LVADs (Left Ventricular Assist Device) are becoming more common and there are patients in our region with them as a bridge to transplant or recovery and in some cases a destination therapy.
The patient and their family will likely know more about this device than you and should have brought spare parts. Our local LVAD centre is Wythenshaw however, there are other units around the country the patient may direct you to.
The patient may not have a palpable pulse, the blood pressure will be low and the heart pump sounds like a buzz when you listen.
If patient is unresponsive or has a history of collapse its important to troubleshoot the device and resusitation may be required
The ACS pathway is for patients where coronary ischemia is in your differential. It is not a blanket pathway for chest pain of unknown cause.
Patients presenting >8hrs post chest pain
If an initial trop is taken >8 hours post chest pain, and patients have no new ECG ischaemia, and no history of unstable angina, there is no compulsion to repeat a second troponin.
ACS Treatment(Not STEMI going for PPCI)
Aspirin 300mg stat
Ticagrelor 180mg stat
Fondaparinux 2.5mg sc stat.
Anticoagulated with a NOAC, or with Warfarin (with a therapeutic INR),
Aspirin 300mg stat
Clopidogrel 300mg stat
Treatment STEMI going for PPCI
Aspirin 300mg stat
Ticagrelor 180mg stat (Hx of CVA)
Prasugrel 60mg stat (NO Hx of CVA)
Direct admissions to CCU
Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.
As it is difficult to be prescriptive for every other circumstance, a discussion with a senior / cardiologist may be worthwhile in order to best place your patient within the hospital. Factors that should make you think about a senior discussion are included on the pathway.
Patients where MI is excluded
If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:
Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.
NB: 2nd Trop should be done >8hr after chest pain (this may be <6hrs from the initial Trop)
Patients on Warfarin/DOAC : Use Asprin and Clopidogrel
When do we take the blood samples? – The initial troponin must be taken at least 2hrs after chest pain, a second trop may be required 6hrs after the 1st (AAU/CDU)
Do we need to do a HEART score? – No, evidence shows the use of risk stratification in these pathways doesn’t increase safety but only increases admissions
Can we rule out ACS after the first trop?[Symptoms of Unstable Angina require admission]
Troponin <5ng and the ecg is normal we can rule out ACS.
Troponin <39ng(female)/58ng(male) and >8hrs from onset of chest pain [this is a pragmatic decision agreed locally by EM/AM?cardiology]
Why does it have different cut offs for male/female? – It is known women have significantly lower troponin to men, ESC recommends using the different cut offs
How should we treat transgender/intersex patients – There is no good evidence I can find (I would suggest using the female cut off – as patients who have transitioned to male are probably not going to have as high a troponin, and those who have transitioned to females may have reduced their baseline troponin with hormone therapy) – Be aware the lab can only report against the one registered sex for the patient.
Doesn’t highSTEACS have a 3hr Trop too? – Yes it does and in time we will be aiming to utilise this too. However, this relies on using Delta’s (i.e. the change in troponin), and it is felt that it is worth delaying introduction of this until we have got used to the new pathway.
Why are the numbers on the official highSTEACS pathway different? – This is because it uses the Abbott test. the highSTEACS pathway has been also validated on the Siemens assay we will be using. As to why the Abbot and Siemens cut-offs are so different, this is due to the way the assays amplify the troponin present (its not as simple as a U&E that just measures what is there).
Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.
GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA is far from a benign condition that can be passed back to the GP’s, it can lead to some significant problems