Tasty Morsels of EM 106 – #FRCEM NICE Guidelines ACS

3 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

There’s a lot of NICE guidance and statements surrounding ACS and it can be quite confusing so I’ve plucked out what i think are some of the more exam related statements here. I’ve included NICE guidance on ACS, STEMI and chest pain of recent onset  and on troponins on early rule out.

What is the Universal Definition MI?

Universal definition)

  • types of MI
    • type 1: the classic, plaque rupture
    • type 2: “ischaemic imbalance”, hypotension, anaemia etc…
    • other types not really relevant…
  • diagnosis of MI
    • “A rise in cardiac biomarkers (preferably cardiac troponin) with at least 1 value above the 99th percentile of the upper reference limit and/or a fall in cardiac biomarkers, together with at least 1 of the following”
      • symptoms of ischaemia
      • new or presumed new T wave changes or LBBB
      • pathological Q
      • imaging evidence of myocardial loss or RWMA
      • thrombus on angio

Symptoms suggestive of ACS as per NICE?

  • pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
  • chest pain associated with nausea and vomiting, marked sweating, breathlessness, or
    particularly a combination of these
  • chest pain associated with haemodynamic instability
  • new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes

Management of suspected NSTEMI?

  • GTN first line for pain, then opiate
  • asprin 300mg
  • oxygen only if needed
  • clopidogrel 300mg (the statement is if risk of 6 month mortality is >1.5%)
  • most of the recs on heparins don’t go beyond consider…
  • note NICE suggests that we do a risk assessment for 6 month mortality as soon as unstable angina or NSTEMI is diagnosed and use GRACE as the example. Obviously TIMI would be another. ((HEART score would be more prior to making a diagnosis)

What about new or presumed new LBBB?

Comment on new or presumed new LBBB

New or presumably new LBBB has been considered a STEMI equivalent. Most cases of LBBB at time of presentation, however, are “not known to be old” because of prior electrocardiogram (ECG) is not available for comparison. New or presumably new LBBB at presentation occurs infrequently, may interfere with ST-elevation analysis, and should not be considered diagnostic of acute myocardial infarction (MI) in isolation

How should we use HS Troponins and early rule out?

(from NICE 2014)

(also see the king of troponin, Rick Body on this)

  • test at time zero on ED arrival and at 3 hrs
  • cut offs are manufacturer dependant
  • some have sex specific cut offs

How should we manage STEMI?

(From NICE 2013)

  • within 12 hrs of onset and within 120 mins of “when fibrinolysis could have been given” (which is pretty much after ED arrival, brief history, exam and ECG)
  • can be used outside these windows if evidence of ongoing ischaemia


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