NHS England “High quality care for all, now and for future generations.”
Better care for heart attacks. New models for management of non-ST
elevation acute coronary syndromes North of England Cardiovascular Network
Version Control
Purpose / Change Author Date
2.0 References updated NS 15-09-16
2.1&2 Learning points from Barts NS 22-09-16
3.1 Revisions following meeting 29/9 NS 30-09-16
3.2 JB/NS redraft, improved readability JB/NS 06-10-16
3.3 References around early rule out/BPT/QS99 NS 10-10-16
3.4 Amendments following Group meeting 2016 NS 24-01-17
3.5 Final version approved by CAG Business meeting NS/JB 27-01-17
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 1
Contents Introduction – the case for change ......................................................................................................... 1
Proposed guidelines for best practice in management of NSTEACS ...................................................... 2
Notes on guidance and challenges to implementation .......................................................................... 3
Impact of NSTEACS proposed changes on other NHS services ............................................................... 9
Next steps ............................................................................................................................................. 10
Summary ............................................................................................................................................... 11
References ............................................................................................................................................ 12
Appendix ............................................................................................................................................... 15
Glossary ................................................................................................................................................. 17
Introduction – the case for change
Heart attack care is of a high standard in the North of England. We have been at the forefront of
improvements in care for many years. We were one of the first regions to have a primary PCI
program for ST elevation MI. We have developed regional strategies for the antiplatelet treatment
of non-ST elevation ACS and for out of hospital cardiac arrest care. Mortality rates for heart attacks
have fallen faster in the North of England than in most other areas. These developments have been
due to agreement by all involved, mediated by the Cardiovascular Network. This is now part of the
Northern England Strategic Clinical Networks.
Non ST elevation acute coronary syndromes (NSTEACS) are common and, in many cases, a form of
serious heart attack. Recent national documents and analyses of UK results have looked at
management of NSTEACS. There are regional variations in care. It is common that patients do not
receive all the interventions that trials have shown to be of benefit. Delays in treatment are
commonplace.
UK data have suggested that lives are being lost as a result. Patients currently spend longer in
hospital than those admitted with an ST elevation- type heart attack. This is frustrating for patients.
It is a poor use of NHS resources, especially bed days in hospital.
This paper looks at how we can build on the achievements we’ve made in heart attack care. It sets
out a series of proposals for best practice. They are based on latest national and European
guidelines.
These changes involve reshaping of some existing services. Such changes can be difficult. We believe
they can be implemented, however, with careful planning and appropriate resources. This will
benefit people with this type of heart attack, without adversely impacting other areas of cardiology
care.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 2
Proposed guidelines for best practice in management of NSTEACS The following proposals all represent significant shifts in current practice. They are a gold standard
for care, based on current available best evidence. Adopting these changes will require major
resource shifts and training. It is envisaged therefore that the changes will take time.
1) All patients with suspected NSTEACS should have an ECG, risk assessment (e.g. GRACE or TIMI)
and high sensitivity troponin testing on admission and, usually, at three hours after arrival.
2) Patients meeting a ‘rule out’ protocol should go home within four hours. If a cardiac cause other
than ACS is suspected, OP referral to a chest pain clinic may be appropriate. All patients
discharged from A&E should be advised to seek timely primary care review if symptoms recur.
3) Patients in whom a NSTEACS has been diagnosed should be assessed and admitted and seen by
an appropriate consultant within 14 hours.
4) Patients with NSTEACS should be assessed with a Fast Track Pathway Tool. Those meeting all
criteria should be discussed at middle grade or higher level with the PCI centre registrar on call.
Those accepted should be transferred directly to the PCI centre.
5) Patients with very high risk features of ongoing cardiac chest pain and ECG changes / haemo-
dynamic instability should be discussed by ambulance crews with the PCI centre with a view to
direct admission to that unit.
6) Patients with NSTEACS should be assessed by a consultant cardiologist within 24 hours of
admission and daily thereafter, unless it has been determined that this would not affect the
patient’s care pathway.
7) Out of normal working hours, a cardiology consultant should be available on-call for telephone
advice and, when necessary, ‘return to base’ at all sites admitting NSTEACS patients.
8) Patients assessed as high risk should be transferred to a PCI centre for coronary angiography and,
where appropriate, PCI within 24 hours.
9) Patients with intermediate risk should be transferred to a PCI centre for coronary angiography
and, where appropriate, PCI within 72 hours.
