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Friday, July 30

CLINICAL CARE GUIDELINE


CHEST PAIN AND ACUTE CORONARY SYNDROME

These systematically developed statements have been created to assist the practitioner in the formulation of health care decisions in specific clinical circumstances. They are not to be construed as an inflexible set of correct procedures or protocols.

In each clinical circumstance the exercise of individual judgment is essential.

Guidelines are based upon statistical averages and opinions of practicing clinicians. Variation from these guidelines does not constitute improper care or improper professional judgment. Evaluation of these variations requires detailed analysis of the facts and circumstances surrounding the individual patient’s care.

SUBJECT: Chest Pain and Acute Coronary Syndromes



OBJECTIVE

The goal of these guidelines is to improve the quality and efficiency of management of adult patients with acute coronary syndromes in accordance with the ACC/AHA Acute Coronary Syndromes Clinical Practice Guidelines. Specifically:

1. Provide management and diagnostic guidelines for patients assigned to these categories: chest pain, unstable angina, acute myocardial infarction, Non-ST Segment Elevation myocardial infarction (NSTEMI), and ST-Segment Elevation myocardial infarction (STEMI).

2. Provide recommendations and supporting evidence for the continued management of patients with these conditions in both inpatient and outpatient settings.

3. Provide critical pathway as standard for rapid ACS risk assessment and rapid comprehensive therapy for optimal patient care and cost-effectiveness.

4. Rapid initiation of therapy aimed at achieving reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) with goal of door to PCI (percutaneous coronary intervention) of 120 minutes.

5. Reduce the risk of cardiac damage and death in patients who present with symptoms suggestive of unstable angina and Non-ST Segment Elevation myocardial infarction (NSTEMI).

6. Provide standard discharge treatment plan based on Cardiac Hospitalization Atherosclerosis Management Program (CHAMP).

7. Provide recommendations for ambulatory setting for post discharge patients with chest pain, unstable angina, and acute myocardial infarction.

DEFINITIONS

For the purpose of this guideline, the following definitions apply:

Chest pain - Patients without evidence of acute myocardial infarction or active myocardial ischemia on ECG with chest pain that is not definite angina. These patients are defined as not having features that give them an intermediate or high likelihood of significant coronary artery disease.

Unstable Angina - Patients without evidence of acute myocardial infarction who have chest pain and are felt to have an intermediate or high likelihood of significant coronary artery disease.

Non ST-Segment Myocardial Infarction - Patients with clinical presentations similar to unstable angina with detectable quantities of markers of myocardial injury in circulation, most commonly troponin I or CK-MB. ECG ST-segment or T-wave changes may be persistent.

ST-Segment Myocardial Infarction - Patients with symptoms suggestive of myocardial infarction and an ECG with ST elevation of 1mm or left bundle branch block. Patients with medically refractory chest pain associated with ischemic ECG changes that persist for greater than 20 minutes (refractory unstable angina/non Q-wave myocardial infarction) are included in this category.


POSITION STATEMENTS

Patients with acute myocardial infarction require rapid initiation of therapy aimed at achieving reperfusion.

All patients with acute coronary syndrome require appropriate risk stratification to determine optimal choice and timing of therapies.

Discharge planning and education should include emphasis on secondary prevention to alter the natural history of underlying cardiac disease and prolong long-term survival outcomes.


PROCEDURE

Emergency Department

I. Assessment/Diagnosis (Early Risk Stratification)

A. History (likelihood of ischemia due to CAD)

1. Nature of anginal symptoms (definite angina, probable angina, probably not angina, and not angina).

2. Prior history of CAD or myocardial infarction.

3. Sex.

4. Age.

5. Number of traditional risk factors: smoking, hyperlipidemia, diabetes mellitus, family history, cocaine use, hypertension, post menopausal.

6. Special considerations.

a. Women may present more frequently than men with atypical chest pain and symptoms.

b. Diabetics and elderly may have atypical symptoms.

B. Electrocardiogram – 12 lead ECG should be obtained and reviewed immediately within 10 minutes in patients with ongoing chest discomfort or as rapidly as possible in patients with history of chest discomfort consistent with ACS, but has resolved by time of evaluation.

1. Diagnostic criteria for STEMI.

a. 1mm ST elevation in 2 or more contiguous limb or precordial lead left bundle branch block, not known to be old.

2. ECG findings useful for establishing the likelihood of CAD NSTEMI, unstable angina.

a. ST segment depression >1mm.

b. Inverted T-waves > 1mm in two or more contiguous leads.

