1. No category

Policy Directive
Ministry of Health, NSW
73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
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Chest Pain Evaluation (NSW Chest Pain Pathway)
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Document Number PD2011_037
Publication date 09-Jun-2011
Functional Sub group Clinical/ Patient Services - Governance and Service Delivery
Clinical/ Patient Services - Medical Treatment
Summary The Policy outlines the minimum standards for the management of
patients presenting with Chest Pain or other symptoms of myocardial
ischaemia.
NOTE: This Policy also applies to Local Health Networks until Local
Health Districts commence on 1 July 2011.
Author Branch Agency for Clinical Innovation
Branch contact Agency for Clinical Innovation
Applies to Local Health Networks, Board Governed Statutory Health Corporations,
Specialty Network Governed Statutory Health Corporations, NSW
Ambulance Service, Public Hospitals
Audience All staff involved in the management and risk stratification of patients who
present with chest pain
Distributed to Public Health System, Divisions of General Practice, Government
Medical Officers, Health Associations Unions, NSW Ambulance Service,
Ministry of Health, Tertiary Education Institutes
Review date 09-Jun-2016
Policy Manual Patient Matters
File No.
Status Active
Director-General
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This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.
POLICY STATEMENT
IMPLEMENTATION OF MINIMUM STANDARDS FOR CHEST PAIN
EVALUATION (NSW CHEST PAIN PATHWAY)
PURPOSE
The policy mandates the implementation of minimum standards for chest pain
evaluation, by all hospitals in the NSW Health system for patients presenting to
Emergency Departments with chest pain. Compliance with these minimum standards
for chest pain evaluation will improve the management of patients by guiding clinicians
through risk stratification and outlining the best practice management. Facilities may
continue to use existing local Pathways provided that they meet all of the minimum
standards and are in active use in emergency departments.
Facilities who do not use an existing Chest Pain Pathway that meets the minimum
standards must implement the standard NSW Chest Pain Pathway. The NSW Chest
Pain Pathway aligns with the National Heart Foundation/Cardiac Society of Australia
and New Zealand Guidelines for the management of acute coronary syndromes.
MANDATORY REQUIREMENTS
1. All facilities with Emergency Departments must have and use a pathway that
meets the following minimum standards for chest pain patients:
• Assigns triage category 2
• Includes risk stratification
• ECGs are taken and reviewed
• Troponin levels are taken and reviewed
• Vital signs are taken and documented
• Critical times are documented (symptom onset, presentation)
• Aspirin is given, unless contraindicated
• A Senior Medical Officer is assigned to provide advice and support on
chest pain assessment and initial management, 24/7
• A nominated Cardiologist is assigned to provide advice on further
management 24/7
• The pathway gives instruction regarding atypical chest pain presentations
• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection,
Pulmonary Embolism & Pericarditis.
• Sites that do not have 24/7 PCI capability must have Thrombolysis as the
default STEMI management strategy unless there is an existing
documented system for transfer.
2. All facilities who do not use an existing Chest Pain Pathway that meets the
minimum standards must implement the standard NSW Chest Pain Pathway that
matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to
use the Primary PCI site Pathway) as the minimum standard.
PD2010_037
Issue date: June 2011
Page 1 of 3
POLICY STATEMENT
IMPLEMENTATION
ROLES AND RESPONSIBILITIES
NSW Department of Health:
• Review the minimum standards of a Chest Pain Pathway in line with relevant
national guidelines and best practice evidence.
• Develop and make accessible implementation support tools.
• Evaluate Chest Pain Pathway implementation and performance against the
minimum standards across the NSW Health system.