10) In the majority of cases, NSTEACS patients at sites without the capability to progress to PCI
should not undergo invasive angiography prior to transfer to a PCI centre.
11) Patients referred to a PCI centre should be transferred within 24 hours when resources allow.
12) NSTEACS angiography/PCI will occur routinely seven days a week at the PCI centres.
13) NSTEACS patients must be offered advice and cardiac rehabilitation (e.g. smoking cessation,
dietary and lipid management) as well as secondary prevention treatment and echocardiography.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 3
Notes on guidance and challenges to implementation
An outline algorithm incorporating the various proposals is included in the Appendix below.
1) All patients with suspected NSTEACS should have an ECG, risk assessment (e.g. GRACE or TIMI)
and high sensitivity troponin testing on admission and, usually, at three hours after arrival.
hs-troponin testing is not widely available. In many units, troponin testing is part of a combined
contract for various tests and using hs-troponin testing may have contract/cost implications
preventing that change in the short term.
Systems need to be expedited, if a three hour hs-troponin test result is to be returned to the
frontline with enough time to allow A&E to discharge within four hours. There are studies (1)(2)(3)
(4,5) suggesting much earlier time points may be safe with the most recent hs troponin assays,
coupled with ED staff clinical judgement.
Risk assessment usually means the use of a validated scoring system (6), although clinical features
alone are often used to make decisions on management, depending on local practice.
2) Patients meeting a ‘rule out’ protocol should go home within four hours. If a cardiac cause other
than ACS is suspected, OP referral to a chest pain clinic may be appropriate. All patients
discharged from A&E should be advised to seek timely primary care review, if symptoms recur.
The Network expects that all units will adopt a pathway to suit their own admission/A&E units. A&E
(or acute admission unit) decision-makers need to be trained and empowered to discharge
appropriate patients within the four hour window.
Various models exist to encompass this, based on published studies. An early rule out algorithm is
currently in use at NUTH (see below). Other models are detailed in various papers, some allowing
for even earlier “rule-out”(7)(1,2,8–10)
Note: It is possible to have a high GRACE or TIMI risk score despite being troponin negative and such
people should not be discharged without review by cardiology specialists.
Follow up of patients where ACS has been ruled out will depend on clinical judgement and local
availability of outpatient services. Local units should develop their own pathways of care to ensure
that patients with ongoing chest pain are assessed for non-cardiac causes.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 4
3) Patients in whom a NSTEACS has been diagnosed should be assessed and admitted and should
be seen by an appropriate consultant within 14 hours.
6) Patients with NSTEACS should be assessed by a consultant cardiologist within 24 hours of
admission and daily thereafter, unless it has been determined that this would not affect the
patient’s care pathway.
7) Out of normal working hours, a cardiology consultant should be available on-call for telephone
advice and, when necessary, ‘return to base’ at all sites admitting NSTEACS patients.
Review by an appropriate consultant within a 14 hour timeframe is in keeping with the Keogh report
on 7 day services. Often for unselected chest pain patients, the first consultant review may be by an
acute physician. However, where a NSTEACS is confirmed, or where the person is admitted direct to
a cardiology unit/CCU, that review will be by a consultant cardiologist. In this document,
“consultant” would include other post-CCT cardiology doctors. It may be appropriate in limited
circumstances for a non-medical member of the cardiology team (e.g. cardiology specialist nurse) or
an appropriately qualified non-cardiology consultant to assess some of these NSTEACS patients. For
example, it is possible that some patients will have slightly raised hs-troponins, but are otherwise
very low risk on GRACE/TIMI score. Local protocols should be developed about how such people are
managed. This may vary according to local availability of tests, such as cardiac CT/CMR and
angiography. Medical management should follow current NICE/ESC guidance and NECVN guidance
on antiplatelet therapy (http://www.nescn.nhs.uk/wp-content/uploads/2015/02/Antiplatelet-
Therapy-NSTEMI-v2-21.pdf). Review of NSTEACS patients should not be of a lower quality at
weekend than during the week and should not be by non-cardiology staff alone. BCS guidance (11)
has specified that on call cover must include the potential of return to base by the on call consultant
where necessary, rather than obtaining phone advice from regional centres. Telephone advice is
only acceptable if there are arrangements for immediate transfer to a specialist unit.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 5
4) Patients with NSTEACS should be assessed with a Fast Track Pathway Tool. Those meeting all
criteria should be discussed at middle grade or higher level with the PCI centre registrar on call.
Those accepted should be transferred directly to the PCI centre.
