Policy Directive

Chest Pain Evaluation (NSW Chest Pain Pathway)

Summary The Policy outlines the minimum standards for the management of patients presenting
with Chest Pain or other symptoms of myocardial ischaemia.

NOTE: This Policy also applies to Local Health Networks until Local Health Districts
commence on 1 July 2011.
Document type Policy Directive
Document number PD2011_037
Publication date 09 June 2011
Author branch Agency for Clinical Innovation
Branch contact
Review date 30 November 2017
Policy manual Patient Matters
File number
Previous reference N/A
Status Review
Functional group Clinical/Patient Services - Governance and Service Delivery, Medical Treatment
Applies to Local Health Networks, Board Governed Statutory Health Corporations, Specialty
Network Governed Statutory Health Corporations, NSW Ambulance Service, Public
Hospitals
Distributed to Public Health System, Divisions of General Practice, Government Medical Officers, Health
Associations Unions, NSW Ambulance Service, Ministry of Health, Tertiary Education
Institutes
Audience All staff involved in the management and risk stratification of patients who present with
chest pain

Secretary, NSW Health

This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.
 POLICY STATEMENT

IMPLEMENTATION OF MINIMUM STANDARDS FOR CHEST PAIN

EVALUATION (NSW CHEST PAIN PATHWAY)

PURPOSE
The policy mandates the implementation of minimum standards for chest pain
evaluation, by all hospitals in the NSW Health system for patients presenting to
Emergency Departments with chest pain. Compliance with these minimum standards
for chest pain evaluation will improve the management of patients by guiding clinicians
through risk stratification and outlining the best practice management. Facilities may
continue to use existing local Pathways provided that they meet all of the minimum
standards and are in active use in emergency departments.
Facilities who do not use an existing Chest Pain Pathway that meets the minimum
standards must implement the standard NSW Chest Pain Pathway. The NSW Chest
Pain Pathway aligns with the National Heart Foundation/Cardiac Society of Australia
and New Zealand Guidelines for the management of acute coronary syndromes.

MANDATORY REQUIREMENTS

1. All facilities with Emergency Departments must have and use a pathway that
meets the following minimum standards for chest pain patients:
• Assigns triage category 2
• Includes risk stratification
• ECGs are taken and reviewed
• Troponin levels are taken and reviewed
• Vital signs are taken and documented
• Critical times are documented (symptom onset, presentation)
• Aspirin is given, unless contraindicated
• A Senior Medical Officer is assigned to provide advice and support on
chest pain assessment and initial management, 24/7
• A nominated Cardiologist is assigned to provide advice on further
management 24/7
• The pathway gives instruction regarding atypical chest pain presentations
• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection,
Pulmonary Embolism & Pericarditis.
• Sites that do not have 24/7 PCI capability must have Thrombolysis as the
default STEMI management strategy unless there is an existing
documented system for transfer.

2. All facilities who do not use an existing Chest Pain Pathway that meets the
minimum standards must implement the standard NSW Chest Pain Pathway that
matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to
use the Primary PCI site Pathway) as the minimum standard.

PD2010_037 Issue date: June 2011 Page 1 of 3

 POLICY STATEMENT

IMPLEMENTATION
ROLES AND RESPONSIBILITIES
NSW Department of Health:
• Review the minimum standards of a Chest Pain Pathway in line with relevant
national guidelines and best practice evidence.
• Develop and make accessible implementation support tools.
• Evaluate Chest Pain Pathway implementation and performance against the
minimum standards across the NSW Health system.

LHN Chief Executives:

• Ensure effective implementation of the minimum standards for chest pain
evaluation in all LHN Emergency Departments
• Report minimum standards for chest pain evaluation implementation to the LHN
Governing Council
• Report Chest Pain Pathway implementation and performance against the
minimum standards to NSW Department of Health as requested

LHN Directors of Clinical Governance:

• Direct a LHN gap analysis against the chest pain evaluation minimum standards
• Develop and lead implementation strategy
• Coordinate appropriate educational resources for clinicians
• Evaluate LHN Chest Pain Pathway implementation and performance against the
minimum standards
• Investigate RCA incidents relating to the minimum standards for chest pain
evaluation

Facility General Managers and Heads of Cardiology and Emergency Departments:

