Chest Pain Pathway. Temp ( o c) Dose Route Prescriber Signature

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1 ECG Recorded at hrs, Chest Pain Pathway Care Pathway Triage Category Review by...(name) (designation) at hrs Contents: Page 2 - ECG - ST elevation or presumed new left bundle branch block (LBBB). Consider for primary percutaneous coronary intervention (PPCI) Page 5 - ACS without ST elevation or presumed new LBBB Non-cardiac chest pain If pain is fleeting, left sided, localised, altered by inspiration or movement consider non-cardiac causes of chest pain (page 5) and risks of anti-thrombotic therapy. Nurse Triage Presentation: Self O Ambulance O Ambulance sheet (E/U No) BP Pulse SA 0 2 Temp ( o c) Resp rate Current Medicines (name, dose, frequency) Allergy Status : NKDA O Or Details of allergy: BM Pain score Name Signature Bleep /ext Oxygen Treatment If SA O 2 < 94% then prescribe oxygen to achieve SA O 2 > 94% If the patient has COPD, SA O 2 < 88-92% should be maintained Date O O Time Dose Route Prescriber Signature Date / Time Given by time/date Checked by Glyceryl trinitrate micrograms stat Sl N/A Morphine mg(10mg/ml) stat Iv Metoclopramide 10mg stat Iv Prescribe either fondaparinux or enoxaparin. If CrCl<20ml/min or Creatinine > 265 or full anticoagulation needed use enoxaparin* 1 Fondaparinux *1 2.5 mg stat Sc Enoxaparin (1mg/kg) stat Sc Antiplatelet: Aspirin and either ticagrelor* 2 or clopidogrel. If aspirin contraindicated give clopidogrel monotherapy Aspirin mg stat Chew If ticagrelor contraindicated or fibrinolytic therapy indicated use clopidogrel. 1 st line: 180mg, stat Po Ticagrelor* 2 2 nd line: Clopidogrel mg, stat Po *1 Fondaparinux 2.5mg provides only prophylactic level of anticoagulation, if full anticoagulation is needed also (e.g. mechanical prosthetic valve), treat ACS with treatment dose enoxaparin 1mg/kg twice daily if CrCl< 30ml/min reduce to once daily dosing instead. * 2 TICAGRELOR is Contraindicated in: documented allergy, pre or post fibrinolytic use, active bleeding, history of intracranial bleeding, AV heart block, moderate to severe hepatic impairment, interactions with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, nefazodone, ritonavir, and atazanavir), pregnancy and breast-feeding. Monotherapy without aspirin is not licensed. (see prescribing guideline) Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 1 of 11

2 Suspected ACS / MI with ecg showing ST elevation or presumed LBBB 1. Primary Percutaneous Coronary Intervention (PPCI) History Yes No Current cardiac sounding chest pain for 30 mins up to 12 hour Intermittent, cardiac sounding, chest pain for up to 24 hours Patients resuscitated from cardiac arrest not requiring intubation/ventilation with ECG criteria as below If yes to any of the above continue below ECG Yes No New or Presumed new left bundle branch block Typical ST elevation > 2mm in 2 or more adjacent chest leads Typical ST elevation > 1mm in 2 or more limb leads with reciprocal changes If yes to any of the above continue below 2. Consent Consent Yes No Patient consented and understands reason for urgent transfer to Liverpool Heart and Chest Hospital (LHCH) for PPCI. If NO go to Section 5 3. Transfer to Liverpool Heart and Chest Hospital (LHCH) Door to transfer time target 30 minutes Contact Yes No Telephone LHCH: Ambulance control centre Quote transfer to LHCH for Primary PCI Complete LHCH Hospital PPCI Checklist (Found on back of pathway) and fax to: Inform relatives and give them Primary PCI information sheet 4. Medication required before transfer (in total) Medication & Dose (Stat) Tick if given Route All patients. Oral Aspirin 600mg If contra indicated use clopidogrel monotherapy as below In addition to aspirin all patients must receive ticagrelor or clopidogrel. 1 st line: Ticagrelor* 2 180mg Oral 2 nd line: Clopidogrel mg Oral Prescribe and sign chart on page 1 and document on transfer form 5. Thrombolysis Alternative Management to PPCI Door to needle target 30 minutes Indication Yes No Patient meets criteria in Section 1 Patient has not consented to emergency transfer to LHCH (Section 2) If yes to any of the above continue below Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 2 of 11