This change would have the greatest impact on service configuration in the region. The aim is that
the majority of patients with uncomplicated NSTEACS will follow this process. Fast Track patients
would be identified in A&E Departments and transferred without admission locally at all. This would
minimise delays to revascularisation and avoid the tariff costs currently inherent in two separate
admissions. Published data suggest reductions in length of stay can be considerable with such an
approach, in the order of nine days to three (9).
A NECVN Fast Track NSTEACS Pathway tool has been created (see Appendix). It aims to prevent large
numbers of non-ACS patients, or patients whose comorbidities make immediate angiography/PCI
inappropriate, being brought directly to the PCI centre.
One such pathway has been implemented in Glasgow and another, used at the London Chest
Hospital, is described in Gallagher et al (12).
Where local services allow (such as in Cramlington), rapid assessment of NSTEACS patients can be
made by cardiologists. Elsewhere patients eligible for Fast Track transfer will be discussed by the
middle grade or higher decision maker in A&E/acute admission unit with the on call registrar or
equivalent in the PCI centre, aided by electronic transfer of ECGs. Patients meeting the criteria will
then be transferred immediately.
Complex needs, requiring prompt assessment by an experienced cardiologist locally would include
advanced non-cardiac disease/frailty/cognitive impairment/extreme old age. It is important that
local units are adequately staffed and resourced to assess such people to determine which of them
might also benefit from angiography. Such assessment should not however delay angiography and
revascularisation when indicated unduly, which should still be within the 24/72 hour window
wherever possible. Consultant cardiologist numbers need to be adequate to offer seven day
availability for review and assessment, as well as an out of hours on call service. This is not currently
the case.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 6
5) Patients with very high risk features of ongoing cardiac chest pain and ECG
changes/haemodynamic instability should be discussed by ambulance crews with the PCI centre
with a view to direct admission to that unit.
Patients in this group constitute a minority of NSTEACS cases, but are likely to be in the highest risk
groups. To some extent, patients in this highest risk group may need urgent treatment in much the
same way as those with ST elevation. However, it would require additional training of paramedic
crews to identify such patients reliably. Very high risk patients would be those with:
Note: Other post-arrest patients may also be very high risk. Until region-wide arrangements are in
place, however, ventilated/poorly responsive cardiac arrest survivors should still be assessed in
nearest A&E. Such patients can then be discussed with the cardiology team at the PCI centre for an
individualised management plan.
8) Patients assessed as high risk should be transferred to a PCI centre for coronary angiography
and, where appropriate, PCI within 24 hours of admission.
11) Patients referred to a PCI centre should be transferred within 24 hours when resources allow.
High risk patients are defined as those with a GRACE risk of > 6% mortality at 6 months, TIMI score of
≥ 5 or equivalent. Note: Current ESC guidance (13) suggests that all patients with a raised troponin
should be considered as high risk, independent of GRACE score.
Robust transport arrangements (including appropriately skilled ambulance personnel) need to be
commissioned to be able to achieve this routinely. We note the use of non-paramedic crews from a
private ambulance provider (http://ems-uk.co.uk/) in some parts of the Network already, alongside
NEAS and YAS services. Currently, limitations in ambulance capacity mean that this category of
patients cannot consistently be transferred in the desired timeframe.
9) Patients with intermediate risk should be transferred to a PCI centre for coronary angiography
and, where appropriate, PCI within 72 hours.
12) NSTEACS angiography/PCI will occur routinely seven days a week at the PCI centres.
Intermediate risk patients are defined as those with a GRACE risk of 3-6%, TIMI score of 3-4 or
equivalent. Note: previous NECVN guidance (http://www.nescn.nhs.uk/wp-
content/uploads/2015/02/NetworkXACSXflowchartX2008.pdf) has considered all troponin positive
patients to be, at least, of intermediate risk.
Ongoing cardiac chest pain and
Any of the following:
- haemodynamic compromise (systolic BP <90mmHg or ventricular arrhythmias)
- ≥ 2mm ST depression in more than one lead
- Resuscitated cardiac arrest, now alert or responsive to verbal stimuli
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 7
Low risk ACS patients (GRACE risk<3% or TIMI score 0-2) should be assessed by local cardiology
teams (which may include appropriately trained non-medical staff). After assessment according to
local practice, it may be felt that they should be offered invasive angiography, in which case they
should be referred in the same way as those with intermediate risk.
