GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH NON … · ∗ Acute ST segment elevation MI (STEMI)...

Produced by the South East Wales Cardiac Network (based on a document developed by the North Wales Cardiac Network in association with Merseyside and Cheshire Cardiac Network)

GUIDELINES FOR THE MANAGEMENT OF

PATIENTS WITH NON-ST SEGMENT ELEVATION

ACUTE CORONARY SYNDROME (NSTEACS)

INCLUDING UNSTABLE ANGINA AND NON-Q WAVE MYOCARDIAL INFARCTION

August 2008 Review date August 2009

(original version December 2007)

_____________________________________________________________________________________________________ South East Wales Cardiac Network of 24 Guidelines for the Management of patients with NSTEACS v5 – August 2008

CONTENTS PAGE Non-St Segment Elevation Acute Coronary Syndrome (NSTEACS) Guideline Pathway 3 Introduction 4-6 Management of Unstable Angina and Non-St Elevation MI

1. Initial Risk Stratification 7-8

2. Initial Medical Management 9-12

3. Later Risk Stratification 13

4. Later Medical Management > 12 hours 14

5. Role of Coronary Angiography – who, when and where? 15-16

6. Arrangements for inpatient transfer to UHW 17-19 References 20 Appendices Appendix 1 – Clinical Features to Classify Chest Pains 21 Appendix 2 – Risk Score Sheet See Separate Document Appendix 3 – Two Page Transfer Check See Separate Document Appendix 4 – DGH Link Cardiologists/Senior Nurse Champions 23-24


NSTEACS

(suspected /probable/definite)

Initial risk stratification-

use SCORE SHEET

> 6 3 - 6 < 3

aspirin, clopidogrel, statin,

LMWH, beta blockers, nitrates,

(consider GPIIb/IIIa)

aspirin, clopidogrel,

statin, LMWH, beta

blockers, nitrates

aspirin, clopidogrel,statin,

LMWH, beta blockers, nitrates

FBC, U&E, LFT, lipids,

random blood sugar, chest

Xray, TnT/I

secondary prevention -

initiate aggressive

management

of risk factors ASAP

Later risk stratification >12 hrs post onset-include repeat TnT/I result if earlier

result <12hours. USE SCORE SHEET.

use SCORE SHEET

< 33 - 6> 6

continue aspirin

statins and

other cardiac

drugs as

indicated (stop

clopidogrel)

continue aspirin,

clopidogrel, statins,

LWMH, beta blockers,

nitrates (consider

GPIIb/IIIa)

consider suitability for coronary angiogram,check patient preference (if greater than or equal to 8 and out of hours liase directly with on call cardiology UHW)

continue aspirin,

clopidogrel, statins,

LMWH, beta blockers,

nitrates (consider

GPIIb/IIIa)

consider coronary

angio.within

current hospitalisation

liaise with local cardiologist re.

coronary angio.

coronary angio.

not indicated -

consider

further

assessment

complete TRANSFER CHECKLIST and fax

to UHW with SCORE SHEET (review 'transfer crew' as per protocol)

agree transfer

to UHWconsider coronary

angio.in DGH setting

further ECG for dynamic or

sequential changes,

fasting blood sugar,

HbA1c if random glucose raised

NON-ST SEGMENT ELEVATION ACUTE CORONARY SYNDROME (NSTEACS) GUIDELINE PATHWAY


GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH NON-ST SEGMENT ELEVATION ACUTE CORONARY SYNDROME

(NSTEACS) INCLUDING UNSTABLE ANGINA AND NON-Q WAVE MYOCARDIAL INFARCTION

These guidelines represent the views of the South East Wales Cardiac Network, which were arrived at after consideration of the available evidence1-3

and the development of consensus by representatives of the four NHS Hospital Trusts in South East Wales. They have been based on the guidance developed by the North Wales Cardiac Network in association with the Cheshire and Merseyside Cardiac Network. The guidelines do not override the responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient in consultation with the patient and/or guardian or carer. They are intended to facilitate the optimal management of all those patients with NSTEACS in an equitable fashion across SEWCN. More specifically, the risk scoring system has been developed to support the prompt and appropriate selection of those patients that require an invasive strategy to deal with their condition and to ensure that all the necessary information is made available to facilitate the transfer of these patients. The accompanying document is intended to provide updated management guidelines for NSTEACS (UAP and NSTEMI) which are largely consistent across the SEWCN. For more detailed guidance we recommend the use of the ESC guidelines. It is essential that operation of the guidelines in day to day practice is properly evaluated and so health professionals are asked to complete the score sheet on ALL patients with a diagnosis of suspected, probable or definite NSTEACS and to complete the transfer checklist for those patients transferred to a tertiary centre. The ORIGINALS of both documents should be submitted to the locally agreed ACS collection point (for review by each referring hospital’s ACS coordinator) and copies kept in the patient’s case notes.

