Name:

DoB:

Pt Number: Or addressograph Care Pathway

Chest Pain Pathway Triage Category

ECG Recorded at …… hrs,

Review by ……………………...... (name) ……………………(designation) at ………hrs Contents: Page 2 - ECG - ST elevation or presumed new left bundle branch block (LBBB). Consider for primary percutaneous coronary intervention (PPCI) Page 5 - ACS without ST elevation or presumed new LBBB

Non-cardiac chest pain If pain is fleeting, left sided, localised, altered by inspiration or movement consider non-cardiac causes of chest pain (page 5) and risks of anti-thrombotic therapy. Nurse Triage Presentation: Self O Ambulance O Ambulance sheet (E/U No)______BP Pulse SA Temp Resp BM Pain o 02 ( c) rate score Current Medicines (name, dose, frequency) Allergy Status : NKDA O Or Details of allergy:

Name Signature Bleep Date Time /ext

Oxygen Treatment

If SA O2 < 94% then prescribe oxygen to achieve SA O2 > 94% O If the patient has COPD, SA O2 < 88-92% should be maintained O

Dose Route Prescriber Date / Given by Checked Signature Time time/date by Glyceryl trinitrate _____micrograms stat S l N/A Morphine _____mg(10mg/mL) stat Iv Metoclopramide 10mg stat Iv Prescribe either fondaparinux or enoxaparin . If CrCl<20ml/min or Creatinine > 265 or full anticoagulation needed use enoxaparin*1 Fondaparinux *1 2.5 mg stat Sc Enoxaparin ______(1mg/kg) stat Sc Antiplatelet: and either *2 or . If aspirin contraindicated give clopidogrel monotherapy Aspirin ______mg stat Chew If ticagrelor contraindicated or fibrinolytic therapy indicated use clopidogrel. 1st line: 180mg, stat Po Ticagrelor*2 2nd line: ______mg, stat Po Clopidogrel

*1Fondaparinux 2.5mg provides only prophylactic level of anticoagulation, if full anticoagulation is needed also (e.g. mechanical prosthetic valve), treat ACS with treatment dose enoxaparin 1mg/kg twice daily if CrCl< 30ml/min reduce to once daily dosing instead. *2TICAGRELOR is Contraindicated in: documented allergy, pre or post fibrinolytic use, active bleeding, history of intracranial bleeding, AV heart block, moderate to severe hepatic impairment, interactions with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, nefazodone, ritonavir, and atazanavir), pregnancy and breast-feeding. Monotherapy without aspirin is not licensed. (see prescribing guideline)

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 1 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number: Or addressograph

Suspected ACS / MI with ecg showing ST elevation or presumed LBBB

1. Primary Percutaneous Coronary Intervention (PPCI) History Yes No Current cardiac sounding chest pain for 30 mins up to 12 hour Intermittent, cardiac sounding, chest pain for up to 24 hours Patients resuscitated from cardiac arrest not requiring intubation/ventilation with ECG criteria as below If yes to any of the above continue below

ECG Yes No New or Presumed new left bundle branch block Typical ST elevation > 2mm in 2 or more adjacent chest leads Typical ST elevation > 1mm in 2 or more limb leads with reciprocal changes If yes to any of the above continue below

2. Consent Consent Yes No Patient consented and understands reason for urgent transfer to Liverpool Heart and Chest Hospital (LHCH) for PPCI. If NO go to Section 5

3. Transfer to Liverpool Heart and Chest Hospital (LHCH) Door to transfer time target 30 minutes Contact Yes No Telephone LHCH: 0151 600 1817 Ambulance control centre 0151 261 4301 Quote ‘ transfer to LHCH for Primary PCI’ Complete LHCH ‘Hospital PPCI Checklist’ (Found on back of pathway) and fax to: 0151 600 1699 Inform relatives and give them ‘Primary PCI information sheet’

4. Medication – required before transfer (in total) Medication & Dose (Stat) Tick if given Route All patients.  Oral Aspirin 600mg If contra indicated use clopidogrel monotherapy as below In addition to aspirin all patients must receive ticagrelor or clopidogrel. 1st line: Ticagrelor*2 180mg  Oral 2nd line: Clopidogrel _____mg  Oral Prescribe and sign chart on page 1 and document on transfer form

5. – Alternative Management to PPCI Door to needle target 30 minutes Indication Yes No Patient meets criteria in Section 1 Patient has not consented to emergency transfer to LHCH (Section 2) If yes to any of the above continue below

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 2 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number: Or addressograph

6. Are there contra-indications to fibrinolytic therapy Absolute – NOT for treatment Yes No Patient is currently taking (if YES – SEE BELOW) INR >2.0 consider risk/benefit. SEEK EXPERT ADVICE Patient taking a new oral e.g. . SEEK EXPERT ADVICE Recent major surgery, trauma, head injury within 3 weeks? Recent stroke within 6 months? G.I. Bleed within 1 month? Haemorrhagic diathesis? Aortic dissection?

