1. Acute Coronary Syndromes in West Hertfordshire Masood Khan

2. Cardiology Connect Meeting 16 June 2010 Chronology of Atherosclerotic Vascular Disease

3. Cardiology Connect Meeting 16 June 2010 Antithrombotic Therapy Stable Angina Unstable Angina Non– Q-wave MI Thrombolysis Primary PCI Q-wave MI Minutes- hours Days- weeks STEMI NSTEMI Atherothrombosis New term Old term Plaque Rupture Current terminology in ACS Normal cardiac enzymes Elevated cardiac enzymes Unstable Angina

4. Cardiology Connect Meeting 16 June 2010 Outcomes: Admission to 6 Months Global Registry of Acute Coronary Events

5. Cardiology Connect Meeting 16 June 2010 Treatment of ACS STEMI Immediate PCI NSTEMI Early PCI UA Non-invasive or PCI Risk assessment Lifestyle changes and secondary prevention Chest pain Early suspicion and diagnosis

6. Cardiology Connect Meeting 16 June 2010

7. ACS pain  Pain in chest, arms, back or jaw >15 min  Associated with:  Nausea/vomiting  Breathlessness  Sweating  Do not assess symptoms differently  ethnic groups, or  gender  Do not use response to GTN to make diagnosis

8. Cardiology Connect Meeting 16 June 2010 ACS hospital referral  Currently in pain, or  Pain free, but pain in last 12 hours and ECG abnormal or unavailable Same day:  Chest pain within 12 hours, but  Now pain free, and  ECG normal or  Chest pain 12-72 hours

9. Cardiology Connect Meeting 16 June 2010 ACS – start management immediately! Chest pain Pain relief  GTN  Opiate Aspirin 300mg Pulse oximetery  O2 if SpO2 < 94% 12 lead ECG  STE or LBBB?  ACS not excluded if ECG normal

10. Cardiology Connect Meeting 16 June 2010 Secondary prevention Aspirin 75 mg od  Dyspepsia: + low dose PPI  Healed Ulcer: + high dose PPI Β-blocker Clopidogrel 7mg od for 1 yr ACE inhib or A2 antag Statin  dose and drug controversial Aldosterone antag. If present in heart failure

11. Cardiology Connect Meeting 16 June 2010 ACS in W Herts  2 consultant cardiology ward rounds each week day, 1 each Sat & Sun  All cardiology patients & referrals  Appropriate management decisions  Timely discharge  Cardiac catheter lab available 5 days/week  Dedicated slots for in patients

12. Cardiology Connect Meeting 16 June 2010 ACS in W Herts Data from NW London IHT 603 inpatient referrals to WGH cathlab in 2009 0 NICE target <96 hrs

13. Cardiology Connect Meeting 16 June 2010 West Herts. Heart Attack Centre National target

14. Cardiology Connect Meeting 16 June 2010 ACS in W Herts  Currently auditing appropriateness of discharge medication  100% referral to cardiac rehabilitation  All patients undergoing PCI offered follow up in cardiology clinic  follow up time should be shorter

15. Thank you