Physical examination / clinical history Electrocardiogram Cardiac biomarkers Risk stratification Further investigations

1. Clinical Assessment
& Risk Stratification
Frank Hearl
Senior Charge Nurse
Coronary Care Unit
Golden Jubilee National Hospital
PPCI and Direct Admission of High Risk NSTEMI

4. Risk Criteria
Very High Risk:
• Haemodynamic instability
• Recurrent chest pain
• Life threatening arrhythmia
• Acute heart failure
• Dynamic ST-T wave changes
High Risk:
• Rise and fall in troponin
• Dynamic ST or T wave changes
• GRACE score >140
PPCI and Direct Admission of High Risk NSTEMI
Immediate Invasive management
Early Invasive management

5. Clinical Assessment
• Physical examination / clinical history
• Electrocardiogram
• Cardiac biomarkers
• Risk stratification
• Further investigations
PPCI and Direct Admission of High Risk NSTEMI

7. Diagnosis
Angina pain in NSTE-ACS patients may have the following
presentations:
• Prolonged (>20 min) angina pain at rest
• New onset angina
• Recent destabilization of previously stable angina (Crescendo Angina)
• Post-MI angina.
PPCI and Direct Admission of High Risk NSTEMI

8. Investigations
• Electrocardiogram
• Biomarkers- HScTnT/I
• HEART Score
• Quantitative assessment- GRACE
• Cardiac rhythm monitoring
• Bleeding risk assessment- CRUSADE
• Baseline biochemistry & haematology
• CXR
• Echocardiography
PPCI and Direct Admission of High Risk NSTEMI

9. Cardiac Troponin
PPCI and Direct Admission of High Risk NSTEMI

13. Rule in / Rule out
Algorithm
PPCI and Direct Admission of High Risk NSTEMI

15. Patient presents with chest pain to GRI ED/AAU
Nursing assessment in triage
Multiple other complaints
or multiple comorbidities
or pleuritic pain
or pain mainly epigastric or posterior
No other unrelated complaints
and no other acute comorbidities
and pain not pleuritic
and not mainly epigastric or posterior
ECG and troponin within 15 minutes Chest pain assessment form completed by Usual medical management pathways
HEART SCORE < 5
History suggests possible cardiac pain
and non-diagnostic ECG
0800-1700 – CPAU in Zone 3 (ext 25097)
1700-0800 and weekends: Ward 46
High risk chest pain
Ischaemic ECG changes
(for example 2mm ST depression in 2
adjacent leads of deep symmetrical T wave
inversion)
or ongoing typical cardiac pain
or HEART score >5
STEMI
(for example ≥2mm ST elevation in 2
consecutive chest leads
or >1mm in 2 adjacent limb leads
or new LBBB
or >2mm ST depression V1-V3 suggestive
of posterior infarct)
Consider aspirin 300mg stat
Arrange CXR
<5ng/L
(caveat early
presenters < 2 ho urs:
follow 3 hour
>16 ng/L (women)
>34 ng/L (men)
≥5 ng/L
AND
≤16 ng/L (women)
CHANGE <3 ng/L
AND
≤16 ng/L (women)
≥16 ng/L (women)
≥34 ng/L (men)
CHANGE ≥3 ng/L
AND
≤16 ng/L (women)
Troponin 6 hours post-admission (PEAK)
≤16 ng/L (women)
≤34 ng/L (men)
≥16 ng/L (women)
≥34 ng/L (men)
Negative MI screen discharge plans
A) Clear alternative diagnosis
(typically musculoskeletal or GI pain)
Reassure, offer advice on management
such as analgesia or PPI.
B) Atypical chest pain or cardiac-type
pain but previous negative
investigations
Reassure patient of very low cardiac
risk. Offer simple analgesia, advice and
GP follow up
C) Atypical or mild exertional pain, not
previously investigated
Reassure, d/c with aspirin 75mg od and
s/l GTN spray
Consider RACPC referral and inform
patient
D) Typical cardiac pain with no previous
investigations (or equivocal results)
Arrange inpatient or next day ETT, if
appropriate. Admit to Wd 46.
Treat as presumed ACS
Refer to cardiology
Give aspirin 300mg stat
Arrange CXR
Clerk in and write kardex
DO NOT GIVE Ticagrelor or
Fondaparinux unless discussed with
cardiology
Treat as STEMI
Call 999 for emergency PCI transfer
Refer GJNH 0791 761 6501
Fax ECG to 0141 951 5867
Aspirin 300mg stat
Ticagrelor 180mg stat
IV Heparin 5000u (if not anticoagulated)
Manage as ACS
Nursing:
Apply cardiac monitor
Inform senior medical staff
Arrange for first ARU bed
(if no immediate cardiology beds)
Inform patient, offer to inform relatives
Medical:
Full medical review including
routine bloods, ECG & CXR
Consider other causes of raised TnI
(PTE / LVF / arrhythmia / sepsis)
Complete meds rec and kardex
ensure not on any anticoagulants
Rx Ticagrelor 180mg stat then 90mg bd
Rx Fondaparinux 2.5mg s/c stat then od
Rx PRN sublingual GTN spray
Troponin 3 hours post-baseline (usually in CPAU / Wd 46)
Review baseline troponin
Troponin 6 hours post-admission (PEAK)
SUSPECTED ACUTE CARDIAC CHEST PAIN
PROTOCOL
Patient presents with chest pain to GRI ED/AAU
Nursing assessment in triage
Multiple other complaints
or multiple comorbidities
or pleuritic pain
or pain mainly epigastric or posterior
No other unrelated complaints
and no other acute comorbidities
and pain not pleuritic
and not mainly epigastric or posterior
ECG and troponin within 15 minutes Chest pain assessment form completed by Usual medical management pathways
HEART SCORE < 5
History suggests possible cardiac pain
and non-diagnostic ECG
0800-1700 – CPAU in Zone 3 (ext 25097)
1700-0800 and weekends: Ward 46
High risk chest pain
Ischaemic ECG changes
(for example 2mm ST depression in 2
adjacent leads of deep symmetrical T wave
inversion)
or ongoing typical cardiac pain
or HEART score >5
STEMI
(for example ≥2mm ST elevation in 2
consecutive chest leads
or >1mm in 2 adjacent limb leads
or new LBBB
or >2mm ST depression V1-V3 suggestive
of posterior infarct)
Consider aspirin 300mg stat
Arrange CXR
<5ng/L
(caveat early
presenters < 2 ho urs:
follow 3 hour
>16 ng/L (women)
>34 ng/L (men)
≥5 ng/L
AND
≤16 ng/L (women)
CHANGE <3 ng/L
AND
≤16 ng/L (women)
≥16 ng/L (women)
≥34 ng/L (men)
CHANGE ≥3 ng/L
AND
≤16 ng/L (women)
Troponin 6 hours post-admission (PEAK)
≤16 ng/L (women)
≤34 ng/L (men)
≥16 ng/L (women)
≥34 ng/L (men)
Negative MI screen discharge plans
A) Clear alternative diagnosis
(typically musculoskeletal or GI pain)
Reassure, offer advice on management
such as analgesia or PPI.
B) Atypical chest pain or cardiac-type
pain but previous negative
investigations
Reassure patient of very low cardiac
risk. Offer simple analgesia, advice and
GP follow up
C) Atypical or mild exertional pain, not
previously investigated
Reassure, d/c with aspirin 75mg od and
s/l GTN spray
Consider RACPC referral and inform
patient
D) Typical cardiac pain with no previous
investigations (or equivocal results)
Arrange inpatient or next day ETT, if
appropriate. Admit to Wd 46.
Treat as presumed ACS
Refer to cardiology
Give aspirin 300mg stat
Arrange CXR
Clerk in and write kardex
DO NOT GIVE Ticagrelor or
Fondaparinux unless discussed with
cardiology
Treat as STEMI
Call 999 for emergency PCI transfer
Refer GJNH 0791 761 6501
Fax ECG to 0141 951 5867
Aspirin 300mg stat
Ticagrelor 180mg stat
IV Heparin 5000u (if not anticoagulated)
Manage as ACS
Nursing:
Apply cardiac monitor
Inform senior medical staff
Arrange for first ARU bed
(if no immediate cardiology beds)
Inform patient, offer to inform relatives
Medical:
Full medical review including
routine bloods, ECG & CXR
Consider other causes of raised TnI
(PTE / LVF / arrhythmia / sepsis)
Complete meds rec and kardex
ensure not on any anticoagulants
Rx Ticagrelor 180mg stat then 90mg bd
Rx Fondaparinux 2.5mg s/c stat then od
Rx PRN sublingual GTN spray
Troponin 3 hours post-baseline (usually in CPAU / Wd 46)
Review baseline troponin
Troponin 6 hours post-admission (PEAK)
SUSPECTED ACUTE CARDIAC CHEST PAIN
PROTOCOL