• Direct a local gap analysis against the chest pain evaluation minimum standards
• Implement the chest pain evaluation minimum standards locally
• Evaluate and monitor local implementation and performance against the chest
pain evaluation minimum standards
• Coordinate local education requirements for clinicians
• Coordinate local rostering to ensure that a senior clinician is available to assist
24/7 as per the chest pain evaluation minimum standards or utilise documented
referral network

Clinicians:
• Comply with the minimum standards of chest pain evaluation
• Escalate management of deteriorating patients as per Between the Flags
(PD2010_026)
• In Emergency Departments that do not have a medical officer accessible 24/7, it
will be necessary to implement processes where the nurse in charge of the ED
signs the Chest Pain Pathway form in place of the medical officer.

PD2010_037 Issue date: June 2011 Page 2 of 3

 POLICY STATEMENT

REVISION HISTORY
Version Approved by Amendment notes
June 2011 Dr Tim Smyth, New Policy
(PD2011_037) Deputy Director-
General, HSQPID

ATTACHMENTS
1. NSW Chest Pain Pathway: Primary PCI Site
2. NSW Chest Pain Pathway: Non Primary PCI Site

PD2010_037 Issue date: June 2011 Page 3 of 3

 ◆◆◆◆◆◆
◆◆◆◆◆◆
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FAMILY NAME MRN ◆◆◆◆◆◆ FAMILY NAME MRN
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
GIVEN NAME ◆◆◆◆◆◆ GIVEN NAME
MALE FEMALE ◆◆◆◆◆◆ MALE FEMALE
◆◆◆◆◆◆
◆◆◆◆◆◆
D.O.B. _______ / _______ / _______ M.O. ◆◆◆◆◆◆ D.O.B. _______ / _______ / _______ M.O.
◆◆◆◆◆◆
Facility: ◆◆◆◆◆◆
◆◆◆◆◆◆
Facility:
ADDRESS ◆◆◆◆◆◆ ADDRESS
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
CHEST PAIN PATHWAY ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
CHEST PAIN PATHWAY
◆◆◆◆◆◆
LOCATION / WARD ◆◆◆◆◆◆ LOCATION / WARD
◆◆◆◆◆◆
PRIMARY PCI SITE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
◆◆◆◆◆◆
◆◆◆◆◆◆
PRIMARY PCI SITE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
◆◆◆◆◆◆
◆◆◆◆◆◆
Date of Presentation / / Time : Time of Symptom Onset: : ◆◆◆◆◆◆
◆◆◆◆◆◆ Contraindications and cautions for thrombolysis use in STEMI1
◆◆◆◆◆◆ Absolute contraindications:
General Management ◆◆◆◆◆◆
◆◆◆◆◆◆ Risk of bleeding
ECG & Vital Signs, expert Oxygen ◆◆◆◆◆◆
◆◆◆◆◆◆ - Active bleeding or bleeding diathesis (excluding menses)
CHEST PAIN interpretation within 10 minutes Aspirin ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Significant closed head or facial trauma within 3 months
IV Access
or
◆◆◆◆◆◆ - Suspected aortic dissection (including new neurological symptoms)
◆◆◆◆◆◆
Pain Relief ◆◆◆◆◆◆ Risk of intracranial haemorrhage
◆◆◆◆◆◆
OTHER ST ELEVATION Pathology incl Troponin
Chest X-ray
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Any prior intracranial haemorrhage
- Ischaemic stroke within 3 months
or (presumed new) LBBB
SYMPTOMS of
◆◆◆◆◆◆ - Known structural cerebral vascular lesion (eg, arteriovenous malformation)
◆◆◆◆◆◆
Y ◆◆◆◆◆◆ - Known malignant intracranial neoplasm (primary or metastatic)
◆◆◆◆◆◆
MYOCARDIAL Consider Aortic Dissection
Consider Pericarditis ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
Relative contraindications:
N (sharp chest pain, respiratory or ◆◆◆◆◆◆ Risk of bleeding
ISCHAEMIA (back pain, hypertension, absent
pulse, BP difference)
positional component) ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Current use of anticoagulants: the higher the international normalised ratio (INR), the higher the risk of bleeding
- Non-compressible vascular punctures
◆◆◆◆◆◆
Consider Pulmonary ◆◆◆◆◆◆
◆◆◆◆◆◆
- Recent major surgery (< 3 weeks)
(eg sweating, sudden orthopnea, Embolism ◆◆◆◆◆◆ - Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation
syncope, dyspnoea, epigastric ◆◆◆◆◆◆
(severe dyspnoea, respiratory ◆◆◆◆◆◆ - Recent (within 4 weeks) internal bleeding (eg, gastrointestinal or urinary tract haemorrhage)
discomfort, jaw pain, arm pain) N ◆◆◆◆◆◆
◆◆◆◆◆◆ - Active peptic ulcer
distress, low subscript O2 saturation) ◆◆◆◆◆◆
Be aware: ◆◆◆◆◆◆ Risk of intracranial haemorrhage
◆◆◆◆◆◆
HIGH RISK ATYPICAL N ◆◆◆◆◆◆
◆◆◆◆◆◆
- History of chronic, severe, poorly controlled hypertension
PRESENTATIONS ◆◆◆◆◆◆ - Severe uncontrolled hypertension on presentation (> 180 mmHg systolic or > 110 mmHg diastolic)
Diagnose

