CLINICAL GUIDELINE Management of Acute Coronary Syndrome / NSTEMI For use in (clinical areas): For use by (staff groups): For use for (patients): Document owner: Status: All clinical areas Medical and Nursing Staff Possible Cardiac Chest Pain/ACS Dr Ajit Agarwal APPROVED Purpose of the Guideline Acute coronary syndrome (ACS) is a general term encompassing the conditions of unstable angina (UA) and myocardial infarction (MI). This guideline covers the initial management of patients suffering non-st segment myocardial infarction (NSTEMI) and those with suspected ACS. Patients with an ST-segment elevation MI (STEMI) should be treated in accordance with the Acute Myocardial Infarction Pathway (STEMI). This guideline has been produced to promote consistent care of patients experiencing ACS / NSTEMI across the trust. It may be of particular benefit to staff that do not care for these patients routinely. Whilst based on scientific evidence or professional consensus these guidelines are not intended to replace clinical judgment. Contents. Page Treatment pathway for the management of patients with suspected ACS 2 Pathway for anti-platelet therapy in patients prescribed warfarin 3 Clinical management specific elements of treatment / management o Presentation with Suspected ACS 4 o ECG 5 o Blood Tests 5 o When acute coronary syndrome is confirmed 5 Appendix 1 6 References 7 Source: Issue date: 5th March 2012 Page 1 of 7
Pathway for the management of acute coronary syndromes (ACS) Suspected cardiac chest pain 12 lead ECG IMMEDIATELY Changes suggestive of NEW STEMI or LBBB Consider Urgent Referral for PPCI at Papworth NEW Changes indicative of NSTEMI / ACS GTN S/L, O 2 100% - Refer to O 2 guideline if saturations <94%, Aspirin & Clopidogrel 300mg PO stat unless given pre-hospital, Fondaparinux 2.5mg S/C or THROMBOLYSIS (CCU or ED) see PPCI pathway on Pink Book Secure IV access and Px morphine / diamorphine IV and cyclizine / metocolpramide PRN Trop. T ve Stop fondaparinux and clopidogrel Non-cardiac chest pain: Review remaining medications based upon cardiovascular risk factors and consider discharge home if stable Cardiac chest pain: Refer for ETT either as as O/P or I/P or MPI as O/P Review medication according to clinical picture Where appropriate Px: Aspirin 75mg PO OM Clopidogrel 75mg PO OM Fondaparinux 2.5mg S/C OD* Simvastatin 40mg PO Nocté Bisoprolol low dose and titrate according to response Ramipril low dose and titrate according to response Troponin T level 12 hours after onset of symptoms Trop. T +ve Continue fondaparinux for up to 8/7 or hospital discharge (which ever is the sooner) Continue clopidogrel for 1 year Refer for Cardiology review prior to hospital discharge Home Day 5 1-3% (low risk) & pain free transfer to G3 repeat ECG Complete Grace score if Troponin T level available >3% (high risk) admit to CCU Ischaemic ECG Or On-going pain and High risk patient Haemodynamically compromised Previous MI, PTCA, CABG LV dysfunction > 70 yrs + other risks Consider tirofiban infusion and whiteboard urgent I/P coronary angiogram at Papworth Trop. T level 12 hours after onset of pain Ongoing or recurrent chest pain: give analgesia / antiemetics as required and start GTN IV infusion transfer to CCU for continuous ECG monitoring Trop. T -ve Refer for ETT either as O/P or I/P or MPI as O/P at physician s discretion Review medication according to clinical picture Trop. T +ve Angiogram: I/P if clinically indicated or O/P - Home day 5 * For patients with renal impairment (SeCr >265µmol/L or EGFR <20mL/min) OMIT FONDAPARINUX and prescribe ENOXAPARIN 1mg/kg S/C OD Troponin T on admission if history of chest pain for 12 hrs at the time of arrival. Source: Issue date: 5th March 2012 Page 2 of 7
