The Chest Pain Pathwayfor Acute Coronary Syndromes

Sir Charles Gairdner Hospital

Reviewed and agreed to by: HODs of Cardiology, Emergency Medicine,

Medical Assessment Unit, Clinical Biochemistry

2015, for review 2018Dr James Rippey

SCGHEDCodeSTEMIProtocol

IsitanacuteSTEMI?

Pain<12/24

ECGchangesconsistentwithSTEMI• STelevation>1mmin2contiguouslimbleadsor• STelevation>2mmin2contiguouschestleads

Doesitmeetcriteriatoactivate“CODESTEMI”?

Inclusioncriteria• Symptomonset<12hours• <85years• Ongoingpain• Mobileandindependent

Exclusioncriteria–fordiscussion

• >85years• LBBB• PriorCABG• Significantcomorbidities• Outofhospitalcardiacarrest• Pulmonaryoedema• Cardiogenicshock• Recentmajorsurgery(<2/52)• Activebleeding

EDconsultant/nightSRdiscusswithon-callGeneralCardiologist

(notcardiologyregistrar)

Isprimaryinterventionappropriate?

MedicalManagementEDconsultant/nightSR

DIAL55State“CODESTEMIEDnow”

Activate“CODESTEMI”whereappropriate

PatientpreparationinED

· Aspirin 300mg

· Ticagrelor 180mg or o If contraindicated

Prasugrel 60mg or

o If contraindicated

consider Clopidogrel

600mg

· Heparin 5000 IU IV

· Prepare for transfer

ContraindicationstoP2Y12inhibitors· Active bleeding

· Allergy

Ticagrelor:· Heart rate <50 bpm

· Chronic dyspnoea

· History ICH / TIA / Stroke

Prasugrel:· Weight < 60kg

· Age > 75 yrs

· History ICH / TIA / Stroke

Clopidogrel

· History ICH

TransfertoCathLab(CVIL)

NoYes

Suitableforrapidtransfer· Transfer with ED RN and ED Dr

· Work hours 0730-1700, transfer

without delay

· After hours, transfer 10 minutes

after Code STEMI activation

· Record time of arrival on ECG

· ED staff to stay with patient

until appropriate CVIL team

members arrive

Notsuitableforrapidtransfer· Notify cardiology registrar

· Remain in ED until appropriate

CVIL team members arrive and

call for patient

· Transfer to CVIL with ED RN

and cardiology registrar

SirCharlesGairdnerHospitalEmergencyDepartment

ChestPainDischargeAdviceSheet

LowRiskAcuteCoronarySyndromeGroup

YouhavebeenreviewedintheEmergencyDepartmentatSirCharlesGairdnerHospitalafterpresentingwithchestpain.Afterconsideringyourhistory,yourriskfactors,yourECGandyourbloodtests(troponin),youhavebeenfoundtobeatverylowrisk(around1in100)ofhavingamajoradversecardiacevent(likeaheartattack)inthenearfuture.Inthe“lowrisk”group,therisksofdoingfurthertestsandtreatmentasaninpatientoutweighthebenefits.Inmanypatientsinthelowriskgroupfurthertestsofanysortareunnecessary,howeveryoushoulddiscussthisfurtherwithyourgeneralpractitionerwhowillunderstandyourmedicalandpersonalbackgroundbetter.Becausewecanneverdeclareyouat“norisk”wewouldsuggest:

1. Returningformedicalreviewifyouhavefurtherepisodesofchest/armpainorotherconcerningsymptomslikedizziness,collapse,palpitationsorshortnessofbreath

2. Followingupwithyourlocaldoctorwhoconsidertheneedforfurthertestingandwillalsoensurethatanymodifiableriskfactorsyoumayhaveforheartdiseaseareoptimallymanaged.Thesemayinclude:

i. Stoppingsmokingii. Treatinghighbloodpressure

iii. Managinghighcholesterolleveliv. Managingdiabetesv. Increasingexerciseandmanagingyourdiet

IfyouhavefurtherquestionsaboutwhatthismeanspleasediscusswiththedoctorslookingafteryoubeforeyouleavetheEmergencyDepartment,orwithyoulocalgeneralpractitioner.

SirCharlesGairdnerHospitalEmergencyDepartment

ChestPainDischargeAdviceSheet

LowRiskAcuteCoronarySyndromeGroup

YouhavebeenreviewedintheEmergencyDepartmentatSirCharlesGairdnerHospitalafterpresentingwithchestpain.Afterconsideringyourhistory,yourriskfactors,yourECGandyourbloodtests(troponin),youhavebeenfoundtobeatverylowrisk(around1in100)ofhavingamajoradversecardiacevent(likeaheartattack)inthenearfuture.Inthe“lowrisk”group,therisksofdoingfurthertestsandtreatmentasaninpatientoutweighthebenefits.Inmanypatientsinthelowriskgroupfurthertestsofanysortareunnecessary,howeveryoushoulddiscussthisfurtherwithyourgeneralpractitionerwhowillunderstandyourmedicalandpersonalbackgroundbetter.Becausewecanneverdeclareyouat“norisk”wewouldsuggest:

1. Returningformedicalreviewifyouhavefurtherepisodesofchest/armpainorotherconcerningsymptomslikedizziness,collapse,palpitationsorshortnessofbreath

2. Followingupwithyourlocaldoctorwhoconsidertheneedforfurthertestingandwillalsoensurethatanymodifiableriskfactorsyoumayhaveforheartdiseaseareoptimallymanaged.Thesemayinclude:

i. Stoppingsmokingii. Treatinghighbloodpressure

iii. Managinghighcholesterolleveliv. Managingdiabetesv. Increasingexerciseandmanagingyourdiet

IfyouhavefurtherquestionsaboutwhatthismeanspleasediscusswiththedoctorslookingafteryoubeforeyouleavetheEmergencyDepartment,orwithyoulocalgeneralpractitioner.

Low risk

GP consider further investigation

Come back if concerns

Manage risk factors

Feedback:

Dr James RippeyCall via switchboard