PATHWAY
ED Chest Pain Assessment Flow
Step 1 · Arrival
Adult patient presents with chest pain / suspected ACS
Triage immediately. Assign ATS Category 2 or 3.
Step 2 · Immediate Assessment (within 10 min)
Simultaneous Investigations
- 12-lead ECG - interpret immediately, repeat if any symptom change
- IV access · FBC, UEC, i-STAT cTnI (0h), BSL, lipids, coags, group & hold
- Continuous cardiac monitoring · SpO₂ · vital signs (BP both arms if dissection suspected)
- Chest X-ray (PA or AP)
- Brief focused history: onset, character, radiation, severity
Step 3 · Decision
STEMI / Haemodynamic Instability?
ST elevation ≥1 mm (limb) / ≥2 mm (chest) · New LBBB · Cardiogenic shock · Cardiac arrest · Suspected aortic dissection
YES — STEMI
⚡ STEMI Pathway — PAH & Ipswich >60 min away
Fibrinolysis First → Transfer to PAH
Primary PCI not achievable within 120 min → Lyse if no contraindications
- Aspirin 300 mg PO + Clopidogrel 300 mg PO if <75 yr, or 75 mg PO if ≥75 yr, stat
- Screen contraindications - see Fibrinolysis tab
- Tenecteplase (TNKase) IV bolus - weight-based dosing
- Heparin IV per fibrinolysis protocol
- Target door-to-needle <30 minutes
- Notify QAS + PAH Cath Lab
- Transfer to PAH: rescue PCI if failed reperfusion, or routine angio 3-24 h if successful
Aortic dissection suspected? Do NOT give lysis. Immediate transfer to PAH for CT aortogram and surgical assessment.
NO
Standard Pathway
Proceed to HEART Score
Calculate HEART Score using initial ECG, history, age, risk factors, and 0h cTnI result.
Step 4 · Risk Stratification
Calculate HEART Score (0-10)
H - History | E - ECG | A - Age | R - Risk Factors | T - cTnI (local threshold 0.04 ug/L) · See HEART Calculator tab.
Step 5 · Serial Troponins
i-STAT cTnI: 0h · 3h · 6h
All HEART 4-10 patients require serial sampling. Low HEART + 0h negative: may discharge after 3h if delta <0.02 ng/mL and clinically well.
Step 6 · Disposition
HEART Score + Troponin Result → Disposition
Low Risk
HEART 0-3
HEART 0-3
MACE risk <2%
- Two negative troponins
- No ECG changes
- Discharge from ED
- GP follow-up 72 h
- Discharge letter
- Safety-netting
- Consider outpatient ETT
Intermediate
HEART 4-6
HEART 4-6
MACE risk 2-20%
- Serial troponins mandatory
- Cardiology review
- Admit or extended obs
- Consider ETT or CTA
- Refer to Ipswich Hospital
High Risk
HEART 7-10
HEART 7-10
MACE risk >20%
- Urgent cardiology consult
- Admit under cardiology
- Transfer to Ipswich Hospital
- STEMI/unstable → PAH via fibrinolysis pathway
STEMI PROTOCOLFibrinolysis Pathway - Tenecteplase (TNKase)
When to use this pathwayLaidley Hospital is >60 minutes from both Ipswich Hospital and Princess Alexandra Hospital (PAH). When total ischaemic time from first medical contact to primary PCI would exceed 120 minutes, fibrinolysis is the recommended reperfusion strategy. Target door-to-needle <30 minutes.
Reperfusion decision algorithmSTEMI confirmed → Can PAH PCI be achieved within 120 min of first medical contact? No (Laidley context) → Fibrinolysis indicated if no contraindications → Give TNKase → Transfer to PAH for rescue PCI (if failed) or routine angiography (3-24 h if successful).
STEP 1 — Screen Absolute Contraindications (tick to confirm ABSENT)
- Prior intracranial haemorrhage - at any time
- Ischaemic stroke within the last 3 months
- Known intracranial neoplasm, AVM, or aneurysm
- Significant closed-head or facial trauma within 3 months
- Active internal bleeding (excluding menses)
- Suspected aortic dissection - do NOT lyse; transfer to PAH immediately
- Intracranial or spinal surgery within 2 months
- Severe uncontrolled hypertension on presentation (SBP >180 / DBP >110 not responding to treatment)
STEP 2 — Note Relative Contraindications (senior clinician decision)
- —History of chronic, severe, poorly controlled hypertension
- —Ischaemic stroke >3 months ago
- —Traumatic or prolonged CPR (>10 min) or major surgery <3 weeks
- —Recent (2-4 weeks) internal bleeding
- —Non-compressible vascular punctures
- —Pregnancy
- —Active peptic ulcer disease
- —Current use of anticoagulants (INR >2-3)
STEP 3 — Tenecteplase (TNKase) Weight-Based Dosing
| Patient Weight | TNKase Dose | Volume (5 mg/mL reconstituted) |
|---|---|---|
| <60 kg | 30 mg | 6 mL IV bolus over 5-10 sec |
| 60-69 kg | 35 mg | 7 mL IV bolus over 5-10 sec |
| 70-79 kg | 40 mg | 8 mL IV bolus over 5-10 sec |
| 80-89 kg | 45 mg | 9 mL IV bolus over 5-10 sec |
| ≥90 kg | 50 mg (maximum) | 10 mL IV bolus over 5-10 sec |
Age ≥75 yearsUse Clopidogrel 75 mg with no loading dose. TNKase dose is unchanged, but discuss with the senior clinician if bleeding risk is high.