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◆◆◆◆◆◆ - Ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered in contraindications
(eg diabetes, renal failure, female, ◆◆◆◆◆◆
elderly or Aboriginal) NON ST ELEVATION ACUTE Go immediately
◆◆◆◆◆◆
◆◆◆◆◆◆ Other
CORONARY SYNDROME (ACS) to
◆◆◆◆◆◆
◆◆◆◆◆◆ - Pregnancy
◆◆◆◆◆◆ 1
Adapted from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
TRIAGE
◆◆◆◆◆◆
STEMI ◆◆◆◆◆◆
◆◆◆◆◆◆
MANAGEMENT ◆◆◆◆◆◆ Contraindications to Exercise Testing (ACC/AHA Guidelines)2
CATEGORY (page 3)
◆◆◆◆◆◆
◆◆◆◆◆◆ Absolute
2 STRATIFY ACS RISK ◆◆◆◆◆◆
◆◆◆◆◆◆
- Recurrent chest pain

PRIMARY PCI SITE

HIGH RISK
Any of the following
 ACS symptoms are repetitive or
prolonged (> 10 min) & still present.
 Syncope
 History of chronic left ventricular
systolic dysfunction (especially if
known LVEF < 40%) OR current
clinical evidence of LVF.
 Previous PCI/CABG < 6 months
 Diabetes + typical ACS symptoms
 Chronic renal failure + typical ACS
symptoms
 Haemodynamic compromise
(sustained SBP < 90 mmHg and / or
new onset mitral regurgitation)
INTERMEDIATE RISK
Any of the following and no high risk
features
 ACS symptoms within 48 hrs that
occurred at rest, or were repetitive or
prolonged (but currently resolved)
 Previous PCI/CABG > 6 months
 Known coronary heart disease-
Esp if prior AMI or known coronary
lesion > 50% stenosis
 Two or more risk factors of:
Hypertension, family history,
active smoking or hyperlipidaemia
 Chronic renal failure (especially if
known GFR < 60 mL/min) +
atypical ACS symptoms
 Diabetes + atypical ACS symptoms
 Age > 65 years
CHEST PAIN PATHWAY
- Acute myocardial infarction, within 2 days
- High-risk unstable angina
LOW RISK - Uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise
Any of the following and no high or
intermediate risk features - Symptomatic severe aortic stenosis
 Presentation with clinical features - Uncontrolled symptomatic heart failure
consistent with ACS without - Acute pulmonary embolus or pulmonary infarction
intermediate- risk or high-risk - Acute myocarditis or pericarditis
features.
- Acute aortic dissection
Relative
- Critical left main coronary stenosis
- Moderate stenotic valvular heart disease
- Electrolyte abnormalities
- Systolic hypertension > 200 mmHg
- Diastolic hypertension > 100 mmHg
- Tachyarrhythmias or bradyarrhythmias
- New onset atrial fibrillation
- Hypertrophic cardiomyopathy and other forms of outflow obstruction