A seven day service is needed at specialist centres, in keeping with multiple NHS-England,
Department of Health and BCS guidance from recent years (11)(14–19). Providing such a service will
be difficult without increased resources, if it is not to impact adversely on other parts of cardiology
services. Staffing issues , particularly recruitment and retention of medical and physiologist staff (20)
may delay the implementation of a truly seven day cardiology service. The 72 hour window is in
keeping with ESC, NICE Quality standards and NICE Implementation Collaboration guidance (21) (22).
NHS England has published a Best Practice Tariff, tying increased tariff to achievement of this 72
hour target (23). Currently, BCIS data
(http://www.bcis.org.uk/documents/39F_BCIS_Audit_2014_23022016_for_web.pdf) would suggest
that (in 2014) Sunderland was achieving a rate of around 75% of patients undergoing PCI within 72
hours of admission. South Tees achieved around 50% and Freeman around 30%. National average
was 54.3%. Local data (personal communication from N Swanson and Raj Das) show variation in the
tertiary centres depending on whether the person was directly admitted (in which case PCI occurred
around 24 hours faster) or not. Delay to treatment also varies according to which local hospital the
patient was admitted to initially. Slowest times to PCI were for people who had diagnostic only
angiography in admitting units, without PCI capability. These findings are also in keeping with
national data. Delay in providing angiography is more than just inefficient – there are data to suggest
that such delay is associated with excess deaths and recurrent events (24)(25).
The benefits of a true seven day service include consistent flow of patients and reduced length of
hospital stay. Current provision is variable across existing PCI centres. Freeman has one all day list on
both Saturdays and Sundays – about 2/3 of the NSTEACS throughput of a weekday. James Cook has a
Saturday morning list. Sunderland has no routine provision for NSTEACS at weekends. Likely limiters
to further expansion include lack of catheter lab staff and the impact on weekday consultant
presence if there is increased weekend working.
10) In the majority of cases, NSTEACS patients at sites without the capability to progress to PCI
should not undergo invasive angiography prior to transfer to a PCI centre.
This recommendation is in line with NICE Implementation Collaborative guidance (21). It seeks to
avoid the risks from multiple interventions, their cumulative costs and aims to shorten transfer times
and hospital lengths of stay. Some patients, in whom the diagnosis is uncertain or in those with or
complex needs, may benefit from diagnostic angiography (but no more than 10% of total NSTEACS
population). In time, CT coronary angiography may be the more appropriate investigation for such
patients.
13) NSTEACS patients must be offered advice and cardiac rehabilitation (e.g. smoking cessation,
dietary and lipid management) as well as secondary prevention treatment and echocardiography.
Other elements of care in NSTEACS are of great importance and analysis of MINAP data has shown
that not only are elements of this care often omitted (including our region)(26), but also that such
omission can be correlated with increased mortality(27)(28). NSTEACS secondary prevention should
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 8
be in line with NICE CG172 (29) and QS99 (30). Best practice tariff targets for this have been set as
expecting rehabilitation to be started within three days of initial event and while still an inpatient
(23). Given the accelerated care pathway and shortened lengths of stay envisaged in these
recommendations, risk factor advice and intervention may need to be identified and addressed
routinely during the rehabilitation phase after hospital discharge. This is in part recognising that
patients do not retain information well when delivered in an emergency setting. It is increasingly
common that patients post PCI for NSTEACS are offered same day discharge, including those
transferred from other hospitals. Rehabilitation will be provided by the existing teams in the
patient’s local area. Particular attention needs to be paid to the psychological impact of the cardiac
event especially given the speed with which treatment and discharge may occur. Furthermore, it is
noteworthy that smoking cessation programs are funded through Public Health, not by CCGs.
Echocardiography for all NSTEACS patients is strongly recommended by current ESC guidance (13)
and NICE Quality Standard on secondary prevention post MI (30).
Other points relating to guidance.
NSTEACS can present with out of hospital cardiac arrest. This pathway does not fully address
such patients, although there are network guidelines (http://www.nescn.nhs.uk/wp-
content/uploads/2015/02/NEASXjointXOOHCAXPPCIXprotocol.pdf) available.
Patients with ST elevation should be treated according to existing guidance.
Ongoing management of patients transferred for angiography/PCI is generally left with the
receiving unit. Whilst there are models of care where patients have a “treat and return”
approach, this seems of little value, if post-PCI patients are discharged that same day. People
who need in house urgent CABG will stay in the receiving unit. Patients who have been Fast
Tracked, but do not in fact require angiography/intervention should be repatriated back to
their local hospital, unless they can be dealt with that day and discharged. Similarly, people
post-PCI with complex needs, requiring longer admission, are better served by repatriation.