STEP 4 — Adjunct Antiplatelet & Anticoagulant Therapy
| Drug | Dose | Notes |
|---|---|---|
| Aspirin | 300 mg PO stat, then 100 mg daily | Give immediately. Chew or crush if possible for faster absorption. |
| Clopidogrel | 300 mg PO if <75 yr; 75 mg PO if ≥75 yr | Do NOT use Ticagrelor or Prasugrel pre-fibrinolysis. |
| Unfractionated Heparin (UFH) | 60 units/kg IV bolus (max 4,000 units), then 12 units/kg/hr (max 1,000 units/hr) | Start with TNKase. Adjust to aPTT 50-75 sec. Continue for minimum 48 h or until angiography. |
| GTN | 0.4 mg SL if SBP >100 mmHg and no RV infarct | Avoid if hypotensive or RV infarction suspected. |
| Morphine | 2-4 mg IV titrated for pain | Use cautiously. Adequate analgesia remains important. |
| Oxygen | Only if SpO₂ <94% | Routine O₂ not recommended in normoxic STEMI patients. |
STEP 5 — Assess Reperfusion at 60-90 minutes post-TNKase
Signs of successful reperfusion≥50% resolution of ST elevation in the lead with maximal ST elevation · Reperfusion arrhythmia · Relief of chest pain · Peak troponin earlier than expected
| Reperfusion Status | Action |
|---|---|
| ✓ Successful reperfusion | Transfer to PAH for routine coronary angiography within 3-24 hours. |
| ✗ Failed reperfusion (<50% ST resolution at 90 min) | Rescue PCI required. Call QAS immediately for urgent transfer to PAH. |
TOOLHEART Score Calculator
i-STAT cTnI referenceLaidley local decision threshold = 0.04 ug/L. Manufacturer 99th pct URL = 0.08 ug/L.
HEART Score
0/10
Low Risk
- MACE risk <2%
- Serial troponins: 0h and 3h
- Both negative + clinically well: discharge
- GP follow-up within 72 hours
- Safety-netting counselling documented
- Consider outpatient exercise stress test
PROTOCOLSerial i-STAT cTnI Protocol
Assay: Abbott i-STAT cTnI (conventional)Significant delta = rise ≥0.02 ng/mL between samples. A single negative troponin does NOT exclude ACS in intermediate or high-risk patients.
| Time Point | i-STAT cTnI Threshold | Interpretation & Action |
|---|---|---|
| 0h (Arrival) | <0.04 ug/L = Negative 0.04-0.12 ug/L = 1-3× local threshold >0.12 ug/L = >3× local threshold | Baseline. Informs HEART Troponin score. Do not discharge on single 0h result alone. |
| 3h Sample | Delta <0.02 ug/L = No significant rise | HEART 0-3 + delta <0.02 ug/L + clinically well: safe discharge. Delta ≥0.02 ug/L or result ≥0.04 ug/L: treat as ACS. |
| 6h Sample | Delta <0.02 ug/L = No significant rise | Mandatory for HEART 4-10 and clinical uncertainty. |
⚡ Bedside Delta Calculator — i-STAT cTnI (ug/L)
REFERRALTransfer and Referral Pathways
Geographic context — Laidley HospitalBoth Ipswich Hospital and Princess Alexandra Hospital (PAH) are >60 minutes from Laidley. For STEMI, fibrinolysis is first-line reperfusion.
🏥 Ipswich Hospital — Tertiary Referral
Indications:
Process:
- HEART Score 4-10 - inpatient workup
- Cardiology review required
- Stress testing
- CT Coronary Angiogram
- NSTEMI / UA requiring inpatient management
Process:
- Contact Ipswich ED Consultant on call
- Document HEART score, troponins, ECG findings, and treatment
- Arrange transport as clinically indicated
🚨 Princess Alexandra Hospital — STEMI / Intervention
Indications:
Process:
- Post-fibrinolysis: all STEMI patients
- Suspected aortic dissection
- Haemodynamically unstable ACS
- Cardiac arrest (post-ROSC)
- Requires PCI or cardiac surgery
Process:
- Call QAS for emergency transfer
- Notify PAH Cath Lab
- Transfer documentation: ECG, drug chart, vitals trend, lysis time
DISCHARGESafe Discharge Criteria
All criteria must be metIf any criterion cannot be confirmed, senior clinician review is required prior to discharge.
| # | Criterion | Details |
|---|---|---|
| 1 | HEART Score 0-3 | Low risk confirmed. All five components scored and documented. |
| 2 | Negative serial troponins | Two negative i-STAT cTnI (<0.04 ug/L) at 0h and 3h (or 6h), delta <0.02 ug/L. |
| 3 | No dynamic ECG changes | Serial ECGs during observation - no new ST/T changes. |
| 4 | Symptoms resolved or explained | Symptoms resolved OR clear non-cardiac cause identified. |
| 5 | Clinically well and stable | Haemodynamically stable. No ongoing chest pain. |
| 6 | No high-risk features | No recent PCI/CABG, severe LVD, cocaine use, or other high-risk features. |
| 7 | GP follow-up arranged | Follow-up within 72 hours confirmed. |
| 8 | Safety-netting documented | Patient advised to return if pain recurs/worsens or new symptoms develop. |
GOVERNANCEDocument Control & References
| Field | Detail |
|---|---|
| Author | Dr Ameen Shaikh, Senior Medical Officer, Laidley Hospital Emergency Department |
| Document Owner | Senior Medical Officer, Laidley Hospital Emergency Department |
| Version | 1.2 - corrected clopidogrel dosing for age ≥75 years to 75 mg consistently |
| Effective Date | April 2026 |
| Review Date | April 2027 |
| Troponin Assay | Abbott i-STAT cTnI (conventional) · Local threshold: 0.04 ug/L · Serial: 0h/3h/6h · Delta: ≥0.02 ug/L |
| Risk Tool | HEART Score - validated for ED chest pain risk stratification |