NHS England “High quality care for all, now and for future generations.”

Better care for heart attacks. New models for management of non-ST

elevation acute coronary syndromes North of England Cardiovascular Network

Version Control

Purpose / Change Author Date

2.0 References updated NS 15-09-16

2.1&2 Learning points from Barts NS 22-09-16

3.1 Revisions following meeting 29/9 NS 30-09-16

3.2 JB/NS redraft, improved readability JB/NS 06-10-16

3.3 References around early rule out/BPT/QS99 NS 10-10-16

3.4 Amendments following Group meeting 2016 NS 24-01-17

3.5 Final version approved by CAG Business meeting NS/JB 27-01-17

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 1

Contents Introduction – the case for change ......................................................................................................... 1

Proposed guidelines for best practice in management of NSTEACS ...................................................... 2

Notes on guidance and challenges to implementation .......................................................................... 3

Impact of NSTEACS proposed changes on other NHS services ............................................................... 9

Next steps ............................................................................................................................................. 10

Summary ............................................................................................................................................... 11

References ............................................................................................................................................ 12

Appendix ............................................................................................................................................... 15

Glossary ................................................................................................................................................. 17

Introduction – the case for change

Heart attack care is of a high standard in the North of England. We have been at the forefront of

improvements in care for many years. We were one of the first regions to have a primary PCI

program for ST elevation MI. We have developed regional strategies for the antiplatelet treatment

of non-ST elevation ACS and for out of hospital cardiac arrest care. Mortality rates for heart attacks

have fallen faster in the North of England than in most other areas. These developments have been

due to agreement by all involved, mediated by the Cardiovascular Network. This is now part of the

Northern England Strategic Clinical Networks.

Non ST elevation acute coronary syndromes (NSTEACS) are common and, in many cases, a form of

serious heart attack. Recent national documents and analyses of UK results have looked at

management of NSTEACS. There are regional variations in care. It is common that patients do not

receive all the interventions that trials have shown to be of benefit. Delays in treatment are

commonplace.

UK data have suggested that lives are being lost as a result. Patients currently spend longer in

hospital than those admitted with an ST elevation- type heart attack. This is frustrating for patients.

It is a poor use of NHS resources, especially bed days in hospital.

This paper looks at how we can build on the achievements we’ve made in heart attack care. It sets

out a series of proposals for best practice. They are based on latest national and European

guidelines.

These changes involve reshaping of some existing services. Such changes can be difficult. We believe

they can be implemented, however, with careful planning and appropriate resources. This will

benefit people with this type of heart attack, without adversely impacting other areas of cardiology

care.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 2

Proposed guidelines for best practice in management of NSTEACS The following proposals all represent significant shifts in current practice. They are a gold standard

for care, based on current available best evidence. Adopting these changes will require major

resource shifts and training. It is envisaged therefore that the changes will take time.

1) All patients with suspected NSTEACS should have an ECG, risk assessment (e.g. GRACE or TIMI)

and high sensitivity troponin testing on admission and, usually, at three hours after arrival.

2) Patients meeting a ‘rule out’ protocol should go home within four hours. If a cardiac cause other

than ACS is suspected, OP referral to a chest pain clinic may be appropriate. All patients

discharged from A&E should be advised to seek timely primary care review if symptoms recur.

3) Patients in whom a NSTEACS has been diagnosed should be assessed and admitted and seen by

an appropriate consultant within 14 hours.

4) Patients with NSTEACS should be assessed with a Fast Track Pathway Tool. Those meeting all

criteria should be discussed at middle grade or higher level with the PCI centre registrar on call.

Those accepted should be transferred directly to the PCI centre.

5) Patients with very high risk features of ongoing cardiac chest pain and ECG changes / haemo-

dynamic instability should be discussed by ambulance crews with the PCI centre with a view to

direct admission to that unit.

6) Patients with NSTEACS should be assessed by a consultant cardiologist within 24 hours of

admission and daily thereafter, unless it has been determined that this would not affect the

patient’s care pathway.

7) Out of normal working hours, a cardiology consultant should be available on-call for telephone

advice and, when necessary, ‘return to base’ at all sites admitting NSTEACS patients.

8) Patients assessed as high risk should be transferred to a PCI centre for coronary angiography and,

where appropriate, PCI within 24 hours.

9) Patients with intermediate risk should be transferred to a PCI centre for coronary angiography

and, where appropriate, PCI within 72 hours.