3 6. Are there contra-indications to fibrinolytic therapy Absolute NOT for treatment Yes No Patient is currently taking Warfarin (if YES SEE BELOW) INR >2.0 consider risk/benefit. SEEK EXPERT ADVICE Patient taking a new oral anticoagulant e.g. Dabigatran. SEEK EXPERT ADVICE Recent major surgery, trauma, head injury within 3 weeks? Recent stroke within 6 months? G.I. Bleed within 1 month? Haemorrhagic diathesis? Aortic dissection? Relative. If yes to any below, consider RISK/BENEFIT, SEEK EXPERT ADVICE >80 years inferior MI with minimal ST elevation without ST depression Blood pressure >180mmHg systolic, >100mmHg diastolic? Prolonged chest compression? Active peptic ulcer? Other significant risk of haemorrhage? Pregnant or post partum 1 week? If No to all of the above then give fibrinolytic. Heart block is not an exclusion. 7. Consent Yes No Patient informed of diagnosis of AMI. Explained the benefits and risks of transfer for PPCI versus thrombolysis. Risk of GI Bleeds, CVA or Mortality. Consent obtained by: Signature:. Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 3 of 11

4 8. Administration of fibrinolytic therapy Prescribe a single, weight related dose of: heparin and tenecteplase, then either fondaparinux *1 or enoxaparin based on CrCl. Body weight =. kgs Route Prescriber time/date Heparin Sodium 5000units IV bolus Heparin Sodium 4000units if <65kg IV bolus Tenecteplase <60kg = 30mg (6mL 6000 units) 60-69kg = 35mg (7mL 7000 units) IV bolus 70-79kg = 40mg (8mL 8000 units) 10secs 80-89kg = 45mg (9mL 9000 units) >90kg = 50mg (10mL 10,000 units) Given by time/date In addition to heparin and tenecteplase prescribe fondaparinux or enoxaparin. Fondaparinux 2.5mg stat *1 S/C then once daily, minimum 48hrs OR (if CrCl <20ml/min) Enoxaparin 1mg/kg Stat then once daily (renal dose) Minimum 48hrs..mg S/C Ensure the patient is prescribed the following antiplatelet treatment: (sign chart on page 1) Aspirin 300mg, oral, stat, then 75mg, po, daily and Clopidogrel 300mg, oral, stat immediately, then 75mg, oral, daily. Do not give ticagrelor before or after fibrinolytic use. Consider other medicines as page Failed Reperfusion Following Thrombolysis Failure, after 90 minutes of receiving fibrinolytic, to reduce STsegment elevation (in lead showing maximum ST-elevation pre-thrombolysis) at least 50% Within 12 hours of onset of chest pain Patient fit and willing to transfer and undergo PCI at LHCH Yes No If yes to all of the above contact on call SPR at LHCH on to discuss transfer for rescue PCI Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 4 of 11

