatelets
Pain relief

MRN _________________________
Surname _____________________
Given names _________________
DOB _________________________

STEMI
Admit to CCU with a monitored bed
Consult with specialist..
Consider early transfer to a referral centre for patients with ALL STEMIs, ongoing pain,
clinically unstable, large area of myocardium at risk, known poor left ventricular function and
renal impairment.
Continuous Cardiac preferably with ST segment monitoring.
Full resuscitation equipment to be immediately available.
Record HR, BP, RR, SpO2, 15 minutely prn until stable
Aspirin 300mg orally STAT then 100mg daily AND
Clopidogrel 300mg orally STAT.
Anginine 300 - 600ug SL if systolic BP > 100mmHg
Morphine 2.5mg increments until painfree
Consider GTN infusion as per product guide

Thrombolysis
INDICATIONS FOR USE:
History of cardiac ischaemic
pain lasting for at least 10-15
minutes, onset within 12
hours and not completely
responsive to buccal nitrates.
ECG changes:
ST elevation > 1mm in 2
adjacent limb leads
ST elevation>2mm in 2
adjacent pre cordial leads
New left bundle branch block

NB: "Patients ineligible


for thrombolysis require
urgent discussion with
specialist physician
regarding transfer for
invasive management"
Thrombolytic administration
Should be administered on the
basis of body weight with a
maximum dose of 50 mg by a
medical officer only. Give as a
single IV bolus over approx 10
seconds.

Heparin

Other medications
Complications

Investigations
APPT (mandatory check at 6
hrs)

IV Cannula
Baseline Bloods
2nd Troponin ( 8 hrs post

CONTRA-INDICATIONS FOR USE:


Absolute
Risk of bleeding- Active bleeding or bleeding
diathesis (excluding menses)
- Significant closed head or facial
trauma within 3 months
- Suspected aortic dissection
(including new neurological
symptoms)
Risk of intracranial
haemorrhage
- Any prior intracranial
haemorrhage
- Ischaemic stroke within 3 months
- Known structural cerebral
vascular lesion (eg arteriovenous
malformation)
- Known malignant intracranial
neoplasm (primary or metastatic).

Relative
Risk of bleeding
- Current use of anticoagulants: the higher the INR, the higher the
risk of bleeding
- Non-compressible vascular punctures
- Recent major surgery (< 3 weeks)
- Traumatic or prolonged (>10 mins) CPR
- Recent (<4weeks) internal bleeding (eg GIT, UT)
- Active peptic ulcer
Risk of intracranial haemorrhage
- History of chronic, severe, poorly controlled hypertension.
- Severe uncontrolled hypertension on presentation (>180mmHg
systolic or > 110mmHg diastolic)
- Ischaemic stroke more than 3 months ago, dementia, or known
intracranial abnormality not covered in contraindications.
Other
- Pregnancy
NB: The potential benefit versus the relative risk should always
be considered with relative contraindications.

METALYSE (TNK)
Pts wt (kg)
TNK (mg)
TNK u/s
<60
30
6000
60-70
35
7000
70-80
40
8000
80-90
45
9000
>90
50
10,000
Give IV Heparin 5000us stat bolus
Reconstitute Heparin 10,000 units in 100mls of Normal Saline (100us/ml)
Start Heparin infusion at 10mls/hr.
Check APPT in 6 hours time and titrate heparin rate to maintain APPT at 60-80 secs
Continue infusion for 24 hours
Betablocker- Metoprolol 25mg BD or atenolol 50 mg daily (dependent on BP)
Statin- Atorvastatin 20mg daily and increase prn
ACEi- Perindopril 2mg daily and increase as per product instruction
Observe closely for further chest pain, hypotension, arrhythmias, pulmonary oedema and
cardiogenic shock. If any of these complications arise, consult with a specialist physician.
If after 60-90 mins, patients with large infarcts have not clinically reperfused, as indicated by
failure of >50% ST elevation resolution, urgently contact a physician to discuss rescue
Percutaneous Coronary Intervention (PCI), further thrombolysis or other therapy.
Titrate heparin infusion to maintain APPT at 60-80 seconds.
Time to be taken __________
X2
FBC, UECs, troponin, total CK (for 48 hours in patients with AMI)