INTRODUCTION

• The “acute coronary syndromes” (ACS) represents a spectrum of conditions, which include

∗ Unstable angina (UAP)

∗ Non-ST segment elevation myocardial infarction (NSTEMI)

∗ Acute ST segment elevation MI (STEMI)

• The term non-ST elevation acute coronary syndrome (NSTEACS) is often used to cover both UAP and NSTEMI

• Although these conditions share a common pathophysiology and present in a similar way, the treatment of UAP and NSTEMI is different from that for STEMI.


DIAGNOSIS Diagnosis is based on the clinical history, examination, admission (or subsequent) 12 lead ECG and cardiac Troponin levels. Various imaging tests can help by identifying myocardial perfusion or wall motion abnormalities. HISTORY Patients with NSTEACS usually present with one of the following patterns of symptoms. i) New onset (<2 months) of severe angina (CCS# Class III or IV) ii) Abrupt worsening of previous angina, with symptoms becoming more frequent,

more severe or prolonged (>15 minutes) and less responsive to nitro-glycerine (crescendo pattern)

iii) Prolonged angina occurring at rest iv) Post Percutaneous Coronary Intervention (PCI) or in the first few days after a

previous MI ECG The ECG may be NORMAL or may show:

- ST segment depression - Transient ST segment elevation that resolves spontaneously or after GTN - T wave inversion - Evidence of previous MI - Old left bundle branch block - Minor non-specific changes

But should not show persistent acute ST segment elevation. Continuous ECG ST segment monitoring can provide additional information on diagnosis and risk assessment.

CONVENTIONAL CARDIAC ENZYMES Conventional cardiac enzymes (CK, CK-MB, AST, LDH) may be normal or elevated. TROPONIN LEVELS Detection in the blood of elevated Troponin T (or I) concentrations is highly specific for myocardial damage and identifies patients at high risk of complications. See Table 1.

• Troponin T or I quantitative assessment is the method of choice for the detection of myocardial injury in patients with ACS and should be available in all hospitals managing such patients.

• Normal or undetectable Troponin levels 12 hours after the onset of symptoms exclude an acute MI and suggests a low risk of early complications.

# Canadian Cardiovascular Society Classification


• Troponin T levels are used throughout these guidelines. Equivalent Troponin I levels have been provided for the Gwent Healthcare Trust and at the Royal Glamorgan Hospital.

• A Troponin T or I should be done a minimum of 12 hrs after the onset of the index symptoms. If the patient is initially assessed < 12 hours post onset of index symptoms an earlier TnT/I may be taken according to local practice but this should be in addition to and not instead of the ≥12 hours sample.)

• A conventional cardiac enzyme (e.g. CK-MB) should be substituted in cases of suspected re-infarction occurring within 2 weeks of a proven acute MI.

Table 1

CTnI (Gwent) CTnI (RGlH)

CTnT ≥ 0.20 ≥0.36 ≥0.68 Consistent

with NSTEMI

CTnT ≥ 0.10 but <0.20

≥0.18 but <0.36 ≥0.35 but <0.68 Consistent with high risk ACS

CTnT ≥ 0.07 but <0.10

≥0.13 but <0.18 ≥0.25 but <0.35 Consistent with low-medium risk ACS

CTnT ≥ 0.03 but <0.07

≥0.08 but <0.13 ≥0.11 but <0.25 Consistent with low-medium risk ACS

CTnT < 0.03

<0.08 <0.11 Normal or consistent with low risk ACS

INITIAL CLASSIFICATION a) Patients presenting with symptoms consistent with an acute coronary syndrome

require urgent cardiac assessment including history and examination (See Appendix 1: Clinical Features to Classify Chest Pain).

b) All patients should have a 12 lead ECG performed immediately on arrival

or as soon as possible thereafter.

• Patients whose ECG shows persistent ST segment elevation or acute Q wave MI should be managed using the guidelines for STEMI including consideration of thrombolysis or primary PCI and not these guidelines for NSTEACS.

• Patients thought to have non-cardiac diagnoses should be managed appropriately and not using these guidelines for NSTEACS.