10) In the majority of cases, NSTEACS patients at sites without the capability to progress to PCI

should not undergo invasive angiography prior to transfer to a PCI centre.

11) Patients referred to a PCI centre should be transferred within 24 hours when resources allow.

12) NSTEACS angiography/PCI will occur routinely seven days a week at the PCI centres.

13) NSTEACS patients must be offered advice and cardiac rehabilitation (e.g. smoking cessation,

dietary and lipid management) as well as secondary prevention treatment and echocardiography.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 3

Notes on guidance and challenges to implementation

An outline algorithm incorporating the various proposals is included in the Appendix below.

1) All patients with suspected NSTEACS should have an ECG, risk assessment (e.g. GRACE or TIMI)

and high sensitivity troponin testing on admission and, usually, at three hours after arrival.

hs-troponin testing is not widely available. In many units, troponin testing is part of a combined

contract for various tests and using hs-troponin testing may have contract/cost implications

preventing that change in the short term.

Systems need to be expedited, if a three hour hs-troponin test result is to be returned to the

frontline with enough time to allow A&E to discharge within four hours. There are studies (1)(2)(3)

(4,5) suggesting much earlier time points may be safe with the most recent hs troponin assays,

coupled with ED staff clinical judgement.

Risk assessment usually means the use of a validated scoring system (6), although clinical features

alone are often used to make decisions on management, depending on local practice.

2) Patients meeting a ‘rule out’ protocol should go home within four hours. If a cardiac cause other

than ACS is suspected, OP referral to a chest pain clinic may be appropriate. All patients

discharged from A&E should be advised to seek timely primary care review, if symptoms recur.

The Network expects that all units will adopt a pathway to suit their own admission/A&E units. A&E

(or acute admission unit) decision-makers need to be trained and empowered to discharge

appropriate patients within the four hour window.

Various models exist to encompass this, based on published studies. An early rule out algorithm is

currently in use at NUTH (see below). Other models are detailed in various papers, some allowing

for even earlier “rule-out”(7)(1,2,8–10)

Note: It is possible to have a high GRACE or TIMI risk score despite being troponin negative and such

people should not be discharged without review by cardiology specialists.

Follow up of patients where ACS has been ruled out will depend on clinical judgement and local

availability of outpatient services. Local units should develop their own pathways of care to ensure

that patients with ongoing chest pain are assessed for non-cardiac causes.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 4

3) Patients in whom a NSTEACS has been diagnosed should be assessed and admitted and should

be seen by an appropriate consultant within 14 hours.

6) Patients with NSTEACS should be assessed by a consultant cardiologist within 24 hours of

admission and daily thereafter, unless it has been determined that this would not affect the

patient’s care pathway.

7) Out of normal working hours, a cardiology consultant should be available on-call for telephone

advice and, when necessary, ‘return to base’ at all sites admitting NSTEACS patients.

Review by an appropriate consultant within a 14 hour timeframe is in keeping with the Keogh report

on 7 day services. Often for unselected chest pain patients, the first consultant review may be by an

acute physician. However, where a NSTEACS is confirmed, or where the person is admitted direct to

a cardiology unit/CCU, that review will be by a consultant cardiologist. In this document,

“consultant” would include other post-CCT cardiology doctors. It may be appropriate in limited

circumstances for a non-medical member of the cardiology team (e.g. cardiology specialist nurse) or

an appropriately qualified non-cardiology consultant to assess some of these NSTEACS patients. For

example, it is possible that some patients will have slightly raised hs-troponins, but are otherwise

very low risk on GRACE/TIMI score. Local protocols should be developed about how such people are

managed. This may vary according to local availability of tests, such as cardiac CT/CMR and

angiography. Medical management should follow current NICE/ESC guidance and NECVN guidance

on antiplatelet therapy (http://www.nescn.nhs.uk/wp-content/uploads/2015/02/Antiplatelet-

Therapy-NSTEMI-v2-21.pdf). Review of NSTEACS patients should not be of a lower quality at

weekend than during the week and should not be by non-cardiology staff alone. BCS guidance (11)

has specified that on call cover must include the potential of return to base by the on call consultant

where necessary, rather than obtaining phone advice from regional centres. Telephone advice is

only acceptable if there are arrangements for immediate transfer to a specialist unit.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 5

4) Patients with NSTEACS should be assessed with a Fast Track Pathway Tool. Those meeting all

criteria should be discussed at middle grade or higher level with the PCI centre registrar on call.

