ACUTE CORONARY SYNDROME (ACS)

Transcription

1 Date of admission. Time. Consultant ACUTE CORONARY SYNDROME (ACS) CARE PATHWAY Includes: All patients with cardiac sounding chest pain to be included in this pathway Excludes: Patients NOT managed as ACS ALL STAFF Each professional making an entry in this CP must complete the sample signature section on this page. You can then use your initials when recording care. When activities are completed you should initial in the space provided and enter the time. If the activity is not completed or you need to vary the care outlined in the pathway, then you must record this as a variance next to the activity, and include the time and your initials. It may be necessary to record N/A against some activities outlined in the CP. Any extra care provided for the patients can be entered in the multidisciplinary notes. This CP is a multi-disciplinary plan of care based on evidence from research, and incorporates national and local guidelines for patients who present with Acute Chest Pain. It does not replace clinical judgement. NAME (PRINT) DESIGNATION SIGNATURE INITIALS DATE If you have any queries regarding this CP, please contact your line manager and/or the Cardiac Specialist Nurses on EXT 4489 Lister Hospital or Bleep 0190 QEII

2 CONCOMITANT TREATMENTS ASPIRIN All patients should receive aspirin 300mg on onset of symptoms, unless contraindicated, followed by 75mg daily indefinitely (avoid higher doses to minimise risk of gastrointestinal side effects). CLOPIDOGREL Treatment for PPCI patients should receive a loading dose 600mg clopidogrel Treatment for patients with all other ACS and mini GRACE score low risk or above ( 71: see page 8): loading dose clopidogrel 300mg. If already on clopidogrel, give 75mg clopidogrel (NICE Guidelines 2004). Clopidogrel 75mg should continue for 12 months. OXYGEN All patients to receive supplemental oxygen unless contraindicated. Please refer to local guidelines on oxygen therapy. NITRATES 2 metered doses of GTN s/l spray to those with pain due to ischaemia or infarction except if hypotensive. Isosorbide dinitrate 0.05% (Isoket 25mg/50ml) 4-20ml/hr or GTN (50mg/50mls) 1-10ml/hr should be initiated if continuing pain or left ventricular failure. Use with caution if blood pressure <100 systolic. Stop if blood pressure <90 systolic. BETA BLOCKERS Treatment with oral metoprolol 12.5mg-25mg should be considered in all haemodynamically stable patients who present within 12 h of the onset of symptoms of acute MI and who are free of contraindications. Start with metoprolol and change to oral atenolol once daily or bisoprolol once daily once stable. For haemodynamically stable ACS patients without ST elevation, start atenolol 25 mg or bisoprolol 2.5 mg once daily ACE INHIBITORS The drug of choice is ramipril 2.5mg once daily titrated up to 10 mg. Where hypotension or heart failure is a problem, consider using divided doses (1.25mg twice a day). This is given orally to everyone, starting on day 2 unless contra-indicated. Routine ACE is contraindicated in pregnancy. Only use under specialist supervision when BP<100mmHg systolic, K+ 5mmols or poor renal function (Creatinine 180 µmol/l). STATINS Start on Day 1 for everyone. The drug of choice is simvastatin 40mg-80mg once daily Caution if alcoholic or liver disease, check baseline liver function tests. INSULIN Insulin infusion should be started on all patients who have random Blood glucose 10mmols. Aim for blood glucose between 4-8mmols. See protocol on page 23. The insulin infusion should be stopped with great care following the instructions given. Consideration of continuation of s/c insulin therapy after discharge should be decided by the Diabetic Specialist Team in all patients with elevated blood glucose. Please refer to the diabetes team as early as possible. FONDAPARINUX Give dose 2.5mg once daily s/c for all ACS patients. Use in caution in patients with a high bleeding risk. Consider unfractionated heparin, with dose adjusted to clotting function for patients with creatinine > 265mmols/l (NICE clinical guideline 94, March 2010). EPLERENONE Consider starting 25mg on Days 3-14 post-mi for patients with heart failure and LVEF 40%. Avoid if hyperkalaemia or renal impairment (egfr < 50 mls/min).change to spironolactone after 12 months if ongoing therapy needed. 2