Pathway for anti-platelet therapy in patients taking warfarin prior to admission Warfarin used for AF / VTE: STAT doses of each: Aspirin 300mg PO Clopidogrel 300mg PO Fondaparinux 2.5mg SC Withhold warfarin Suspected ACS Trop. T 12 hours after onset of pain If > 30ng/L and diagnosis of ACS confirmed Warfarin used for valve prosthesis: STAT doses of each: Aspirin 300mg PO Clopidogrel 300mg PO Continue warfarin If INR 2 the give additional fondaparinux 2.5mg SC OD until INR therapeutic Prescribe the following regularly: Aspirin 75mg PO OD Clopidogrel 75mg PO OD Fondaparinux 2.5mg SC OD for up to 8/7 or hospital discharge Prescribe the following regularly: Continue warfarin Aspirin 75mg PO OD Clopidogrel 75mg PO OD Fondaparinux 2.5mg SC OD for up to 8/7 or hospital discharge 1-2 days prior to cessation of fondaparinux test INR and re-load / re-prescribe warfarin maintenance dose accordingly On discharge: Aspirin 75mg PO OD Clopidogrel 75mg PO OD for 1-6 months depending upon bleeding risk Warfarin continue On discharge: Aspirin 75mg PO OD Clopidogrel 75mg PO OD for 1-6 months depending upon bleeding risk Warfarin - continue When prescribing warfarin discharge doses and INR test dates please consider any new drug interactions which affect the INR Clinical judgment should still be used when considering use of antiplatelet agents patients with confirmed ACS balance treatment of ACS vs. risk of bleeding with combination therapy For patients with renal impairment (SeCr >265µmol/L or EGFR <20mL/min) OMIT FONDAPARINUX and prescribe ENOXAPARIN 1mg/kg S/C OD Source: Issue date: 5th March 2012 Page 3 of 7
1. Presentation with Suspected ACS 1.1 Patients with suspected cardiac pain, continual or recurrent, and unresolved after 20 minutes should be taken to an acute hospital. All patients with suspected ACS should receive: - GTN - S/L or buccal & prescribed PRN - Oxygen 100% (if O 2 saturations <94% see O 2 guideline) - Aspirin 300mg PO STAT - Clopidogrel 300mg PO STAT (unless administered prior to admission) - Fondaparinux 2.5 mg SC (for patients with renal impairment (SeCr >265µmol/L of EGFR <20mL/min)) OMIT fondaparinux and prescribe enoxaparin 1mg/Kg For further prescribing advise regarding the use of fondaparinux please see separate fondaparinux guideline - IV access - Diamorphine 2.5-5mg / Morphine 5-10mg IV PRN for pain relief. - Beta-blocker introduce cautiously if large MI, titrate to response and withhold if acute heart failure - Statin therapy prescribe simvastatin 40mg PO nocte as first line and adjust dose depending upon drug interactions and monitor liver function - ACE inhibitor prescribe ramipril as first line at night and titrate dose to maximum tolerated licensed dose (target ramipril 10mg OD). Monitor renal function closely. - Cardiac rhythm monitoring - Standard 12 lead ECG - Baseline vital signs - BP, Pulse, SaO 2, Resp rate and Temp Clinical judgment should still be used when considering use of antiplatelets in suspected/confirmed ACS balance risk of ACS with risk of bleeding when prescribing. Standard prescribing recommendations for drugs mentioned above apply. 1.2 All patients should be referred to, and assessed by a cardiologist within 24 hours of presentation if possible (except during the weekend when referrals will have to be made as soon as possible on Monday morning). 1.3 Risk assessment to guide appropriate treatment and placement on Cardiac Care Unit (CCU) or cardiac ward (G3) calculate Global Registry of Acute Cardiac Events (GRACE) score at http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html and see appendix 1 for respective risk. The link above can be accessed directly through the WSH intranet home page via Patient Info, Cardiology, and Grace Calculator. 1.4 Low risk suspected ACS patients should be admitted to G3. Moderate to high risk patients should be admitted to CCU. 1.5 PLEASE NOTE: Cardiac arrest and subsequent neuro-protective strategies (e.g. cooling of core body temperature conducted in Critical Care) should not preclude application of this guideline where appropriate. Source: Issue date: 5th March 2012 Page 4 of 7
