Emergency Department BH

Cardiac Chest Pain

This guideline describes how to rule out Acute Coronary Syndrome (ACS) and how to manage the patient if ACS is confirmed
If there is a clear non-cardiac cause for the chest pain (trauma, pneumonia) do not follow this guideline
Patients are divided into risk based on clinical assessment of the symptoms and ECG. If ECG shows STEMI, see STEMI pathway

Notes on Troponin Rule Out Regime

· Negative = Lab < 15 ng / L Lab < 3 ng / L = undetectable Lab troponin taken on arrival (NB if within an hour of onset this may be unreliable)
POCT < 17 ng/L 2nd troponin taken 3 hours from arrival if required
· POCT troponin taken on arrival is useful as a ‘rule in test’ for high risk
Late presentation: Arrival 6+ hours from max pain (moderate or low risk)
patients where this will change immediate management
Lab trop on arrival < 15 ng/L – 2nd trop not needed
· A lab high sensitive troponin sent at 3 hours from arrival is a good
‘rule out test’ for ACS. It does not rule out unstable angina Low risk: Lab trop < 3 ng/L on arrival – 2nd trop not needed
· For conditions where troponin is chronically raised look for delta 2nd lab trop at 3 hours post arrival < 15 ng/L
change of 20% between 2 samples taken 3 hours apart
· Troponin should not be used as a ‘screening test’ eg collapsed Mod risk: All patients require 2nd trop (unless late presentation)
patient Lab trop at 3 hours from arrival < 15 ng/L
· Elevation may also be caused by:
·Dysrhythmia, heart failure, cardiomyopathy, myocarditis High risk: Consider POCT trop on arrival as ‘rule in’
·Pulmonary embolism , sepsis, shock All patients require 2nd trop
·Aortic dissection, trauma, renal failure Lab trop at 3 hours from arrival < 15 ng/L

Low Clinical Risk Moderate Risk High Risk

Low suspicion of ACS, expected rule out Moderate suspicion of ACS, high on the
AND differential diagnosis
Normal or non-specific ECG AND
Normal or non-specific ECG
**Not all chest pain needs
cardiac testing** eg exertional pain, radiation, systemic
features, same as usual angina
On-going or recurrent cardiac chest pain
AND one of the following:
· Transient ST elevation / ST elevation aVR
· ST depression > 1mm in 2 leads
· T wave inversion V1-V4 (LAD syndrome)
· Dynamic T wave inversion > 2 mm in 2 leads
· Heart failure or ventricular dysrhythmia thought to be due to
ischaemia

Investigations
Lab troponin, FBC, VBG, on arrival. Consider POCT troponin if high risk and would change immediate management

Treatment
Give Aspirin 300 mg to all if not already given
If ischaemic ECG or troponin positive:
· Clopidogrel 600 mg + Fondaparinux 2.5 mg sc. Add GTN infusion if on-going ischaemic pain: 50 mg in 50 mL 0.9% saline, run at 2 – 10 mL/hour
· Metoprolol 25 mg if no contraindications (severe asthma, systolic BP <100 mmHg, pulse < 60, pulmonary oedema)

Suitable for CDU / Ambulatory ACS pathway? Refer Barts Heart Centre
Exclusion criteria: Discuss with Cardiology Registrar 07833 237 316
· HIGH risk chest pain Do not need to wait for Troponin if high risk ECG
· History consistent with unstable angina (e.g. prolonged anginal chest pain
occurring at rest or precipitated by progressively less exertion) Trop +ve? · High risk ECG
· Chest pain within 6 weeks of AMI or angiogram · Trop+ (unless known chronic)
· Ventricular dysrhythmia · On-going cardiac pain not responding to treatment
· Cardiac failure · Exclusions (may still need discussion)
· Significant co-morbidity requiring admission Acute haemorrhage
· Known IHD, unless current pain very atypical – seek senior advice Unexplained microcytic anaemia Hb < 10
Hypoxia
Yes No LOC or significant trauma
Inter-current other acute illness
Admit CDU / Ambulatory Admit Medics Patient refuses consent or lacks capacity
Trop +ve?
Monitor not required Monitored bed if abnormal ECG,
on-going pain or troponin positive

Discharge Referral Accepted?

