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| ===Immediate Management of a Suspected Acute Coronary Syndrome=== | | ===Immediate Management of a Suspected Acute Coronary Syndrome=== |
| * Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances. | | * '''Management of ACS should start as soon as it is suspected''', but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances. |
| * Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected. | | * '''Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected'''. |
| * Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. * If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance. | | * Offer people a '''single loading dose of 300 mg aspirin''' as soon as possible unless there is clear evidence that they are allergic to it. |
| | * If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance. |
| * Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to: | | * Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to: |
| ** People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98% | | ** People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98% |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Priyamvada Singh, M.B.B.S. [3]
Overview
The American College of Cardiology, American Heart Association,and National Institute for Health and Clinical Excellence (NICE) guidelines recommends performance of ECG for all patients with cardiac chest pain. Additionally, chest X-rays in patients with suspected congestive heart failure, aortic dissection, aortic aneurysm, valvular heart disease, pericardial disease. However, the guidelines recommend exercise testing in low and intermediate risk patients only after they have been screened for high risk features and other indications for hospital admission.
NICE guidelines for the management of patients with acute chest pain (DO NOT EDIT) [1]
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Initial Assessment and Referral to Hospital
- Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours.
- Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering:
- The history of the chest pain
- The presence of cardiovascular risk factors
- History of ischaemic heart disease and any previous treatment
- Previous investigations for chest pain
- Initially assess people for any of the following symptoms, which may indicate an ACS:
- Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
- Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
- Chest pain associated with haemodynamic instability
- New onset chest pain or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes
- Do not use people's response to glyceryl trinitrate (GTN) to make a diagnosis.
- Do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant feature.
- Do not assess symptoms of an ACS differently in ethnic groups. There are no major differences in symptoms of an ACS among different ethnic groups.
- Refer people to hospital as an emergency if an ACS is suspected and:
- They currently have chest pain or
- They are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead electrocardiography (ECG) is abnormal or not available.
- If an ACS is suspected and there are no reasons for emergency referral, refer people for urgent same-day assessment if:
- They had chest pain in the last 12 hours, but are now pain free with a normal resting 12-lead ECG or
- The last episode of pain was 12–72 hours ago.
- Refer people for assessment in hospital if an ACS is suspected and:
- The pain has resolved and
- There are signs of complications such as pulmonary edema
- Use clinical judgment to decide whether referral should be as an emergency or urgent same-day assessment.
- If a recent ACS is suspected in people whose last episode of chest pain was more than 72 hours ago and who have no complications such as pulmonary oedema:
- Carry out a detailed clinical assessment
- Confirm the diagnosis by resting 12-lead ECG and blood troponin level
- Take into account the length of time since the suspected ACS when interpreting the troponin level.
- Use clinical judgment to decide whether referral is necessary and how urgent this should be.
- Refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain.
- When an ACS is suspected, start management immediately in the order appropriate to the circumstances and take a resting 12-lead ECG. Take the ECG as soon as possible, but do not delay transfer to hospital.
- If an ACS is not suspected, consider other causes of the chest pain, some of which may be life-threatening.
Resting 12-Lead ECG
- Take a resting 12-lead ECG as soon as possible.
- When people are referred, send the results to hospital before they arrive if possible.
- Recording and sending the ECG should not delay transfer to hospital.
- Follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor.
- Follow Unstable angina and NSTEMI for people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive of a NSTEMI or unstable angina until a firm diagnosis is made. Continue to monitor.
- Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider following Unstable angina and NSTEMI if these conditions are likely. Continue to monitor.
- Do not exclude an ACS when people have a normal resting 12-lead ECG.
- If a diagnosis of ACS is in doubt, consider:
- Taking serial resting 12-lead ECGs
- Reviewing previous resting 12-lead ECGs
- Recording additional ECG leads
- Use clinical judgment to decide how often this should be done. Note that the results may not be conclusive.
- Obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated interpretation.
- If clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor.
Immediate Management of a Suspected Acute Coronary Syndrome
- Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances.
- Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected.
- Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.
- If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance.
- Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
- People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%
- People with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88–92% until blood gas analysis is available.
- Monitor people with acute chest pain, using clinical judgment to decide how often this should be done, until a firm diagnosis is made. This should include:
- Exacerbations of pain and/or other symptoms
- Pulse and blood pressure
- Heart rhythm
- Oxygen saturation by pulse oximetry
- Repeated resting 12-lead ECGs and
- Checking pain relief is effective
- Manage other therapeutic interventions using appropriate guidance.
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References
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