How to Investigate in ED “Chest Pain ? Cardiac”

1. How to Investigate in ED“Chest Pain ? Cardiac” Summary Notes The Health Roundtable Cross-Chapter Workshop 17 May 2002

2. Unstable Angina Guidelines 2000 Recommended Management of chest pain or discomfort MJA Vol 173 16 Oct 2000 ECG ST elevation (or LBBB) ? Consider Reperfusion therapy YES ST elevation No ST elevation High Risk Intermediate Risk Low Risk Rapid Chest Pain Evaluation Strategy No recurrent Ischaemia NEG. TROPONIN CCU HDU Recurrent Ischaemia POS. TROPONIN POS EST? OPD/GP Follow-up Yes No Coronary Angiogram PTCA Medical Therapy CABG

3. Unstable Angina Guidelines 2000: MJA Vol 173 16 Oct 2000Recommended Management of chest pain or discomfort • Baseline assess & tests • ECG < 5 mins, Troponin (or CK-MB if unavail), FBC, creatinine, electrolytes, CK, lipids (<24 hrs), BSL & Chest x-ray • History & physical < 10 mins • Assessed most appropriately qualified person • ECG sole test to select emergency reperfusion (thrombolytic or direct PCI) • Continuous/serial ECG if high/intermediate risk • NEG TROP = Repeat > 6 hours after presentation • If AMI, serial CK for 48 hours

4. New terminology for acute coronary syndromes Unstable Angina Guidelines 2000: MJA Vol 173 16 Oct 2000 UNSTABLE ANGINA MYOCARDIAL INFARCTION High Risk ‘Minor Myocardial Damage’ ST Elevation Low Risk Non-ST Elevation Troponin Cardiac Markers CK Mortality TROP NEG POS POS POS CK NEG NEG POS POS ECG on arrival NEG POS POS POS ST elevation ST depress or transient ST elevation ECG on discharge NEG No Q wave No Q wave Q or no Q wave

5. How to manage chest pain before definitive diagnosis • ED’s aim is to risk stratify • Start safe treatment at all hours without always making a definitive diagnosis [can be during hours by cardiology] • Which patients to admit or send home? • Up-skill ED staff to meet increasing community demand for 24/7 expertise at front-line • Meet monthly to review ED-Cardiology relationship • Use and audit “risk stratification and filtering” decision trees and check lists

6. Terminology for Standardising Care • “Clinical Practice Guidelines” • High level, usually National consensus statements summarising the evidence e.g. • Unstable Angina 2000, MJA Vol 173 16 Oct 2000 • “Protocol” / “Decision Tree” / “Algorithm” • Branching diagram of decision & interventions in sequence • Based on guideline evidence – more accessible • “Clinical pathways” • For condition-specific & predictable care (elective origin) • Specifies timing of interventions • Can reduce cycle time e.g. inpatient LOS 36 hrs to 18 hours (50%): Low Risk Angina Pathway (Fury)

7. Diagnosis-specific pathway • Use only when definitive diagnosis confirmed • Question use if patient does not fit (“falls off”) • Develop and routinely audit - by personnel expected to use across care continuum: • problems occur often at Dept interfaces • check appropriate use and improve tool • Must help practitioner - not hinder • Take no more time when used

8. ECG ST elevation ? ED Chest Pain Roundtable 2002 Assessment of Chest pain in ED YES ST elevation • Monitor • CCU/HDU No ST elevation arrival TROPONIN anytime EST available 24/7? NEG. POS. Yes No home + EST booked on Aspirin +/- statin +/- B blocker (cease pre-EST) POS EST? Coronary Angiogram High Risk Yes No • OPD Cardiology GP Follow-up • ?myocardial perf scan • Repeat selected tests Low Risk PTCA CABG Medical Therapy

9. TROPONIN for Risk Stratification Typical test timing Interpretation 4hr post pain 12hr post pain TWO POS TROP AMI Admit “ideal” ONE POS TROP Monitor until 12 hr TROP 12hr post pain On ED arrival “pragmatic” 1st NEG TROP Off monitor + 6hr TROP 12hr post pain “adequate” + Neg EST = low not no risk TWO NEG TROP W.H.O.: cardiac marker levels must rise and fall to be diagnostic

10. Exercise Stress Test pre-discharge from ED? • Thunder has EST available 7 days so can perform pre-discharge: • Until 8pm week nights and weekend mornings • Nurse performed and Cardiology Registrar interprets results (and backs-up if problems) • One stop shop better patient care if efficient with no delays and bed blockage • May complicate Medicare reimbursement potential for some hospitals ?

11. Angiogram vs Treadmill • Angiogram remains gold standard for diagnosis of CHD and AMI risk stratification • Use earlier where high overall risk and benefit e.g. airline pilots • Exercise stress test is non-invasive approximation • Use earlier in more active people • One hosp does routine EST before home (7 day fast track access needed e.g. nurses perform, read registrar) • Use with protocol/criteria to reduce LOS • Nuclear med scans better but more expensive/slow

12. Trends ED Chest Pain Assessment Chest Pain to ED History & Physical ECG <10m Cardiac Markers Exercise Stress Test • Shift to early as possible tests to risk stratify • before ED discharge • ECG <10 mins -continuous monitor ST elevation ideal • Repeated troponins - mainstay to risk stratification • Exercise Stress Test – before discharge ideal • Expert practitioner assessment in ED 24 hours/7 days