LHN Chief Executives:
• Ensure effective implementation of the minimum standards for chest pain
evaluation in all LHN Emergency Departments
• Report minimum standards for chest pain evaluation implementation to the LHN
Governing Council
• Report Chest Pain Pathway implementation and performance against the
minimum standards to NSW Department of Health as requested
LHN Directors of Clinical Governance:
• Direct a LHN gap analysis against the chest pain evaluation minimum standards
• Develop and lead implementation strategy
• Coordinate appropriate educational resources for clinicians
• Evaluate LHN Chest Pain Pathway implementation and performance against the
minimum standards
• Investigate RCA incidents relating to the minimum standards for chest pain
evaluation
Facility General Managers and Heads of Cardiology and Emergency Departments:
• Direct a local gap analysis against the chest pain evaluation minimum standards
• Implement the chest pain evaluation minimum standards locally
• Evaluate and monitor local implementation and performance against the chest
pain evaluation minimum standards
• Coordinate local education requirements for clinicians
• Coordinate local rostering to ensure that a senior clinician is available to assist
24/7 as per the chest pain evaluation minimum standards or utilise documented
referral network
Clinicians:
• Comply with the minimum standards of chest pain evaluation
• Escalate management of deteriorating patients as per Between the Flags
(PD2010_026)
• In Emergency Departments that do not have a medical officer accessible 24/7, it
will be necessary to implement processes where the nurse in charge of the ED
signs the Chest Pain Pathway form in place of the medical officer.
PD2010_037
Issue date: June 2011
Page 2 of 3
POLICY STATEMENT
REVISION HISTORY
Version
June 2011
(PD2011_037)
Approved by
Dr Tim Smyth,
Deputy DirectorGeneral, HSQPID
Amendment notes
New Policy
ATTACHMENTS
1. NSW Chest Pain Pathway: Primary PCI Site
2. NSW Chest Pain Pathway: Non Primary PCI Site
PD2010_037
Issue date: June 2011
Page 3 of 3
FAMILY NAME
MRN
GIVEN NAME
MALE
D.O.B. _______ / _______ / _______
Facility:
FEMALE
M.O.
ADDRESS
CHEST PAIN PATHWAY
LOCATION / WARD
PRIMARY PCI SITE
Date of Presentation
/
CHEST PAIN
or
OTHER
SYMPTOMS of
MYOCARDIAL
ISCHAEMIA
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
/
Time
Y
 Chronic renal failure + typical ACS
symptoms
 Haemodynamic compromise
(sustained SBP < 90 mmHg and / or
new onset mitral regurgitation)
N
N
Diagnose
NON ST ELEVATION ACUTE
CORONARY SYNDROME (ACS)
Go immediately
to
STEMI
MANAGEMENT
(page 3)
STRATIFY ACS RISK
INTERMEDIATE RISK
Any of the following and no high risk
features
LOW RISK
Any of the following and no high or
intermediate risk features
 ACS symptoms within 48 hrs that
 Presentation with clinical features
occurred at rest, or were repetitive or
consistent with ACS without
prolonged (but currently resolved)
intermediate- risk or high-risk
features.
 Previous PCI/CABG > 6 months
 Known coronary heart diseaseEsp if prior AMI or known coronary
lesion > 50% stenosis
 Two or more risk factors of:
Hypertension, family history,
active smoking or hyperlipidaemia
 Chronic renal failure (especially if
known GFR < 60 mL/min) +
atypical ACS symptoms
 Diabetes + atypical ACS symptoms
 Age > 65 years
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual
clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING
NSW HEALTH PRIMARY PCI SITE CP ASSESSMENT.indd 1
Page 1 of 4
D.O.B. _______ / _______ / _______
Facility:
MALE
FEMALE
M.O.
ADDRESS
CHEST PAIN PATHWAY
PRIMARY PCI SITE
LOCATION / WARD
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Contraindications and cautions for thrombolysis use in STEMI1
Absolute contraindications:
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 contraindications:
Risk of bleeding
- Current use of anticoagulants: the higher the international normalised ratio (INR), the higher the risk of bleeding
- Non-compressible vascular punctures
- Recent major surgery (< 3 weeks)
- Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation
- Recent (within 4 weeks) internal bleeding (eg, gastrointestinal or urinary tract haemorrhage)
- Active peptic ulcer
Risk of intracranial haemorrhage
- History of chronic, severe, poorly controlled hypertension
- Severe uncontrolled hypertension on presentation (> 180 mmHg systolic or > 110 mmHg diastolic)
- Ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered in contraindications
Other
- Pregnancy
1
Adapted from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
Contraindications to Exercise Testing (ACC/AHA Guidelines)2
Absolute
- Recurrent chest pain
- Acute myocardial infarction, within 2 days
- High-risk unstable angina
- Uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise
- Symptomatic severe aortic stenosis
- Uncontrolled symptomatic heart failure
- Acute pulmonary embolus or pulmonary infarction
- Acute myocarditis or pericarditis
- Acute aortic dissection
Relative
- Critical left main coronary stenosis
- Electrolyte abnormalities
- Systolic hypertension > 200 mmHg
- Diastolic hypertension > 100 mmHg
- Tachyarrhythmias or bradyarrhythmias
- New onset atrial fibrillation
- Hypertrophic cardiomyopathy and other forms of outflow obstruction
¶SMRÊ(ÎfuÄ
Recommended Management on page 2
GIVEN NAME
SMR080070
All cases to be discussed with Senior Medical Officer
MRN
- Moderate stenotic valvular heart disease
- Mental or physical impairment leading to the inability to exercise adequately
- High-degree atrioventricular block
- Resting ECG which will make EST interpretation difficult (eg LBBB, LVH with strain, Ventricular pacing, Ventricular preexcitation.)