 Elevated Troponin
(consider haemolysis, renal failure)
 Persistent or dynamic ECG changes of  ECG is not normal and has changed  ECG Normal or unchanged from
 ST depression ≥ 0.5 mm or
 new T wave inversion ≥ 2 mm
 Transient ST elevation (≥ 0.5 mm) in
more than two contiguous leads
 Sustained VT
SMR080070
¶SMRÊ(ÎfuÄ
- Mental or physical impairment leading to the inability to exercise adequately
- High-degree atrioventricular block
- Resting ECG which will make EST interpretation difficult (eg LBBB, LVH with strain, Ventricular pacing, Ventricular preexcitation.)
from previous pain free ECG but does previous pain free ECG 2
not contain high risk changes. Gibbons etal, Circulation 106:1883,2002
Abbreviations:
ACS – Acute Coronary Syndrome CABG – Coronary Artery Bypass Graft
SMR080.070

ECG – Electrocardiogram EST – Exercise Stress Test

All cases to be discussed with Senior Medical Officer FMC – First Medical Contact GTN – Glyceryl trinitrate
Recommended Management on page 2 LBBB – Left Bundle Branch Block LVF – Left Ventricular Failure
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual LVH – Left Ventricular Hypertrophy PCI – Percutaneous Coronary Intervention
clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. SMO – Senior Medical officer STEMI – ST Elevation Myocardial Infarction
NO WRITING Page 1 of 4 NO WRITING Page 4 of 4

NSW HEALTH PRIMARY PCI SITE CP ASSESSMENT.indd 1 20/05/2011 11:48:47 AM

 FAMILY NAME MRN FAMILY NAME MRN

GIVEN NAME MALE FEMALE GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O. D.O.B. _______ / _______ / _______ M.O.
Facility: Facility:
ADDRESS ADDRESS
¶SMRÊ(ÎfuÄ
CHEST PAIN PATHWAY
CHEST PAIN PATHWAY PRIMARY PCI SITE
LOCATION / WARD LOCATION / WARD
SMR080070

PRIMARY PCI SITE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE STEMI MANAGEMENT COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Recommended Further Management Refer to drug protocols &/or Therapeutic Guidelines Chest pain > 30 min and < 12 hrs Time of
1.
Persistent ST segment elevation of ≥ 1 mm in two or more diagnostic
HIGH RISK INTERMEDIATE RISK LOW RISK CONFIRM
ECG
INDICATIONS for contiguous limb leads or ST segment elevation of ≥ 2 mm
ADMIT or TRANSFER RESTRATIFY DISCHARGE
REPERFUSION in two contiguous chest leads or presumed new LBBB pattern
 Continuous cardiac monitoring &  Continuous cardiac monitoring & frequent  Regular vital signs :
frequent vital signs vital signs Myocardial infarct likely from history
 Repeat ECG immediately if
 Repeat ECG immediately if symptoms  Repeat ECG immediately if symptoms symptoms recur
recurs recur  Repeat ECG 8 hrs post onset 2. Cardiac monitoring ECG IV Cannula X 2
 Repeat ECG 8 hrs post onset of  Repeat ECG 8 hrs post onset of of symptoms GENERAL Routine bloods Oxygen Analgesia – Morphine
symptoms symptoms  Repeat Troponin at 8 hrs if 1st MANAGEMENT Nitrates-Sublingual or IV CXR Beta Blockers
 Repeat Troponin at 8 hrs if 1st sample  Repeat Troponin at 8 hrs if 1st sample sample negative *
negative * negative *  ECG/Troponin review by
 ECG/Troponin review by medical  ECG/Troponin review by medical officer medical officer Confirm administration or give:
3.
officer _______________________ Aspirin 300 mg (soluble) Refer to local
ADMINISTER
Clopidogrel 300 - 600 mg (or prasugrel &/or tirofiban) protocols &/or
Refer for Exercise Stress Test ** if : Restratify Risk if: ANTITHROMBOTIC Therapeutic
Antiplatelet therapy  No further chest pain/symptoms and  Recurrent ischaemic chest THERAPY Enoxaparin 30 mg IV then bd (or IV heparin or bivalirudin) Guidelines