2. ECG 2.1 All patients with suspected ACS should have a 12 lead ECG performed immediately on admission. 2.2 Patients with persistent ST elevation or new left bundle branch block - refer to Pink Book for STEMI / PPCI guidelines and pathway. 2.3 Patients without ST elevation - repeat ECG at 15 minute intervals if pain is ongoing or recurrent. Only discontinue when the ECG is unchanging. Utilise ST segment monitoring if available. 2.4 All patients with abnormal ECG (ST depression - transient ST elevation) should have blood samples taken for Troponin T to aid diagnosis. 3. Blood tests 3.1 Blood sample for cardiac Troponin T should be taken 12 hours after cardiac event / onset of symptoms if timing is accurate. 3.2 Where symptoms were experienced greater than 12 hours ago send blood sample for cardiac Troponin T immediately. 3.3 As a guide the following has been agreed to aid diagnosis of NSTEMI: Detection of a rise (or fall if late presentation) of troponin with at least one result above 29ng/l together with evidence of myocardial ischaemia as recognised by at least one of the following: - Symptoms of ischaemia - ECG changes of new ischemia (ESC 2007) Those patients with high suspicion of cardiac pain and with borderline rises in troponin (14-30ng/l) should have a further troponin 6hrs or more later, to clarify if the troponin level is still rising, and hence confirming the diagnosis of NSTEMI. Clinicians must be aware that troponin levels can rise in non-ischaemic related conditions e.g. sepsis, tachyarrhythmia, severe renal impairment and pulmonary embolus, so caution should be taken when making diagnoses on the basis of a biomarker alone. 3.3 Blood should also be taken for: FBC, U&E, Glucose, lipids & LFT 4 When acute coronary syndrome is confirmed. 4.1 The patient should be admitted to the Emergency Admissions Unit, G3 or CCU and have continuous ECG monitoring. 4.2 The patient should receive aspirin75mg PO OD (to continue lifelong if tolerated) and clopidogrel 75 mg PO OD (to continue for 12 months), Fondaparinux 2.5mg S/C OD for up to 8 days or until hospital discharge (which ever is the sooner), beta-blockers (bisoprolol first line), ACE inhibitor (ramipril first line)and GTN S/L prn. 4.3 For patients with renal impairment (SeCr >265µmol/L or EGFR <20mL/min) omit fondaparinux and prescribe enoxaparin 1mg/kg S/C OD 4.4 For patients who are on warfarin see flowchart above. 4.5 Tirofiban (Glycoprotein IIb/IIIa inhibitor - antiplatelet) and early percutaneous coronary intervention (PCI) should be considered for those with medium / high risk features who experience further / persistent ECG changes and ongoing chest pain(see flowchart) 4.6 Assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality - GRACE. Source: Issue date: 5th March 2012 Page 5 of 7
Appendix 1 Non STE-ACS: In-hospital Mortality Risk Category (tertiles) GRACE Risk Score Probability of Death In-hospital (%) Low 1-108 <1 Intermediate 109-140 1-3 High 141-372 >3 Non STE-ACS: 6 Month Post-discharge Mortality Risk Category (Tertiles) GRACE Risk Score Probability of Death Post-discharge to 6 Months (%) Low 1-88 <3 Intermediate 89-118 3-8 High 119-263 >8 Source: Issue date: 5th March 2012 Page 6 of 7
References Clinical guidelines for the management of suspected ACS/NSTEMI from Peterborough and Stamford Hospital.(2009) Author: Karen Wilkinson British Cardiac Society Guidelines and Medical Practice Committee, and Royal College of Physicians Clinical Effectiveness and Evaluation Unit. (2001) Guideline for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation. Heart; 85:p133-142 National Institute for Clinical Excellence (July 2004) Clopidogrel in the treatment of non -ST-segment -elevation acute coronary syndrome. Department of Health (2000). National Service Framework. Coronary Heart Disease. Heart attacks & other acute coronary syndromes: Chapter 3:12:p5 The European Society of Cardiology (2007) Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. European Heart Journal (2007)28, 726-732 The TIMI risk score for Unstable Angina/Non-ST Elevation MI (2000) Antman et al JAMA vol 284 no.7, 835-842 European Society of Cardiology (2007) The universal definition of myocardial infarction.eur heart journal;28:2525-38 Granger CB, Goldberg RJ, Dabbous OH et al. for the Global Registry of Acute Coronary Events Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003;163:2345 2353. National Institute for Clinical Excellence (June 2010) Unstable angina and NSTEMI National Institute for Clinical Excellence (June 2010) Chest Pain of Acute Onset Author(s): Approved by: Issue no: Dr Ajit Agarwal AKA Source: Issue date: 5th March 2012 Page 7 of 7