This can best be achieved by formalised agreements between units to encourage such
transfers, in order that beds are available at the PCI centre for new referrals.
Electronic referral / data exchange is envisaged to improve inter-hospital (non-emergency)
transfer arrangements.
Echocardiography is a guideline-supported test for all such patients. This should be
undertaken by the hospital where most of the person’s care is provided during their
NSTEACS admission. Currently, this is not being achieved and would require further
resources before it could be achieved consistently.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 9
Impact of NSTEACS proposed changes on other NHS services
Better seven day treatment of NSTEACS risks reducing the ability of organisations to deliver
timely and high quality care for other, equally important acute or elective cardiac conditions.
Increased emphasis on providing urgent and emergency treatment of people with NSTEACS may
require staff to be redeployed - resulting in waiting times increasing for elective PCI and non-PCI
procedures or outpatient assessments.
Increased demand for urgent NSTEACS inter-hospital transfers could impact negatively on
ambulance services for patients with other clinically important conditions.
There is a large group of patients with complex needs in whom the decision to offer angiography
may be nuanced. It is important that admitting units are adequately resourced – in particular
with sufficient cardiology consultants - to assess these more complex patients before deciding
whether they should undergo invasive coronary revascularisation. Local teams need to be able to
discuss such patients seven days a week with an interventional colleague at a PCI centre.
Reducing local admissions and/or angiography in NSTEACS may have adverse financial
implications for the viability of cardiac catheterisation laboratories on non-PCI sites and indeed
financial viability of entire cardiology units.
Several units in the North of England already struggle to recruit and retain cardiology consultants
and support staff. These NSTEACS recommendations envisage concentrating further specialist
services in a small number of hospitals. This could aggravate existing recruitment/retention
problems for units not providing such specialist interventions. In the longer term this could
threaten their ability to deliver high-quality cardiology services in general to their local
populations.
This problem is recognised in the NHS 5 Year Forward Plan (which discusses the concept of
“viable smaller hospitals”). It is vital for the viability of regional cardiology services that changes
in patient flow are seen in this wider context and measures put in place to ensure local cardiology
services thrive.
Developing and sustaining consultant workforces on district and specialist centre sites can
probably be best achieved by greatly increasing cross-site working. This will require a
fundamental change in mind-set and unprecedented collaboration between Trusts across the
region. Even if it can be agreed, it will take time to implement.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 10
Next steps
The Network will work with commissioners and service providers on priorities and timescales for
these changes. Not all of them can be achieved in the short-term. Some require major re-
organisation of services with disruption to existing pathways of care and funding streams.
Early phase implementation
Units in the North of England that admit chest pain patients should start to use recognised
high sensitivity assay for troponin testing. Each unit should involve local biochemistry
departments in the discussion so this can be achieved as soon as possible.
A rule-out protocol, ideally using hs troponin testing, should be developed by each local unit
admitting patients with chest pain. This need not be the same as that used in RVI, although
that model offers a suitable template.
Ambulance providers should be encouraged to begin to refer very high risk NSTEACS
patients, using existing PPCI communication systems.
Rehabilitation services should develop systems to ensure that patients discharged quickly
from hospital have timely access to rehabilitation services across the region.
A 24 hour target for transfer to PCI centre should be adopted as standard.
Medium term implementation
PCI centres should increase their provision of routine NSTEACS angiography/PCI to allow for
seven day working.
All centres should develop on-call rotas to allow for seven day cardiology consultant cover.
This may involve cross-site working.
Impact assessment should be performed of a region wide Fast Track Pathway for most
uncomplicated NSTEACS patients to follow – this would include impact on the receiving
centres, impact on ambulance transfers, reduced funding for local cardiology units,
repatriation for complex patients or those with ongoing needs.
Fast Track Pathways could be trialled in units which are already closely allied with a non-PCI
centre. For example Friarage Hospital/JCUH or South Tyneside/Sunderland.
Long term implementation
Full adoption of a Fast Track Pathway for the majority of NSTEACS patients should be
resourced and implemented.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 11
Summary
NSTEACS patients are a complex group. They present in different ways and with varying levels of
other major comorbidities. Their care is currently less than ideal.
NSTEACS care is not compliant with best practice. MINAP data show that most patients do not get
all the guideline recommended interventions. These omissions are associated with preventable
deaths. Delay in angiography, especially, is associated with worse outcomes. We need to do better,
since doing so may save lives.