}
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Yes Discuss with  2 negative Troponin tests and pain or 1 mg/kg subcut (Max 100 mg)
cardiologist
 No /SMO  No new ECG changes and  Positive Troponin or
If no reason______________________  No contraindications to stress test  New ECG changes PRIMARY PCI UNLESS
_______________________________ (page 4) Significant delay to availability of Cath Lab or interventional team or
If low Risk ACS
4. Patient does not consent to primary PCI
Betablocker
CHOOSE
 Yes Restratify to High Risk if:  Discharge History, contrast allergy
REPERFUSION
 No  Follow up GP/LMO within 3-5 Vascular access problems
 Recurrent ischaemic chest pain or METHOD
days of D/C
If no reason______________________  Positive Troponin or Discuss with Interventional cardiologist: Time :
 Consider Specialist follow up
_______________________________  New ECG changes or Decision regarding reperfusion method: Time :
 Consider discharge on
Anticoagulant  Positive stress test
Aspirin (discuss with SMO)
 Yes THROMBOLYSE if appropriate
 No
 Vital signs prior to discharge 5. TRANSFER TO CATH LAB OR
Restratify to Low Risk & Discharge if: No contraindications (see page 4)
If no reason______________________  Negative stress test or Tenecteplase / Reteplase
If unlikely cardiac cause Discuss adjunctive treatment
________________________________  Stress test available within 72 hrs** Body Weight ________kg Dose ________
Consider alternative diagnosis with Cardiologist
and

Symptomatic treatment of ongoing  No further chest pain/symptoms

Exit Pathway Time administered :
pain/hypertension  Repeat ECG & vital signs, if stable Cath Lab arrival time
discharge please use
 IV GTN (titrate against pain & BP)
 IV Morphine NB: ** If stress test is not : 24 hr Clock
available within 72 hrs of
Repeat ECG at 60 mins post thrombolytic
 Refer to nominated cardiologist discharge, treatment plan On table time Discuss further mx with cardiologist
for further management should be guided by nominated Failure to reperfuse (less than 50%
SMO/Cardiologist : reduction in ST elevation)
Pharmacological stress test or First device use time Consider Rescue Angioplasty
CT coronary angiography may be
indicated :

*If a high sensitivity troponin assay is used, the testing interval may be reduced to 3 hours, provided the second Time to Revascularisation (TIMI 3 flow) Yes / No Time :
0-30 mins 31-45 mins 46-60 mins 61-75 mins 76-90 mins
sample is taken at least 6 hours after symptom onset.
>90 mins Reason for delay
NH606600 - 120511

Medical Officer: Print name & sign_____________________________________________ Date_____________ Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________ Medical Officer Designation______________________________________________________
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.

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NSW HEALTH PRIMARY PCI SITE CP ASSESSMENT.indd 2 20/05/2011 11:48:54 AM

 ◆◆◆◆◆◆
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FAMILY NAME MRN ◆◆◆◆◆◆ FAMILY NAME MRN
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
GIVEN NAME ◆◆◆◆◆◆ GIVEN NAME
MALE FEMALE ◆◆◆◆◆◆ MALE FEMALE
◆◆◆◆◆◆
◆◆◆◆◆◆
D.O.B. _______ / _______ / _______ M.O. ◆◆◆◆◆◆ D.O.B. _______ / _______ / _______ M.O.
Facility: ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
Facility:
ADDRESS ◆◆◆◆◆◆ ADDRESS
◆◆◆◆◆◆
◆◆◆◆◆◆