2
Gibbons etal, Circulation 106:1883,2002
Abbreviations:
SMR080.070
 Elevated Troponin
(consider haemolysis, renal failure)
 Persistent or dynamic ECG changes of  ECG is not normal and has changed  ECG Normal or unchanged from
 ST depression ≥ 0.5 mm or
from previous pain free ECG but does
previous pain free ECG
 new T wave inversion ≥ 2 mm
not contain high risk changes.
 Transient ST elevation (≥ 0.5 mm) in
more than two contiguous leads
 Sustained VT
FAMILY NAME
BINDING MARGIN - NO WRITING
 Diabetes + typical ACS symptoms
(back pain, hypertension, absent
pulse, BP difference)
CHEST PAIN PATHWAY
PRIMARY PCI SITE
 Previous PCI/CABG < 6 months
Consider Pericarditis
(sharp chest pain, respiratory or
positional component)
(severe dyspnoea, respiratory
distress, low subscript O2 saturation)
Any of the following
 History of chronic left ventricular
systolic dysfunction (especially if
known LVEF < 40%) OR current
clinical evidence of LVF.
Consider Aortic Dissection
Consider Pulmonary
Embolism
HIGH RISK
 Syncope
Oxygen
Aspirin
IV Access
Pain Relief
Pathology incl Troponin
Chest X-ray
ST ELEVATION
N
:
General Management
or (presumed new) LBBB
TRIAGE
CATEGORY
2
 ACS symptoms are repetitive or
prolonged (> 10 min) & still present.
Time of Symptom Onset:
ECG & Vital Signs, expert
interpretation within 10 minutes
(eg sweating, sudden orthopnea,
syncope, dyspnoea, epigastric
discomfort, jaw pain, arm pain)
Be aware:
HIGH RISK ATYPICAL
PRESENTATIONS
(eg diabetes, renal failure, female,
elderly or Aboriginal)
:
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ACS – Acute Coronary Syndrome
CABG – Coronary Artery Bypass Graft
ECG – Electrocardiogram
EST – Exercise Stress Test
FMC – First Medical Contact
GTN – Glyceryl trinitrate
LBBB – Left Bundle Branch Block
LVF – Left Ventricular Failure
LVH – Left Ventricular Hypertrophy
PCI – Percutaneous Coronary Intervention
SMO – Senior Medical officer
STEMI – ST Elevation Myocardial Infarction
NO WRITING
Page 4 of 4
20/05/2011 11:48:47 AM
FAMILY NAME
GIVEN NAME
D.O.B. _______ / _______ / _______
Facility:
FAMILY NAME
MRN
MALE
GIVEN NAME
FEMALE
M.O.