MANAGEMENT OF UNSTABLE ANGINA AND NON-ST ELEVATION MI

Once a diagnosis of suspected, probable or definite NSTEACS has been reached it is important to initiate a management plan as soon as possible since time to onset of treatment affects outcome for NSTEACS. The optimal management of NSTEACS will vary considerably from patient to patient. It is important therefore to consider the following steps in every patient in order to obtain an appropriate individual management plan: -

1. Initial Risk Stratification 2. Initial Medical Management 3. Later Risk Stratification 4. Later Medical Management 5. Role of Coronary Angiography 6. Arrangements for In-Hospital Patient Transfer to UHW

1 INITIAL RISK STRATIFICATION

1.1 Purpose

ACS is a spectrum of conditions of varying prognosis. Overall, the risk of death or of a further infarct in patients presenting with NSTEACS is about 10% during the first 30 days whilst an additional 35-50% will experience recurrent ischaemia despite medical therapy. However, within this heterogeneous group of NSTEACS patients, there is a wide variation in the 30-day event rate ranging from 1-20%. Appropriate treatment depends on an individual’s risk status. It is thus important to risk-stratify ACS patients as soon as possible to allow the earliest possible treatment.

1.2 Risk Assessment Scoring Tool

We have adopted the Cheshire and Merseyside Cardiac Network Task Group risk scoring scheme. This has been presented at national meetings and subjected to rigorous audit. The relevant risk indicators and appropriate scoring are shown in Table 2, overleaf. Initial risk stratification may occur before TnT/I results are available. Table 2 should be used but omitting a score for TnT/I at this stage.


Table 2 RISK STRATIFICATION

EVENT-RELATED RISK INDICATORS

Score

1. Initial risk stratification: Ischaemic chest pain ongoing or recurrent on arrival

Later risk stratification: Ischaemic chest pain ongoing or recurrent despite conventional in-hospital medical management

3

2. Haemodynamic instability identified by a minimum of one of the following:

� Systolic blood pressure < 90, not associated with bradycardia or hypovolaemia

� Persistent sinus tachycardia (Heart Rate ≥ 100) � Unequivocal acute pulmonary oedema, usually demonstrated

radiologically � Sustained ventricular tachycardia or recurrent ventricular fibrillation

in the setting of acute ischaemia

3

3. ECG: � Unequivocal, ST-segment depression ≥ 1 mm in two or more

contiguous leads which is new and either persistent or transient � Or transient ST-segment elevation ≥ 1mm in two or more

contiguous leads � Or deep symmetrical T wave inversion ≥ 3 mm in anterior leads

which is new and persistent

3

4. Troponin T level (see table 1 for equivalent CTnI levels) � ≥ 0.20 � ≥ 0.10 but <0.20 � ≥ 0.07 but <0.10 � ≥ 0.03 but <0.07

If other serum markers are used the local laboratory and cardiology services should produce a table of values equivalent to those of Troponin T

4 3 2 1

PRE-EXISTING RISK INDICATORS

1 Age over 65 years 0.5 2 Diabetes mellitus 1 3 CAD Risk factors: a minimum of two of the following present � Family history of ≥ 1 first degree relative ≤ 65 years old � Cigarette smoker or ex-smoker < 1 year � Hypertension � Dyslipidaemia � Remote STEMI > 3 months � Significant peripheral vascular disease � Chronic renal impairment (creatinine >200umol/l)

0.5

4 History: a minimum of one of the following � Previous CABG � PCI within the last 7 days � NSTEACS within previous 3 months

1

5 Pre-existing left ventricular dysfunction 0.5 For sample of actual Risk Stratification Score Sheet, see Appendix 2.


2 INITIAL MEDICAL MANAGEMENT

2.1 Initial Investigations

• FBC, U&E, LFT, Lipids

• Random blood sugar

• Chest X-ray

• Troponin T/I when ≥ 12 hours post onset of index symptoms. If the patient is initially assessed < 12 hours post onset of index symptoms an earlier TnT/I should be taken but this should be in addition to and not instead of the ≥ 12 hours sample.)

2.2 Menu Of Available Medical Treatments

Currently available treatments that may be considered in the management of NTEACS fall into three categories as listed below: -

Anti-thrombotic - • Aspirin

• Heparin (LMWH) • Clopidogrel • GPIIb/IIIa platelet inhibitors • Factor Xa inhibitors • Direct thrombin inhibitors

Anti-ischaemic - • Nitrates (IV, SC, buccal) • Beta blockers • Calcium antagonists • Nicorandil • Ivabradine

Other Drugs - • Statins • ACEI • Omacor

It is important to tailor the treatment regime to an individual patient. It should be based primarily on risk status but also take into account relevant patient factors, such as co-morbidity, bleeding risk, contra-indications and patient preference. Indications and dosages for the key individual treatments are:

• Summarised in relation to risk status in Section 2.3.

• Detailed in Sections 2.4 to 2.6.

• Placed in overall context in the Flow Diagram on page 1. 2.3 Drug Choice Based On Risk Status

The patient’s risk score, according to Table 3 below, should be the major factor in determining the initial choice of drug regime.