3 Cardiac sounding chest pain Perform ECG and BM and show to most senior doctor available and contact Cardiology Nurse on Bleep 0190 at QEII or Bleep 4489 at Lister STEMI ST elevation or new onset LBBB Acute MI Consider PPCI Discuss contraindications P.6 MEETS PPCI Criteria P.6 All Other ACS Unstable Angina, NSTEMI (ST depression, T wave inversion, or Normal ECG with convincing story) YES PPCI Follow PPCI protocol Mon-Fri call Lister ext4668 Afterhours/bank holidays EofE ambulance Ambulance NO PPCI Mini GRACE Score all ACS patients see p8 Consider s/l GTN or iv GTN / ISDN Consider iv morphine repeat ECG every 30 min until changes & pain resolved See page 9 for complete management algorithm Give 300mg aspirin & 600mg clopidogrel Discuss URGENTLYwith cardiology team or medical team after hours regarding management Abbreviations used throughout this CP ACS Acute Coronary Syndrome NSTEMI Non-ST-elevation MI BM Blood Sugar Monitoring O2 Sats Oxygen saturation CABG Coronary Artery Bypass Graft prn Pro Re Nata (as required) CAD Coronary Artery Disease PCI Percutaneous Coronary Intervention CCU Coronary Care Unit PPCI Primary Percutaneous Coronary Intervention EofE East of England s/c Sub-cutaneous GTN Glyceryl Trinitrate s/l Sub-lingual ISDN Isosorbide Dinitrate STEMI ST-elevation myocardial Infarction iv Intravenous TIMI Thrombolysis in Myocardial Infarction LBBB Left Bundle Branch Block TTO Medication To Take Out MI Myocardial Infarction 3

4 DAY OF ADMISSION (DAY 1) Presenting Complaint: History of presenting complaint: Date & Time of onset of pain: Date & Time of call for medical assistance: Date & Time of arrival in Hospital: Past Medical History Risk factors (include details of prior MI, PCI, CABG, heart failure, valve disease) } Smoker Current / Ex / N Hypertension Y/N Diabetes Y/N Hyperlipidemia Y/N Family History Y/N Renal failure Y/N Drug History: Social History Drug Allergies 4

5 DAY OF ADMISSION (DAY 1) Height (m) Weight (kg) BMI Ethnic origin Temp C O2 Sat% BM If >10 start sliding scale- see page 23 Cardiovascular System Pulse (rate/rhythm) BP JVP Carotid Bruits? Apex Heart sounds Ankle oedema Y/N Peripheral pulses Respiratory System Abdomen CNS GCS Pupils Limb power Reflexes Impression 12 lead ECG / Differential (describe): Diagnosis Provisional diagnosis: Plan: Signed: Bleep: Date: / / Time 5

