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THE CHEST PAIN UNIT MANAGEMENT PROTOCOL

Dr Mehdi Shahriyari AfsharInterventional Cardiologist Iranian hospitalDubai-Sep 2014

CHEST PAIN (CPU) assessment:

is defined as follows:1) The CPU should be able to directly identify and assessPatients with chest pain as they arrive in the emergency department. Ideally it should be based in emergency department

2) The CPU should provide up to six hours of observation, serial ECG recording and biochemical cardiac testing, ideally consisting of an early maker ( HFABP,CK-MB (mass)) and a later marker (Troponin) these should be either be point-of-care or provided by laboratories with a turn around time of one hour.

3) The CPU should provide exercise stress testing within 24 hours of attendance at the emergency department (preferably immediate ETT, but next working day is acceptable)

4) Patient selection and management will be determined by protocol, but with staff having the discretion to over-rule.

5) Patient management will be led by specialist nursing staff (Chest Pain Nurses) and ED physicians

6)The CPU may be physically located away from theemergency department , provided CPU staff are readily available in the ED to assess patients and support ED staff

7) The CPU may need to be defined located.

8) Continues ECG monitoring is routinely required

9) Patients can be discharged home between observation/ marker testing and stress testing, provided their markers are negative as they are asymptomatic

CHEST PAIN UINT

Staffing:3 chest pain nurses (8 hours duty Shifts) that has ACLS and dedicated for cardiac caring. Medical input provided by emergency or CCU medical staff coordinated by a physician of emergency department.

Structures:A four -bedded unit located within the area of the emergency department, with the potential to expand into more beds.

Opening hours:24 hours/7 days round the clock patients attending with chest pain or equivalent symptoms as dyspnea, palpitation are admitted to the CPU

Exclusion criteria:In screening room of emergency department every patient with chest pain should be checked by ED Physicians regarding the exclusion criteria for CPU :

1.Any of the following ECG changes, :unless known to be old=>1mm ST elevation or depression or > 0.5 mm T wave inversion in two contiguous leads ; Atrial fibrillation ;Tachyarrhythmia (>120 beats per minute ); bradyarryhthimia ( 40 beats per minute ), 2nd or 3rd degree heart block ;or left bundle branch block should be admitted in CCU

ECG MANIFESTATION IN IN AMI NEW DEFINITIONNew ST elevation at the J point

> or = 2 mm V2-V3 in men> or = 1.5 mm V2-V3 in women

> or = 1 mm in other leads in both genders

New ST Depression horizontal or down slopping in two contiguous leads > or =0.5 mm

T inversion > 1 mm in two leads with prominent R wave (R/S>1)

2. Known CHD (Coronary Heart Disease) with anginal pain that consists of recurrent episodes or episodes lasting more than one hour should be admitted in CCU.

3. Minimal risk of ACS (Acute Coronary Syndrome), i.e. pain that is stabbing, pleuritic, positional or reproduced by palpation in a patient with no history of, a few rick factors for CHD managed by ED physician as an outpatients

4.Co-Morbidity requiring hospital admission, e.g. heart failure, poor social support.

5. Suspected or proven alternative cause requiring hospital admission, e.g. pulmonary embolus, dissecting aortic aneurysm.

Routine management in CPU:

Fill up the special history sheet for any patient that admitted to CPU and follow the routine management by specialized CPU nurse as:

Establish IV line and saline infusion as K.V.O.Blood tests for general checking as: CBC, BS, Cr, K and Cardiac enzymes as the following mannerGive Aspirin 300 mg chew (if no contraindication)Give Librium (chlordiazepoxide) 5 mg P.O. for reducing the patient's tension In case of Hypertension or high sugar or other abnormalities follow the ED physician order.

Serial ECG recording:An ECG is recorded every hour .the patient is admitted in CCU if any of the following are recorded :=>1mm ST elevation or depression in any two contiguous lead T wave changes change unrelated to posture or hyperventilation Arrhythmia, 2nd or 3rd degree heart block ; left bundle branch block

Cardiac enzyme measurement:

This depends upon the time from the most significant episode of pain to presentation at hospital:

If more than 12 hours one blood sample is taken for troponin I and CK-MB (mass) measurement (CK-MB-troponin), that sending the sample to the laboratory.

If less than 12 hours two blood samples are taken: The first is taken immediately for cardiac panel (myogolobin tropinin, CK-MB (mass), BNP,-D Dimer) and HFABP (Heart type Fatty Acid Binding Protein) tests in CPU. The second is taken at least 2 hours later and at least 6 hours after the onset of pain for cardiac panel and HFABP tests in CPU

The patient is admitted in CCU if HFABP level > 5.8 microgram/lit, Troponin I level > 0.4 ng/ml ,CK-MB (mass) level > 4.3 ng/ml, the patient should be considered for CCU admission if positive myogolobin > 107 ng/ml, if abnormal D Dimer >600 ng/ml, if abnormal BNP >100 pg/ml by cardiac panel.

Exercise treadmill testing (ETT):This uses the Burse protocol and is interpreted as follows:Early positive: arrhythmia ;> 1mm ST elevation; or>1mm horizontal or down-sloping ST depression at stage 1 or 2 of the burse protocol.Late positive: any of the above changes occurring at stage 3 or beyond.Negative: at least stage 3 and 85% of predicted maximal heart rate achieved without the above ECG changes.Inconclusive: no ECG changes but the patient are unavailable to achieve stage 3 or 85% of the predicted maximal heart rate

Discharge issue:*Patients with early positive ETT tests are admitted *those with negative tests are discharge*Patients with late positive ETT, equivocal or inconclusive ETT tests;who are unable to perform ETT or known to have CHD are discharged with appropriate follow-up unless they have ongoing angial pain.

The follow up appointment for cardiology clinic for first coming cardiology clinic would be determined by CPU nurse and the referral sheet and the copy of patient's documents such as ECGs and blood tests should be sent to the cardiologist

The teaching pamphlet regarding chest pain and necessary information and sublingual nitrate (3 S.O.S. pills) and instruction for using it will be given to the patient at discharge time.