Table 3 MEDICATION AFTER INITIAL ASSESSMENT Total risk score

Medication

>6

Aspirin, clopidogrel, statins, low molecular weight heparin (LMWH)# beta blockers * and nitrates PLUS consideration of small molecule GP IIb/IIIa inhibitors

3-6

Aspirin, clopidogrel, statins, LMWH, beta blockers* and nitrates

<3

Aspirin, clopidogrel, statins, LWMH, beta blockers* and nitrates

*Substitute diltiazem or verapamil in the absence of heart block if beta blockers are contra-indicated # The European Guidelines1 recommend that in the setting of initial medical management the use of LMWH is preferable to the use of unfractionated heparin. The Task Group supported this approach in the belief that the use of LWMH should allow a more predictable effect.


2.4 Anti-thrombotic Agents Table 4 ASPIRIN ALL PATIENTS should receive dispersible aspirin 300 mg orally stat as

soon as NSTEACS is suspected, followed by 75 mg daily unless

• The patient is genuinely intolerant of aspirin defined as: - proven hypersensitivity to aspirin-containing medicines - history of severe dyspepsia induced by low-dose aspirin despite gastro-protection

• The patient has a history of - active or recent PU - previous GI bleed NOTE: - Quiescent, old or operated PU, mild dyspepsia, hiatus hernia, or vague indigestion are insufficient reasons to deprive patients of this life saving drug.

HEPARIN ALL PATIENTS with no contraindications should receive SC LMWH (Clexane, enoxaparin) 1mg/kg bd for a minimum of 48 hrs but aiming to continue for 24 hrs after the patient has become pain free. It may be required for >1 week when pain is recurrent, where there is extensive anterior ischaemia/infarction or where myocardial revascularisation is planned but delayed. The dose of enoxaparin should be adjusted beyond 48 hour use in those with significantly impaired renal function (estimated GFR <80m l/min). It is generally recommended that the dose of enoxaparin is reduced by 0.1mg/kg for every 10 ml/min fall in eGFR below 80 ml/min.

CLOPIDOGREL (note – role of new thienopyridines eg. prasugrel and cangrelor, incompletely defined)

In combination with aspirin, this antiplatelet agent has shown significant benefit over aspirin alone for patients with unstable coronary artery disease (CURE study4). However, not all patients benefit equally and so in line with NICE Guidelines5, its use is recommended as indicated below: INSTEAD of aspirin for those NSTEACS patients who are genuinely intolerant of aspirin (see above). IN ADDITION to aspirin for • High and very high risk patients (>3) When appropriately indicated as above, clopidogrel should be given as an initial 300 mg oral dose followed by 75 mg orally daily. This should continue in the absence of side effects for a maximum of 12 months at which point it should usually be stopped and dispersible aspirin alone continued.

GPIIb/IIIa INHIBITOR

Clinical trials and recent NICE Guidelines6 indicate that a small molecule agent should be considered for all high risk NSTEACS patients but in particular, those with continuing or recurrent pain. Greatest benefit occurs when patients: • Can be treated early i.e. within a few hours of pain onset • And/or have a TnT raised ≥ 0.1 • And/or are planned to undergo early PCI The upstream use of tirofiban pre-transfer to UHW should be directed by the interventional cardiologists accepting the patient.

WARFARIN If the patient is already being treated with warfarin, anti-thrombotic management should be discussed with a senior medical colleague.

Factor-Xa inhibitors (fondaparinux)

Role locally not established but may have a role in the non-urgent situation ‘early invasive or conservative’ strategy but not the ‘urgent invasive’ strategy (see ESC guidelines). Has been incorporated in recently published guidance by SIGN as alternative to LMWH.

Direct thrombin inhibitors (bivalirudin)

Role locally not established but may have a role in the ‘urgent invasive’ strategy (see ESC guidelines).


Anti-ischaemic Agents Table 5

NITRATES Should be given initially buccally, IV or sublingually, as appropriate, to relieve pain due to ischaemia. They have no benefit on event rate, or mortality. Subsequently, oral nitrates can be used for continuing angina.

BETA BLOCKERS (B- blockers)

Should be given IV and/or orally to relieve pain and ischaemia provided there are no contra-indications such as heart failure, hypotension (SBP <100mm Hg), excessive bradycardia (<60 bpm), asthma or PVD. In addition to symptomatic benefit, B-blockers (particularly when initiated early IV) may improve prognosis.

