• Clinical Resources

  • Ischaemic Chest Pain Pathway SSOU Guideline

    Definition

    • Chest pain can be caused by a number of different pathologies which may include
      • Ischaemic chest pain
      • Pulmonary embolism
      • Pneumonia
      • Pneumothorax
      • Gastritis
      • Pericarditis
      • Aortic dissection
      • Among many others
    • Ischaemic chest pain may be stable angina, unstable angina, NSTEMI and STEMI

    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 expected to be in normal range in low risk patients

    Exclusion criteria

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

    Scoring system

    EDACS Emergency Department Assessment of Chest pain score

    Investigations

    • FBE
    • UEC
    • Troponin
    • 12 lead ECG
    • Consider
      • CXR- this may not always be required, consider when patient has last had a CXR and if this is clinically indicated
      • D-dimer- if requesting this please refer to “Pulmonary Embolism Pathway”
    • Additional
      • Requested repeat troponin with appropriate time to be taken
      • Repeat 12 lead ECG with second troponin

    Suggested medications

    Drug

    Dose

    Frequency

    Route

    Aspirin

    300mg

    Once

    PO

    GTN

    300-600mcg

    PRN 5min

    SL

    Paracetamol

    1g

    PRN 4hrly

    PO

    Oxycodone IR

    5-10mg

    PRN 4hrly

    PO

    Ondansetron

    4-8mg

    PRN 8hrly

    SL/ PO

    Metoclopramide

    10mg

    PRN 8hrly

    PO

    Specific observations

    • Cardiac monitoring
    • Report any chest/ arm/ jaw discomfort or shortness of breath to SSOU HMO. Please complete a repeat ECG.
    • Repeat ECG to be reviewed by senior SSOU doctor

     Consultations

    • Consider discussion with cardiology

     Discharge criteria

    • Resolved pain, no further symptoms
    • Unchanged ECG
    • No troponin rise
    • Follow-up arranged

    Admit to hospital if any of the following apply

    • Recurrent chest pain or significant symptoms
    • ECG changes/ arrythmia
    • Troponin rise

    Discharge follow-up

    • Follow-up testing is not required if patient is <50yo AND has <3 risk factors AND no previous CAD or MI

    PULMONARY EMBOLISM

     Definition

    • A pulmonary embolism (PE) is a blood clot that develops in a blood vessel elsewhere in the body (often the leg) and travels to an artery in the lung, causing a sudden blockage of blood flow to part of the lungs
    • Annual incidence of 0.31 per 1000 in Australia

     Admission Criteria

    • Stable vital signs
    • No O2 requirement
    • No increased WOB
    • ECG- no signs of right heart strain
    • Low or Very Low Risk PESI score
    • PERC score >0 (as if 0 will rule out PE)

     Exclusion criteria

    • PERC 0
    • PESI score risk class 3-5

     Scoring system

    • Calculate Wells score to determine need for d-dimer and CTPA
      • If patient low risk calculate PERC score
        • If PERC 0 <2% chance of PE indicating no need for further work-up for PE
        • If PERC >=1 D-dimer is required
      • If patient Intermediate or high risk consider CTPA or VQ scan
    • Calculate PESI score to determine mortality risk if patient has PE
      • If Very Low Risk or Low Risk PE – can go to SSOU
      • If risk class 3-5 requires medical admission

     PERC Score

    Criteria

    Point

    Age >= 50 years

    1

    Heart rate >= 100bpm

    1

    SaO2 on room air <95%

    1

    Haemoptysis

    1

    Current oestrogen use

    1

    Surgery or trauma requiring hospitalization within 4 weeks

    1

    Prior DVT or PE

    1

    Unilateral leg swelling

    1

     Score

    • 0 points or No to all = <2% risk of PE
    • >=1 or yes to any= cannot rule out PE

     WELLS Score

    Criteria

    Points

    Clinical signs/ symptoms of DVT

    3

    PE most likely diagnosis

    3

    Tachycardia (>100bpm)

    1.5

    Immobilisation/ surgery in previous 4 weeks

    1.5

    Prior DVT/ PE

    1.5

    Haemoptysis

    1

    Active malignancy (treatment within last 6months)

    1

     Score

    • Low risk <2 points- 2-4% probability of PE
    • Intermediate risk 2-6 points- 19-20% probability of PE
    • High risk >6 points – 50-67% probability of PE

     PESI score

    Predictors

    Points

    Demographic Characteristics

    Age (yr)

    1pt/ yr

    Male sex

    +10

    Comorbid Disease

    Cancer

    +30

    Heart failure

    +10

    Chronic lung disease

    +10

    Clinical Findings

    Pulse >110/min

    +20

    SBP <100mmHg

    +30

    RR >30/min

    +20

    Temp <36C

    +20

    Altered Mental status

    +60

    Arterial O2 sat (PaO2) <90%

    +20

     Severity index

    • The PESI score predicts 30-day all cause mortality
      • Very low risk- Risk class 1 (PESI <66) = 0.8%
      • Low risk- Risk class 2 (PESI 66-85) = 2.5%
      • Risk class 3 (PESI 86-105) = 4.3%
      • Risk class 4 (PESI 106-125) = 9.9%
      • Risk class 5 (PESI >125) = 27.1%

    Flow chart

    Investigations

    • FBE UEC
    • D-dimer if requires as per flowchart
    • ECG- looking for signs of right heart strain
    • CXR to rule out other causes of chest pain or respiratory symptoms prior to CTPA
    • CTPA
    • Consider
      • pro-thrombotic screen if PE present and unprovoked.
      • troponin

    Suggested medications

    Drug

    Dose

    Frequency

    Route

    Paracetamol

    1g

    PRN 4hrly

    PO

    Oxycodone IR

    5-10mg

    PRN 4hrly

    PO

    Ondansetron

    4-8mg

    PRN 8hrly

    SL/ PO

    Metoclopramide

    10mg

    PRN 8hrly

    PO

    Apixaban

    If CrCl 25mL/min

    5mg

    BD

    PO

    If CrCl <25mL/min or

    Any 2 of the following weight <60kg, age >80yo, Cr >133micromol/L

    2.5mg

    BD

    PO

    Therapeutic Enoxaparin

    If CrCl ≥ 30mL/min

    1mg/kg

    12hrly

    SC

    If CrCl <30mL/min

    1mg/kg

    24hrly

    SC

    Specific observations

    • Cardiac monitoring
    • Report any chest pain or worsening shortness of breath to SSOU HMO.
    • If chest pain present please complete ECG and

     Consultations

    • Discussion with haematology if PE present, patient <45yo and unprovoked PE or if pregnant
    • Obstetrics if patient pregnant

     Discharge criteria

    • If PE present
      • Low and Very Low risk PESI score
      • Discharge after 4-6hours observation in ED/ SSOU total
      • Ensure first dose of DOAC given in ED
      • Ensure that patient is discharged with therapeutic DOAC script for 3 months
      • Education / counselling for ALL patients commences on anticoagulation either via pharmacy or medical staff
      • Refer to haematology clinic
    • Symptoms resolved/ much improved
    • Observations within normal range
    • Follow-up organised

     Admit to hospital if any of the following apply

    • O2 required
    • Submassive or massive PE present
    • Troponin rise

    Discharge follow-up

    • GP
    • Haematology if PE present and unprovoked

     

     

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