• Chest Pain SSOU Guideline

    Definition

    Adult patient (over 18) with potentially ischaemic chest pain with normal ECG.

    Note that the three major errors encountered in chest pain admissions to SSOU are:

    1. Forcing the case onto a chest pain pathway when the primary problem is something else (usually something more complicated or nebulous)
    2. Admitting patients to SSOU on the basis of a normal ECG/Troponin when the story is clearly one of crescendo angina or severe unstable angina which requires prompt inpatient workup
    3. Failure to consider non-cardiac causes of chest pain

    Admission Criteria

    • Pain/other symptoms resolved
    • Risk stratification intermediate or low requiring investigations
    • Serious non-cardiac cause clinically unlikely
    • Stable Rhythm
    • Stable vital signs
    • No acute ischaemic ECG changes
    • 1st troponin likely to be normal

     

    Exclusion Criteria

    • Persistent symptoms eg pain, dizziness, dyspnoea
    • Unstable or abnormal vital signs
    • Risk stratification high
    • Unstable cardiac rhythm
    • Abnormal ECG
    • Cardiac enzyme rise

     

    Emergency Department Assessment of Chest Pain Score (EDACS)

    The EDACS score is used to furhter stratify low risk chest pain to identify patients who can be excluded with a 2 hour troponin.

    Click here to open EDACS calculator. 

    EDACS < 16? Document in notes and order  2 hour troponin and ECG

    EDACS >= 16? Document in notes and order a 6 hour troponin and ECG

    In all cases, indicate in SSOU admission note what time the troponin is to be taken 

    Investigations

    • CXR
    • UEC
    • Glucose
    • FBE
    • 12 lead ECG
    • Troponin
    • Repeat troponin as indicated by EDACS score

     

     

    Suggested Medications

     
    Drug Dose Frequency Route
     Aspirin 300mg once oral
     Aspirin 100-150mg daily oral
     GTN 300-900mcg  prn sublingual
     Morphine  2.5 mg increments   prn to 15mg max  IV 
     Metaclopramide  10mg    6/24 prn  oral/IV  

     

    Specific Observations

    • Cardaic Monitoring
    • Report any chest, arm, jaw discomfort or any shortness of breath
    • Report any new ECG changes

     

    Specific Management Issues

    • ECG and notify doctor if chest pain develops
    • Consider stress test or other cardiac follow up
    • Patients with other than trivial risk of ischaemic heart disease should be discharged with aspirin and GTN until investigation or review

     

    Discharge Criteria

    • Resolved pain, no further symptoms
    • Unchanged ECG
    • No Troponin rise
    • Follow up arrnaged

     

    Hospital Admission Criteria

    • Recurrent chest pain or significant symptoms
    • ECG changes / arrhythmia
    • Tropinin rise