C. Physical Examination

1. Goal: to identify potential precipitating causes of myocardial ischemia (e.g., hypertension, thyrotoxicosis).

2. Complete a thorough cardiovascular and chest examination.

3. Sign of left ventricular dysfunction is single strongest predictor of subsequent cardiac death in patients with CAD: cardiogenic shock, sustained ventricular arrhythmia, complete heart block, pulmonary edema.

D. Biochemical Cardiac Markers (see Table 1)

1. For initial MI rule out, Cardiac labs (CK-MB, Troponin I, and total CPK).

2. Labs to be drawn q6 hours x 3, and then at physician’s discretion.

E. Conclusion of Initial Evaluation with Documentation Using Risk Stratification Guideline (see Table 2)

1. Focused history with symptom characteristics, response to nitroglycerin.

2. Presence of coronary artery disease risk factors.

3. ECG findings.

4. Physical Exam: presence of pulmonary edema, hypotension, or ventricular arrhythmia.

5. Document risk stratification with appropriate diagnosis.

a. Possible ACS.

b. Likely or definite ACS (without continuing ischemic pain or high-risk features).

c. Definite ACS with continuing ischemic pain, other high-risk features, or planned intervention.

II. Care Treatment Plan

A. ST-Segment Elevation Myocardial Infarction (STEMI) (see Addendum 1)

1. Goal: rapid initiation of therapy aimed at reperfusion, time from door to percutaneous coronary intervention (PCI) of 120 minutes.

a. Contact Interventional Attending and CCU fellow immediately.

b. All patients should receive regular ASA 325mg as soon as possible. (Definite contraindications: evidence of life-threatening hemorrhage or clear history of severe hypersensitivity to ASA.)

c. All patients should be given intravenous bolus of heparin and started on heparin drip. (Definite contraindications: acute pericarditis, aortic dissection, heparin allergy, major life threatening hemorrhage.)

d. Patients should be treated with intravenous beta-blocker, followed by oral beta-blockers. (Definite contraindications: cardiogenic shock, hypotension, severe COPD/asthma, AV block > 1st degree.)

e. Patients with ongoing chest pain despite SL NTG and beta-blockers, with SBP >90 mmHg should be started on intravenous nitroglycerin drip.

B. Unstable Angina/Non-ST Elevation MI (NSTEMI)

1. Goal: medical therapy or revascularization to prevent the evolution to MI and diagnostic testing (coronary angiography or physiologic stress testing) to assess coronary risk.

C. Chest Pain

1. Patients who are pain free, have either normal or non-diagnostic ECG, and have a normal set of initial cardiac marker should be considered for further evaluation to screen for non-ischemic discomfort versus low risk ACS.

2. Patients will be observed in the ED with continuous cardiac monitoring.

3. Follow up at 2 hours with ECG and cardiac markers (CK, CK-MB, Troponin-I).

4. An increase in CK-MB level of +1.5 ng/mL or greater, or cardiac troponin I level of +0.2ng/mL or greater is defined as significant and an abnormal marker.

a. Patients who develop recurrent pain during observation, new ECG changes, or abnormal cardiac markers should be admitted.

5. If no interval change in ECG, symptoms, or change in delta CK-MB and troponin-I at 2 hour follow up period, patients may be discharged from the ED and return for stress test as outpatient within 72 hours.

6. In the following situations, patients will be provided with a cardiology referral for outpatient follow-up of a cardiology workup and/or stress test.

a. Completion of the accelerated chest pain protocol, and following clearance for discharge from the ED (NOTE: excluding cocaine chest pain).

b. Patients with a likelihood of coronary heart disease as determined by cardiac risk factors and clinical assessment.

III. Discharge Education and Planning

A. Patients should be given written discharge instructions with review of treatments, and symptoms that would require contact of their physician.

B. Patients should be instructed to call their primary care physician to arrange a follow-up appointment within 72 hours of discharge.






Inpatient Care

I. Assessment/Diagnosis

A. The CCU fellow and the cardiology team shall determine whether patient will be monitored on 6WSD or CCU based on risk stratification.

B. Nursing staff shall notify the CCU resident of patient’s arrival on the unit, tele-monitor assigned, and nursing admission database to be completed.

C. Nursing staff shall notify the CCU resident of any changes in patient’s clinical condition, any arrhythmias recorded on telemetry monitor, and any abnormal lab values.

II. Care Treatment Plan

A. ST-Elevation Myocardial Infarction (STEMI) (see Addendum 1)

1. Goal: rapid initiation of therapy aimed at reperfusion, initiation of thrombolytic therapy within 30 minutes or time from door to PCI (direct catheterization) of 120 minutes.