Lipids/BSL

YES
Time to be taken _______
Fasting within 24 hours of admission

CXR

Within 24 hours of admission

12 lead ECG

Repeat & review PRN at 60 minutes following completion of thrombolysis and then daily

symptom onset- mandatory)

ACS HNE Nthn Developed March 2003 Revised July 2006 v 11

HUNTER NEW ENGLAND HEALTH


NON-STEMI ACS (NSTEACS)
General Management Principles
ACTION
Disposition

Monitoring
Parameters Temp,
HR, BP, RR, SpO2,
INVESTIGATIONS
12 lead ECG
CXR
Coronary
Angiography
Exercise stress test
IV Cannula
Baseline Bloods
2nd Troponin
(mandatory 8 hrs
post symptom onset)
Lipids
BSL
MEDICATIONS
Pain relief

Antiplatelets

LMWH (clexane)
Other oral
medications to
consider
See product information
for specific directions to
prepare the solutions
and to calculate the
infusion rate according
to weight.

Patient information
sheet
Cardiac Rehabilitation

HIGH RISK

MRN _________________________
Surname _____________________
Given names _________________
DOB _________________________
INTERMEDIATE RISK

LOW RISK

Admit CCU
Monitored bed
If unstable, consult with
specialist and consider early
transfer to referral centre
Continuous Cardiac

In absence of stress testing,


ADMIT to a monitored bed.

Discharge with information


sheet and advise follow up
within 2 weeks with GP
unless further symptoms

Continuous Cardiac

As required

15 minutely prn until stable

30 minutely prn until stable

60 minutely or PRN

Repeated and reviewed PRN


and daily
Within 24 hours of admission

Repeated and reviewed PRN


and daily
Within 24 hours of admission

Recorded PRN and


reviewed
As required

Consider angiography except


in those with severe comorbidities within 48 hours
When asymptomatic and
stable
Prior to discharge
X1
FBC, UECs, troponin,
YES
Time to be taken _______

Consider angiography except


in those with severe comorbidities.
Stress Test within first 24
hours to better risk stratify

As outpatient if indicated

Fasting within 24 hours of


admission

X1
FBC, UECs, troponin,
YES
Time to be taken ________
Fasting within 24 hours of
admission

As outpatient if indicated
X1 prn
FBC, UECs, troponin,
YES
Time to be taken _____
Not applicable

Anginine 300 - 600ug SL if systolic BP > 100mmHg


IV Morphine 2.5mg increments until painfree
Consider GTN infusion as per product guide
If patient remains symptomatic, need to consider early transfer for angioplasty.
Aspirin 300mg orally STAT
Aspirin 300mg orally STAT then 100mg daily
then 100mg daily AND
Clopidogrel 300mg orally
STAT (unless the need for
acute CABG is likely)
LMWH (clexane) 1mg/kg
LMWH (clexane) 1mg/kg
Not indicated
Betablockers- Metoprolol
Betablockers Metoprolol
As required
25mg BD or atenolol 50 mg
25mg BD or atenolol 50
daily
mg daily
StatinStatinAtorvastatin 20mg daily
Atorvastatin 20mg daily
and increase prn
and increase prn
Ace inhibitors
Ace inhibitors
Perindopril 2mg daily and
Perindopril 2mg daily and
increase as per product
increase as per product
instruction
instruction
If unstable and after specialist
consultation consider
IV Tirofiban (Aggrastat)Used when pt is unstable,
symptomatic & resistant to
standard medical treatment.
0.4mcgs/kg/min IV for 30 mins,
followed by 0.1mcg/kg/min for up
to 48 hrs.
Fact sheet must be given to all patients to inform them of their management and treatment options.
All cardiac patients should be referred to cardiac rehabilitation for follow-up, counseling and secondary
prevention management.