6 DAY OF ADMISSION (DAY 1) ACUTE ST-elevation MI (Write any comments below) MONDAY TO FRIDAY Primary PCI AT LISTER HRS ext 4468 AFTER HOURS, WEEKENDS & BANK HOLIDAYS E of E number PATIENT PRESENTS WITH CARDIAC SOUNDING CHEST PAIN ECG meets criteria as below: a) ST elevation 1mm in 2 or more contiguous limb leads or b) ST elevation 2mm in 2 or more contiguous chest leads or c) LBBB with cardiac sounding chest pain or d) True posterior ST depression V2-V3 and dominant R waves If the answer is YES then PPCI is indicated. Now assess for absolute contra-indications to PPCI 1 Is the patient unconscious? Y/ N 2 Is the patient actively bleeding e.g. haematemesis, malaena Y/ N 3 Have cardiac arrest resuscitation attempts failed? Y/N 4 Has the patient been resuscitated from a cardiac arrest but the underlying diagnosis is uncertain? Y/ N If there are no absolute contra-indications for PPCI then go on to assess for relative contra-indications 1 Does the history or ECG suggest pericarditis, e.g. ST elevation in all leads or pain worse on deep inspiration? Y/N 2 Has the patient been involved in an incident causing traumatic bodily injury (not CPR)? Y/N 3 Does the ECG show LBBB or paced rhythm without a clinical picture of AMI? Y/ N If the answer to any of the above contra-indications is YES then the patient may not be suitable for PPCI. Ask for expert help for further advice. In working hours, bleep cardio spr or call Cardiac suite Lister ext 4668 Out of hours, contact on call cardiology spr at Harefield hospital ( bleep 108). PPCI Indicated Load with Aspirin 300mg Clopidogrel 600mg, Oxygen. Do not give fondaparinux. Consider Morphine, Nitrates, Beta Blockers. Monday-Friday 08:30-17:00hrs Lister Cardiac suite Ext 4668 (dedicated phone line) From QEII Out of hours/bank holidays Call East of England Ambulance Service Category A transfer

7 ACS: Immediate Prescription CHECKLIST for STEMI (ECG: ST Elevation or LBBB) (This does NOT replace the drug chart!) Correct name bracelet applied (Please tick one) ALLERGIES: YES NO N/A Initials. DRUG Aspirin 300 mg po (loading dose) Clopidogrel 600 mg po (loading dose) Oxygen Morphine mg iv Metoclopramide 10 mg iv prn up to three times a day GTN 1-2 puffs s/l prn Consider beta-blocker Consider iv GTN/ISDN Insulin sliding scale (if BM>10 or diabetic, target BM 4-8 mmols) Paracetamol prn Bloods taken: FBC Group & Save U&E LFTs Lipids Glucose BM Troponin 12h HbA1c TFTs Dr s signature Time If variance, state reason and action taken 7

8 All other ACS treatment pathway Unstable Angina, Troponin ve ACS, NSTEMI Age (y) Score Mini GRACE risk score Heart rate (bpm) Score Systolic BP (mmhg) Score Other variables Score Cardiac Arrest on admission 39 ST-segment deviation 28 Elevated cardiac enzymes 14 Calculate Total Risk Score: Score 6-month mortality Risk group 70 <1.6% Lowest %-3.1% Low %-5.5% Intermediate %-9.4% High 112 >9.5% Highest NICE clinical guideline 94, March

9 All other ACS treatment pathway Unstable Angina, Troponin ve ACS, NSTEMI risk score 70 risk score risk score risk score risk score 112 Lowest Risk 6 month mortality <1.6% Low Risk 6 month mortality % Intermediate Risk 6 month mortality % High Risk 6 month mortality % Highest Risk 6 month mortality 9.5% Give loading dose aspirin 300mg, then 75mg indefinitely Give loading dose clopidogrel 300mg, then 75mg for 12 months Give Fondaparinux 2.5mg sc od Initial conservative management Consider inpatient coronary angiography +/- revascularization Consider inpatient coronary angiography +/- revascularization if ongoing ischaemia or positive ETT 9

10 DAY OF ADMISSION (DAY 1) All Other ACS Immediate Prescription CHECKLIST for Unstable Angina, NSTEMI (This does NOT replace the drug chart!) ECG T wave inversion ST depression Minor ST abnormalities Normal ECG Correct name bracelet applied (Please tick one) ALLERGIES: YES NO N/A Initials. DRUG Mini GRACE score calculated Aspirin 300 mg po (loading dose) Clopidogrel 300 mg po (loading dose) if mini GRACE SCORE 71 Oxygen Morphine mg iv Metoclopramide 10 mg iv prn (max three times a day) GTN 1-2 puffs s/l (prn) Fondaparinux 2.5mg s/c once daily Aspirin 75 mg once daily maintenance Clopidogrel 75 mg once daily maintenance if mini GRACE SCORE 71 Statin Beta-blocker Consider iv GTN/ISDN Insulin sliding scale (if >10 or diabetic, target BM 4-8, see page 23) Diamorphine/Morphine Paracetamol prn Bloods taken: FBC U&E LFT Lipids Glucose BM Troponin 12h HbA1c TFTs Dr s signature Time If variance, state reason and action taken 10

