Clinical Assessment & Risk Stratification Frank Hearl Senior Charge Nurse Coronary Care Unit Golden Jubilee National Hospital PPCI and Direct Admission of High Risk NSTEMI
PPCI and Direct Admission of High Risk NSTEMI
Clinical Assessment & Risk Stratification
Frank HearlSenior Charge NurseCoronary Care Unit
Golden Jubilee National Hospital
PPCI and Direct Admission of High Risk NSTEMI
Risk CriteriaVery High Risk:• Haemodynamic instability• Recurrent chest pain• Life threatening arrhythmia• Acute heart failure• Dynamic ST-T wave changes
High Risk:• Rise and fall in troponin• Dynamic ST or T wave changes• GRACE score >140
Immediate Invasive management
Early Invasive management
Clinical Assessment• Physical examination / clinical history• Electrocardiogram• Cardiac biomarkers• Risk stratification
• Further investigations
PPCI and Direct Admission of High Risk NSTEMI
PPCI and Direct Admission of High Risk NSTEMI
DiagnosisAngina pain in NSTE-ACS patients may have the followingpresentations:
• Prolonged (>20 min) angina pain at rest• New onset angina • Recent destabilization of previously stable angina (Crescendo Angina)• Post-MI angina.
PPCI and Direct Admission of High Risk NSTEMI
Investigations• Electrocardiogram• Biomarkers- HScTnT/I• HEART Score• Quantitative assessment- GRACE• Cardiac rhythm monitoring
• Bleeding risk assessment- CRUSADE
• Baseline biochemistry & haematology• CXR• Echocardiography
Cardiac Troponin
PPCI and Direct Admission of High Risk NSTEMI
PPCI and Direct Admission of High Risk NSTEMI
Rule in / Rule out Algorithm
PPCI and Direct Admission of High Risk NSTEMI
Risk Stratification
PPCI and Direct Admission of High Risk NSTEMI
PPCI and Direct Admission of High Risk NSTEMI
HEART Score score 1. History Highly suspicious for ACS 2 Moderately suspicious for ACS 1 Slightly or non-suspicious for ACS 0 2. ECG Significant ST-depression/T wave inversion 2 Nonspecific repolarisation disturbance 1 Normal 0 3. Age ≥65 years 2 45–65 years 1 ≤45 years 0 4. Risk factors ≥3 risk factors, or history of atherosclerotic disease 2 1 or 2 risk factors 1 No risk factors known 0 5. Troponin I ≥ 3 x Normal Limit 2 > 1 - < 3 x Normal Limit 1 ≤ Normal Limit 0 TOTAL
Heart ECG Age Risk factors Troponin
HEART Score- History• Characterise the patients’ chest pain as typical or atypical• Typical pain: central or left-sided chest pain with radiation to the arms or
throat, or associated autonomic symptoms.• Atypical pain Right-sided chest pain, pain that radiated to the back or worse
on inspiration or palpation. Or presentation without chest pain.
2 points if chest pain highly suspicious. i.e. typical pain only1 point if chest pain moderately suspicious. i.e. elements of both typical and
atypical pain0 points if chest pain slightly or moderately suspicious i.e. atypical pain only
PPCI and Direct Admission of High Risk NSTEMI
HEART Score- Risk Factors• Diabetes mellitus• Current or recent (<90 days) smoker• Hypertension • Hypercholesterolemia • Family history of coronary artery disease• Obesity (estimated BMI >30)
3 or more risk factors or prior coronary revascularisation, myocardial infarction (MI), stroke, or peripheral arterial disease give 2 points1-2 risk factors give 1 point0 risk factors give 0 points
PPCI and Direct Admission of High Risk NSTEMI
PPCI and Direct Admission of High Risk NSTEMI
HEART Score• Likelihood of MACE within in the next 6 weeks• Low risk patients have a score 0-3 and have a less than 2% risk of
MACE at 6 weeks.• All other scores are high risk and require further management and
admission.• HEART is sometimes compared to GRACE & TIMI scores, these
measure risk of death for patients with ACS, and not who has ACS in the first place.