5 Suspected ACS / MI without ST-Elevation or Presumed New LBBB Refer to TIMI stratification, order high sensitivity Troponin T on presentation and at 3 hours. Consider bleeding risk and co-morbidity when choosing treatment (NICE 2010). Do not give antithrombotics if a non-cardiac cause of chest pain is suspected. TIMI Risk Stratification for ACS / NSTEMI Yes No Troponin T > 14ng/L 1 0 ST depression > 0.5mm 1 0 Age > 65 years 1 0 At least 3 risk factors for coronary heart disease 1 0 At least 2 angina attacks in last 24 hours 1 0 Use of aspirin within the last 7 days 1 0 Coronary angiogram showing significant CHD 1 0 Score ONE point for each yes TIMI RISK SCORE = Risk Score High Risk SCORE 5-7 Medium Risk SCORE 2-4 Low Risk SCORE 0-1 Management 49% - 72% risk of events at 30 days If ongoing chest pain and / or ECG changes CONSIDER Tirofiban (A Glycoprotein IIB IIIA inhibitor) Seek Consultant / Senior Advice Seek LHCH advice Refer to cardiologist and admit CCU 13% - 24% risk of events at 30 days Refer to cardiologist admit 32 < 8% risk of events at 30 days Early discharge if Troponin T 14ng/L AND normal ECG CONSIDER Rapid access Chest Pain Clinic or ADMIT HAC Treatment Antiplatelet treatment for all patients: Aspirin 300mg stat, 75mg daily If contraindicated use clopidogrel monotherapy Prescribe aspirin with either 1 st line: Ticagrelor 180mg Stat. 90mg twice daily - OR 2 nd line (if ticagrelor contraindicated. * 2) : Clopidogrel 300mg stat, 75 mg daily Ticagrelor as monotherapy without aspirin is not licensed. In addition to antiplatelets prescribe either Fondaparinux 2.5mg SC daily maximum 8 days. *1 OR if Crcl <20ml/mins Enoxaparin 1mg/kg SC daily (renal dose) Omit fondaparinux if for urgent PCI within 24hrs of admission. Consider Beta blocker IV GTN if ongoing chest pain Antiplatelet treatment for all patients: Aspirin 300mg Stat, 75mg daily If contraindicated use clopidogrel monotherapy Consider dual antiplatelet: Aspirin with ticagrelor 180mg, oral, stat, 90mg, twice daily if: ST/T wave changes and An additional risk factor -prior MI or ischaemic stroke or diabetes or peripheral arterial disease or EGFR<60 ml/min If ticagrelor contraindicated use aspirin monotherapy Non Cardiac Causes of chest pain: Pulmonary embolism, Aortic dissection, Pneumothorax, Biliary Colic, Pericarditis, Peptic ulcer, or Musculosketal pain. If a non-cardiac cause is suspected, DO NOT start aspirin, ticagrelor/clopidogrel or fondaparinux. Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 5 of 11

6 Other Medication to be considered Early Beta Blockade Indication Yes No Acute MI /ACS Ongoing Chest Pain Tachycardia Contra-indication Yes No Drug Heart rate persistently <60bpm Blood pressure persistently <100mmHg Systolic 2 nd or 3 rd degree heart block Severe heart failure History of bronchospasm / Asthma Already on beta-blocker or verapamil Atenolol 10 to 50mg (NB maximum dose to be given IV 10mg) Route IV Glyceryl Trinitrate (GTN) Indication If ongoing chest pain, despite sublingual GTN & Opiates, prescribe IV GTN. Drug IV Glyceryl Trinitrate 50mg in 50mL Starting at 0.6mL/ hr increasing up to 6mL/hr Increase by increments of 0.6mL/hr. Titrate to BP and chest pain Contra-indication severe aortic stenosis, systolic blood pressure<90mmhg Management of blood sugars in myocardial infarction If answer to either of the questions below is yes, the patient is eligible for insulin therapy Tight glucose should be introduced within 4 hours of admission and continued for 48 hours for eligible patients. Indication Yes No Is the patient an acute MI and known diabetes mellitus? Is the patient an acute MI with BMI >11mmol/L? If eligible then commence GKI refer to the pathway Drug Route Standard GKI IV 10% Glucose (500mL) with 10mmols potassium chloride (KCL) and 10 units of actrapid over 5 hours (100mL/hr) Double Strength GKI (Heart Failure) IV 20% Glucose (500mL) with 20mmols potassium chloride (KCL) and 20 units of actrapid over 10 hours (50mL/hr) Do not discontinue long-acting insulin (e.g. levemir, Lantus ), record BM s hourly and chart Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 6 of 11

7 Accident & Emergency Assessment Seen by Grade Time.:.. History of presenting complaint Time of onset: Hrs Past Medical History / Risk Factors Family history of ischaemic heart disease ACS Angina Smoker Diabetes Mellitus Hypertension Hyperlipidaemia Myocardial infarction Prior CVA/TIA Peripheral arterial disease Renal impairment Prior heart failure Cigarettes:.. per day other:. Type I Type II Social History Alcohol: Yes No how many units per week? if more than 8 units daily for Males or 6 units daily for females, refer to WUTH Alcohol Withdrawal Care Pathway Family History Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 7 of 11