Those accepted should be transferred directly to the PCI centre.

This change would have the greatest impact on service configuration in the region. The aim is that

the majority of patients with uncomplicated NSTEACS will follow this process. Fast Track patients

would be identified in A&E Departments and transferred without admission locally at all. This would

minimise delays to revascularisation and avoid the tariff costs currently inherent in two separate

admissions. Published data suggest reductions in length of stay can be considerable with such an

approach, in the order of nine days to three (9).

A NECVN Fast Track NSTEACS Pathway tool has been created (see Appendix). It aims to prevent large

numbers of non-ACS patients, or patients whose comorbidities make immediate angiography/PCI

inappropriate, being brought directly to the PCI centre.

One such pathway has been implemented in Glasgow and another, used at the London Chest

Hospital, is described in Gallagher et al (12).

Where local services allow (such as in Cramlington), rapid assessment of NSTEACS patients can be

made by cardiologists. Elsewhere patients eligible for Fast Track transfer will be discussed by the

middle grade or higher decision maker in A&E/acute admission unit with the on call registrar or

equivalent in the PCI centre, aided by electronic transfer of ECGs. Patients meeting the criteria will

then be transferred immediately.

Complex needs, requiring prompt assessment by an experienced cardiologist locally would include

advanced non-cardiac disease/frailty/cognitive impairment/extreme old age. It is important that

local units are adequately staffed and resourced to assess such people to determine which of them

might also benefit from angiography. Such assessment should not however delay angiography and

revascularisation when indicated unduly, which should still be within the 24/72 hour window

wherever possible. Consultant cardiologist numbers need to be adequate to offer seven day

availability for review and assessment, as well as an out of hours on call service. This is not currently

the case.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 6

5) Patients with very high risk features of ongoing cardiac chest pain and ECG

changes/haemodynamic instability should be discussed by ambulance crews with the PCI centre

with a view to direct admission to that unit.

Patients in this group constitute a minority of NSTEACS cases, but are likely to be in the highest risk

groups. To some extent, patients in this highest risk group may need urgent treatment in much the

same way as those with ST elevation. However, it would require additional training of paramedic

crews to identify such patients reliably. Very high risk patients would be those with:

Note: Other post-arrest patients may also be very high risk. Until region-wide arrangements are in

place, however, ventilated/poorly responsive cardiac arrest survivors should still be assessed in

nearest A&E. Such patients can then be discussed with the cardiology team at the PCI centre for an

individualised management plan.

8) Patients assessed as high risk should be transferred to a PCI centre for coronary angiography

and, where appropriate, PCI within 24 hours of admission.

11) Patients referred to a PCI centre should be transferred within 24 hours when resources allow.

High risk patients are defined as those with a GRACE risk of > 6% mortality at 6 months, TIMI score of

≥ 5 or equivalent. Note: Current ESC guidance (13) suggests that all patients with a raised troponin

should be considered as high risk, independent of GRACE score.

Robust transport arrangements (including appropriately skilled ambulance personnel) need to be

commissioned to be able to achieve this routinely. We note the use of non-paramedic crews from a

private ambulance provider (http://ems-uk.co.uk/) in some parts of the Network already, alongside

NEAS and YAS services. Currently, limitations in ambulance capacity mean that this category of

patients cannot consistently be transferred in the desired timeframe.

9) Patients with intermediate risk should be transferred to a PCI centre for coronary angiography

and, where appropriate, PCI within 72 hours.

12) NSTEACS angiography/PCI will occur routinely seven days a week at the PCI centres.

Intermediate risk patients are defined as those with a GRACE risk of 3-6%, TIMI score of 3-4 or

equivalent. Note: previous NECVN guidance (http://www.nescn.nhs.uk/wp-

content/uploads/2015/02/NetworkXACSXflowchartX2008.pdf) has considered all troponin positive

patients to be, at least, of intermediate risk.

Ongoing cardiac chest pain and

Any of the following:

- haemodynamic compromise (systolic BP <90mmHg or ventricular arrhythmias)

- ≥ 2mm ST depression in more than one lead

- Resuscitated cardiac arrest, now alert or responsive to verbal stimuli

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 7

Low risk ACS patients (GRACE risk<3% or TIMI score 0-2) should be assessed by local cardiology

teams (which may include appropriately trained non-medical staff). After assessment according to

local practice, it may be felt that they should be offered invasive angiography, in which case they

should be referred in the same way as those with intermediate risk.