11 DAY OF ADMISSION (DAY 1) Continuing Nursing Assessment All categories Take observations: TPR, BP and O2 sats 15mins for 1 hour, ½ hourly for 2 hours then 4 hourly if stable ECG performed on arrival to ward Admit to CCU if bed available (STEMI and High Risk ACS) Hourly blood glucose if on insulin infusion Cardiac monitoring commenced Patient remains pain free (if recurrent pain then repeat ECG and Analgesia) Patient advised to report all episodes of chest pain Initials and time am pm Nocte Date Multidisciplinary Notes DAY 1 If variance, state reason and action taken Initials & time Initials & time 11

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14 DAY 2 Medical Activity (please tick as appropriate) Bloods: Fasting Blood glucose and Lipids Y/N U&E Y/N Troponin if not already done Y/N APTT if on Heparin Y/N HbA1c (if known diabetic or high glucose) Y/N Medication Review: ACE-inhibitor Beta-blockers Statins Insulin If lowest or low risk (mini GRACE risk score 87) then consider inpatient ETT. ETT ordered Y/ N If intermediate or higher risk (mini GRACE risk score 88) or ongoing ischaemia then refer to cardiology Echo requested (If STEMI or CCF) Y/N Discharge planning Anticipated discharge date discussed with patient and family Potential problems and assistance required assessed If low-risk PPCI (Zwolle score 3) then aim for discharge after 48 hrs. Referrals Inform diabetes/endocrinology of admission if started on sliding scale or known diabetic Appropriate referral made and detail on Nursing Profile and assessment sheet Cardiac Rehabilitation Cardiac Rehabilitation referral Time Initials If variance, state reason and action taken Initials & time Date Multidisciplinary Notes DAY 2 Initials & time 14

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16 ACS Take bloods if appropriate DAY 3 Medical Activity (please tick as appropriate) Review medication Switch B-blocker to once daily e.g. atenolol or bisoprolol ACE inhibitor dose: up-titration, aim for 10mg ramipril once daily Consider eplerenone 25mg if LVEF 40% and heart failure in MI patients If lowest or low risk (mini GRACE risk score 87) then consider inpatient ETT. If intermediate or higher risk (mini GRACE risk score 88) or ongoing ischaemia then refer to cardiology Refer to Endocrinologist/diabetes if newly diagnosed diabetic or known diabetic not previously on Insulin Time Initials If variance, state reason and action taken Initials & time Cardiac Rehabilitation Cardiac Rehabilitation continues Discharge Planning Anticipated discharge date discussed with patient and family. Referrals Inform Diabetes Specialist Nurse of planned discharge date Seen by Diabetes Specialist Nurse Referral made for specialist Diabetes follow up Date Multidisciplinary Notes DAY 3 Initials & time 16

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18 Medical Activity DAY 4 (please tick as appropriate) Take bloods if appropriate TTO s written and sent to pharmacy prn GTN aspirin Statin ACE-inhibitor beta blocker Insulin clopidogrel eplerenone All to be kept on insulin post discharge unless indicated by Diabetes Team. Inpatient ETT ordered yes no Echo ordered yes no Patient mobilising around ward Discharge Planning Anticipated discharge date discussed with patient and family. Referrals Inform Diabetes Specialist Nurse of planned discharge date Seen by Diabetes Specialist Nurse Time Initials If variance, state reason and action taken Initials & time Date Multidisciplinary Notes DAY 4 Initials & time 18