8 Examination BP..../... PULSE. SA O 2 % TEMP. 0 C RESP. BM Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 8 of 11

9 Examination continued: Plan Investigations ECG:. Chest xray.. Bloods Initial Troponin T at 0 hours... Repeat Troponin T at 3 hours.. Clinical impression:. Complete TIMI Score (page 5) for all patients with ACS Score = /7 Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 9 of 11

10 Diagnosis This should ideally be confirmed by a cardiologist before the patient is discharged ST Elevation Myocardial Infarction (STEMI) Non ST-Elevation Myocardial Infarction (NSTEMI) Unstable angina Angina Other diagnosis (please specify) If ticagrelor has been prescribed then the diagnosis of unstable angina must be confirmed prior to discharge. This should ideally be confirmed by a cardiologist, but if not available, a senior doctor. Secondary Preventative Discharge Drugs Yes No Contra-indicated (state reason Antiplatelet therapy: All patients: Aspirin 75mg daily If contra indicated use clopidogrel monotherapy indefinately If dual therapy indicated use either ticagrelor *2 or clopidogrel in addition to aspirin 1 st line: Ticagrelor, 90mg, twice daily, for 12 months (must be prescribed with aspirin) Or Clopidogrel 75mg, daily for 12 months If AMI / ACS that is troponin-t positive Atorvastatin 80mg (>80 years 40mg) for 6 months Beta blocker ACE inhibitor Omacor (post STEMI only) Smoking Cessation Cardiac Rehab Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 10 of 11

11 PRIMARY PCI TRANSFER CHECKLIST DATE HOSPITAL A&E NUMBER HOSPITAL NUMBER 1. PATIENT DETAILS (use label if available) NHS NUMBER DOB GENDER SURNAME FORENAME ADDRESS (including postcode) 2. BROUGHT IN BY AMBULANCE YES/NO (if yes, please include initial NWAS ECG with transfer checklist) PATIENT REPORT FORM (prf) COPY ATTACHED YES/ NO (If no, complete ambulance details below) EMERGENCY/URGENT (E/U) NUMBER) TIME OF 999 CALL : TIME OF HOSPITAL ARRIVAL : STEMI DIAGNOSED ON ARRIVAL IN A&E YES/NO If no, TIME AND DATE STEMI DIAGNOSED : / : 3. CLINICAL DETAILS TIME & DATE OF ONSET OF CHEST PAIN : TIME OF ECG INDICATING STEMI CALL : (please include first diagnostic ECG with transfer checklist) 4. DRUGS REQUIRED BEFORE TRANSFER Aspirin (600MG): In addition Ticagrelor (180mg) : Or Clopidogrel ( 300mg/600mg): DOSE GIVEN BY TIME : DOSE GIVEN BY TIME : DOSE GIVEN BY TIME : 5. CONSENT PATIENT UNDERSTANDS REASON FOR TRANSFER AND HAS VERBALLY CONSENTED? YES/NO If appropriate, relative understands reason for transfer and has been given next of kin information booklet? YES/NO State relationship ( ) 6. REQUEST EMERGENCY AMBULANCE TRANSFER TO LHCH!!THIS SHOULD BE DONE IMMEDIATELY AFTER STEMI DIAGNOSED!! Emergency line Clinician must request **EMERGENCY TRANSFER FOR PRIMARY PCI** TIME AMBULANCE REQUESTED: : BOOKING NUMBER 7. ACTIVATE PPCI PATHWAY IT IS THE RESPONSIBILITY OF REFERRING HOSPITAL/CLINICIAN TO INFORM LHCH OF TRANSFER Activate internal primary PCI policy at LHCH by telephoning TIME LHCH INFORMED OF PATIENT : TELEPHONED BY 8. RESPONSIBILITIES RESPONSIBLE CONSULTANT REFERRING DOCTOR SIGNATURE OF REFERRING DOCTOR ********COMPLETED FORM, COPY OF diagnostic ECG (plus initial NWAS ECG if performed) AND PRF TO BE HANDED TO TRANSFERRING AMBULANCE CREW. No other documents are required ************ Chest Pain Pathway Care Pathway, v2a Principal author: Dr N Newall Page 11 of 11

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