2. Initial Therapy.

a. Notify CCU fellow and cardiac cath team immediately with determination of diagnosis.

b. All patients should receive regular ASA 325 mg as soon as possible. (Definite contraindication: evidence of life-threatening hemorrhage or clear history of severe hypersensitivity to ASA.)

c. All patients should be given intravenous bolus of heparin at 5000 units or 65 units/kg and started on heparin drip at 12units/kg/hr (1000 units/ml) or 1000 units/hr. (Definite contraindications: acute pericarditis, aortic dissection, heparin allergy, major life threatening hemorrhage.)

d. Patients should be treated with intravenous beta-blockers, followed by oral beta-blockers. Initiate intravenous Metoprolol 5mg x 3 every 5 minutes, followed by 50mg Q6hours x 8 doses and then 50-100mg BID. (Definite contraindications: cardiogenic shock, hypotension, severe COPD/asthma, AV block > first degree.)

e. Patients with ongoing chest pain despite SL NTG and beta-blockers, with SBP >90 mmHg should be started on intravenous nitroglycerin drip (follow Nitroglycerin protocol).

f. Patients should be taken immediately to cath lab for catheter based intervention.

g. Glycoprotein IIb/IIIa inhibitor (Abciximab, Eptifibatide) should be strongly in conjunction with catheter based intervention. (see Addendum 3)

h. Thrombolytic Therapy - per interventional attending’s discretion - is indicated for chest pain <>

i. Oxygen therapy: maintain pulse oximeter saturation > 92%.

3. Sub-acute Therapy

a. Patients should be continuously monitored on ECG for 48-72 hours in uncomplicated myocardial infarction (MI).

b. Continue ASA 325mg po qd on all patients.

c. Continue beta-blocker on all patients unless contraindicated.

d. All MI patients without contraindications should be started on ACE inhibitors within two weeks of acute myocardial infarction onset, even if blood pressure and ejection fraction are normal.

e. ACE Inhibitors should be started on all patients with LV dysfunction (LV function <>

f. Statins or other lipid lowering agents should be started on all patients.

g. Anticoagulation with Warfarin is indicated for a trial fibrillation or LV thrombus post myocardial infarction.

h. Consultations ordered for cardiac rehab, social worker, dietitian, or chaplain.

i. Initially bed rest is recommended followed by an advance with ambulation on day 2 or 3.

j. Patients should be placed on a cardiac diet.

B. Unstable Angina/Non-ST Elevation Myocardial Infarction (NSTEMI) (see Addendum 2)

1. Treatment Strategies.

a. Early conservative strategy: coronary angiography is reserved for patients with evidence of recurrent ischemia or chest pain, congestive heart failure or depressed LV function, malignant ventricular arrhythmias, or a strongly positive stress test.

b. Early invasive strategy: coronary angiography is the initial diagnostic strategy for unstable angina patients with persistent chest pain/ischemia despite anti-ischemic therapy, elevated troponin I level, new or presumable new ST-segment depression, symptoms of congestive heart failure or depressed LV systolic function, high-risk findings on noninvasive testing, hemodynamicin stability, sustained ventricular arrhythmias, prior PCI (within 6 months), and prior CABG.

2. General Care

a. Patients should remain on continuous ECG monitoring for ischemia and arrhythmia detection.

b. Maintain pulse oximeter saturation <>

c. Patients should be placed on bed rest during initial phase of management.

d. Patients should remain NPO except meds until clinical stability is demonstrated and cardiac catheterization need and timing is determined.

e. Consider and initiate consultations as needed: cardiac rehab, dietitian, social worker, and chaplain.

3. Pharmacologic Treatment

a. All patients should receive ASA 325mg as soon as possible, unless contraindicated.

b. Patients risk stratified at intermediate or high likelihood ACS should be on anticoagulation with heparin, bolus (follow hospital Normogram or Lovenox at 1mg/kg sq q12); Continue Heparin 2 - 4 days or until revascularization is performed.

c. Beta-blockers should be started on all patients unless contraindicated. Initiate with IV metoprolol 5mg x 3 every 5 minutes to total dose of 15mg, followed in 2 hours by 25-50mg PO every 6hr. (Definite contraindications: cardiogenic shock, hypotension, AV block > 1st degree, severe COPD/Asthma.)

d. Patients where beta-blockers are contraindicated, consider calcium channel blockers (Diltiazem or Verapamil).

e. Patients with definite ACS, positive cardiac markers, should be started on Glycoprotein IIb/IIIa Inhibitor: 180mcg/kg Eptifibatide (Integrillin) IV bolus, followed by 2.0mcg/kg/min Eptifibatide IV infusion; If Creatinine is 2.0 - 4.0, infuse 1.0mcg/kg/min. (Hold Eptifibatide if patient is on dialysis.) (see Addendum 3)

f. Nitroglycerin 0.4mg SL should be given promptly with presentation of chest pain every 5 minutes x 3 or until pain relief or SBP <>

g. Morphine sulfate can be considered for patients whose symptoms are not relieved with nitroglycerin and beta-blockers. (Definite contraindications: hypotension, respiratory insufficiency, intolerance.)