ACS HNE Nthn Developed March 2003 Revised July 2006 v 11

58799

HUNTER NEW ENGLAND HEALTH

MRN
Surname
Given Names
Date of Birth
Sex
Please affix Patient Identification Label Here

ACS Clinical
Management Summary
Hospital name ___________________________
Emergency Department clinician to complete

PRESENTATION DATE
HOSPITAL READMISSION?

Hospital ID

(If known)

PRESENTATION TIME

yes - within 48 hours

yes - within 28 days

no

MEDICATIONS GIVEN IN ED
Aspirin 300mg given?
Antiplatelet therapy

Yes
No
Clopidogrel

Antithrombotic
Betablockers

Clexane
Yes

No

Allergy/contraindicated
IV Tirofiban
Combination
IV Heparin
Warfarin
Contraindicated

Contraindicated

Contraindicated

None

None

PATHOLOGY
Was the troponin measured 8-12 hours post symptom onset?
Was the troponin elevated

PATIENT'S RISK CATEGORY

STEMI

IF A STEMI

a) Acute revascularisation?

HIGH

b) What thrombolytic was given?


c) Delay in revascularisation?

tPA
0-30

NO
NO

INTERMEDIATE

Thrombolysis

(By which method)

YES
YES

PTCA

SK
31-45

rPA
46-60

LOW

nil
tNK
61-75

76-90

>90

(Presentation to thrombolysis time in mins)


(If discharged from the Emergency Department, please complete section below)

Emergency Clinician Sign

DISCHARGE FROM HOSPITAL (Discharging Clinician to complete)


DISCHARGE DIAGNOSIS
STEMI

NSTEMI

Unstable angina

STRESS TEST Date of test


Result
CARDIAC CATHETER
PTCA
CABG

Chest Pain ?ACS

negative

No - not indicated

Time of test

positive

not done

done at this hospital

Post discharge - same hospital


Inpatient
Post discharge
Inpatient
Post discharge

No
No

Non Cardiac Chest pain

Other

equivocal

unable to exercise

transferred to another hospital

Post discharge - another hospital

ADVERSE EVENTS (in hospital)


Recurrent ischaemia
Myocardial Infarct during admission
Unplanned transfer to ICU
CVA during admission
Bleeding during admission

REFERRED TO CARDIAC REHAB


DISCHARGE MEDICATION
Aspirin
ACEI

Yes
Yes

SEPARATION

Yes with ECG changes


Yes without ECG changes
YES
NO
YES
NO
YES
NO
Life threatening
Major
Minor
None
Yes

No
No

Contra-indicated
Contra-indicated

Died in hospital

Home

No

No
Anginine
Statin
Beta Blocker

Yes
Yes
Yes

No
No
No

Contra-indicated
Contra-indicated
Contra-indicated

Transferred to another hospital

Discharging Clinician sign______________________________


Developed 2003
Version 6

WHEN COMPLETE PLEASE FAX CLINICAL MANAGEMENT SUMMARY


to 49223890

FAXED - YES

FACT SHEET

Chest pain

Information for people with


Chest Pain
Hunter New England Area
Health Service

Acute Coronary Syndrome


Acute Coronary Syndrome refers to symptoms
that result from a lack of blood supply to the
heart muscle. It occurs when a blood clot blocks
a blood vessel or artery, or when a blood vessel
is so narrowed from a build up of plaque that it
doesnt allow enough blood to get through.
This disrupts the flow and restricts oxygen
getting to the heart, resulting in potential
damage.
Cardiac cells die as the result of this injury.
These cells usually die between minutes to hours
after the heart attack starts.
With the death of cardiac muscle cells, the heart
can lose its ability to pump the blood effectively
around the body. This can result in low blood
pressure, cardiac failure, and chest pain.
Acute Coronary Syndrome includes:
Myocardial Infarction (heart attack)
Angina
Coronary Artery Spasm
Coronary heart disease is the greatest single
cause of death among Australians.