¶SMRÊ(ÎfuÄ
CHEST PAIN PATHWAY
PRIMARY PCI SITE
SMR080070
LOCATION / WARD
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Refer to drug protocols &/or Therapeutic Guidelines
HIGH RISK
INTERMEDIATE RISK
LOW RISK
ADMIT or TRANSFER
RESTRATIFY
DISCHARGE
 Continuous cardiac monitoring & frequent  Regular vital signs
vital signs
 Repeat ECG immediately if
symptoms recur
 Repeat ECG immediately if symptoms  Repeat ECG immediately if symptoms
recur
recurs
 Repeat ECG 8 hrs post onset
 Continuous cardiac monitoring &
frequent vital signs
 Repeat ECG 8 hrs post onset of
symptoms
 Repeat ECG 8 hrs post onset of
symptoms
 Repeat Troponin at 8 hrs if 1st sample  Repeat Troponin at 8 hrs if 1st sample
negative *
negative *
 ECG/Troponin review by medical
officer
BINDING MARGIN - NO WRITING
Antiplatelet therapy
Yes

No
}
Discuss with
cardiologist
/SMO
If no reason______________________
_______________________________
 ECG/Troponin review by medical officer
of symptoms
 Repeat Troponin at 8 hrs if 1st
sample negative *
 ECG/Troponin review by
medical officer
_______________________
Refer for Exercise Stress Test ** if :
Restratify Risk if:
 No further chest pain/symptoms and
 2 negative Troponin tests and
 Recurrent ischaemic chest
pain or
 No new ECG changes and
 Positive Troponin or
 No contraindications to stress test
 New ECG changes
If low Risk ACS
 Yes
Restratify to High Risk if:
 Discharge
 No
 Recurrent ischaemic chest pain or
If no reason______________________
 Positive Troponin or
 Follow up GP/LMO within 3-5
days of D/C
_______________________________
 New ECG changes or
Anticoagulant
 Positive stress test
 Yes
 No
Restratify to Low Risk & Discharge if:
If no reason______________________
 Negative stress test or
________________________________
 Stress test available within 72 hrs**
and
Symptomatic treatment of ongoing  No further chest pain/symptoms
 Repeat ECG & vital signs, if stable
pain/hypertension
 IV GTN (titrate against pain & BP)
 IV Morphine
 Refer to nominated cardiologist
for further management
STEMI MANAGEMENT
1.
CONFIRM
INDICATIONS for
REPERFUSION
2.
GENERAL
MANAGEMENT
3.
ADMINISTER
ANTITHROMBOTIC
THERAPY
4.
CHOOSE
REPERFUSION
METHOD
LOCATION / WARD
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Time of
diagnostic
ECG
Chest pain > 30 min and < 12 hrs
Persistent ST segment elevation of ≥ 1 mm in two or more
contiguous limb leads or ST segment elevation of ≥ 2 mm
in two contiguous chest leads or presumed new LBBB pattern
Myocardial infarct likely from history
Cardiac monitoring
Routine bloods
Nitrates-Sublingual or IV
ECG
Oxygen
CXR
:
IV Cannula X 2
Analgesia – Morphine
Beta Blockers
Confirm administration or give:
Aspirin
Clopidogrel
Enoxaparin
300 mg (soluble)
300 - 600 mg
(or prasugrel &/or tirofiban)
30 mg IV then bd (or IV heparin or bivalirudin)
1 mg/kg subcut (Max 100 mg)
Refer to local
protocols &/or
Therapeutic
Guidelines
Significant delay to availability of Cath Lab or interventional team or
Patient does not consent to primary PCI
History, contrast allergy
Vascular access problems
Discuss with Interventional cardiologist:
 Consider Specialist follow up
Aspirin (discuss with SMO)
 Vital signs prior to discharge
If unlikely cardiac cause
Consider alternative diagnosis
Exit Pathway
5. TRANSFER TO CATH LAB
:
NB: ** If stress test is not
available within 72 hrs of
discharge, treatment plan
should be guided by nominated
SMO/Cardiologist
OR
Discuss adjunctive treatment
with Cardiologist
Cath Lab arrival time
discharge
Time
Decision regarding reperfusion method:
 Consider discharge on
please use
24 hr Clock
:
Time
:
THROMBOLYSE if appropriate
No contraindications (see page 4)
Tenecteplase / Reteplase
Body Weight ________kg Dose ________
Time administered
:
Repeat ECG at 60 mins post thrombolytic
Discuss further mx with cardiologist
Failure to reperfuse (less than 50%
reduction in ST elevation)
Consider Rescue Angioplasty
On table time
:
First device use time
Pharmacological stress test or
CT coronary angiography may be
indicated
NH606600 - 120511
M.O.