Relative. If yes to any below, consider RISK/BENEFIT, SEEK EXPERT Yes No ADVICE >80 years inferior MI with minimal ST elevation without ST depression Blood pressure >180mmHg systolic, >100mmHg diastolic? Prolonged chest compression? Active peptic ulcer? Other significant risk of haemorrhage? Pregnant or post partum 1 week?

If No to all of the above then give fibrinolytic. Heart block is not an exclusion.

7. Consent

Patient informed of diagnosis of AMI. Explained the benefits and risks of transfer for PPCI versus thrombolysis. Risk of GI Bleeds, CVA or Mortality.

Consent obtained by: ……………………………………… Signature: …………………………………………………….

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 3 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number: Or addressograph

8. Administration of fibrinolytic therapy Prescribe a single, weight related dose of: and , then either fondaparinux *1 or enoxaparin based on CrCl.

Body weight = ….… kgs Route Prescriber Given by time/date time/date Heparin Sodium 5000units  IV bolus Heparin Sodium 4000units if <65kg  IV bolus Tenecteplase <60kg = 30mg (6mL 6000 units)  60-69kg = 35mg (7mL 7000 units)  IV bolus 70-79kg = 40mg (8mL 8000 units)  10secs 80-89kg = 45mg (9mL 9000 units)  >90kg = 50mg (10mL 10,000 units) 

In addition to heparin and tenecteplase prescribe fondaparinux or enoxaparin. Fondaparinux 2.5mg stat*1  S/C then once daily, minimum 48hrs OR (if CrCl <20ml/min) Enoxaparin 1mg/kg Stat  …..mg S/C then once daily (renal dose) Minimum 48hrs

Ensure the patient is prescribed the following antiplatelet treatment: (sign chart on page 1) Aspirin 300mg, oral, stat, then 75mg, po, daily and Clopidogrel 300mg, oral, stat immediately, then 75mg, oral, daily.

Do not give ticagrelor before or after fibrinolytic use.

Consider other medicines as page 6.

9. Failed Reperfusion Following Thrombolysis

Yes No Failure, after 90 minutes of receiving fibrinolytic, to reduce ST- segment elevation (in lead showing maximum ST-elevation pre-thrombolysis) at least 50% Within 12 hours of onset of chest pain Patient fit and willing to transfer and undergo PCI at LHCH

If yes to all of the above contact on call SPR at LHCH on 0151 228 1616 to discuss transfer for rescue PCI

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 4 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name: Suspected ACS / MI without ST-Elevation or Presumed New LBBB DoB: Refer to TIMI stratification, repeat troponin at 12 hours. Consider Pt Number: Or addressograph bleeding risk and co-morbidity when choosing treatment (NICE 2010). Do not give if a non-cardiac cause of chest pain is suspected.

TIMI Risk Stratification for ACS / NSTEMI Yes No

Troponin T > 0.03 UG/L 1  0  ST depression > 0.5mm 1  0  Age > 65 years 1  0  At least 3 risk factors for coronary heart disease 1  0  At least 2 angina attacks in last 24 hours 1  0  Use of aspirin within the last 7 days 1  0  Coronary angiogram showing significant CHD 1  0  Score ONE point for each yes TIMI RISK SCORE = ______