A seven day service is needed at specialist centres, in keeping with multiple NHS-England,

Department of Health and BCS guidance from recent years (11)(14–19). Providing such a service will

be difficult without increased resources, if it is not to impact adversely on other parts of cardiology

services. Staffing issues , particularly recruitment and retention of medical and physiologist staff (20)

may delay the implementation of a truly seven day cardiology service. The 72 hour window is in

keeping with ESC, NICE Quality standards and NICE Implementation Collaboration guidance (21) (22).

NHS England has published a Best Practice Tariff, tying increased tariff to achievement of this 72

hour target (23). Currently, BCIS data

(http://www.bcis.org.uk/documents/39F_BCIS_Audit_2014_23022016_for_web.pdf) would suggest

that (in 2014) Sunderland was achieving a rate of around 75% of patients undergoing PCI within 72

hours of admission. South Tees achieved around 50% and Freeman around 30%. National average

was 54.3%. Local data (personal communication from N Swanson and Raj Das) show variation in the

tertiary centres depending on whether the person was directly admitted (in which case PCI occurred

around 24 hours faster) or not. Delay to treatment also varies according to which local hospital the

patient was admitted to initially. Slowest times to PCI were for people who had diagnostic only

angiography in admitting units, without PCI capability. These findings are also in keeping with

national data. Delay in providing angiography is more than just inefficient – there are data to suggest

that such delay is associated with excess deaths and recurrent events (24)(25).

The benefits of a true seven day service include consistent flow of patients and reduced length of

hospital stay. Current provision is variable across existing PCI centres. Freeman has one all day list on

both Saturdays and Sundays – about 2/3 of the NSTEACS throughput of a weekday. James Cook has a

Saturday morning list. Sunderland has no routine provision for NSTEACS at weekends. Likely limiters

to further expansion include lack of catheter lab staff and the impact on weekday consultant

presence if there is increased weekend working.

10) In the majority of cases, NSTEACS patients at sites without the capability to progress to PCI

should not undergo invasive angiography prior to transfer to a PCI centre.

This recommendation is in line with NICE Implementation Collaborative guidance (21). It seeks to

avoid the risks from multiple interventions, their cumulative costs and aims to shorten transfer times

and hospital lengths of stay. Some patients, in whom the diagnosis is uncertain or in those with or

complex needs, may benefit from diagnostic angiography (but no more than 10% of total NSTEACS

population). In time, CT coronary angiography may be the more appropriate investigation for such

patients.

13) NSTEACS patients must be offered advice and cardiac rehabilitation (e.g. smoking cessation,

dietary and lipid management) as well as secondary prevention treatment and echocardiography.

Other elements of care in NSTEACS are of great importance and analysis of MINAP data has shown

that not only are elements of this care often omitted (including our region)(26), but also that such

omission can be correlated with increased mortality(27)(28). NSTEACS secondary prevention should

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 8

be in line with NICE CG172 (29) and QS99 (30). Best practice tariff targets for this have been set as

expecting rehabilitation to be started within three days of initial event and while still an inpatient

(23). Given the accelerated care pathway and shortened lengths of stay envisaged in these

recommendations, risk factor advice and intervention may need to be identified and addressed

routinely during the rehabilitation phase after hospital discharge. This is in part recognising that

patients do not retain information well when delivered in an emergency setting. It is increasingly

common that patients post PCI for NSTEACS are offered same day discharge, including those

transferred from other hospitals. Rehabilitation will be provided by the existing teams in the

patient’s local area. Particular attention needs to be paid to the psychological impact of the cardiac

event especially given the speed with which treatment and discharge may occur. Furthermore, it is

noteworthy that smoking cessation programs are funded through Public Health, not by CCGs.

Echocardiography for all NSTEACS patients is strongly recommended by current ESC guidance (13)

and NICE Quality Standard on secondary prevention post MI (30).

Other points relating to guidance.

NSTEACS can present with out of hospital cardiac arrest. This pathway does not fully address

such patients, although there are network guidelines (http://www.nescn.nhs.uk/wp-

content/uploads/2015/02/NEASXjointXOOHCAXPPCIXprotocol.pdf) available.