CHEST PAIN PATHWAY CHEST PAIN PATHWAY

◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
LOCATION / WARD ◆◆◆◆◆◆ LOCATION / WARD
◆◆◆◆◆◆
NON PRIMARY PCI SITE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
◆◆◆◆◆◆
◆◆◆◆◆◆ NON PRIMARY PCI SITE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
◆◆◆◆◆◆
◆◆◆◆◆◆
Date of Presentation / / Time : Time of Symptom Onset: : ◆◆◆◆◆◆
◆◆◆◆◆◆ Contraindications and cautions for thrombolysis use in STEMI1
◆◆◆◆◆◆ Absolute contraindications:
General Management ◆◆◆◆◆◆
◆◆◆◆◆◆ Risk of bleeding
ECG & Vital Signs, expert Oxygen ◆◆◆◆◆◆
◆◆◆◆◆◆ - Active bleeding or bleeding diathesis (excluding menses)
CHEST PAIN interpretation within 10 minutes Aspirin ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Significant closed head or facial trauma within 3 months
IV Access - Suspected aortic dissection (including new neurological symptoms)
or
◆◆◆◆◆◆
◆◆◆◆◆◆
Pain Relief ◆◆◆◆◆◆ Risk of intracranial haemorrhage
◆◆◆◆◆◆
OTHER ST ELEVATION Pathology incl Troponin
Chest X-ray
◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Any prior intracranial haemorrhage
- Ischaemic stroke within 3 months
or (presumed new) LBBB
SYMPTOMS of
◆◆◆◆◆◆ - Known structural cerebral vascular lesion (eg, arteriovenous malformation)
◆◆◆◆◆◆
Y ◆◆◆◆◆◆
◆◆◆◆◆◆ - Known malignant intracranial neoplasm (primary or metastatic)
MYOCARDIAL Consider Aortic Dissection
Consider Pericarditis ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
Relative contraindications:
N (sharp chest pain, respiratory or ◆◆◆◆◆◆ Risk of bleeding
ISCHAEMIA (back pain, hypertension, absent
pulse, BP difference)
positional component) ◆◆◆◆◆◆
◆◆◆◆◆◆
◆◆◆◆◆◆
- Current use of anticoagulants: the higher the international normalised ratio (INR), the higher the risk of bleeding
- Non-compressible vascular punctures
◆◆◆◆◆◆
Consider Pulmonary ◆◆◆◆◆◆
◆◆◆◆◆◆
- Recent major surgery (< 3 weeks)
(eg sweating, sudden orthopnea, Embolism ◆◆◆◆◆◆ - Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation
syncope, dyspnoea, epigastric ◆◆◆◆◆◆
(severe dyspnoea, respiratory ◆◆◆◆◆◆ - Recent (within 4 weeks) internal bleeding (eg, gastrointestinal or urinary tract haemorrhage)
discomfort, jaw pain, arm pain) N ◆◆◆◆◆◆
◆◆◆◆◆◆ - Active peptic ulcer
distress, low subscript O2 saturation) ◆◆◆◆◆◆
Be aware: ◆◆◆◆◆◆ Risk of intracranial haemorrhage
◆◆◆◆◆◆
HIGH RISK ATYPICAL N ◆◆◆◆◆◆
◆◆◆◆◆◆
- History of chronic, severe, poorly controlled hypertension
PRESENTATIONS ◆◆◆◆◆◆ - Severe uncontrolled hypertension on presentation (> 180 mmHg systolic or > 110 mmHg diastolic)
Diagnose

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◆◆◆◆◆◆ - Ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered in contraindications
(eg diabetes, renal failure, female, ◆◆◆◆◆◆
elderly or Aboriginal) NON ST ELEVATION ACUTE Go immediately
◆◆◆◆◆◆
◆◆◆◆◆◆ Other
◆◆◆◆◆◆
CORONARY SYNDROME (ACS) to ◆◆◆◆◆◆ - Pregnancy
◆◆◆◆◆◆ 1
Adapted from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
◆◆◆◆◆◆
TRIAGE STEMI ◆◆◆◆◆◆
◆◆◆◆◆◆
MANAGEMENT ◆◆◆◆◆◆ Contraindications to Exercise Testing (ACC/AHA Guidelines)2
CATEGORY (page 3)
◆◆◆◆◆◆
◆◆◆◆◆◆ Absolute
2 STRATIFY ACS RISK ◆◆◆◆◆◆
◆◆◆◆◆◆
- Recurrent chest pain