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20 Medical /Multidisciplinary Activity DAY 5 (please tick as appropriate) Ensure TTO is prepared and include prn GTN Echo performed Refer to cardiology if: intermediate or higher risk (mini GRACE risk score 88) or ongoing ischaemia or positive ETT Other criteria for discharge: Pain free for 48 hours No heart murmurs on auscultation No signs of heart failure Seen by Cardiac Rehabilitation Nurse Pre discharge ECG given to patient Discharge Planning Patient and relative aware Book outpatient Echo if not done Book nurse-led post MI/PCI clinic Book outpatient diabetes follow up as indicated by diabetes team Discharge Yes No Time Initials If variance, state reason and action taken Initials & time Date Multidisciplinary Notes DAY 5 Initials & time 20

21 Date Multidisciplinary Notes DAY 5 Initials & time 21

22 TITAN-ACS All patients presenting with cardiac sounding chest pain should have a BM measured AS SOON AS POSSIBLE (preferably in the ambulance, if not in A&E or Cath Lab) IF BM 10 or higher start insulin sliding scale as follows (do NOT wait for the troponin): 50 units human soluble insulin in 49.5ml 0.9% sodium chloride AND 5% Dextrose with 40mmol KCl at 30ml/hr via a non-reflow Y connector. If there is concern about the volume of fluid this can be replaced by 10% dextrose with 20mmol KCL at 15ml/hr. Follow instructions on flow chart for the next 24 hours and contact DSN/Diabetes team ASAP Note1. If the patient is known diabetic on Lantus ( Glargine) or Levemir ( Detemir) Continue this background insulin AS WELL as starting insulin infusion Note2. If the patient is a known diabetic and their BM is <10 for 2 hours after admission Continue on their usual diabetes treatment regime EXCEPT 1. Stop Metformin 2. Ensure BM monitoring at least 4 hourly Note 3. Stopping the Infusion Refer to the diabetes/endo team as soon as practically possible and they can advise on how to take down the sliding scale safely and follow up as appropriate If the infusion is due to end outside of their available times: If the patient is a known diabetic on insulin and is able to eat and drink normally they can be restarted on their usual regime until review by the diabetes team. Prescribe their usual regime and wait until their next usual dose would be due. Ensure that they receive their next due dose with that meal 1 hour BEFORE the IV insulin is switched off If the patient is NOT usually on insulin (whether previously diagnosed with diabetes or not) and is able to eat and drink normally: 1. Calculate the amount of insulin they have received in the previous 24 hours: this is TDD (total daily dose) eg 66 units 2. Divide the TDD into two separate doses and decrease by 10% eg 60 units: Dose A (0800 with breakfast ) = 60% of TDD eg 40 units Dose B (1800 with evening meal) = 30% of TDD eg 20 units 3. Prescribe Novomix 30 as per your calculation. 4. Give the next dose subcut. with the next available meal and stop insulin /dextrose infusions one hour LATER Other investigations required: i) Serum K+ on admission and at 24 hours (iv insulin may lower serum K+ which may require replacement). If sustained arrhythmia K+ should be checked and recorded. ii) HbA1c iii) Fasting glucose after an overnight fast- a minimum of 12 hours after discontinuation of the insulin infusion 22

23 TITAN ACS FLOWCHART Glucose >= 10mmol. troponin -ve Patient excluded from audit data but continue infusion as per protocol. Refer to diabetes team Patient with suspected ACS Glucose >= 10 mmol, troponin +ve Start insulin infusion and fluids. Monitor glucose hourly See Note 1. Glucose mmol Glucose range 4-8 mmol for 2 h. Reduce monitoring to 2 hourly check glucose at 1 and 2 hours glucose >= 10 mmol Glucose 4-8 mmol for 6 hours. Stop infusion. Record time. glucose < 10 mmol Check glucose at 1 and 2 h. Restart infusion if glucose >8 mmol Patient excluded. If known diabetes,see note 2. Continue infusion to 24h; further management See note 3. glucose <4 mmol. Stop insulin, manage by local protocol Check glucose frequently until stable 4-8 mmol Blood Glucose Insulin infusion (mls/hr = Units/hr) < 4 mmol 0ml: Treat hypoglycaemia according to local protocol mmol 1ml mmol 2ml mmol 3ml mmol 4ml mmol 5ml 14.1 mmol 6ml: If BM 14.1 for 2 hours, then call doctor to increase insulin infusion rate In obesity or known diabetic using >60 units per day: start at 3-4 ml/hr, May 2010 Updated version with reference to NICE clinical guideline 94, March