Patients with ST elevation should be treated according to existing guidance.

Ongoing management of patients transferred for angiography/PCI is generally left with the

receiving unit. Whilst there are models of care where patients have a “treat and return”

approach, this seems of little value, if post-PCI patients are discharged that same day. People

who need in house urgent CABG will stay in the receiving unit. Patients who have been Fast

Tracked, but do not in fact require angiography/intervention should be repatriated back to

their local hospital, unless they can be dealt with that day and discharged. Similarly, people

post-PCI with complex needs, requiring longer admission, are better served by repatriation.

This can best be achieved by formalised agreements between units to encourage such

transfers, in order that beds are available at the PCI centre for new referrals.

Electronic referral / data exchange is envisaged to improve inter-hospital (non-emergency)

transfer arrangements.

Echocardiography is a guideline-supported test for all such patients. This should be

undertaken by the hospital where most of the person’s care is provided during their

NSTEACS admission. Currently, this is not being achieved and would require further

resources before it could be achieved consistently.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 9

Impact of NSTEACS proposed changes on other NHS services

Better seven day treatment of NSTEACS risks reducing the ability of organisations to deliver

timely and high quality care for other, equally important acute or elective cardiac conditions.

Increased emphasis on providing urgent and emergency treatment of people with NSTEACS may

require staff to be redeployed - resulting in waiting times increasing for elective PCI and non-PCI

procedures or outpatient assessments.

Increased demand for urgent NSTEACS inter-hospital transfers could impact negatively on

ambulance services for patients with other clinically important conditions.

There is a large group of patients with complex needs in whom the decision to offer angiography

may be nuanced. It is important that admitting units are adequately resourced – in particular

with sufficient cardiology consultants - to assess these more complex patients before deciding

whether they should undergo invasive coronary revascularisation. Local teams need to be able to

discuss such patients seven days a week with an interventional colleague at a PCI centre.

Reducing local admissions and/or angiography in NSTEACS may have adverse financial

implications for the viability of cardiac catheterisation laboratories on non-PCI sites and indeed

financial viability of entire cardiology units.

Several units in the North of England already struggle to recruit and retain cardiology consultants

and support staff. These NSTEACS recommendations envisage concentrating further specialist

services in a small number of hospitals. This could aggravate existing recruitment/retention

problems for units not providing such specialist interventions. In the longer term this could

threaten their ability to deliver high-quality cardiology services in general to their local

populations.

This problem is recognised in the NHS 5 Year Forward Plan (which discusses the concept of

“viable smaller hospitals”). It is vital for the viability of regional cardiology services that changes

in patient flow are seen in this wider context and measures put in place to ensure local cardiology

services thrive.

Developing and sustaining consultant workforces on district and specialist centre sites can

probably be best achieved by greatly increasing cross-site working. This will require a

fundamental change in mind-set and unprecedented collaboration between Trusts across the

region. Even if it can be agreed, it will take time to implement.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 10

Next steps

The Network will work with commissioners and service providers on priorities and timescales for

these changes. Not all of them can be achieved in the short-term. Some require major re-

organisation of services with disruption to existing pathways of care and funding streams.

Early phase implementation

Units in the North of England that admit chest pain patients should start to use recognised

high sensitivity assay for troponin testing. Each unit should involve local biochemistry

departments in the discussion so this can be achieved as soon as possible.

A rule-out protocol, ideally using hs troponin testing, should be developed by each local unit

admitting patients with chest pain. This need not be the same as that used in RVI, although

that model offers a suitable template.

Ambulance providers should be encouraged to begin to refer very high risk NSTEACS

patients, using existing PPCI communication systems.

Rehabilitation services should develop systems to ensure that patients discharged quickly

from hospital have timely access to rehabilitation services across the region.

A 24 hour target for transfer to PCI centre should be adopted as standard.

Medium term implementation

PCI centres should increase their provision of routine NSTEACS angiography/PCI to allow for

seven day working.

All centres should develop on-call rotas to allow for seven day cardiology consultant cover.

This may involve cross-site working.

Impact assessment should be performed of a region wide Fast Track Pathway for most

uncomplicated NSTEACS patients to follow – this would include impact on the receiving

centres, impact on ambulance transfers, reduced funding for local cardiology units,

repatriation for complex patients or those with ongoing needs.