NON PRIMARY PCI SITE

HIGH RISK
Any of the following
£ ACS symptoms are repetitive or
prolonged (> 10 min) & still present.
£ Syncope
£ History of chronic left ventricular - Acute aortic dissection
systolic dysfunction (especially if
known LVEF < 40%) OR current
clinical evidence of LVF.
£ Previous PCI/CABG < 6 months
£ Diabetes + typical ACS symptoms
£ Chronic renal failure + typical ACS
symptoms
£ Haemodynamic compromise
(sustained SBP < 90 mmHg and / or £ Age > 65 years
new onset mitral regurgitation)
INTERMEDIATE RISK
Any of the following and no high risk
features
£ ACS symptoms within 48 hrs that
occurred at rest, or were repetitive or consistent with ACS without
prolonged (but currently resolved)
£ Previous PCI/CABG > 6 months
£ Known coronary heart disease-
Esp if prior AMI or known coronary
lesion > 50% stenosis
£ Two or more risk factors of:
Hypertension, family history,
active smoking or hyperlipidaemia
£ Chronic renal failure (especially if
known GFR < 60 mL/min) +
atypical ACS symptoms
£ Diabetes + atypical ACS symptoms
CHEST PAIN PATHWAY
- Acute myocardial infarction, within 2 days
- High-risk unstable angina
LOW RISK - Uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise
Any of the following and no high or
intermediate risk features - Symptomatic severe aortic stenosis
£ Presentation with clinical features - Uncontrolled symptomatic heart failure
- Acute pulmonary embolus or pulmonary infarction
intermediate- risk or high-risk - Acute myocarditis or pericarditis
features.
Relative
- Critical left main coronary stenosis
- Moderate stenotic valvular heart disease
- Electrolyte abnormalities
- Systolic hypertension > 200 mmHg
- Diastolic hypertension > 100 mmHg
- Tachyarrhythmias or bradyarrhythmias
- New onset atrial fibrillation
- Hypertrophic cardiomyopathy and other forms of outflow obstruction

SMR080071
¶SMRÊ(Îg|Ä
£ Elevated Troponin - Mental or physical impairment leading to the inability to exercise adequately
(consider haemolysis, renal failure) - High-degree atrioventricular block
£ Persistent or dynamic ECG changes of £ ECG is not normal and has changed £ ECG Normal or unchanged from
- Resting ECG which will make EST interpretation difficult (eg LBBB, LVH with strain, Ventricular pacing, Ventricular preexcitation.)
l ST depression ≥ 0.5 mm or from previous pain free ECG but does previous pain free ECG 2
l new T wave inversion ≥ 2 mm not contain high risk changes. Gibbons etal, Circulation 106:1883,2002
£ Transient ST elevation (≥ 0.5 mm) in Abbreviations:
more than two contiguous leads
ACS – Acute Coronary Syndrome CABG – Coronary Artery Bypass Graft
£ Sustained VT
SMR080.071

ECG – Electrocardiogram EST – Exercise Stress Test

All cases to be discussed with Senior Medical Officer
Recommended Management on page 2
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual
clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.
NO WRITING Page 1 of 4
FMC – First Medical Contact GTN – Glyceryl trinitrate
LBBB – Left Bundle Branch Block LVF – Left Ventricular Failure
LVH – Left Ventricular Hypertrophy PCI – Percutaneous Coronary Intervention
SMO – Senior Medical officer STEMI – ST Elevation Myocardial Infarction
NO WRITING Page 4 of 4

NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 1 12/05/2011 10:32:22 AM

 FAMILY NAME MRN FAMILY NAME MRN

GIVEN NAME MALE FEMALE GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O. D.O.B. _______ / _______ / _______ M.O.
Facility: Facility:
ADDRESS ADDRESS

CHEST PAIN PATHWAY

CHEST PAIN PATHWAY
¶SMRÊ(Îg|Ä
NON PRIMARY PCI SITE
LOCATION / WARD LOCATION / WARD
NON PRIMARY PCI SITE STEMI MANAGEMENT
SMR080071

COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

Recommended Further Management Refer to drug protocols &/or Therapeutic Guidelines Chest pain > 30 min and < 12 hrs Time of
1.
Persistent ST segment elevation of ≥ 1 mm in two or more diagnostic
HIGH RISK INTERMEDIATE RISK LOW RISK CONFIRM
ECG
INDICATIONS for contiguous limb leads or ST segment elevation of ≥ 2 mm
ADMIT or TRANSFER RESTRATIFY DISCHARGE
REPERFUSION in two contiguous chest leads or presumed new LBBB pattern
£ Continuous cardiac monitoring & £ Continuous cardiac monitoring & frequent £ Regular vital signs :
frequent vital signs vital signs Myocardial infarct likely from history
£ Repeat ECG immediately if
£ Repeat ECG immediately if symptoms £ Repeat ECG immediately if symptoms symptoms recur
recurs recur £ Repeat ECG 8 hrs post onset 2. Cardiac monitoring ECG IV Cannula X 2
£ Repeat ECG 8 hrs post onset of £ Repeat ECG 8 hrs post onset of of symptoms GENERAL Routine bloods Oxygen Analgesia – Morphine
symptoms symptoms £ Repeat Troponin at 8 hrs if 1st MANAGEMENT Nitrates-Sublingual or IV CXR Beta Blockers
£ Repeat Troponin at 8 hrs if 1st sample £ Repeat Troponin at 8 hrs if 1st sample sample negative *
negative * negative * £ ECG/Troponin review by
£ ECG/Troponin review by medical £ ECG/Troponin review by medical officer medical officer Confirm administration or give:
3.
officer _______________________ ADMINISTER Aspirin 300 mg (soluble) Refer to local
Clopidogrel 300 - 600 mg (or prasugrel &/or tirofiban) protocols &/or
Refer for Exercise Stress Test ** if : Restratify Risk if: ANTITHROMBOTIC Therapeutic
Antiplatelet therapy THERAPY Enoxaparin 30 mg IV then bd (or IV heparin or bivalirudin)

}
£ No further chest pain/symptoms and £ Recurrent ischaemic chest Guidelines
BINDING MARGIN - NO WRITING

£ Yes Discuss with £ 2 negative Troponin tests and pain or 1 mg/kg subcut (Max 100 mg)
cardiologist
£ No /SMO £ No new ECG changes and £ Positive Troponin or
If no reason______________________ £ No contraindications to stress test £ New ECG changes
THROMBOLYSIS UNLESS
_______________________________ (page 4)
4. Absolute or unacceptable relative contraindications (see page 4) or
Betablocker If low Risk ACS
CHOOSE Patient does not consent to thrombolysis or
£ Yes Restratify to High Risk if: £ Discharge
REPERFUSION Documented system for transfer to PRIMARY PCI SITE in place
£ No £ Follow up GP/LMO within 3-5
£ Recurrent ischaemic chest pain or METHOD
days of D/C
If no reason______________________ £ Positive Troponin or
£ Consider Specialist follow up Discussed with cardiologist: Time :
_______________________________ £ New ECG changes or
£ Consider discharge on
Anticoagulant £ Positive stress test
Aspirin (discuss with SMO)
£ YES Transfer to PRIMARY PCI SITE if
£ Vital signs prior to discharge 5. THROMBOLYSE OR
£ No Restratify to Low Risk & Discharge if: appropriate
Tenecteplase / Reteplase
If no reason______________________ £ Negative stress test or (As per table below)
If unlikely cardiac cause Body Weight _____kg Dose _____
________________________________ £ Stress test available within 72 hrs**
Consider alternative diagnosis Maximum Acceptable Delay from First Medical Contact (FMC):
and Time administered :
Time since symptom Acceptable delay from FMC to
Symptomatic treatment of ongoing £ No further chest pain/symptoms onset percutaneous intervention
Exit Pathway
pain/hypertension £ Repeat ECG & vital signs, if stable < 1hours 60 minutes
discharge
£ IV GTN (titrate against pain & BP) 1-3 hours 90 minutes
£ IV Morphine NB: ** If stress test is not
3-12 hours 120 minutes
available within 72 hrs of
£ Refer to nominated cardiologist discharge, treatment plan >12hours Not routinely recommended
for further management should be guided by nominated from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
SMO/Cardiologist

Pharmacological stress test or Discuss further management immediately with nominated cardiologist
CT coronary angiography may be
indicated Prioritise urgency of transfer with nominated cardiologist
Organise transfer to PCI-capable hospital (as per locally agreed protocol)
*If a high sensitivity troponin assay is used, the testing interval may be reduced to 3 hours, provided the second
Repeat ECG at 60 mins post thrombolytic
sample is taken at least 6 hours after symptom onset.

Medical Officer: Print name & sign_____________________________________________ Date_____________ Medical Officer: Print name & sign_____________________________________________ Date_____________
Medical Officer Designation______________________________________________________ Medical Officer Designation______________________________________________________
This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical
120511

judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically.

NO WRITING Page 2 of 4 NO WRITING Page 3 of 4

NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 2 12/05/2011 10:32:22 AM