Nottingham Cardiac Chest Pain Guidelines

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1 Nottingham Cardiac Chest Pain Guidelines Dr John Walsh Consultant Cardiologist Nottingham University Hospitals September 2015 Modified from original pathways Dr Martin Wiese Emergency Medicine University Hospitals of Leicester

2 Chest pain made easy The Cardiac Cascade 1 - Cardiac or Non-Cardiac 2 - Non-cardiac Reassure 3 Stable or Unstable 4 Unstable admit 5 Stable Cardiac Diagnosis (Known) - Treat and/or refer 6 Stable Cardiac Diagnosis (Unknown) - Predict, treat and/or refer 7 - Predict - <10%- Reassure/discharge % -? Treat and refer % - Treat and refer - 90% - Treat and review 8 - Cardiac Prognosis - Diagnosis confirmed and ongoing symptoms -REFER

3 NUH ACS pathway ED and AMU Use in all patients aged >24 years unless : -No chest pain past 72 hrs -Clearly stable angina -Clearly noncardiac -Suspect oesophageal rupture, aortic dissection, PE. REFER NCH URGENTLY FOR STEMI/NEW LBBB Always use clinical judgment in managing individual patients 2 * *on admission 4. Troponin guide NSTEMI requires a significant rise and/or fall of ctni with at least one value >Upper Reference Limit (URL) AND symptoms of ischaemia or new ECG changes. Baseline troponin elevated beyond URL- admit for repeat at 3h. If 3h troponin >URL and 20% change from initial value Δ NSTEMI Baseline troponin less than URL and HEART score >4 admit for repeat at 3h. If 3h troponin >URL and 50% increase of URL Δ NSTEMI 5 NSTEMI management 1 Assessment by 2 Senior sign-off by (quality indicator; consultant if present, ST4-6 if not) 1 2 Print name Signature Position Date Time Calculate NSTEMI GRACE risk (see box 3) Refer CATS team if unavailable within 15 mins bleep cardiology SpR at QMC or NCH or call Cisco Phone /70091 Contact ACU NCH or CCU QMC direct if necessary

4 NUH ACS pathway ED and AMU Always use clinical judgment in managing individual patients

5 For link to online calculator click on any ED shop floor PC and look in ED favorites folder For ED Acute chest pain: NSTEMI rule in/out tool (this document) Box ➂ NSTEMI GRACE risk

6 NUH ED/Acute medicine CAD predictive assessment tool To be used following ACS rule-out to enable appropriate planning of further management and referral Do not use if ACS diagnosed 3 Always use clinical judgment in managing individual patients * *on admission *In ED if cholesterol level unknown assume to be raised when predicting initial CAD likelihood 1 Assessment by 2 Senior sign-off by (consultant, substantive ST4-6 or cardiac nurse/reg) 1 2 Print name Signature Position Date Time

7 NUH ED/Acute medicine CAD predictive assessment tool To be used following ACS rule-out to enable appropriate planning of further management and referral Do not use if ACS diagnosed Always use clinical judgment in managing individual patients

8 Anti-Anginal Options Always refer to prescribing guidance Beta blockers Bisoprolol mg od. Atenolol mg 0d Calcium channel blockers Diltiazem mg tds.*(avoid if on beta blockers) Amlodipine 5-10mg od Nitrates Isosorbide mononitrate 10-60mg bd Others Nicorandil 10-30mg bd. Ranolazine mg bd.

9 Cardiac Chest Pain Service (CCPS) Nottingham University Hospitals Trust Tel: ext 57410/57460 Fax: External internal Dear Doctor, Date Your patient attended NUH ED/acute Medical Unit with chest pain of recent onset. History in one single sentence: We have excluded an acute coronary syndrome (ACS) using a validated rule-out protocol. [1] Suggested further management (EDU/Acute medicine) clinician please tick the statement(s) below as applicable) We have assessed the likelihood that your patient has symptomatic coronary artery disease (CAD), using an approach recommended by NICE. [2] Our suggestions for further management are as followed: Your patient has an established diagnosis of CAD and reports typical anginal pain continue / optimize treatment for stable angina as recommended by NICE. [3] but we are not certain that your patients chest pain is caused by CAD. Consider (re-)referral for diagnostic testing. Non-anginal pain was described but you may wish to consider the patients CV risk and implement primary prevention strategies. CAD is <10% likely and diagnostic testing is not required. Consider other causes of chest pain (e.g. gastrointestinal and musculoskeletal conditions) when reviewing the patient. CAD is <10% likely but your patient reports typical anginal pain. Testing for CAD is not indicated but consider referral to a cardiologist to look for non-cad causes of angina (such as hypertrophic cardiomyopathy or syndrome X). CAD is between 10 and 60% likely. We have/have not (circle as appropriate) yet started anti-anginal therapy and referred your patient to the Cardiac Chest Pain Service (CCPS) for further investigation. CAD is between 61 and 90% likely. We have started your patient on anti-anginal therapy and referred your patient to the Cardiac Chest Pain Service (CCPS) for further investigation. Your patient reports typical anginal pain and CAD is >90% likely. We have referred him / her for follow-up within 4/52 to the Acute Coronary Syndrome nurse. We recommend treatment for stable angina as per NICE guidance. [3] References 1. HammCW, BassandJP, AgewallS et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2011;32: National Institute for Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (clinical guideline 95) National Institute for Health and Clinical Excellence. Management of stable angina (clinical guideline 126) Please do not hesitate to contact myself or ED consultant if you have questions about our management of this case. EDU Clinician Print Name Signature Role

10 NUH Cardiology CAD likelihood assessment tool for Chest Pain Recent Onset Primary Care Referral Guidance to NUH Cardiac Chest Pain Service (CCPS) 3 Chest Pain Referral from GP to Cardiac Chest Pain Service (CCPS) Clinic visit 1 -all referrals to be reviewed within 2 weeks Clinic visit 2 - all investigations completed within 4 weeks Symptomatic patients and/or those with positive investigations to be reviewed once in nurse lead clinic subsequent follow up agreed with responsible consultant/spr Asymptomatic patients and/or those with negative investigations contacted by telephone and if necessary offered clinic review

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