First and 2nd (if required) troponin negative and unstable angina excluded
Complete HEART Score proforma: No Yes
LOW risk = Score 3 or less = GP follow-up
MOD or HIGH risk = Score 4 or more = Rapid access chest pain clinic (Cardiology) NST-ACS Transfer
Admit
Prescribe B blocker and statin (if not already) if score 4+ and ask GP to continue. Call LAS on
Give patient advice leaflet and copy of discharge letter Medical Registrar 0207 902 2511
Request an
Monitored bed Immediate Transfer
Notes on Fondaparinux
ACS to BHC
Absolute Contraindications: Relative Contraindications:
*Anticoagulated (on warfarin) *Known bleeding disorder
*Severe renal impairment *Severe uncontrolled HT
eGFR < 20 (SBP > 200 mmHg)
*Active bleeding *Severe hepatic failure
*Recent intracranial haemorrhage *CVA within 2 years
*Major surgery within 2 months *Thrombocytopaenia
*Acute bacterial endocarditis
EM Network Guideline Group v2.1 March 2019 [review March 2022]
 Emergency Department BH
Low Risk Chest Pain

Low Clinical Risk

Low suspicion of ACS, expected rule out

AND
Normal or non-specific ECG

**Not all chest pain needs cardiac testing**

Treatment
Give Aspirin 300 mg if not already given

Investigations
VBG, lab troponin on arrival

Admit CDU / Ambulatory

Monitor not required

Lab troponin < 3 ng / L Lab troponin 4-14 ng / L Lab troponin > 14 ng / L

Did patient arrive 6+ hours from max pain?

Yes No

Repeat Lab troponin

3 hours from arrival

Lab troponin < 15 ng / L Lab troponin > 14 ng / L

ACS Ruled out ACS Ruled In

Remember that negative troponin does not rule out unstable angina
Consider alternative diagnosis
Give Aspirin 300 mg to all if not already given
Clopidogrel 600 mg + Fondaparinux 2.5 mg sc (if not contraindicated)
GTN infusion if on-going ischaemic pain: 50 mg in 50 mL 0.9% saline,
run at 2 – 10 mL/hour
Metoprolol 25 mg if no contraindications
(severe asthma, systolic BP <100 mmHg, pulse < 60, pulmonary oedema)

Discharge Refer Barts Heart Centre

Complete HEART Score proforma: Discuss with Cardiology Registrar 07833 237 316
LOW risk = Score 3 or less = GP follow-up
MOD or HIGH risk = Score 4 or more = RACPC (Cardiology) If decision to transfer, call LAS on 0207 902 2511 and request
Immediate Transfer
If score 4 or more, prescribe (if not already):
If decision to not to transfer, refer to Medical Registrar
· Aspirin 75 mg od
Monitored bed
· GTN spray prn
· Bisoprolol 5 mg od (2.5 mg od if borderline low BP or bradycardia)
· Atorvastatin 40 mg od
Ask GP to continue

Give patient advice leaflet and copy of discharge letter

EM Network Guideline Group v2.1 March 2019 [review March 2022]

 Emergency Department BH
Moderate Risk Chest Pain

Moderate Risk

Moderate suspicion of ACS, high on the differential diagnosis

AND
Normal or non-specific ECG

eg exertional pain, radiation, systemic features, same as usual angina

Treatment
Give Aspirin 300 mg if not already given

Consider POCT troponin if high risk

Investigations symptoms where earlier result may
VBG, lab troponin on arrival change management – senior review

Suitable for CDU / Ambulatory ACS pathway?