13. Evidence for Chest Pain Units • CHEEP study • most recognised supported cost benefit and safety • Mayo Clinic study • concluded saving time and money • Sheffield (UK) study • 20% reduction in admission. • Alfred Hospital study • Cardiac & OPD tests increased [vs. ED treated patients] • Faster access to EST and myoc perfusion studies • Reduced admissions and increased discharged home • Near double cost per patient [vs. ED treated patients] • Can lead to decrease in invasive testing • e.g. US hosp reported 17% decrease coronary angiograms • www.SCPCP.org • chest pain unit references [members only]

14. Patient expectations > best practice now for medico-legal defence • Bollam overturned by Rogers vs Whittaker • Bollam vs Frien 1957 • “sufficient if exercises the ordinary skill of an ordinary competent man exercising that particular art” • Rogers vs Whittaker 1990s • What a reasonable patient might expect from care takes precedence even over consensus of expert, evidence-based opinion • 1 in 14,000 risk of complications should have been advised to the patient even though not done by expert peers • Duty of care to ensure follow-up post-ED • ED referral to GP for follow-up incl. cardiology

15. Expertise transfer • Nothing now available beats good clinical judgment & experience • Too many variables for paper-based system • Computerised tools could assist when available • Regular case-driven medical education remains the mainstay • At best, decision tree helps junior staff risk stratify & start safe management until expert makes diagnosis • Ideal as check list of minimum standards

16. Proposed ED Chest Pain CHANGES FURY • Current pathways robust and work well for low risk UA and AMI (near 100% compliance) – useful audit tool and safety net for junior doctors • ED now refers low risk patients to Gen MED because cardiologist prefer to have patient identified with an inpatient team for follow-up, results etc. • Tighten entry to low risk care system by 24 hour senior clinician ‘gatekeeper’ • Improve Winter Plan by triage system & criteria to restrict access to telemetry beds

17. Proposed ED Chest Pain CHANGES ELECTRA • Develop protocol for junior staff to assess chest pain in ED • minimum expected tests, linked to follow-up • overcome view that initial negative tests mean ‘rule out’ of AMI, risk. • Start thrombolysis in ED

18. Proposed ED Chest Pain CHANGES THUNDER • Refine wording of current protocol • basically happy with it • May remove Myoglobin and rapid Troponins from protocol • only centre here using [not being used now to change clinical management]

19. Proposed ED Chest Pain CHANGES VEGA • Happy with current assessment tool and pathway • Funding and staffing needed for earlier access to EST • Low risk chest pains now admitted as the only way to ensure assessment

20. Proposed ED Chest Pain CHANGES CAPELLA • Establish a protocol to manage these patients • Consider continuous ST monitoring in ED for patients with initial normal ECG • while waiting for 9-12 hour Troponin • Streamline ED access to cardiology assessment

21. Proposed ED Chest Pain CHANGES EAGLE • Current chest pain triage protocol works well • Improve reliability of EST timeliness with follow-up for low risk patients discharged home from ED • improve access and follow up for EST < 1 week after ED with scheduled OPD notified to patient and documented in notes • Consider ED-based Point of Care testing for Troponins

22. Proposed ED Chest Pain CHANGES TORNADO • Continue TASC Project • Consider initial and 12 hour Troponin tests [now 8 hours after] • would these change our management? • Organise more formal EST follow-up for low risk patients sent home from ED • Regular chest pain/ECG education sessions for junior RMO at start of every term

23. Proposed ED Chest Pain CHANGES CONDOR • No pathways or protocols; happy with medical staff education • Implemented test ordering before documenting history to expedite test ordering. • Show all ECGs to a senior doctor in ED before to Specialist • should prompt ongoing teaching for junior doctors • Review appropriateness of ED routinely monitoring all Triage 2 chest pains without ongoing pain/problems • Problem ceasing monitor when transfer to cardiology and remain in ED • Show initial ECG to doctor then decide monitor second stage decision. • ED staff to establish criteria to restrict access to monitoring in ED or transfer to CCU • after 6 hour/second troponin with normal ECG, transfer patient to CCU for monitoring if desired by cardiologist. • Improve reliability of EST follow-up • now via local GP – consider routine OPD review as alternative

24. Proposed ED Chest Pain CHANGES CYCLONE • Chest pain guidelines in the process of being implemented • Organise timely EST for ED discharged patients • OPD or may need roster in private practices to improve access • Improve liaison between cardiology and ED junior medical staff • e.g. monthly joint audit and education meeting

25. Proposed ED Chest Pain CHANGES COUGAR • No problems with test access or ED-Cardiology relationship • Re-assess Troponin frequency • Eductaional discharge letter sent home with patients about their care • to advise them about the ED assessment process they have just been through and to urge compliance with follow-up arrangements

26. Proposed ED Chest Pain CHANGES ALTAIR • Improve ‘gate-keeping’ at ED Consultant-Registrar levels for inter-hospital referrals • Improve collaboration between private and public cardiology services • To improve access to EST and community follow-up

27. Proposed ED Chest Pain CHANGES STORM • EBM-based indications for monitoring patients to reduce current ED over-crowding • Review causes of ED Access Block • resolve inpatient bed management processes • Protocol to improve discharge strategies from ED Obs Ward - Chest Pain unit • consider starting B blocker, plus Aspirin and Statin while waiting for outpatient EST • Improve direct ED to GP communication by a phone call as well as current letter • Improve access to thallium scans