Cardiology Corner - ACEP Clinical Policy on NSTEMI

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Ian L. -

The Heart Score is a good prompt for determining ischaemic pain but both history and risk factors are subjective .
For Example smoking two packs of cigarettes a day versus a LDL of 3.6 mmol/L.
Settling for 1 in 50 misses if it means deaths or significant reduction in life span is just not going to be accepted .

Clay S. -

The question I've always had when it comes to these is unstable angina. Sending out the patient to try to see their doctor within 1-2 weeks with 1 week of progressive exertional chest pain that resolves with rest with low HEART score seems like a bad idea.

Amal M. -

Clinical judgment supersedes decision instruments

Ian L. -

What about NSTEMI with complete occlusion of proximally located coronary arteries -LAD RCA LCMx ?
This is the OMI manifesto ! Dr Pendal Myers EM Crit podcast 250 June 29 this year - emphasising the belief we need to worry with hype acute T waves NSTEMI and NSTEMI with continuing pain despite nitrates ( not morphine ) arrhythmias or heart failure or

Amal M. -

Diagnosing STEMI equivalents wasn't the focus of the ACEP Clinical Policy.

Luke T., Dr -

why is there mention of ASPECT score? isn't it if for MCA Stroke?

Amal M. -

There is an ASPECT score for ACS as well, from around 2011; though the HEART score has been more widely studied and discussed.

Andy M. B. -

So what's the bottom line?

Most patients present w ongoing chest pain not chest pain that ended 6 hrs prior to coming to the ER , other wise they would go to their primary.

So........ please sum it up here...cant we use the onset of pain...doesnt make sense to wait until the pain has stopped.

I would like this clarified a little more.

To send home we need:

Normal troponin : Pain for 6 hrs - 1 negative troponin . Pain for less than 6 hrs : Neg troponin at time 0 and 3hrs.

High Sensitivity Troponin: Pain for 6 hrs- 1 negative troponin. Pain for less than 6 hrs: Neg troponin at 0 and 2hrs

is this what you are saying?

Amal M. -

The HEART score studies generally did not bother to make a distinction between people that waxing and waning pain, on and off pain, continuous pain, or resolved pain. They just took ALL comers and lumped them into the same study...TN at arrival, and (in the Wake Forest studies) a second TN at 3 hours...regardless of the time course of the pain. That's why I like the studies...they apply to all of those groups.

It's my opinion that if a patient's pain resolved more than 3-6 hours ago, you can probably just get the 1 TN and EKG. But if the pain is ongoing, my preference is to simply get the TN at arrival and (depending on shared decision making) another one at 6 hours.

You mention--what if the pain has been ongoing for at least 6 hours...can't you just get 1 TN. Probably you can, and I think there are papers that support that. But our choice has been to follow the studies exactly how they did them...which means we don't worry about when the pain started or stopped. We lump them all together, just as the studies did.

We don't have hs-TN, but if we did, we would go with 0 and 2 hours rather than 3 hours.

I hope that helps.

Robert P., III -

For pts with risk of MACE < 1 % over next 30 days (determined by a clinical decision rule like HEART score and negative serial troponins):

1) Does the outpatient followup have to be with a cardiologist? Or will (non-cardiologist) primary care be okay in some cases?

2) Especially given that this recommendation is level C, is anyone actually using 1-2 weeks as the recommended followup time instead of something shorter? 48-72 hours is what the AHA/ACC guidelines say.

Amal M. -

In our protocol in our system (14 hospitals), we have a protocol that they simply need followup with a primary care doc or a cardiologist; either is fine, and they can get further risk stratification from there, initiate risk factor modification (e.g. htn meds, better control of sugar, dietary counseling, smoking cessation, etc.). We recommend 1 week. The 48-72 hour rec by the AHA/ACC is quite old, and I would suggest that the ACEP policy is newer, more specialty specific, and supersedes the ACC/AHA guideline.

Thanks, take care


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