Risk Management Treatment Score High 49% - 72% risk of events at 30 Antiplatelet treatment for all patients: Risk days Aspirin 300mg stat, 75mg daily If contraindicated use clopidogrel monotherapy If ongoing chest pain and / or ECG Prescribe aspirin with either SCORE changes 1st line: Ticagrelor 180mg Stat. 90mg twice daily - 5-7 CONSIDER OR (A Glycoprotein IIB 2nd line (if ticagrelor contraindicated. *2): Clopidogrel IIIA inhibitor) 300mg stat, 75 mg daily Seek Consultant / Senior Ticagrelor as monotherapy without aspirin is not Advice licensed. Seek LHCH advice Refer to cardiologist and admit In addition to antiplatelets prescribe either *1 CCU Fondaparinux 2.5mg SC daily maximum 8 days. Medium 13% - 24% risk of events at 30 OR if Crcl <20ml/mins Risk days Enoxaparin 1mg/kg SC daily (renal dose) Omit fondaparinux if for urgent PCI within 24hrs of SCORE admission. 2-4 Refer to cardiologist admit 32 Consider Beta blocker IV GTN if ongoing chest pain Low Risk < 8% risk of events at 30 days Antiplatelet treatment for all patients: Aspirin 300mg Stat, 75mg daily Early discharge if Trop T <0.03 If contraindicated use clopidogrel monotherapy SCORE UG/L AND normal ECG Consider dual antiplatelet: 0-1 CONSIDER Aspirin with ticagrelor 180mg, oral, stat, 90mg, twice Rapid access Chest Pain daily if: Clinic or ADMIT HAC ST/T wave changes and An additional risk factor -prior MI or ischaemic stroke or diabetes or peripheral arterial disease or EGFR<60 ml/min If ticagrelor contraindicated use aspirin monotherapy

Non Cardiac Causes of chest pain: , Aortic dissection, Pneumothorax, Biliary Colic, Pericarditis, Peptic ulcer, or Musculosketal pain. If a non-cardiac cause is suspected, DO NOT start aspirin, ticagrelor/clopidogrel or fondaparinux.

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 5 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Nam e:

DoB: Other Medication to be considered Pt Number: Or addressograph

Early Beta Blockade Indication Yes No

Acute MI /ACS Ongoing Chest Pain Tachycardia

Contra-indication Yes No

Heart rate persistently <60bpm Blood pressure persistently <100mmHg Systolic 2nd or 3rd degree heart block Severe heart failure History of bronchospasm / Asthma Already on beta-blocker or verapamil

Drug Route Atenolol 10 to 50mg (NB – maximum dose to be given IV 10mg)

IV Glyceryl Trinitrate (GTN) Indication

If ongoing chest pain, despite sublingual GTN & Opiates, prescribe IV GTN . Drug

IV Glyceryl Trinitrate – 50mg in 50mL Starting at 0.6mL/ hr increasing up to 6mL/hr Increase by increments of 0.6mL/hr. Titrate to BP and chest pain Contra-indication – severe aortic stenosis, systolic blood pressure<90mmHg

Management of blood sugars in myocardial infarction If answer to either of the questions below is yes, the patient is eligible for insulin therapy Tight glucose should be introduced within 4 hours of admission and continued for 48 hours for eligible patients.

Indication Yes No

Is the patient an acute MI and known diabetes mellitus? Is the patient an acute MI with BMI >11mmol/L? If eligible then commence GKI – refer to the pathway

Drug Route

Standard GKI IV 10% Glucose (500mL) with 10mmols potassium chloride (KCL) and 10 units of actrapid over 5 hours (100mL/hr) Double Strength GKI (Heart Failure) IV 20% Glucose (500mL) with 20mmols potassium chloride (KCL) and 20 units of actrapid over 10 hours (50mL/hr) Do not discontinue long-acting insulin (e.g. levemir® , Lantus®), record BM’s hourly and chart

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 6 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB: Accident & Emergency Assessment

Pt Number: Seen by …………………………Grade…………… Time ….:….. Or addressograph

History of presenting complaint – Time of onset: ……………… Hrs

Past Medical History / Risk Factors

Family history of ischaemic heart disease Y/N ACS Y/N Angina Y/N Smoker Y/N Cigarettes: …….. per day other: ………. Diabetes Mellitus Y/N Type I  Type II  Hypertension Y/N Hyperlipidaemia Y/N Myocardial infarction Y/N Prior CVA/TIA Y/N Peripheral arterial disease Y/N Renal impairment Y/N Prior heart failure Y/N

Social History

Alcohol: Yes  No  how many units per week? …… if more than 8 units daily for Males or 6 units daily for females, refer to WUTH Alcohol Withdrawal Care Pathway

Family History

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 7 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number:

Or addressograph

0 Examination BP .…..../.….. PULSE………. SA O2……% TEMP .……… C RESP………. BM……

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 8 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number: Or addressograph

Examination continued:

Plan

Investigations

ECG: ……………………………………………. Chest xray …………………………………..