Fast Track Pathways could be trialled in units which are already closely allied with a non-PCI

centre. For example Friarage Hospital/JCUH or South Tyneside/Sunderland.

Long term implementation

Full adoption of a Fast Track Pathway for the majority of NSTEACS patients should be

resourced and implemented.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 11

Summary

NSTEACS patients are a complex group. They present in different ways and with varying levels of

other major comorbidities. Their care is currently less than ideal.

NSTEACS care is not compliant with best practice. MINAP data show that most patients do not get

all the guideline recommended interventions. These omissions are associated with preventable

deaths. Delay in angiography, especially, is associated with worse outcomes. We need to do better,

since doing so may save lives.

Treatment of these patients is slow. Such delays are costly and inefficient.

Acute chest pain presentations are rising. Techniques are available to have NSTEACS ruled out early

in A&E. Currently, large numbers are admitted unnecessarily to hospital.

Non-emergency cases are generally not treated on a seven day basis. Variability through the week

leads to uneven flow of patients and unacceptable variation in quality of care.

Changing the systems of care for these patients is not going to be quick or easy. It will involve effort

across many hospitals and many different teams. It will require reorganisation of current resources

and funding. These changes may have unwanted consequences elsewhere in the healthcare system.

These may only become apparent over time.

However, the Cardiovascular Network considers that, with proper resources and determination, care

for this important patient group can and must be improved.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 12

References

1. Carlton EW, Cullen L, Than M, Gamble J, Khattab A, Greaves K. A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart [Internet]. BMJ Publishing Group Ltd and British Cardiovascular Society; 2015 Jul [cited 2016 Jul 7];101(13):1041–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25691511

2. Than M, Aldous S, Lord SJ, Goodacre S, Frampton CMA, Troughton R, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med [Internet]. 2014 Jan [cited 2016 Jan 25];174(1):51–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100783

3. Zhelev Z, Hyde C, Youngman E, Rogers M, Fleming S, Slade T, et al. Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ [Internet]. British Medical Journal Publishing Group; 2015 [cited 2016 Jul 11];350(2):h15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25646632

4. Body R, Cook G, Burrows G, Carley S, Lewis PS. Can emergency physicians “rule in” and “rule out” acute myocardial infarction with clinical judgement? Emerg Med J [Internet]. 2014;31(11):872–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25016388\nhttp://emj.bmj.com/content/31/11/872.full.pdf

5. Jaeger C, Wildi K, Twerenbold R, Reichlin T, Rubini Gimenez M, Neuhaus JD, et al. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am Heart J. 2016;171(1):92–102.e5.

6. Breall JA. Risk stratification after non-ST elevation acute coronary syndrome - UpToDate [Internet]. UptoDate. 2016 [cited 2016 Oct 3]. Available from: https://www.uptodate.com/contents/risk-stratification-after-non-st-elevation-acute-coronary-syndrome?source=search_result&search=risk stratification in acs&selectedTitle=1~150

7. R. B, R. N, B. L, E. G, C. M. The use of very low levels of high sensitivity troponin T to rule out acute myocardial infarction using a single blood test [Internet]. Academic Emergency Medicine. 2015 [cited 2016 Jul 7]. p. S55–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27178492

8. Charpentier S, Peschanski N, Chouihed T, Ray P, Chenevier-Gobeaux C. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med [Internet]. 2016 Jun [cited 2016 Jul 7];67(6):793–4. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0196064416001402

9. Mueller C, Giannitsis E, Christ M, Ordóñez-Llanos J, deFilippi C, McCord J, et al. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med [Internet]. Elsevier; 2016 Jul [cited 2016 Jul 7];68(1):76–87.e4. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0196064415015012

10. Neumann JT, Sörensen NA, Schwemer T, Ojeda F, Bourry R, Sciacca V, et al. Diagnosis of

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 13

Myocardial Infarction Using a High-Sensitivity Troponin I 1-Hour Algorithm. JAMA Cardiol [Internet]. 2016 Jun 1 [cited 2016 Jul 7];306(24):2684–93. Available from: http://cardiology.jamanetwork.com/article.aspx?doi=10.1001/jamacardio.2016.0695

11. BCS Working Group. Out-Of-Hours Cardiovascular Care: Management of Cardiac Emergencies and Hospital In-Patients [Internet]. 2016 [cited 2016 Sep 9]. Available from: http://www.bcs.com/documents/BCSOOHWP_Final_Report_05092016.pdf

