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Title of GuidelineAcute Coronary Syndrome/Chest PainContact Name and Job Title (Author)Dr Gohar Rahman, Consultant CardiologistDivision & SpecialtyMedicine/CardiologyGuideline NumberCG15-162Version Number1.1 Amendments July 2016Date of ReviewNovember 2017Approving Committee(s)Medicine Governance & RiskDate of ApprovalNovember 2015Explicit definition of patient group to which it appliesAbstractStatement of evidence base of the guideline
Evidence Base (1-5)
1a
Meta analysis of RCT
1b
At least 1 RCT
2a
At least 1 well designed controlled study without randomisation
2b
At least 1 other well designed quasi experimental study
3
Well designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
4
Expert committee reports or opinions and / or clinical
experiences of respected authorities
5
Recommended best practise based on the clinical
experience of the guideline developer
Nice guidelines, European guideline, RCT PLUS LOCAL CARDIOLOGY DEPARTMENT CONSENSUS.Consultation ProcessCardiology department consensus/approvalTarget AudienceA & E, MAUThis guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
PAGE \* MERGEFORMAT 2
Title of Guideline: Acute Coronary Syndrome/Chest Pain
Date of Review: November 2017
Chest Pain / Discomfort, Arms / Shoulder(s) / Jaw YES (symptoms of Angina Pectoris)
(No other apparent cause excluded by initial evaluation)
(Exclude aortic dissection/trauma or any other apparent cause by clinical evaluation)
Perform initial usual observation/investigation pulse, BP (blood pressure), ECG (electro-cardiogram) (and repeat in 30 minutes), CXR (chest X-Ray), SpO2 (Oxygen saturation), Troponin I, two trop I measurements required, at presentation & 6 hours later. Must be interpreted in the clinical context.
LOW RISK
None of the high/moderate signs and symptoms
MODERATE RISK
Unstable angina (pattern of worsening stable angina, pain at rest/increased frequency and duration)
Pain within 6 weeks of Myocardial Infarction (MI)/revascularisation (pain pattern the same as previous MI)
HIGH RISK
ECG consistent with Myocardial Ischemia/Infarction/Dynamic ST/T wave changes
Elevated trop level (Elevated trop I (33% change between the 2 results, at least one Trop I must be > 40). Absence of significant change exclude acute MI.
Recurrent/persistent chest pain
Haemodynamic instability
Arrhythmia (sustained Ventricular Tachycardia)
Pulmonary oedema
Discharge
But risk factors for CAD (coronary Artery Disease) ( Ref to cardio OPD or angina specialist nurse (Jane Caton)
Admit, Cardiology Review for further decision
Admit to CCU / cardiology ward
Urgent cardiology review.
Please also refer to grace score for stratification - use this link (Ctrl + Click link):
HYPERLINK "https://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html" https://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html
Medications
Load aspirin 300milligrams if not already done (Contra Indications (C.I.) active Gastro Intestinal bleeding)
Clopidogril 300 milligrams or
Ticagrelor 180 milligrams if no C.I. like cerebral bleed, moderate/severe liver disease or taking clarithromycin or ketoconazole.
GTN spray followed by infusion if needed
Diamorphine, Oxygen supplements, Statin (dose depends on EGFR (Renal function & Glomerulo Filtration rate), Beta Blocker (if no C.I.), ACEI (Angiotension Converting Enzyme Inhibitors), Fondaparinux 2.5milligrams s/c (subcutaneous)
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