State of Queensland (Queensland Health) 2015
Licensed under: http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en
Contact: Clinical_Pathways_Program@health.qld.gov.au
(Affix identification label here)
URN:
Possible Cardiac Chest Pain
Clinical Pathway
Facility:
.........................................................................................................
Family name:
Given name(s):
Address:
Date of birth: Sex:
Clinical pathways never replace clinical judgement
Care outlined in this pathway must be altered if not clinically appropriate for the individual patient
Document all variances in patient notes
Presentation time / date: ......... : .........
POSSIBLE
CARDIAC
CHEST PAIN
and / or
(e.g. diaphoresis,
sudden orthopnea,
syncope, dyspnoea,
epigastric discomfort,
jaw pain, arm pain)
Consider:
Atypical
Presentations
(e.g. diabetes, renal
failure, female, elderly
or Aboriginal /
Torres Strait Islander)
TRIAGE
CATEGORY 2
Always consider other
critical causes
(e.g. Aortic Dissection,
Pulmonary Embolism)
v1.00 - 05/2015
Do not use this pathway
if a non-ACS cause for
chest pain can
be diagnosed.
ECG* and vital signs
reviewed by Senior
MO within 10 mins
Symptom onset time / date: ......... : .........
ST-ELEVATION OR (presumed new) LBBB
NO
1. Confirm Indications for Reperfusion
Review time: ......... : .........
Chest pain >30 min and <12 hours
Right-sided ECG
(V4R) if inferior
ST-elevation present
*Contact cardiology
referral service if ECG
advice required
.......... / .......... / ..........
NO
TO
ANY
Persistent ST-elevation 1 mm in 2 contiguous limb leads
or persistent ST-elevation 2 mm in 2 contiguous chest
leads or new or presumed new LBBB
Myocardial infarct likely from history
2. Choose Reperfusion Method
General management:
Aspirin
Primary PCI
If possible within 90 mins
of first medical contact
urgently contact the on-call
interventional cardiologist
Nitrates S/L or IVI
IV access
Pathology, including
Troponin, on
admission
NO
Exit this pathway
and commence
Thrombolysis
for STEMI
Clinical
Pathway
Notify Retrieval Services
Queensland (1300 799 127)
for immediate transfer to
interventional cardiac facility
Pain relief
Continuous Cardiac
Monitoring
OR
Transfer to on-site Cardiac
Catheter Lab as directed
Oxygen if SpO2
<93% or evidence of
shock
Thrombolyse
(if appropriate)
within 30 mins
of first medical
contact
3. Administer Antithrombotic Therapy
Confirm administration or give:
Chest X-ray
Aspirin 300 mg (soluble)
Repeat ECG if
recurrent chest pain
Ticagrelor 180 mg (or alternative if advised by
interventional cardiologist)
Frequent
observations
Enoxaparin or Unfractionated Heparin (confirm with
interventional cardiologist)
Prepare for urgent MEDEVAC transfer OR
Possible:
NON ST-ELEVATION ACUTE CORONARY
SYNDROME (NSTEACS)
Admit to Coronary Care Unit post primary PCI
Accepting Cardiologist
SW574
SW574%
Dr: .........................................................................................................................................
RISK STRATIFY ACS
Medical staff to complete Risk Stratification
on reverse of this form
Referral time: ......... : ......... Facility: ....................................................................
Treating Emergency Medical Officer
Dr: ............................................................................................. Initial: .........................
Follow local referral and / or transfer processes
Signature Log Every person documenting in this pathway must supply a sample of their initials and signature below
Initials
Signature
Print name
Role
Initials
Page 1 of 2
Signature
Print name
Role
Possible Cardiac Chest Pain Clinical Pathway
Do Not Write in this binding margin
OTHER
SYMPTOMS of
MYOCARDIAL
ISCHAEMIA
.......... / .......... / ..........
(Affix identification label here)
URN:
Possible Cardiac Chest Pain
Clinical Pathway
(For use in non-ACRE facilities only)
Facility:
.........................................................................................................