CALCIUM BLOCKERS

Should be used in the following circumstances: - IN ADDITION to B-blockers if further angina or ischaemia occurs or if hypertension persists. INSTEAD of a B-blocker if the latter is contra-indicated. Substitute diltiazem or verapamil in the absence of heart block

POTASSIUM CHANNEL OPENER

Nicorandil 20 mg bd orally has been shown to significantly reduce transient ischaemia, SVT and VT compared to placebo when added to standard therapy. It may therefore be added to nitrates, B-blockers and calcium blockers if there is recurrent ischaemia or angina, although it should be realised that this is currently an unlicensed indication in unstable angina.

IVABRADINE Selectively inhibits the primary pacemaker current in the sinus node and may be used in patients with beta blocker contraindications. Role not been fully established in the setting of a NSTEACS.

2.5 Other Drugs Table 6

STATINS Patients who have experienced an ACS benefit from an intensive early lipid- lowering ‘statin regimen.7 This is supported by recently published NICE guidance.8 Referring hospitals in SEW have different local ‘statin policies.

ACE INHIBITORS (ACEIs)

These agents are of proven prognostic benefit for STEMI especially where the MI is large, anterior or has resulted in moderate-severe LV dysfunction or clinical heart failure. No such evidence exists specifically for NSTEACS. ACEI use is, however, appropriate in NSTEACS as follows: • Where co-existing hypertension, LV dysfunction or clinical

heart failure exists. • As part of secondary prevention using ramipril as per the

HOPE9 study or perindopril as per the EUROPA10 study • Where NSTEACS occurs in a patient with diabetes The use of angiotensin antagonists (ARB) for ACEI intolerant patients has also not been clearly defined in patients with NSTEACS but trial evidence supports the use of valsartan for post-MI patients with LV dysfunction (VALIANT)11 and telmisartan for ‘high risk’ patients, as in the HOPE trial (ONTARGET)12.


3 LATER RISK STRATIFICATION

3.1 Purpose

To refine the initial risk stratification (Section 1) in the light of the results of the TnT/I test and hence to help determine further management.

3.2 Risk Assessment Scoring Tool

The same tool should be used as in Section 1.2 and Table 2 but can now be utilised fully by incorporating a score for the TnT/I.


4 LATER MEDICAL MANAGEMENT >12 hours

4.1 Further investigations

∗ Fasting blood sugar and HbA1c if random glucose raised

∗ Second or further ECG to identify dynamic or sequential changes

4.2 Drug choice based on refined risk score The drug combination initially chosen should be reconsidered in the light of the fuller risk assessment undertaken following the Troponin estimation (Introduction, page 3). Continuing therapy should be modified as indicated in the Table 7 below.

Table 7

MEDICATION AFTER LATER RISK ASSESSMENT Total risk score Medication

>6

Continue aspirin, clopidogrel, statins, LMWH, beta blockers* and nitrates (Continue/initiate small molecule GP IIb/IIIa inhibitors as directed by interventional cardiologist).

3-6

Continue aspirin, clopidogrel, statins, LMWH, beta blockers* and nitrates (Continue/initiate small molecule GP IIb/IIIa inhibitors as directed by interventional cardiologist).

<3

Continue aspirin, statins, LMWH, beta blockers* and nitrates. No indication for GP IIb/IIIa inhibitors or clopidogrel.

* Consider substituting diltiazem or verapamil in the absence of heart block if beta blockers are contra-indicated

4.3 Secondary Prevention

In all cases aggressive management of risk factors must be initiated as soon as possible

∗ Hypertension – blood pressure should be optimally controlled to keep levels less than 140/85 (130/80 if patient diabetic). Suitable drugs include beta-blockers, calcium antagonists and ACEIs.

* Smoking – all patients must be strongly advised and encouraged to cease

smoking entirely. This advice should be backed up by written literature and the offer of referral to a smoking cessation service.

∗ Diabetes mellitus – carbohydrate intolerance and frank diabetes should be managed appropriately – advice from the diabetic team should be sought if necessary.

∗ Lipids – statin therapy should have already been initiated.


5 ROLE OF CORONARY ANGIOGRAPHY – who, when and where?

In the setting of NSTEACS management, coronary angiography is performed partly for diagnostic reasons to confirm the presence of coronary artery disease, but more importantly as a means of identifying patients in whom coronary revascularisation by PCI or CABG would be appropriate. However, it is important to recognise that the assessed risk of death or further cardiac event on its own does not always equate with a patient’s capacity to benefit from coronary revascularisation. It is very important in making the decision as to whether to embark on the pathway of coronary angiography +/- coronary revascularisation, to take into account other factors such as clinical context, co-morbidity, contraindications and patient preference. 5.1 Who and When?

The decision as to which patients should undergo coronary angiography with a view to revascularisation and where and when that test should take place needs to be made by a senior cardiac specialist/physician. Ideally, all referrals for coronary angiography should involve a cardiologist at the referring hospital but when this is not possible must involve the consultant physician on-call.