Exclusion criteria:
· HIGH risk chest pain
· History consistent with unstable angina (e.g. prolonged anginal chest pain occurring at
rest or precipitated by progressively less exertion)
· Chest pain within 6 weeks of AMI or angiogram
· Ventricular dysrhythmia
· Cardiac failure
· Significant co-morbidity requiring admission
· Known IHD, unless current pain very atypical – seek senior advice

Yes No

Admit CDU / Ambulatory Admit Medics

Monitor not required Monitored bed if abnormal ECG,
on-going pain or troponin positive

Lab troponin < 15 ng / L Lab troponin > 14 ng / L

Did patient arrive 6+ hours from max pain?

Yes No

Repeat Lab troponin

3 hours from arrival

Lab troponin < 15 ng / L Lab troponin > 14 ng / L

ACS Ruled out ACS Ruled In

Remember that negative troponin does not rule out unstable angina Give Aspirin 300 mg to all if not already given
Consider alternative diagnosis Clopidogrel 600 mg + Fondaparinux 2.5 mg sc (if not contraindicated)
GTN infusion if on-going ischaemic pain: 50 mg in 50 mL 0.9% saline,
run at 2 – 10 mL/hour
Discharge Metoprolol 25 mg if no contraindications
(severe asthma, systolic BP <100 mmHg, pulse < 60, pulmonary oedema)
Complete HEART Score proforma:
LOW risk = Score 3 or less = GP follow-up
MOD or HIGH risk = Score 4 or more = RACPC (Cardiology)
Refer Barts Heart Centre
If score 4 or more, prescribe (if not already – ask GP to continue): Discuss with Cardiology Registrar 07833 237 316
· Aspirin 75 mg od
· GTN spray prn If decision to transfer, call LAS on 0207 902 2511 and request
· Bisoprolol 5 mg od (2.5 mg od if borderline low BP or bradycardia) Immediate Transfer
· Atorvastatin 40 mg od
If decision to not to transfer, refer to Medical Registrar
Give patient advice leaflet and copy of discharge letter Monitored bed

EM Network Guideline Group v2.1 March 2019 [review March 2022]

 Emergency Department BH
High Risk Chest Pain

High Risk
On-going or recurrent cardiac chest pain
AND one of the following:
· Transient ST elevation / ST elevation aVR
· ST depression > 1mm in 2 leads
· T wave inversion V1-V4 (LAD syndrome)
· Dynamic T wave inversion > 2 mm in 2 leads
· Heart failure or ventricular dysrhythmia thought to be due to
ischaemia

Investigations
VBG, UE, FBC, lab and POCT troponin on arrival

Treatment
Give Aspirin 300 mg to all if not already given
Clopidogrel 600 mg + Fondaparinux 2.5 mg sc (if not contraindicated)
GTN infusion if on-going ischaemic pain: 50 mg in 50 mL 0.9% saline,
run at 2 – 10 mL/hour
Metoprolol 25 mg if no contraindications
(severe asthma, systolic BP <100 mmHg, pulse < 60, pulmonary oedema)

Refer Barts Heart Centre

Discuss with Cardiology Registrar 07833 237 316
Do not need to wait for trop result if high risk ECG / symptoms

· Exclusions (may still need discussion)

Acute haemorrhage
Unexplained microcytic anaemia Hb < 10
Hypoxia
LOC or significant trauma
Inter-current other acute illness
Patient refuses consent or lacks capacity

If decision to transfer, call LAS on 0207 902 2511 and request

Immediate Transfer

If decision to not to transfer, refer to Medical Registrar

Monitored bed

Discharge and follow up to be determined by inpatient team

EM Network Guideline Group v2.1 March 2019 [review March 2022]

 Emergency Department BH
Cardiac Chest Pain

Lead Author

Consultant Emergency Medicine

Co-Authors / Collaborators

Consultant Cardiologists
Barts Heart Centre

Reference Documents

Chest pain of recent onset, NICE CG 95 March 2010, updated November 2016

EM Network Guideline Group v2.1 March 2019 [review March 2022]