Family name:
Given name(s):
Address:
Date of birth: Sex:
Clinical pathways never replace clinical judgement
Care outlined in this pathway must be altered if it is not clinically appropriate for the individual patient
All variances must be clearly documented in the patient's clinical progress notes
High Risk NSTEACS
EMERGENCY DEPARTMENT
Commence ACS pathway
Do not use this pathway if a non-ACS cause for
chest pain can be diagnosed. Manage as per
diagnosis.
Continuous cardiac monitoring
Admit to appropriate cardiac monitored unit (e.g. CCU / HDU)
HIGH RISK FEATURES - Clinical features
consistent with ACS and any of the following:
Repetitive or prolonged (>10 mins) ongoing
chest pain or discomfort
Elevated Troponin
Notify cardiology referral service for consideration of next
day transfer to interventional cardiac facility for angiography
(immediate transfer if clinically unstable)
YES
TO
ANY
Persistent or dynamic ECG changes of
ST-segment depression 0.5mm or new T-wave
inversion 2mm
RE-STRATIFY
Admit to: ........................................................................................................................
Regular vital observations
Sustained ventricular tachycardia
Repeat ECG and Troponin at 36 hours (OR 68 hours for
point-of-care test)
Does not require continuous cardiac monitoring if first (0 hour)
Troponin negative, ECG normal, and no further chest pain
Syncope
Left ventricular systolic dysfunction (left
ventricular ejection fraction <0.40), and / or
clinical evidence of heart failure
INTERMEDIATE / LOW RISK FEATURES Clinical features consistent with ACS and
any of the following:
Resolved chest pain or discomfort within the
past 48 hours that occurred at rest, or was
repetitive or prolonged (>10 mins)
Age >65 years
Diabetes with typical or atypical symptoms
of ACS
Chronic kidney disease (eGFR <60 mL / minute)
with typical or atypical symptoms of ACS)
Known Coronary Artery Disease (CAD) or
previous Myocardial Infarction (MI)
Two or more of the following risk factors: known
hypertension, family history, active smoking or
hyperlipidaemia
MO review following repeat ECG and Troponin
YES
TO
ANY
Manage as HIGH RISK if YES to any:
Positive Troponin
New ECG changes
Recurrent chest pain or develops other high risk features
NO TO ALL
Consider direct cardiology referral if known CAD and
presents with typical symptoms of unstable angina OR
TIMI risk score
Refer for appropriate
diagnostic testing:
Age 65 years
3 CAD risk factors
Known CAD (stenosis 50%)
ASA use in past 7 days
Recent (24 hours)
severe angina
Troponin
ST deviation 0.5mm
If TIMI risk score 0
Discharge and refer for OPD
Exercise Stress Test (EST)
or alternative testing within
14 days
If TIMI risk score 14
Refer for urgent in-patient
EST or alternative testing
TIMI risk score
(add up ticks)
Prior regular aspirin use
Recent onset of crescendo or unstable
angina symptoms
NO TO ALL
Discharge home if repeat ECG normal, Troponin
negative at 36 hours (or 68 hours if using
point-of-care testing), and no further chest pain
DISCHARGE HOME:
Chest Pain Action Plan given to patient
Aspirin (if appropriate)
Investigations plan (if applicable)
Cardiology OPD follow up (if appropriate)
GP follow up for risk factor modification
Discharge summary / referral letter
Follow local referral and / or transfer processes
Page 2 of 2
Do Not Write in this binding margin
Transfer to another health care facility if required
Haemodynamic compromise - systolic
blood pressure <90mmHg, cool peripheries,
diaphoresis, Killip Class >1, and / or new-onset
mitral regurgitation
NO TO ALL
Time: ......... : .........
Discussed with: .........................................................................................................
(accepting Cardiologist / Cardiology Registrar)
Transient ST-segment elevation ( 0.5mm) in
more than two contiguous leads
Prior percutaneous coronary intervention
within 6 months or prior coronary artery
bypass surgery
Referral date: ......... / ......... / .....................