∗ Risk status – this will help guide the initial decision. When there is no local cardiologist available the calculated risk score for the patient is considered to be crucial in directing which patients’ cases should be discussed with the on call UHW cardiology service. Table 8 below, sets out recommendations for which risk categories should be considered for coronary angiography and when.

Table 8

∗ Patient Suitability – patients who are candidates for coronary angiography should have their suitability assessed for that investigation and for the associated coronary revascularisation. This includes a consideration of:

ROLE OF CORONARY ANGIOGRAPHY AND TIMING Total risk score Timing of Coronary Angiogram

>8

Discuss case with local cardiologist – if unavailable discuss with on call UHW cardiology service (see contact details below)

3-8

Discuss with local cardiologist.

<3

Does not need to be arranged as inpatient – further assessment including functional testing should be considered


Clinical context – pre-morbid functional status, frailty etc. Co-morbidity including known severe peripheral vascular disease, COPD, renal impairment, previous strokes, anaemia, co-existent malignancy etc Contra-indications including bleeding risk etc.

∗ Patient preference – where patients are in an appropriate risk category and are suitable as defined above, the final determination in the selection of invasive management strategy should always be that of patient preference. Careful attention should be given to ensuring that patients understand the potential benefits and risks of the treatment options proposed and why other options are not proposed. It is important that realistic estimates of risk, discomfort and benefits are given in order to avoid unrealistic expectations.

5.2 Where? Three DGH-based catheter laboratories have been established within SEWCN. The decision to undertake coronary angiography in NSTEACS patients needs to be taken on an individualised basis by the local cardiologist (if appropriate after discussion with the on call interventionalist at UHW) and guided by consideration of those factors listed in Table 9. At UHW a Regional Transfer Unit has been established. This unit has been set up to reduce inpatient waits for transfer of patients referred from other hospitals to UHW to undergo an invasive strategy. For the RTU to function effectively patients must be carefully selected (minimal co-morbidity, uncomplicated NSTEACS) and referring hospitals must also be prepared to take these patients back promptly if necessary.

Table 9

SELECTION OF DGH OR TERTIARY CENTRE FOR CORONARY ANGIOGRAPHY – FACTORS SUPPORTING REFERRAL TO UHW � A risk score of ≥ 8 � Shocked or moribund patient

� Pulmonary oedema or Class IV heart failure

� Left main coronary artery disease: known (previous cardiac catheterisation) or strong suspicion from non-invasive testing

� Severe valvular disease associated with ongoing heart failure

� Complex adult congenital heart disease � Pulmonary hypertension

� Single procedure highly desirable (eg access issues, renal failure) Cardiologists in those hospitals that do not have their own cardiac catheter facilities will have to network with UHW to ensure that the threshold for angiography is consistent across SEWCN. This may mean use of their own elective lists in conjunction with interventional colleagues at UHW to catheterise lower risk NSTEACS patients.


6 ARRANGEMENTS FOR INPATIENT TRANSFER TO UHW 6.1 Urgent Transfer for Coronary Angiography at UHW

Patients requiring transfer to UHW for coronary angiography should first be assessed at the DGH for clinical problems that may significantly delay the initiation of their treatment at UHW. This includes ongoing infection, pulmonary oedema making lying flat difficult, diarrhoea and vomiting, and significant anaemia. Whenever possible, these co-existent problems should be dealt with before transfer and certainly the timing of transfer should be reviewed in the light of these problems. It should be stressed to the patient that they are being transferred to UHW for consideration of angiography (and not necessarily angioplasty). In certain instances the cardiologist at UHW may, having seen the patient, deem that angiography is not indicated.

Appendix 3 contains a relevant checklist as an aide-memoire to assessing patients prior to transfer to UHW. Once the checklist has been completed and the patient is considered suitable for transfer, UHW should be contacted (details below). The relevant details should be passed on and any further information requested supplied. Having done so, the patient’s score sheet and checklist should be faxed to UHW. Patients with significant co-morbidity should be highlighted to the person accepting the referral at UHW to help decide suitability for transfer to the RTU. Arrangements must be in place at the referring centre to accept the patient back if necessary.

UHW Cardiology contact details Weekdays between 0800-2000: Contact the Cardiology Referral Nurse Coordinator (Louise or Marc) via UHW switchboard (bleep 6237). Weekends and 2000-0800: Contact the on-call Cardiology SpR via UHW switchboard (bleep 5770). Fax number: 02920 745346 Once the referral is made and accepted, there will then be an expectation that the patient will be transferred to UHW without the need for further discussion. It will be the responsibility of UHW to prioritise the patient, to locate an available bed as soon as possible and then to agree transfer arrangements with the host hospital and with the ambulance service. Should the patient’s condition significantly change whilst awaiting transfer, the UHW consultant accepting responsibility for the patient should be informed.