12. Gallagher SM, Lovell MJ, Jones DA, Ferguson E, Ahktar A, Buckhoree Z, et al. Does a “direct” transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study. BMJ Open [Internet]. British Medical Journal Publishing Group; 2014 [cited 2016 Jul 8];4(9):e005525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25270854

13. Authors/Task Force Members, Roffi M, Patrono C, Collet J-P, Mueller C, Valgimigli M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J [Internet]. 2015 Aug 29 [cited 2015 Aug 31];37(3):ehv320. Available from: http://eurheartj.oxfordjournals.org/content/37/3/267

14. Seven Day Services Clinical Standards February 2016. 2016;(February).

15. Department of Health. 7-day NHS services: a factsheet [Internet]. NHS 7-day Services. 2015 [cited 2016 Jul 8]. Available from: https://www.gov.uk/government/publications/7-day-nhs-services-a-factsheet/7-day-nhs-services-a-factsheet

16. Delivering the Forward View: NHS planning guidance. 2016.

17. Board NC. Everyone counts - improving outcomes for patients [Internet]. Www.England.Nhs.Uk/Everyonecounts/. 2013 [cited 2016 Jul 8]. Available from: https://www.england.nhs.uk/wp-content/uploads/2012/12/everyonecounts-planning.pdf

18. NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England TDA. Five Year Forward View [Internet]. 2014 [cited 2016 Jul 8]. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

19. Satish S, Zhang DD, Goodwin JS. Clinical significance of falling blood pressure among older adults. J Clin Epidemiol. 2001;54(9):961–7.

20. Strategic Review of Cardiac Physiology Services in England STRATEGIC REVIEW OF CARDIAC PHYSIOLOGY SERVICES IN ENGLAND: FINAL REPORT Strategic Review of Cardiac Physiology Services in England [Internet]. [cited 2016 Jul 8]. Available from: http://www.scst.org.uk/resources/SRCPS_Final_Report_12_05_2015.pdf

21. NICE Implementation Collaborative. NSTEACS: aiming to improve patient outcomes and experiences [Internet]. 2016 [cited 2016 Sep 16]. Available from: http://www.innovation.england.nhs.uk/documents/45122/131788/NIC+project+clinical+consensus+report.pdf/2f5ad736-769e-42cd-b7f9-23493e1fffd9

22. National Institute for Health and Care Excellence. Acute coronary syndromes in adults [Internet]. 2014 [cited 2016 Jul 8]. Available from: https://www.nice.org.uk/guidance/qs68/resources/acute-coronary-syndromes-in-adults-2098794360517

23. NHS England. Additional Information: Best Practice Tariff proposals [Internet]. NHS England. 2016 [cited 2016 Oct 10]. p. 1–42. Available from: https://www.england.nhs.uk/wp-

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 14

content/uploads/2016/08/best-practice-tariff-prop.pdf

24. Lindholm D, Alfredsson J, Angerås O, Böhm F, Calais F, Koul S, et al. Timing of PCI in patients with non-ST-elevation myocardial infarction – a SWEDEHEART study. Eur Hear J - Qual Care Clin Outcomes [Internet]. 2016 Aug 28 [cited 2016 Sep 27];qcw044. Available from: http://ehjqcco.oxfordjournals.org/lookup/doi/10.1093/ehjqcco/qcw044

25. Hall M, Dondo TB, Yan AT, Goodman SG, Bueno H, Chew DP, et al. Association of Clinical Factors and Therapeutic Strategies With Improvements in Survival Following Non-ST-Elevation Myocardial Infarction, 2003-2013. JAMA [Internet]. American Medical Association; 2016 Sep 13 [cited 2016 Sep 27];316(10):1073. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2016.10766

26. MINAP public report, 2014 [Internet]. 2014 [cited 2016 Jul 8]. Available from: http://www.ucl.ac.uk/nicor/audits/minap/documents/annual_reports/minap-public-report-2014

27. Dondo TB, Hall M, Timmis AD, Gilthorpe MS, Alabas OA, Batin PD, et al. Excess mortality and guideline-indicated care following non-ST-elevation myocardial infarction. Eur Hear J Acute Cardiovasc Care [Internet]. SAGE Publications; 2016 May 3 [cited 2016 Jul 8];2048872616647705. Available from: http://acc.sagepub.com/lookup/doi/10.1177/2048872616647705