24 ACS Venous Thromboembolism (VTE) Risk Assessment for all Adult Medical Patients ALL adult medical patients must be: 1) Risk assessed and considered for thromboprophylaxis 2) If at risk, checked for contraindications 3) Prescribed appropriate thromboprophylaxis on drug chart NB Patients outside the given criteria should be assessed on a case-by-case basis Please tick all appropriate boxes and assign a Risk Category. Then sign, date and file sheet in patient s Medical Record. Risk Factors Age >40 years History of VTE/thrombophilia Inflammatory bowel disease Acute infectious disease Pregnancy and the post partum period Hormone therapy eg HRT/COCP Active cancer or treatment Obesity (BMI 30kg/m 2 ) Acute exacerbation of heart failure Acute myocardial infarction Ischaemic stroke Acute on chronic respiratory disease Rheumatic disease Contraindications to Enoxaparin 40mg Creatinine >150µmol/(eGFR<30ml/min) use Enoxaparin 20mg daily Active bleeding Thrombocytopenia (platelet count <50) Known bleeding disorder Previous HIT or allergy to Enoxaparin On therapeutic anticoagulation (1) Patient NOT at risk of VTE Nephrotic syndrome Dehydration Myeloproliferative disorders Paraplegia Prolonged immobility Contraindications to TEDS Severe peripheral vascular disease Severe dermatitis/ulceration of leg Leg oedema Risk Category Gross leg deformity Peripheral neuropathy Recent skin graft Tick (2) Patient > 40 years, hospitalised with an acute medical illness or other risk factors and with NO contraindications to low molecular weight heparin Recommended Prophylaxis: Timing: Duration: Enoxaparin 40mg per day + TED stockings (if no contraindications) + Early mobilisation Enoxaparin should be given once daily subcutaneously Enoxaparin should be given for at least 6 days with a maximum of 14 days. Where therapy is long term (>14 days) for high risk patients the platelet count should be monitored fortnightly for Heparin Induced Thrombocytopenia (HIT) Obesity: Use Enoxaparin: 40mg twice daily if body weight > 100kg 60mg twice daily if body weight > 150kg (3) Patient unable to receive low molecular weight heparin due to contraindications Recommended Prophylaxis: TED stockings (if no contraindications) + Early mobilisation Risk Assessment carried out by: Name:... Signature:..... Date:.., May 2010 Updated version with reference to NICE clinical guideline 94, March

25 , May 2010 Updated version with reference to NICE clinical guideline 94, March

26 Date Time U & E s Sodium mmol/l Potassium mmol/l Urea mmol/l Creatinine µmol/l egfr LFT Bilirubin 0-17 µmol/l Alk Phos IU/l GGT IU/l ALT 5-55 IU/l Albumin g/l Cardiac Enzymes Troponin I < 0.08 CK IU/L Other Calcium mmol/l Corrected Ca mmol/l Inorg Phos mmol/l Magnesium mmol/l CRP 0-5 mg/l Amylase IU/L Glucose mmol/l HbA1c Lactate mmol/l TSH mlu/l Free T pmol/l Lipids Total Cholesterol <5.0mmols Triglycerides mmol/l HDL > mmols LDL <3.0mmols FBC WBC /L RBC /L HB g/dl Hct L/L MCV fl MCH pg MCHC % Platelets /L Coagulation Prothrombin Time 9-12 secs APTT secs APTT Ratio Fibrinogen g/l, May 2010 Updated version with reference to NICE clinical guideline 94, March