6.2 Protocol for requesting cardiac transfers (developed by the Welsh Ambulance Service protocol)

Patient requires ambulance transfer to UHW for

Cardiac related Investigation/Intervention

• Is patient relatively stable, requiring no more than oxygen during transfer?

• Is the patient able to self-administer GTN?

• Is patient suitable for High Dependency Crew?

Contact Ambulance Control

01495 769654 to arrange transfer

Is the patient likely to require advanced life support interventions or intravenous drugs during transfer?

REQUEST EMT CREW

REQUEST PARAMEDIC

CREW

URGENT

IMMEDIATE 999 REQUEST?

NOT AVAILABLE/

DELAYED?

CONSIDER

NURSE/ MEDICAL Escort

REQUEST HDS

CREW

YES NO YES


6.3 Transfer for Emergency PCI or Surgery at UHW The outcome after coronary angiography in a DGH setting will be one of the following: � Normal/minimal/mild CAD - does not require revascularisation, treat

medically � Risk score ≤ 6 and suitable coronary anatomy and patient clinically stable

- treat medically, discharge and refer for revascularisation electively. � Risk score >6 and suitable coronary anatomy – transfer to UHW for

revascularisation during index admission.

This should be arranged after discussion between consultant and interventional cardiologist or cardiac surgeon following transfer of appropriate angiogram films (preferably electronically).

The checklist contained in Appendix 3 must then be completed and faxed to the UHW.

The rota for on-call interventionalist and cardiac surgeon (with contact numbers) will be made available to DGH cath. labs.

PCI referral contact details The referring DGH Cardiologist should discuss the case with the on-call interventionalist and complete the referral form. The Cardiology Nurse Coordinators should also be contacted and the referral form faxed as above. If, after assessment of the patient at UHW, the interventional cardiologist takes the decision that CABG is the preferred revascularisation procedure, she/he will initiate the appropriate surgical referral so that any delay is minimised Once a decision has been made for CABG surgery and provided the patient is stable, it is appropriate that the patient will wait at the referring hospital prior to surgery. The work-up for cardiac surgery (carotid Dopplers, PFTS, echocardiogram) will then be pursued at the referring hospital directed and supported by the Cardiac Surgery Nurse Coordinators

Cardiac surgery referral contact details The referring DGH Cardiologist should prepare a formal referral letter to the on-call cardiac surgeon and contact them directly, involving the Cardiac Surgical Nurse Coordinators Mabel and Cath (contactable via switchboard - bleep 5970 or 029 2074 8093/2892, fax 029 2074 3057). The referral form should also be completed and faxed. There will then be an expectation that the patient will be transferred to UHW. It will be the responsibility of UHW to prioritise the patient, to locate an available bed as soon as possible and to agree transfer arrangements with the host hospital and with the ambulance service.


7 REFERENCES

1. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Report of Taskforce of European Society of Cardiology. Eur Heart J. 2007; 28: 1598-1660

2. American College of Cardiology/American Heart Association 2002 Guideline

Update for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction – Summary Article. JACC2002; 40: 1366-74

3. Management of acute coronary syndromes clinical guideline. South African

Medical Association/Acute Coronary Syndrome Working Group, SAMJ 2001; 91: 882-895

4. The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial

Investigators. Effects of clopidogrel in addition to aspirin in patients with ACS without ST elevation.N Engl. J Med. 2001; 345: 495-502

5. National Institute for Clinical Excellence Technology Appraisal No 80.

Clopidogrel in the treatment of non-ST-elevation acute coronary syndrome. July 2004

6. National Institute for Clinical Excellence Technology Appraisal No. 47.

Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes September 2002

7. Intensive versus moderate lipid lowering with statins after acute coronary

syndromes (PROVE-IT TIMI 22 Study). N Engl. J Med; 350:1495-504 8. National Institute for Clinical Excellence 47Clinical Guideline 67. Lipid

Modification. September 2008. 9. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an

angiotensin-converting-enzyme releasing inhibitor, ramipiril on cardiovascular events in high risk patients N Engl. J Med 2000; 342: 145-53

10. The EURopean trial On reduction of cardiac events with Perindopril in stable

coronary Artery disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2003; 362: 782-88.

11. Valsartan in Acute Myocardial Trial Investigators. NEngl J Med 2003;349:1893-

906. 12. ONTARGET. N Engl J Med 2008;358:1547-59.


