Chest pain protocol

History nature of pain, radiation, associated features sweating, breathlessness,

palpitations and nausea.
Assess Pain score (1 to 10)
VITALS = BP, HR, SpO2, temp + Exam start O2 if spO2 <95%.
IV ACESS- bloods, Troponin and CKMB , Glucose, cholesterol
ECG ST elevation or depression, T wave inversion, new LBBB
OLD ECG ? to compare
ECG again (In 10 Min), CXR in 30 min
Bring crash cart and defibrillator nearby
Aspirin 160 mg chew + S/L GTN (recheck pain score in 5 min) max 3 x GTN every
5 min
Pain still present (despite 3 x GTN) start GTN infusion until pain free and then Isordil
10 mg TDS.
Morphine 2 mg IV if pain not relieved
LMWH 30 mg iv bolus and 1 mg/kg BD in < 75 years old and no bolus and 0.75
mg /kg BD in age > 75
Renal failure/Elderly Unfractionated heparin
STEMI PROTOCOL 1 : If ST elevation or new LBBB treat as STEMI
NSTEMI PROTOCOL or HIGH RISK UA PROTOCOL 2 : If ST depression and pain
suggests ischemia treat as high risk UA (negative TR ) or NSTEMI (raised TR)
If ECG normal but TIMI score is 5, 6 or 7 treat as high risk UA
LOW RISK UA PROTOCOL 3 : If ECG is normal and pain suggests ischemia, TR is
negative and TIMI score is 1,2,3 or 4 treat as low risk UA
STEMI assess for bleeding risk thrombolysis within 30 mins of arrival (if pain
duration is < 12 hours) vs PCI if door to balloon time can be < 90 mins. All STEMI
patients should receive aspirin, clopidogrel and LMWH before thrombolysis. ECG
repeated after 90 min. < 50 % resolution in ECG means successful lysis. If
unsuccessful rescue PCI (class II)

If you decide on primary PCI start aspirin, 600 mg clopi, UFH, abciximab and then PCI
STEMI UFH (class I) or LMWH (class IIA) Abciximab (Class IIA) PCI

Low risk UA
Aspirin 160 mg chew
Clopidogrel 300 mg plus 75 mg daily
IV GTN if necessary or s/l or oral
LMWH as indicated before
Bisoprolol 5 mg + Valsartan 80 mg + Atorva 80 mg

High risk UA or NSTEMI ---- PCI within 24 hours

Aspirin 160 mg chew
Clopidogrel 600 mg plus 75 mg daily
Abciximab if patient goes for PCI
Eptifibatide if patient is not going for PCI
IV GTN if necessary or s/l or oral
LMWH
Bisoprolol 5 mg + Valsartan 80 mg + Atorva 80 mg

Precautions in elderly > 75 years old

No bolus dose of LMWH and clopidogrel
LMWH 0.75 mg per kg is enough

Summary
STEMI UFH (class I) or LMWH (class IIA) Abciximab (Class IIA) PCI

NSTEMI and high risk UA LMWH (class I) Clopidogrel 600 mg or Abciximab (class I) PCI
Moderate risk LMWH, Aspirin, Clopidogrel, Statin, Bisoprolol, Atorva 80, Isordil or GTN drip

Angina is considered unstable if it presents in any of the following three ways:

Rest angina, generally lasting longer than 20 minutes

New onset angina that markedly limits physical activity

Increasing angina that is more frequent, lasts longer, or occurs with less
exertion than previous angina

TIMI score for UA

Age >65

Three or more cardiac risk factors

Aspirin use in the preceding seven days

Two or more anginal events in the preceding 24 hours

ST-segment deviation on presenting ECG

Increased cardiac biomarkers

Prior coronary artery stenosis >50 percent

So in summary all patients receive

morphin, oxygen, nitrate, ACE I,
heparin, aspirin, statin,
betablocker, clopidogrel and
glycoprotein 2a/3b inhibitor

(before PCI if needed) MONA HAS

BCG