Bloods …………………………………………… Repeat Trop-T at: …………. hrs

Clinical impression: ………………………………………….

Complete TIMI Score (page 5) for all patients with ACS Score = ……/7

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 9 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

Name:

DoB:

Pt Number: Or addressograph

Diagnosis – This should ideally be confirmed by a cardiologist before the patient is discharged

ST Elevation Myocardial Infarction (STEMI)

Non ST-Elevation Myocardial Infarction (NSTEMI)

Unstable angina

Angina

Other diagnosis (please specify)

If ticagrelor has been prescribed then the diagnosis of unstable angina must be confirmed prior to discharge. This should ideally be confirmed by a cardiologist, but if not available, a senior doctor.

Secondary Preventative Discharge Drugs Yes No Contra-indicated (state reason Antiplatelet therapy: All patients: Aspirin 75mg daily If contra indicated use clopidogrel monotherapy indefinately If dual therapy indicated use either ticagrelor*2 or clopidogrel in addition to aspirin 1st line: Ticagrelor, 90mg, twice daily, for 12 months (must be prescribed with aspirin) Or Clopidogrel 75mg, daily for 12 months If AMI / ACS that is troponin-T positive Atorvastatin 80mg (>80 years 40mg) for 6 months Beta blocker ACE inhibitor Omacor (post STEMI only) Smoking Cessation Cardiac Rehab

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 10 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015

PRIMARY PCI TRANSFER CHECKLIST DATE HOSPITAL A&E HOSPITAL NUMBER NUMBER

1. PATIENT DETAILS (use label if available)

NHS NUMBER ______DOB ______GENDER ______SURNAME______FORENAME ______

ADDRESS (including postcode) ______

2. BROUGHT IN BY AMBULANCE YES/NO (if yes, please include initial NWAS ECG with transfer checklist)

PATIENT REPORT FORM (prf) COPY ATTACHED YES/ NO (If no, complete ambulance details below)

EMERGENCY/URGENT (E/U) NUMBER)______TIME OF 999 CALL ___:___ TIME OF HOSPITAL ARRIVAL ____:____

STEMI DIAGNOSED ON ARRIVAL IN A&E YES/NO If no, TIME AND DATE STEMI DIAGNOSED ___:___/ _____:_____

3. CLINICAL DETAILS

TIME & DATE OF ONSET OF CHEST PAIN _____:______TIME OF ECG INDICATING STEMI CALL _____:____ (please include first diagnostic ECG with transfer checklist)

4. DRUGS REQUIRED BEFORE TRANSFER

Aspirin (600MG): DOSE______GIVEN BY______TIME ______:______

In addition Ticagrelor (180mg) : DOSE______GIVEN BY______TIME ______:______Or

Clopidogrel ( 300mg/600mg): DOSE______GIVEN BY______TIME ______:______

5. CONSENT

PATIENT UNDERSTANDS REASON FOR TRANSFER AND HAS VERBALLY CONSENTED? YES/NO

If appropriate, relative understands reason for transfer and has been given next of kin information booklet? YES/NO

State relationship ( ) 6. REQUEST EMERGENCY AMBULANCE TRANSFER TO LHCH !!THIS SHOULD BE DONE IMMEDIATELY AFTER STEMI DIAGNOSED !!

Emergency line 0151 261 4301 Clinician must request **EMERGENCY TRANSFER FOR PRIMARY PCI**

TIME AMBULANCE REQUESTED: ______:______BOOKING NUMBER ______7. ACTIVATE PPCI PATHWAY IT IS THE RESPONSIBILITY OF REFERRING HOSPITAL/CLINICIAN TO INFORM LHCH OF TRANSFER

Activate internal primary PCI policy at LHCH by telephoning 0151 600 1817

TIME LHCH INFORMED OF PATIENT ______:______TELEPHONED BY ______

8. RESPONSIBILITIES

RESPONSIBLE CONSULTANT ______REFERRING DOCTOR ______

SIGNATURE OF REFERRING DOCTOR ********COMPLETED FORM, COPY OF diagnostic ECG (plus initial NWAS ECG if performed) AND PRF TO BE HANDED TO TRANSFERRING AMBULANCE CREW. No other documents are required ************

Chest Pain Pathway Care Pathway, v2 Principal author: Dr N Newall Page 11 of 11 Approved by: Medicines Clinical Guidance Subcommittee. Date Sept 2012 Review by: Sept 2015