16. Risk Stratification
PPCI and Direct Admission of High Risk NSTEMI

17. PPCI and Direct Admission of High Risk NSTEMI

18. HEART Score
score
1. History Highly suspicious for ACS 2
Moderately suspicious for ACS 1
Slightly or non-suspicious for ACS 0
2. ECG Significant ST-depression/T wave inversion 2
Nonspecific repolarisation disturbance 1
Normal 0
3. Age ≥65 years 2
45–65 years 1
≤45 years 0
4. Risk factors ≥3 risk factors, or history of atherosclerotic disease 2
1 or 2 risk factors 1
No risk factors known 0
5. Troponin I ≥ 3 x Normal Limit 2
> 1 - < 3 x Normal Limit 1
≤ Normal Limit 0
TOTAL
Heart ECG Age Risk factors Troponin
PPCI and Direct Admission of High Risk NSTEMI

19. HEART Score- History
• Characterise the patients’ chest pain as typical or atypical
• Typical pain: central or left-sided chest pain with radiation to the arms or
throat, or associated autonomic symptoms.
• Atypical pain Right-sided chest pain, pain that radiated to the back or
worse on inspiration or palpation. Or presentation without chest pain.
2 points if chest pain highly suspicious. i.e. typical pain only
1 point if chest pain moderately suspicious. i.e. elements of both typical and
atypical pain
0 points if chest pain slightly or moderately suspicious i.e. atypical pain only
PPCI and Direct Admission of High Risk NSTEMI

20. HEART Score- Risk Factors
• Diabetes mellitus
• Current or recent (<90 days) smoker
• Hypertension
• Hypercholesterolemia
• Family history of coronary artery disease
• Obesity (estimated BMI >30)
3 or more risk factors or prior coronary revascularisation, myocardial
infarction (MI), stroke, or peripheral arterial disease give 2 points
1-2 risk factors give 1 point
0 risk factors give 0 points
PPCI and Direct Admission of High Risk NSTEMI

21. HEART Score
• Likelihood of MACE within in the next 6 weeks
• Low risk patients have a score 0-3 and have a less than 2% risk of
MACE at 6 weeks.
• All other scores are high risk and require further management and
admission.
• HEART is sometimes compared to GRACE & TIMI scores, these
measure risk of death for patients with ACS, and not who has ACS in
the first place.
PPCI and Direct Admission of High Risk NSTEMI

23. Thank you
frank.hearl@gjnh.scot.nhs.uk
PPCI and Direct Admission of High Risk NSTEMI