PRIMARY PCI UNLESS
(page 4)
Betablocker
FEMALE
ADDRESS
CHEST PAIN PATHWAY
Recommended Further Management
MALE
D.O.B. _______ / _______ / _______
Facility:
ADDRESS
PRIMARY PCI SITE
MRN
:
*If a high sensitivity troponin assay is used, the testing interval may be reduced to 3 hours, provided the second
sample is taken at least 6 hours after symptom onset.
Time to Revascularisation (TIMI 3 flow)
Yes / No Time
0-30 mins
31-45 mins
46-60 mins
61-75 mins
>90 mins
Reason for delay
Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________
Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING
NSW HEALTH PRIMARY PCI SITE CP ASSESSMENT.indd 2
Page 2 of 4
:
76-90 mins
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING
Page 3 of 4
20/05/2011 11:48:54 AM
FAMILY NAME
MRN
GIVEN NAME
MALE
D.O.B. _______ / _______ / _______
Facility:
FEMALE
M.O.
ADDRESS
CHEST PAIN PATHWAY
LOCATION / WARD
NON PRIMARY PCI SITE
Date of Presentation
/
CHEST PAIN
or
OTHER
SYMPTOMS of
MYOCARDIAL
ISCHAEMIA
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
/
Time
Y
Consider Pericarditis
(sharp chest pain, respiratory or
positional component)
(back pain, hypertension, absent
pulse, BP difference)
Consider Pulmonary
Embolism
(severe dyspnoea, respiratory
distress, low subscript O2 saturation)
N
N
Go immediately
to
STEMI
MANAGEMENT
(page 3)
STRATIFY ACS RISK
INTERMEDIATE RISK
Any of the following and no high risk
features
LOW RISK
Any of the following and no high or
intermediate risk features
£ Presentation with clinical features
£ ACS symptoms are repetitive or
£ ACS symptoms within 48 hrs that
occurred at rest, or were repetitive or consistent with ACS without
prolonged (> 10 min) & still present.
prolonged (but currently resolved)
intermediate- risk or high-risk
£ Syncope
features.
£ Previous PCI/CABG > 6 months
£ History of chronic left ventricular £ Known coronary heart diseasesystolic dysfunction (especially if
Esp if prior AMI or known coronary known LVEF < 40%) OR current lesion > 50% stenosis
clinical evidence of LVF.
£ Two or more risk factors of:
£ Previous PCI/CABG < 6 months
Hypertension, family history,
active smoking or hyperlipidaemia
£ Diabetes + typical ACS symptoms
£
Chronic renal failure (especially if
£ Chronic renal failure + typical ACS known
GFR < 60 mL/min) +
symptoms
atypical ACS symptoms
£ Haemodynamic compromise
£ Diabetes + atypical ACS symptoms
(sustained SBP < 90 mmHg and / or £ Age > 65 years
new onset mitral regurgitation)
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual
clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING
NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 1
Page 1 of 4
FEMALE
M.O.
ADDRESS
CHEST PAIN PATHWAY
NON PRIMARY PCI SITE
LOCATION / WARD
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Contraindications and cautions for thrombolysis use in STEMI1
Absolute contraindications:
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 contraindications:
Risk of bleeding
- Current use of anticoagulants: the higher the international normalised ratio (INR), the higher the risk of bleeding
- Non-compressible vascular punctures
- Recent major surgery (< 3 weeks)
- Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation
- Recent (within 4 weeks) internal bleeding (eg, gastrointestinal or urinary tract haemorrhage)
- Active peptic ulcer
Risk of intracranial haemorrhage
- History of chronic, severe, poorly controlled hypertension
- Severe uncontrolled hypertension on presentation (> 180 mmHg systolic or > 110 mmHg diastolic)
- Ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered in contraindications
Other
- Pregnancy
1
Adapted from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
Contraindications to Exercise Testing (ACC/AHA Guidelines)2
Absolute
- Recurrent chest pain
- Acute myocardial infarction, within 2 days
- High-risk unstable angina
- Uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise
- Symptomatic severe aortic stenosis
- Uncontrolled symptomatic heart failure
- Acute pulmonary embolus or pulmonary infarction
- Acute myocarditis or pericarditis
- Acute aortic dissection
Relative
- Critical left main coronary stenosis
- Moderate stenotic valvular heart disease
- Electrolyte abnormalities
- Systolic hypertension > 200 mmHg
- Diastolic hypertension > 100 mmHg
- Tachyarrhythmias or bradyarrhythmias
- New onset atrial fibrillation
- Hypertrophic cardiomyopathy and other forms of outflow obstruction
¶SMRÊ(Îg|Ä
Recommended Management on page 2
D.O.B. _______ / _______ / _______
Facility:
MALE
SMR080071
All cases to be discussed with Senior Medical Officer
GIVEN NAME
- Mental or physical impairment leading to the inability to exercise adequately
- High-degree atrioventricular block
- Resting ECG which will make EST interpretation difficult (eg LBBB, LVH with strain, Ventricular pacing, Ventricular preexcitation.)
