1. THE CHEST PAIN UNIT
MANAGEMENT PROTOCOL
Dr Mehdi Shahriyari Afshar
Interventional Cardiologist
Iranian hospital
Dubai-Sep 2014
2. CHEST PAIN (CPU) assessment:
is defined as follows:
1) The CPU should be able to directly
identify and assess
Patients with chest pain as they
arrive in the emergency department.
Ideally it should be based in
emergency department
3. 2) The CPU should provide up to six hours
of observation, serial ECG recording and
biochemical cardiac testing,
ideally consisting of an early maker
( HFABP,CK-MB (mass)) and a later
marker (Troponin) these should be either
be point-of-care or provided by
laboratories with a turn around time of
one hour.
4. 3) The CPU should provide
exercise stress testing within
24 hours of attendance at the
emergency department
(preferably immediate ETT,
but next working day is acceptable)
5. 4) Patient selection and management
will be determined by protocol, but
with staff having the discretion to
over-rule.
5) Patient management will be led
by specialist nursing staff (Chest
Pain Nurses) and ED physicians
6.
7. 6)The CPU may be
physically located away
from the
emergency department ,
provided CPU staff are
readily available in the ED
to assess patients and
support ED staff
8. 7) The CPU may need to be
defined located.
8) Continues ECG
monitoring is routinely
required
9. 9) Patients can be discharged
home between observation/
marker testing and stress
testing, provided their markers
are negative as they are
asymptomatic
11. Staffing:
3 chest pain nurses (8 hours duty
Shifts) that has ACLS and dedicated
for cardiac caring.
Medical input provided by
emergency or CCU medical staff
coordinated by a physician of
emergency department.
12. Structures:
A four -bedded unit located
within the area of the
emergency department,
with the potential to
expand into more beds.
13. Opening hours:
24 hours/7 days round the
clock patients attending
with chest pain or
equivalent symptoms as
dyspnea, palpitation are
admitted to the CPU
14.
15. Exclusion criteria:
In screening room of
emergency department every
patient with chest pain should
be checked by ED Physicians
regarding the exclusion
criteria for CPU :
16. 1.Any of the following ECG changes,
:unless known to be old
=>1mm ST elevation or depression or
> 0.5 mm T wave inversion in two
contiguous leads ;
Atrial fibrillation ;
Tachyarrhythmia (>120 beats per
minute );
bradyarryhthimia ( 40 beats per
minute ),
2nd or 3rd degree heart block ;
or left bundle branch block should be
admitted in CCU
17. ECG MANIFESTATION IN IN
AMI NEW DEFINITION
New ST elevation at the J point
> or = 2 mm V2-V3 in men
> or = 1.5 mm V2-V3 in women
> or = 1 mm in other leads in both genders
18. New ST Depression horizontal or
down –slopping in two
contiguous leads > or =0.5 mm
T inversion > 1 mm in two leads
with prominent R wave (R/S>1)
19. 2. Known CHD (Coronary Heart
Disease) with anginal pain that
consists of recurrent episodes
or episodes lasting more than
one hour should be admitted in
CCU.
20.
21. 3. Minimal risk of ACS (Acute
Coronary Syndrome), i.e. pain
that is stabbing, pleuritic,
positional or reproduced by
palpation in a patient with no
history of, a few rick factors
for CHD managed by ED
physician as an outpatients
23. 5. Suspected or proven
alternative cause requiring
hospital admission, e.g.
pulmonary embolus,
dissecting aortic aneurysm.
24.
25. Routine management in CPU:
Fill up the special history
sheet for any patient that
admitted to CPU and follow
the routine management by
specialized CPU nurse as:
26. Establish IV line and saline infusion as K.V.O.
Blood tests for general checking as: CBC, BS, Cr,
K and Cardiac enzymes as the following
manner
Give Aspirin 300 mg chew (if no
contraindication)
Give Librium (chlordiazepoxide) 5 mg P.O. for
reducing the patient's tension
In case of Hypertension or high sugar or other
abnormalities follow the ED physician order.
27. Serial ECG recording:
An ECG is recorded every hour .
the patient is admitted in CCU if any of
the following are recorded :
=>1mm ST elevation or depression in
any two contiguous lead
T wave changes change unrelated to
posture or hyperventilation Arrhythmia,
2nd or 3rd degree heart block ;
left bundle branch block
30. If more than 12 hours one
blood sample is taken for
troponin I and CK-MB (mass)
measurement (CK-MB-
troponin), that sending the
sample to the laboratory.
31. If less than 12 hours two blood samples are
taken:
The first is taken immediately for cardiac panel
(myogolobin –tropinin, CK-MB (mass), BNP,-D
Dimer) and HFABP (Heart type Fatty Acid
Binding Protein) tests in CPU.
The second is taken at least 2 hours later and
at least 6 hours after the onset of pain for
cardiac panel and HFABP tests in CPU
32.
33. The patient is admitted in CCU if
HFABP level > 5.8 microgram/lit,
Troponin I level > 0.4 ng/ml ,
CK-MB (mass) level > 4.3 ng/ml,
the patient should be considered for
CCU admission if positive myogolobin
> 107 ng/ml, if abnormal D Dimer
>600 ng/ml, if abnormal BNP >100
pg/ml by cardiac panel.
34. Exercise treadmill testing (ETT):
This uses the Burse protocol and is interpreted as
follows:
Early positive: arrhythmia ;> 1mm ST elevation;
or>1mm horizontal or down-sloping ST depression at
stage 1 or 2 of the burse protocol.
Late positive: any of the above changes occurring at
stage 3 or beyond.
Negative: at least stage 3 and 85% of predicted
maximal heart rate achieved without the above ECG
changes.
Inconclusive: no ECG changes but the patient
are unavailable to achieve stage 3 or 85% of
the predicted maximal heart rate
35. Discharge issue:
*Patients with early positive ETT tests are
admitted
*those with negative tests are discharge
*Patients with late positive ETT, equivocal
or inconclusive ETT tests;
who are unable to perform ETT or
known to have CHD are discharged with
appropriate follow-up
unless they have ongoing angial pain.
36.
37. The follow up appointment for
cardiology clinic for first
coming cardiology clinic would
be determined by CPU nurse
and the referral sheet and the
copy of patient's documents
such as ECGs and blood tests
should be sent to the
cardiologist
38. The teaching pamphlet
regarding chest pain and
necessary information and
sublingual nitrate (3 S.O.S.
pills) and instruction for using
it will be given to the patient at
discharge time.
