Download Management of Acute Coronary Syndrome / NSTEMI

CLINICAL GUIDELINE
CG10201-1
Management of Acute Coronary Syndrome / NSTEMI
For use in (clinical areas):
All clinical areas
For use by (staff groups):
Medical and Nursing Staff
For use for (patients):
Possible Cardiac Chest Pain/ACS
Document owner:
Dr Ajit Agarwal
Status:
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:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 1 of 7
West Suffolk Hospitals NHS Trust
CG10201-1
Trust Guidelines Template
Pathway for the management of acute coronary syndromes (ACS)
Suspected cardiac
chest pain
12 lead ECG
IMMEDIATELY
Consider Urgent
Referral for PPCI at
Papworth
Changes suggestive
of NEW STEMI or
LBBB
or THROMBOLYSIS
GTN S/L, O2 100% - Refer to O2 guideline if
saturations <94%, Aspirin & Clopidogrel
300mg PO stat unless given pre-hospital,
Fondaparinux 2.5mg S/C
NEW Changes
indicative of
NSTEMI / ACS
Secure IV access
and Px morphine /
diamorphine IV
and cyclizine /
metocolpramide
PRN
Trop. T –ve
(CCU or ED)
see PPCI pathway on
Pink Book
Complete Grace score if
Troponin T level available
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
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
1-3% (low risk) & pain
free transfer to G3 –
repeat ECG
Ischaemic ECG
Or
On-going pain
Troponin T level 12
hours after onset of
symptoms
and
High –risk patient
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
Ongoing or recurrent
chest pain:
give analgesia / antiemetics as required and
start GTN IV infusion
transfer to CCU for
continuous ECG
monitoring
>3% (high risk)
admit to CCU
• 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
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:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 2 of 7
West Suffolk Hospitals NHS Trust
CG10201-1
Trust Guidelines Template
Pathway for anti-platelet therapy in patients taking warfarin prior to
admission
Warfarin used for AF / VTE:
Suspected ACS
Warfarin used for valve
prosthesis:
STAT doses of each:
•
Aspirin 300mg PO
•
Clopidogrel 300mg PO
•
Fondaparinux 2.5mg SC
STAT doses of each:
Withhold warfarin
Trop. T 12 hours after
onset of pain
•
Aspirin 300mg PO
•
Clopidogrel 300mg PO
•
Continue warfarin
If INR 2 the give additional
fondaparinux 2.5mg SC OD
until INR therapeutic
If > 30ng/L and
diagnosis of ACS
confirmed
Prescribe the following regularly:
Prescribe the following regularly:
•
Aspirin 75mg PO OD
•
Continue warfarin
•
Clopidogrel 75mg PO OD
•
Aspirin 75mg PO OD
•
Fondaparinux 2.5mg SC OD for up to
8/7 or hospital discharge
•
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:
On discharge:
Aspirin 75mg PO OD
Clopidogrel 75mg PO OD
for 1-6 months depending
upon bleeding risk
Warfarin - continue
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:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 3 of 7
West Suffolk Hospitals NHS Trust
1.
CG10201-1
Trust Guidelines Template
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 O2 saturations <94% see O2 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, SaO2, 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:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 4 of 7
West Suffolk Hospitals NHS Trust
2.
3.
CG10201-1
Trust Guidelines Template
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.
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
4
Blood should also be taken for: FBC, U&E, Glucose, lipids & LFT
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:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 5 of 7
West Suffolk Hospitals NHS Trust
CG10201-1
Trust Guidelines Template
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
Source:
Status: Approved
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
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 6 of 7
West Suffolk Hospitals NHS Trust
CG10201-1
Trust Guidelines Template
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):
Dr Ajit Agarwal
Approved by:
AKA
Issue no:
Source:
Status: Approved
Issue date: 5th March 2012
Valid until: 5th March 2014
Page 7 of 7