Treatment of these patients is slow. Such delays are costly and inefficient.
Acute chest pain presentations are rising. Techniques are available to have NSTEACS ruled out early
in A&E. Currently, large numbers are admitted unnecessarily to hospital.
Non-emergency cases are generally not treated on a seven day basis. Variability through the week
leads to uneven flow of patients and unacceptable variation in quality of care.
Changing the systems of care for these patients is not going to be quick or easy. It will involve effort
across many hospitals and many different teams. It will require reorganisation of current resources
and funding. These changes may have unwanted consequences elsewhere in the healthcare system.
These may only become apparent over time.
However, the Cardiovascular Network considers that, with proper resources and determination, care
for this important patient group can and must be improved.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 12
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Appendix
Fast Track NSTEACS Pathway
Not all people with a positive troponin are having a NSTEMI. This will be especially true with hs
troponin assays. Not all patients having a NSTEACS will benefit from urgent angiography. Some
patients with NSTEACS who may well benefit from angiography have other complex comorbidities
that need assessed as part of holistic care.
However, the majority of patients presenting with NSTEACS will be suitable for fast treatment, in
keeping with the relevant trials and guidelines. Identifying these people may be helped by using the
following.
Fast track NSTEACS tool Please discuss with on call cardiology registrar/CCU coordinator at PCI centre
Inclusion. Patients must have:
Symptoms of typical cardiac chest/arm pain at rest for more than ten minutes. AND
High sensitivity troponin result above the 99th percentile upper reference limit And/or ≥1mm ST depression in 2 or more ECG leads
And/or conscious post cardiac arrest.
Patients without typical cardiac chest pain should not follow this pathway.
Exclusion. Patients should not be considered for Fast Track Pathway with ANY of the following:
ST elevation MI – treat according to existing PPCI pathways
Overt sepsis
Major trauma/surgery within one month.
Acute renal failure eGFR<60.
Hb<100 or recent active bleeding.
O2 saturation <90% on air.
Severe comorbidity – e.g. metastatic cancer, moderate/severe dementia or delirium, exercise tolerance<100yds normally, frailty of old age, post-arrest ventilated patients. This list is not exhaustive.
Many patients with conditions excluding them from the Fast Track pathway will also benefit from
urgent angiography, but this should be decided after further assessment by a cardiologist. They can
then be referred urgently to the PCI centre. Similarly, patients with other ECG changes may well
benefit, but this should be assessed by a cardiology specialist locally. Where there is doubt, the
referring team should discuss the case on the phone with the on call cardiology registrar at the
receiving unit who can liaise with the interventional cardiologist responsible. In critically ill patients –
those post arrest, with cardiogenic shock or other very high risk features - the responsible decision
maker locally (e.g. A&E/Acute physician) should discuss the case directly with PCI centre registrar
with a view to immediate transfer.
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 16
Clinical parameters used to generate the GRACE risk score. Calculator available at
(http://www.gracescore.org/website/WebVersion.aspx)
Care Pathway for management of NSTEACS patients. (Dotted line may need deferred until
ambulance crews are suitably trained. Very High risk ACS patients should be discussed with same
person at receiving centre as for STEMI, usually CCU senior nurse.)
NECVN guidance on NSTEACS final v 3.5 January 2017 Swanson/Bourke 17
Glossary
A&E Accident and Emergency Department
ACS Acute Coronary Syndrome (includes NSTEACS and ST elevation MI)
BCS British Cardiovascular Society
CABG Coronary Artery Bypass Grafting
CCT Certificate of Completion of Training
CCU Coronary/cardiac Care Unit
CMR Cardiac Magnetic Resonance imaging
eGFR estimated Glomerular Filtration Rate
ESC European Society of Cardiology
GRACE Global Registry of Acute Coronary Events trial
GTN Glyceryl Trinitrate
hs troponin highly sensitive troponin assay
MINAP Myocardial Ischemia National Audit Project
NEAS North of England Ambulance Service
NECVN North of England Cardiovascular Network
NIC NICE implementation Collaborative
NICE National Institute for Health and Care Excellence
NSTEACS Non ST elevation Acute Coronary Syndrome
NUTH Newcastle University Teaching Hospitals
PCI Percutaneous Coronary Intervention
PPCI primary Percutaneous Coronary Intervention
TIMI Thrombolysis in Myocardial Infarction (scoring system)
URL Upper Reference Limit (for normal population)
YAS Yorkshire Ambulance Service