APPENDIX 1: CLINICAL FEATURES TO CLASSIFY CHEST PAINS

BOX 1 CHEST PAIN FEATURES Typical Ischaemia

• Site – Central retrosternal, L Chest

• Radiation – across chest, L shoulder/arm, throat, jaw, L side neck

• Character – dull, tight, heavy, crushing, ache

Atypical

• Some but not all typical features

• No positive features of alternative cause

Non-Cardiac

• Few if any typical features

• Positive features of alternative cause e.g. postural, pleuritic, post-prandial, tender

BOX 2 PATIENT SETTING Evidence of Cardiovascular Disease

• Previous/known IHD, Angina, MI

• Previous/ known CVA, TIA

• Previous/ known PVD Risk Factors

• Age- M >40 yrs; F >50 yrs

• Gender - M > F

• Family IHD history-especially premature <50 yrs M; <60 yrs F

• Smoking

• Dyslipidaemia

• Hypertension

• Diabetes Mellitus- IDDM, NIDDM

BOX 3 EXAMINATION Acute Coronary Syndrome

• Usually normal

• Arrhythmia-AF, SVT, VT, bradycardia

• LV dysfunction-S3, pulmonary oedema

Non- Ischaemic Cardiac

• Pericardial rub

• Valvular disease –especially AS

• Cardiomyopathy-LVH, CCF

• Aortic dissection-AR Differential arm pulses or BP ( R>L) ?TIA or stroke

Non-cardiac

• Musculoskeletal-chest wall tenderness, +ve physical manoeuvres

• Respiratory-pleural rub, pneumothorax, consolidation

• Other-pyrexia, rash, epigastric


Appendix 2: Risk Score Sheet – See separate document Appendix 3: Two Page Transfer Check List – See separate document

____________________________________________________________________________________________________________________________________________________________________ South East Wales Cardiac Network of 24 Guidelines for the Management of patients with NSTEACS v4 – August 2008

Appendix 4: DGH Link Cardiologists/Senior Nurse Champions

DGH Link Interhospital Transfer Cardiologist

Trust Name Job Title Contact Details Cardiff and Vale NHS Trust (UHW)

Dr Liam Penny Consultant Cardiologist Tel No: 029 2074 3381 [email protected]

Cardiff and Vale NHS Trust (Llandough Hospital)

Dr Richard Anderson Consultant Cardiologist Tel No: 029 2074 3327 [email protected]

Gwent Healthcare NHS Trust (Royal Gwent Hospital)

Dr Nigel Brown Consultant Cardiologist Tel No: 01633 234436 [email protected]

Gwent Healthcare NHS Trust (Nevill Hall Hospital)

Dr Steve Hutchison Consultant Cardiologist Tel No: 01873 732100 [email protected]

Gwent Healthcare NHS Trust (Caerphilly Miners Hospital)

Dr Philip Campbell Consultant Cardiologist Tel No: 01633 238863 (Royal Gwent) 01633 234234 ext 7315 (Caerphilly Miners) [email protected]

Cwm Taf NHS Trust (North) (Prince Charles Hospital)

Dr Ed Griffiths Consultant Cardiologist Tel No: 01685 728754 [email protected]

Cwm Taf NHS Trust (South) (Royal Glamorgan Hospital)

Dr Gethin Ellis Consultant Cardiologist Tel No: 01443 443580 [email protected]

____________________________________________________________________________________________________________________________________________________________________ South East Wales Cardiac Network of 24 Guidelines for the Management of patients with NSTEACS v4 – August 2008

Appendix 4: DGH Link Cardiologists/Senior Nurse Champions Contd

DGH Senior Nurse IHT Champion

Trust Name Job Title Contact Details Pauline Williams Ward Manager

Ward B1 UHW Tel No: 029 2074 4603 [email protected]

Cardiff and Vale NHS Trust (UHW)

Sara Cadogan Junior Sister, Ward B1, UHW

029 2074 4603 [email protected]

Cardiff and Vale NHS Trust (Llandough)

Ben Durham Ward Manager Coronary Care Unit

Tel No: 029 2072 5360 [email protected]

Gwent Healthcare NHS Trust (Royal Gwent Hospital)

Ceri Phillips

Ward Sister Ward D4 East

01633 234234 [email protected]

Gwent Healthcare NHS Trust (Nevill Hall Hospital)

Annie Evans Clinical Nurse Specialist, Cardiology, Coronary Care Unit


Cwm Taf NHS Trust (North) (Prince Charles)

Gaynor Hill Ward Manager, Coronary Care Unit


Cwm Taf NHS Trust (South) (Royal Glamorgan Hospital)

Geraldine Swarfield

Clinical Nurse Specialist, Cardiology Royal Glamorgan Hospital


GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH NON … · ∗ Acute ST segment elevation MI (STEMI)...

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