28. Chung S-C, Sundström J, Gale CP, James S, Deanfield J, Wallentin L, et al. Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries. BMJ [Internet]. British Medical Journal Publishing Group; 2015 [cited 2016 Jul 8];351(14):h3913. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26254445

29. NICE. Myocardial infarction: cardiac rehabilitation and prevention of further MI (clinical guideline 172) [Internet]. 2013 [cited 2016 Jul 8]. Available from: https://www.nice.org.uk/guidance/cg172

30. NICE. Secondary prevention after a myocardial infarction | Guidance and guidelines | NICE [Internet]. NICE; 2015 [cited 2016 Oct 10]. Available from: https://www.nice.org.uk/guidance/qs99

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 15

Appendix

Fast Track NSTEACS Pathway

Not all people with a positive troponin are having a NSTEMI. This will be especially true with hs

troponin assays. Not all patients having a NSTEACS will benefit from urgent angiography. Some

patients with NSTEACS who may well benefit from angiography have other complex comorbidities

that need assessed as part of holistic care.

However, the majority of patients presenting with NSTEACS will be suitable for fast treatment, in

keeping with the relevant trials and guidelines. Identifying these people may be helped by using the

following.

Fast track NSTEACS tool Please discuss with on call cardiology registrar/CCU coordinator at PCI centre

Inclusion. Patients must have:

Symptoms of typical cardiac chest/arm pain at rest for more than ten minutes. AND

High sensitivity troponin result above the 99th percentile upper reference limit And/or ≥1mm ST depression in 2 or more ECG leads

And/or conscious post cardiac arrest.

Patients without typical cardiac chest pain should not follow this pathway.

Exclusion. Patients should not be considered for Fast Track Pathway with ANY of the following:

ST elevation MI – treat according to existing PPCI pathways

Overt sepsis

Major trauma/surgery within one month.

Acute renal failure eGFR<60.

Hb<100 or recent active bleeding.

O2 saturation <90% on air.

Severe comorbidity – e.g. metastatic cancer, moderate/severe dementia or delirium, exercise tolerance<100yds normally, frailty of old age, post-arrest ventilated patients. This list is not exhaustive.

Many patients with conditions excluding them from the Fast Track pathway will also benefit from

urgent angiography, but this should be decided after further assessment by a cardiologist. They can

then be referred urgently to the PCI centre. Similarly, patients with other ECG changes may well

benefit, but this should be assessed by a cardiology specialist locally. Where there is doubt, the

referring team should discuss the case on the phone with the on call cardiology registrar at the

receiving unit who can liaise with the interventional cardiologist responsible. In critically ill patients –

those post arrest, with cardiogenic shock or other very high risk features - the responsible decision

maker locally (e.g. A&E/Acute physician) should discuss the case directly with PCI centre registrar

with a view to immediate transfer.

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 16

Clinical parameters used to generate the GRACE risk score. Calculator available at

(http://www.gracescore.org/website/WebVersion.aspx)

Care Pathway for management of NSTEACS patients. (Dotted line may need deferred until

ambulance crews are suitably trained. Very High risk ACS patients should be discussed with same

person at receiving centre as for STEMI, usually CCU senior nurse.)

NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 17

Glossary

A&E Accident and Emergency Department

ACS Acute Coronary Syndrome (includes NSTEACS and ST elevation MI)

BCS British Cardiovascular Society

CABG Coronary Artery Bypass Grafting

CCT Certificate of Completion of Training

CCU Coronary/cardiac Care Unit

CMR Cardiac Magnetic Resonance imaging

eGFR estimated Glomerular Filtration Rate

ESC European Society of Cardiology

GRACE Global Registry of Acute Coronary Events trial

GTN Glyceryl Trinitrate

hs troponin highly sensitive troponin assay

MINAP Myocardial Ischemia National Audit Project

NEAS North of England Ambulance Service

NECVN North of England Cardiovascular Network

NIC NICE implementation Collaborative

NICE National Institute for Health and Care Excellence

NSTEACS Non ST elevation Acute Coronary Syndrome

NUTH Newcastle University Teaching Hospitals

PCI Percutaneous Coronary Intervention

PPCI primary Percutaneous Coronary Intervention

TIMI Thrombolysis in Myocardial Infarction (scoring system)

URL Upper Reference Limit (for normal population)

YAS Yorkshire Ambulance Service