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.

PPCI and Direct Admission of High Risk NSTEMI

Thank you

frank.hearl@gjnh.scot.nhs.uk