Australian Doctor 14th July Issue 14JULY2023 issue | Page 23

CF

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Table 1 . The HEART score for chest pain patients at the emergency department

Highly suspicious 2

History

Moderately suspicious 1 Slightly or non-suspicious 0 Significant ST-depression 2

ECG

Nonspecific repolarisation disturbance 1 Normal 0 65 years or older 2

Age

45 – 65 years 1 45 years or younger 0 Three or more risk factors , or history of atherosclerotic disease 2

Risk factors

1 or 2 risk factors 1

Source : Backus BE et al 2013 14

No risk factors known 0

Figure 6 .

LV function on transthoracic echocardiogram .

Table 2 . Emergency Department Detection of Chest Pain Score Feature Detail Score

Age 18 – 45 46 – 50 51 – 55 56 – 60 61 – 65 66 – 70 71 – 75 76 – 80 81 – 85 86

+ 2 + 4 + 6 + 8 + 10 + 12 + 14 + 16 + 18 + 20

Selket / CC BY 2.5 / bit . ly / 41AhBSa

Gender Female 0

Signs and symptom

Diaphoresis

Pain radiates to arm , shoulder , neck , or jaw

Pain occurred or worsened with inspiration

Pain is reproduced by palpation

In hospital

The priority on patient arrival at hospital is to identify those with acute coronary occlusion , most commonly characterised by ongoing ischaemic symptoms with ST elevation on the presenting ECG . To improve short- and long-term outcomes with patients presenting with STEMI , the immediate goal is to initiate emergent reperfusion management . 2

PCI is the gold standard for management , with meta-analysis demonstrating superiority over fibrinolysis with reduction in mortality , recurrence of infarction and stroke . 30 Situations whereby a clinician may choose

Male 6

No Yes

No Yes

No Yes

No Yes

Low-risk cohort - EDACS less than 16 AND - ECG shows no new ischaemia AND - 0 to 2-hour troponin both negative Recommendation for low-risk cohort is safe for discharge to early outpatient follow-up investigation ( or proceed to earlier inpatient testing )

Non-low-risk cohort - EDACS greater than or equal to 16 OR - ECG shows new ischaemia OR - 0-hour or 2-hour troponin positive Recommendation for the non-low-risk cohort is to proceed with usual care with further observation and delayed troponin .

This score only applies to patients 18 years or older with normal vital signs , chest pain consistent with ACS , and no ongoing chest pain or crescendo angina .

Source : Emergency Department Assessment of Chest Pain Score ( EDACS ) 15

0 + 3

0 + 5

0 -4

0 -6

to proceed with fibrinolysis over PCI include when there are unacceptable delays to cardiac catheter laboratory activation or patient limiting factors such as a severe contrast allergy or poor vascular access . 2 There are several contraindications to fibrinolytic therapy , which include an uncontrolled systolic blood pressure above 180mmHg , recent trauma / surgery , gastrointestinal or genitourinary bleeding within the previous 2-4 weeks , stroke / TIA within three months and prior intracranial haemorrhage . 2 For patients who receive fibrinolytic therapy at a non-PCI-capable hospital , immediate transfer to a PCI-capable hospital

Box 3 . Causes of elevated troponin other than ACS

• Cardiac causes : — Cardiac surgery or electrophysiological procedure . — Aortic dissection . — Aortic valve disease . — Hypertrophic cardiomyopathy . — Tachyarrhythmia . — Takotsubo cardiomyopathy . — Infiltrative disease ( such as , amyloid , haemochromatosis or sarcoidosis ). — Inflammatory disease ( myocarditis ).

• Non-cardiac causes : — Rhabdomyolysis . — Pulmonary embolism . — Severe pulmonary hypertension . — Renal failure . — Subarachnoid haemorrhage . — Sepsis .

should be performed where possible to allow for early angiography and PCI if indicated . 31

Patients with ongoing symptoms and ST segment elevation of less than 50 % after 60-90 minutes , and / or with ongoing haemodynamic instability , should undergo angiography and PCI if anatomically feasible . 32

For patients with NSTEMI at high risk and very high risk for short-term recurrence of ischaemic events , an early invasive approach with coronary angiography ( from 24-72 hours after presentation ) and appropriate revascularisation with PCI or CABG is recommended . 2

Pre / post-hospital discharge

Secondary prevention strategies are critically important to reduce the occurrence of new vascular events in patients with a confirmed diagnosis of ACS who survive to discharge from hospital . These strategies include healthy behaviours ( for example , quitting smoking , being physically active , healthy eating ), intensive risk factor modification ( for example , controlling hypertension , managing diabetes , lowering cholesterol ) and adherence to proven cardioprotective medications ( such as aspirin , other antiplatelet drugs , statins , beta blockers , ACE / ARBs ). 2

Figure 7 . CT angiography and CAC scoring .

Offer pharmacotherapy to all patients with nicotine dependence ( for example , varenicline , bupropion , nicotine replacement therapy ); these are most effective when combined with behavioural support and follow-up . 33

The Australian Heart Foundation provides several simple recommendations and patient resources to help guide dietary modifications . Its recommendations include limiting eggs to seven per week , regular or reduced fat dairy products , limiting red meat to 1-3 meals per week , and replacing saturated fats with unsaturated fats . 34

They further recommend that patients aged 18-64 years perform 2.5-5 hours of moderate intensity exercise per week , and that those aged 65 years and older accumulate 30 minutes of moderate intensity physical activity on most days . 35

Aspirin is to be continued at a dose of 100-150mg per day indefinitely unless the patient does not tolerate the dose or there is a new indication for therapeutic anticoagulation . If aspirin is not tolerated then clopidogrel can be prescribed as the alternative . Dual antiplatelet therapy ( that is , aspirin and a P2Y12 inhibitor ) for up to 12 months should be prescribed in all patients presenting with ACS whether or not coronary revascularisation was performed .

Consider dual-antiplatelet therapy beyond 12 months in patients where the ischaemic risks outweigh the bleeding risk of P2Y12 inhibitor therapy ; conversely , discontinuation can be considered if bleeding risk