2
Gibbons etal, Circulation 106:1883,2002
Abbreviations:
SMR080.071
£ Elevated Troponin
(consider haemolysis, renal failure)
£ Persistent or dynamic ECG changes of £ ECG is not normal and has changed £ ECG Normal or unchanged from l ST depression ≥ 0.5 mm or from previous pain free ECG but does
previous pain free ECG
l new T wave inversion ≥ 2 mm not contain high risk changes.
£ Transient ST elevation (≥ 0.5 mm) in
more than two contiguous leads
£ Sustained VT
MRN
BINDING MARGIN - NO WRITING
Diagnose
NON ST ELEVATION ACUTE
CORONARY SYNDROME (ACS)
FAMILY NAME
CHEST PAIN PATHWAY
NON PRIMARY PCI SITE
HIGH RISK
Oxygen
Aspirin
IV Access
Pain Relief
Pathology incl Troponin
Chest X-ray
Consider Aortic Dissection
N
:
General Management
ST ELEVATION
or (presumed new) LBBB
TRIAGE
CATEGORY
2
Any of the following
Time of Symptom Onset:
ECG & Vital Signs, expert
interpretation within 10 minutes
(eg sweating, sudden orthopnea, syncope, dyspnoea, epigastric
discomfort, jaw pain, arm pain)
Be aware:
HIGH RISK ATYPICAL
PRESENTATIONS
(eg diabetes, renal failure, female,
elderly or Aboriginal)
:
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ACS – Acute Coronary Syndrome
CABG – Coronary Artery Bypass Graft
ECG – Electrocardiogram
EST – Exercise Stress Test
FMC – First Medical Contact GTN – Glyceryl trinitrate
LBBB – Left Bundle Branch Block
LVF – Left Ventricular Failure
LVH – Left Ventricular Hypertrophy
PCI – Percutaneous Coronary Intervention
SMO – Senior Medical officer
STEMI – ST Elevation Myocardial Infarction
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12/05/2011 10:32:22 AM
FAMILY NAME
GIVEN NAME
D.O.B. _______ / _______ / _______
Facility:
FAMILY NAME
MRN
MALE
GIVEN NAME
FEMALE
M.O.
¶SMRÊ(Îg|Ä
LOCATION / WARD
SMR080071
STEMI MANAGEMENT
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Recommended Further Management
Refer to drug protocols &/or Therapeutic Guidelines
HIGH RISK
INTERMEDIATE RISK
LOW RISK
ADMIT or TRANSFER
RESTRATIFY
DISCHARGE
1.
