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After completing the online module, what are three key things you learned about ECGs? These could be related to the purpose of ECGs, how they work, or how to read them.

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Group 1 – Unstable Angina – Pathophysiology, risk factors and clinical presentation 

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Group 1 – Unstable Angina – Pathophysiology, risk factors and clinical presentation 

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Group 2 – Unstable Angina – Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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Group 2 – Unstable Angina – Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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Group 3 – Non-STEMI - Pathophysiology, risk factors and clinical presentation 

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Group 3 – Non-STEMI - Pathophysiology, risk factors and clinical presentation 

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Group 4 – Non-STEMI - Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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Group 4 – Non-STEMI - Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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Group 5 – STEMI - Pathophysiology, risk factors and clinical presentation 

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Group 5 – STEMI - Pathophysiology, risk factors and clinical presentation 

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Group 6 – STEMI - Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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Group 6 – STEMI - Nursing Assessment (include diagnostic testing), Nursing management (including ADLs affected and how they would support the patient)

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The Pathway for Acute Coronary Syndrome Assessment (PACSA) is a set of documents that outline how to assess and manage patients with suspected acute coronary syndrome (ACS).

PACSA has been designed to standardise practice across all health services operating in NSW, including in rural, regional and metropolitan areas.

It is not designed to be a comprehensive review of the assessment and management of ischaemic heart disease and should be used in conjunction with other clinical resources.

What's new in this update

Updates from the previous version GL2019_014 include:

minor changes to wording around clinical risk assessment classification

formatting changes to the flowcharts and checklists

additional inclusions at initial assessment regarding glyceryl trinitrate (GTN) and oxygen

removal of guidance regarding Prasugrel as anticoagulation before percutaneous coronary intervention

adjustment of dosages for Clopidogrel as anticoagulation before percutaneous coronary intervention.

PACSA resources

PACSA consists of four documents: 2 flow charts and 2 checklists.

The PACSA flowchart and the PACSA STEMI reperfusion flowchart outline each step of patient management with corresponding colour-coded details on the right hand side. Each flow chart has a corresponding c hecklist.

The PACSA flowchart, the PACSA checklist, the PACSA STEMI reperfusion flowchart and the PACSA STEMI reperfusion checklist are available from the NSW Health State Forms catalogue. The product numbers are listed above for each flow chart/checklist. NSW Health staff can order and print forms via Finsbury Green (login required) or use your local print ordering process.

More information for NSW Health staff is available on the HealthShare intranet.

How to use PACSA

The first step in PACSA is to identify patients with ST-elevation myocardial infarction (STEMI) who require reperfusion.

If no STEMI is identified, perform a sequential risk stratification using:

clinical features

troponin testing

electrocardiogram (ECG) findings.

The integration of these results provides a summative risk assessment that directs clinical management of the patient.

Clinical risk assessment

An important principle of PACSA is that the clinical risk of a patient should be assessed before undertaking troponin testing.

The first step in PACSA is to assess if the patient is high clinical risk, using the definition of 'high risk' from the National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ).

If a patient does not meet high risk criteria, they are assessed to see if they are low clinical risk. There are a number of low risk algorithms available.

If the patient is not high risk and is not low risk, they should be classified as intermediate risk.

In high-risk populations, ACS can present at a younger age., These include people with:

diabetes

renal disease

autoimmune disorders

HIV

strong family history of cardiovascular disease.

Aboriginal and Torres Strait Islander ethnicity is not an independent risk factor but is associated with multiple cardiac risk factors.

Psychiatric illness is not an independent risk factor for ACS but is also associated with multiple risk factors for ischaemic heart disease and poorer outcomes.

Atypical symptoms of ACS occur more commonly in women, the elderly and people with diabetes. Atypical symptoms include unusual patterns of pain, fatigue and shortness of breath.

Troponin risk assessment

The predictive value of clinical risk scores is increased when used in conjunction with troponin tests and serial ECGs.,,,,

An initial elevated troponin result does not necessarily indicate acute myocardial infarction (AMI) but it does indicate that the patient is not low-risk. This group has higher all-cause mortality as well as greater risk of ACS.

A repeat troponin test is recommended if a patient has had symptoms within the previous six hours or if the patient is high- or intermediate-risk.

For low-risk patients, a single troponin test may be sufficient if it is performed more than six hours after symptoms cease.

Troponin assays are regarded as positive above a defined threshold (refer to the PACSA Flow Chart). High-sensitivity (HS) troponin assays also allow for a positive result via a change (delta) either up or down, between repeated troponin tests. This is known as a positive delta troponinand is associated with ischaemic causes of chest pain and high risk. A troponin assay is regarded as positive by delta even if both troponin results are in the normal range.

All laboratory-based troponin tests in NSW use HS assays. These should be repeated after two hours to obtain a delta. Absolute delta values are more reliable than relative (or percentage) delta values.

All point of care (POC) troponin tests in NSW use standard-sensitivity assays. POC troponin test results are regarded as positive above a defined threshold (refer to the PACSA Flow Chart). They are not currently reproducible enough to allow the use of delta troponin. A POC troponin test can be repeated at any time and is useful if positive. A patient should not be discharged unless they have had a negative six-hour POC troponin test result.

HS and POC (standard sensitivity) troponin results are not interchangeable.

The threshold and delta levels for all HS troponins used in NSW are listed in the PACSA flowchart.

ECG risk assessment

The initial ECG is performed to identify if the patient has a STEMI. The criteria for STEMI and STEMI equivalents are shown in the PACSA STEMI reperfusion flowchart. STEMI equivalents include left bundle branch block (LBBB) in an unstable patient, LBBB with modified Sgarbossa criteria, posterior infarction and de Winter T waves.

STEMI mimics include Wellens and Brugada syndromes. These are both high-risk conditions and require cardiology referral. However, they are not indications for thrombolysis.

A minimum of two ECGs are required: one on arrival and another at two hours. ECGs should also be performed when repeating troponin tests and every 30 minutes if there are ongoing symptoms. Dynamic ECG changes are a marker of high risk.

Summative risk assessment

The integration of clinical risk, troponin results and serial ECGs determines a summative risk that directs further management of the patient.

Summative risk assessment provides an opportunity for senior decision-makers to modify the risk category determined by PACSA.

Clinical judgement continues to play an important role, as negative troponin results do not exclude coronary artery disease, as a cause of symptoms and positive troponin results are not always due to cardiac ischemia.

Shared decision-making and establishing goals of treatment with each patient is the expected standard of care.

STEMI transfer

Each local health district (LHD) should facilitate transfer of patients with STEMI in line with the State Cardiac Reperfusion Strategy (SCRS).

Background

PACSA was developed to replace the 2011 NSW Health Policy Directive PD2011_037 Chest Pain Evaluation (NSW Chest Pain Pathway).

The Clinical Excellence Commission reviews adverse events associated with acute coronary syndrome. Between July 2015 and June 2017 there were 23 serious incidents, including 13 rated severity assessment code 1 (SAC 1). These were characterised into themes to inform development of a new pathway. More than 300 papers relating to cardiac biomarkers and their use in rapid assessment pathways were examined. Australasian and international chest pain pathways were reviewed.,

NSW Pathology was engaged to derive the PACSA troponin values. There were three rounds of consultation with clinicians across NSW. PACSA was tested in rural, regional and metropolitan facilities.

The evidence regarding assessment and management of suspected ACS is rapidly evolving. PACSA will require revision and updating as new information becomes available.

Show references

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Pathway for Acute Coronary Syndrome (PACSA)

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A set of documents that outline how to assess and manage patients with suspected acute coronary syndrome (ACS).