Notes for presenters
This slide set contains a generic training presentation for use by
clinicians when training ED staff to support implementation of the
London Cardiovascular (LCV) Project NSTEACS pathway.
This template presentation is designed to be tailored for local use.
Areas you may wish to edit are highlighted, with suggestions regarding
local content.
We encourage you to use your Trust’s branded PowerPoint slides.
Notes for presenters
The most up-to-date version of this presentation will be hosted on the
LCV Project website (www.slcsn.nhs.uk/lcv) plus further information
about the project.
Questions regarding this presentation or the LCV Project may be directed
to info@slcsn.nhs.uk.
High risk NSTEACS patients:
Diagnosing and transferring within 24 hours
Insert name
Trust
Date
What we will cover
•
•
•
•
•
Need to implement a new pathway for NSTEACS
Pan-London NSTEACS model
Identification of high risk NSTEACS
Management of high risk NSTEACS
What does / will the service look like
▫ Service aims
▫ Inclusion and exclusion criteria
▫ How to access
Need to implement new pathway for NSTEACS
10
% mortality at six months
Mortality (%)
8
ST-segment elevation
& depression
9.1% (n=1,769)
6
ST-segment
depression
8.9% (n=4,263)
ST-segment elevation
6.8% (n=3,369)
4
2
0
T-wave inversion
3.4% (n=2,723)
0
20
40
60
80 100 120 140 160 180
Days from randomization
NSTEACS has a higher mortality at 6 months than STEMI
References:
Savonitto et al. JAMA. 1999;281:707.
Disease process
Pan-London NSTEACS Model
Pan-London NSTEACS model
999
Patient
presents to
ED
Cardiac cath lab
NSTEACS
centre
Angio +/- PCI
within 24 hrs
(as appropriate)
ED diagnosis
High risk
NSTEACS
Rapid
assessment
Identification of high risk NSTEACS
•
•
•
•
•
Patients clinically suspected as having a non-ST elevation acute coronary syndrome
(NSTEACS) with ongoing or recurrent chest pain/discomfort believed to be of cardiac origin,
together with at least one of the following:
Persistent ECG changes of ST depression >1mm, or transient ST elevation
Pathological T wave inversion in V1-V4 suggesting an ‘LAD syndrome’
Dynamic T wave inversion >2mm in two or more contiguous leads
Haemodynamic (eg: hypotension, pulmonary oedema or heart failure) or electrical instability
(sustained ventricular arrhythmias – VT/VF) which are thought to be due to cardiac
ischaemia.
Troponin 0.1mcg/L
The above statement should not override clinical judgement. Any NSTEACS patient thought
by the admitting hospital staff to be high risk or who potentially may benefit from early
angiography/PCI should be discussed with the local cardiologists and, where appropriate, with
the regional cardiac centre.
A formal risk scoring assessment (eg: GRACE score) should still be undertaken as part of the
assessment on all patients admitted with UA/NSTEMI, in line with NICE guidance.
Identification of high risk NSTEACS
Cardiac enzymes
• Myoglobin (1-3 hours)
▫ Levels peak at 8-12 hours and fall back to normal within 24
hours
• CK-MB (3-4 hours)
▫ Peaks at 18-24 hours and returns to normal within 72 hours.
• Troponin I and T (3-4 hour)
▫ Remain elevated for 10-14 days
Identification of high risk NSTEACS
Other reasons for troponin elevation
•
•
•
•
•
•
•
Acute PE
Acute pericarditis
Acute or severe HF
Myocarditis
Sepsis and/or shock
Renal failure
Dissecting aortic aneurysm
Identification of high risk NSTEACS
A phone call should be made to the receiving hospital, to allow discussion
of the appropriateness of early angiography/PCI, taking account of
factors increasing the risk of intervention, such as co-morbidities and
bleeding risk. If the policy of early intervention/transfer for these patients
proves successful then consideration could later be given to agreeing a
policy of transfer without prior discussion. Having agreed inter-hospital
transfer the referring hospital should initiate an “immediate transfer” with
the LAS.
Management of high risk NSTEACS
NSTEMI drugs
• All ACS patients should get ASA (acetylsalicylic
acid)
• If the ECG suggest NSTEMI all patients should get
clopidogrel
• NSTEMI patients should get fondaparinux unless
contraindicated
What will / does the service look like?
Service aims
• Aims to:
• Insert the aims of the local NSTEACS centre here
What will / does the service look like?
• Insert information about agreed local protocol here
How to access the service
• All patients that meet the high risk NSTEACS
criteria must be discussed with referral SpR for
▫ Confirmation of appropriateness
▫ Bed status
• Ring LAS stating IMMEDIATE transfer
Support
Support is available from the
London Cardiac and Stroke Networks
North West
www.nwlcn.co.uk
020 7009 4075
North Central
www.nclcn.org.uk
020 3317 3717
North East
www.nelcvsn.nhs.uk
020 8926 5157
South
(includes South West and South East)
www.slcsn.nhs.uk
020 8812 5950