CONFIRM
INDICATIONS for
REPERFUSION
£ Continuous cardiac monitoring & frequent £ Regular vital signs
vital signs
£ Repeat ECG immediately if symptoms recur
£ Repeat ECG immediately if symptoms £ Repeat ECG immediately if symptoms recur
recurs
£ Repeat ECG 8 hrs post onset £ Continuous cardiac monitoring &
frequent vital signs
£ Repeat ECG 8 hrs post onset of symptoms
£ Repeat ECG 8 hrs post onset of symptoms
£ Repeat Troponin at 8 hrs if 1st sample £ Repeat Troponin at 8 hrs if 1st sample negative *
negative *
£ ECG/Troponin review by medical officer
BINDING MARGIN - NO WRITING
Antiplatelet therapy
£
Yes
£
No
}
Discuss with
cardiologist
/SMO
If no reason______________________
_______________________________
Betablocker
£ Yes
£ No
If no reason______________________
_______________________________
Anticoagulant
£ ECG/Troponin review by medical officer
Restratify Risk if:
£ No further chest pain/symptoms and
£ Recurrent ischaemic chest
pain or
£ 2 negative Troponin tests and
£ No new ECG changes and
£ No contraindications to stress test
(page 4)
Restratify to High Risk if:
£ Recurrent ischaemic chest pain or
£ Positive Troponin or
£ New ECG changes or
£ Positive stress test
Restratify to Low Risk & Discharge if:
If no reason______________________
£ Negative stress test or
________________________________
£ Stress test available within 72 hrs**
and
Symptomatic treatment of ongoing £ No further chest pain/symptoms
£ Repeat ECG & vital signs, if stable
pain/hypertension
£ Refer to nominated cardiologist
for further management
£ ECG/Troponin review by medical officer
Refer for Exercise Stress Test ** if :
£ No
£ IV Morphine
of symptoms
£ Repeat Troponin at 8 hrs if 1st sample negative *
3.
ADMINISTER
ANTITHROMBOTIC
THERAPY
_______________________
£ YES
£ IV GTN (titrate against pain & BP)
2.
GENERAL
MANAGEMENT
£ New ECG changes
4.
CHOOSE
REPERFUSION
METHOD
If low Risk ACS
£ Discharge
£ Follow up GP/LMO within 3-5 days of D/C
£ Consider Specialist follow up
Aspirin (discuss with SMO)
Time of
diagnostic
ECG
Chest pain > 30 min and < 12 hrs
Persistent ST segment elevation of ≥ 1 mm in two or more
contiguous limb leads or ST segment elevation of ≥ 2 mm
in two contiguous chest leads or presumed new LBBB pattern
Myocardial infarct likely from history
Cardiac monitoring
Routine bloods
Nitrates-Sublingual or IV
ECG
Oxygen
CXR
:
IV Cannula X 2
Analgesia – Morphine
Beta Blockers
Confirm administration or give:
Aspirin
300 mg (soluble)
Clopidogrel 300 - 600 mg
(or prasugrel &/or tirofiban)
Enoxaparin 30 mg IV then bd (or IV heparin or bivalirudin)
1 mg/kg subcut (Max 100 mg)
Refer to local
protocols &/or
Therapeutic
Guidelines
Absolute or unacceptable relative contraindications (see page 4) or
Patient does not consent to thrombolysis or
Documented system for transfer to PRIMARY PCI SITE in place
5. THROMBOLYSE
£ Vital signs prior to discharge
Tenecteplase / Reteplase
Body Weight _____kg Dose _____
If unlikely cardiac cause
Consider alternative diagnosis
Time administered
Exit Pathway
NB: ** If stress test is not
available within 72 hrs of
discharge, treatment plan
should be guided by nominated
SMO/Cardiologist
:
OR
Time
:
Transfer to PRIMARY PCI SITE if
appropriate
(As per table below)
Maximum Acceptable Delay from First Medical Contact (FMC):
Time since symptom
onset
Acceptable delay from FMC to
percutaneous intervention
< 1hours
60 minutes
1-3 hours
90 minutes
3-12 hours
120 minutes
>12hours
Not routinely recommended
from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
Discuss further management immediately with nominated cardiologist
Prioritise urgency of transfer with nominated cardiologist
Organise transfer to PCI-capable hospital (as per locally agreed protocol)
Repeat ECG at 60 mins post thrombolytic
Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________
Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
120511
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Discussed with cardiologist:
£ Consider discharge on
*If a high sensitivity troponin assay is used, the testing interval may be reduced to 3 hours, provided the second
sample is taken at least 6 hours after symptom onset.
NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 2
LOCATION / WARD
THROMBOLYSIS UNLESS
discharge
NO WRITING
M.O.
£ Positive Troponin or
Pharmacological stress test or
CT coronary angiography may be
indicated
FEMALE
ADDRESS
CHEST PAIN PATHWAY
NON PRIMARY PCI SITE
CHEST PAIN PATHWAY
MALE
D.O.B. _______ / _______ / _______
Facility:
ADDRESS
NON PRIMARY PCI SITE
MRN
Page 2 of 4
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING
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12/05/2011 10:32:22 AM