Released: July 2006

What happens in the Emergency


Department?
The triage nurse will see you on arrival.
The nurse will ask you and your family a
series of questions about your health and the
events preceding your visit to Emergency.
General observations such as blood
pressure, heart rate, respirations and oxygen
levels in the blood (finger probe) will be done
regularly
An ECG (Electrocardiograph), which looks at
the electrical activity of your heart, will be
printed. This allows the staff to check your
heart.
Blood will be taken so that the doctors can
identify any changes that they may need to
treat. You will be required to wait until these
results are available.

Many heart attacks are preceded by brief


episodes of chest pain symptoms also
know as Angina

Experts agree that most heart attacks are


preventable. Early detection and
management of risk factors can reduce
the risk of heart attack.

A small plastic tube may be placed in your


arm at the same time as the blood is taken.
This is for giving medication or fluids if
necessary.

A heart attack is an Emergency and


requires medical treatment. It has been
shown that early detection of heart attack
can improve the chances of survival and
the long-term effects.

Other investigations such as a chest x-ray or


an exercise stress test (EST) may be
attended. This will help determine the cause
of your chest pain.

The medical officer will ask further questions


about your general health and the events
prior to arrival in Emergency

Depending on your condition, your ECG and


your blood results, you may be admitted for
further monitoring and tests or you may be
discharged for follow up by your GP

Chest pain

Who else will see you in the Emergency


Department?
You may also be seen by other doctors and
nurses such as medical specialists and cardiac
liaison nurses.
If you or your family have any questions or
concerns please ask the nursing and/or medical
staff.
If you are discharged home, you will be given
some discharge advice from the attending
doctor about your immediate ongoing
management.
When you or someone you are caring for
experiences chest pain symptoms, please
call 000.

High blood pressure is a factor, which


contributes to heart attack. See your local
GP for a management plan
Diabetes - either insulin-dependent (Type 1)
or non-insulin dependent (Type 2) need to be
well controlled. The incidence of heart attack
is increased when diabetes is poorly
controlled.
Lack of exercise. Active people with low body
fat tend to have a lower cholesterol level in
their blood and less likelihood of arterial
disease and risk of a heart attack
Your doctor can advise of strategies to
reduce blood pressure, including weight loss,
stress management, low-sodium diets and/or
medication.

Dont miss the warning signs of angina


What can you do to reduce your risk of
further heart attack?
Know the Risk Factors
Early identification of warning signs and
assessment by your doctor will help reduce
the risk of a heart attack
If you smoke, you are significantly increasing
your risk of heart attack. Seek advice on how
you can quit smoking.
High cholesterol level is a factor, which
contributes to the risk of heart attack. Avoid
foods that have excess fat, cholesterol or
have been fried.
Avoid foods, which have excess salt. Try to
eat fresh foods. Check the sodium content of
processed foods.
Obesity often leads to heart disease and
Type 2 Diabetes. Seek the advice of your
doctor.
Limit alcohol intake (1-2 standard drinks per
day). For heavy drinkers the incidence of
heart attack increases 3 times.

Chest pain/discomfort that is tight, gripping,


or squeezing, ranging from mild to severe.
Chest pain/discomfort that can be central, or
spreading to either shoulder, neck or jaw or
down the arm and hands.
Chest pain/discomfort at rest or at exercise
or exertion

Further information regarding chest pain


can be obtained from:
The National Heart Foundation (NSW
Division) Newcastle Office
Suite 5 OTP House
Bradford Close
Kotara. NSW 2289
Ph: 02 49524699
Heartline

Ph: 1300 36 27 87

Local Cardiac Rehabilitation Group


Local GP