C. Chest Pain

1. Patients admitted with diagnosis of chest pain should be placed on R/O MI protocol with EKG and cardiac markers (CPK, CK-MB, Troponin I) every 6 hours x 3. The CCU resident or fellow should be notified with every EKG readings and any abnormal lab values.

2. All patients should receive 325mg aspirin.

3. Patients should be given nitroglycerin SL and assessed for pain relief.

4. Decision for noninvasive stress testing will be based on patient’s history.

a. Exercise treadmill with additional imaging.

b. Pharmacologic stress testing with imaging for patients unable to exercise due to physical limitations.

III. Discharge Education and Planning

A. Patients should be sent home on aspirin 81mg to 325mg indefinitely.

B. Patients should be sent home on clopidogrel (plavix) 75mg qd if post stent, brachytherapy, or unable to tolerate aspirin.

C. Patients should be sent home on statin or lipid lowering agent, goal of LDL<>

D. If LVSF <>

E. Within two weeks of discharge, all post PCI, UA, MI, stable CAD, PVD, CVD and diabetic patients should receive an ACE inhibitor.

F. Patients should be sent home on beta-blocker, unless contraindicated.

G. Calcium channel blockers (Diltiazem or Verapamil) are indicated if beta-blockers are contraindicated.

H. Nitrates should be considered as a second line after beta-blocker for symptomatic control of angina.

I. Patients should be instructed to complete and aerobic exercise program on minimum of 3-5 times per week; Post MI patients should be referred to cardiac rehab program.

J. Patients with current tobacco use who are ready to quit should be referred to smoking cessation clinic, and this should be clearly documented.

K. Patients should receive dietary counseling on the National Cholesterol Education Program Step 2 Diet during hospitalization (refer to dietitian as need).

L. Patients and family should receive education throughout the hospitalization course on all the above treatment plans, monitoring of symptoms, and follow up.

M. Acute MI education folder should be given to all post MI patients with appropriate documentation.

N. Continuation of the above targeted therapies is pertinent with continued education.

O. The discharge planner assigned to the specific location or unit should be involved in the discharge plan throughout the hospitalization course with proper communication and documentation.

P. Patients should have a follow up appointment with their Primary Care Physician (PCP) within 2 weeks.

Q. Patients should have a follow up appointment with the Cardiologist in 1-2 weeks.

R. Patients should be instructed to bring their ACS discharge instruction sheet to their first follow up appointments with their PCP and Cardiologist.

S. Other follow up appointments should also be given and documented in Gemini by physician.




Outpatient Clinic Follow Up Care

I. Assessment/Diagnosis

A. Cardiovascular and anginal symptoms.

B. Compliance with medications, diet, exercise program, smoking cessation follow up.

C. Physical examination, including groin exam for patients post coronary angiography.

D. EKG as needed.

II. Care Treatment Plan

A. Chest pain.

1. Patients considered low risk, was ruled out for MI, should undergo exercise or pharmacologic stress testing.

2. Follow the guideline for risk stratification and treatment plan for noninvasive stress testing.

3. Patients with positive stress testing should be referred for cardiac catheterization.

B. Unstable Angina

1. Aggressive risk factor modifications and reinforcement of lifestyle changes, including AHA step II diet, exercise program or cardiac rehab, smoking cessation.

2. Continued medical management with aspirin, beta-blockers, ace-inhibitors, nitrates, and cholesterol-lowering agents.

3. Management and referral to appropriate care for co-morbid conditions (i.e., hypertension, diabetes, heart failure).

C. Acute Myocardial Infarction (STEMI and NSTEMI)

1. Continue targeted therapy as outline in Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP).

a) Aspirin.

b) Beta-blockers.

c) Statins or cholesterol-lowering agent with target LDL <>

d) Ace-Inhibitors.

e) Clopidogrel (plavix) for post PTCA/stent, Drug-Eluting stent, brachytherapy.

f) Exercise program or cardiac rehab.

g) Smoking cessation.

h) AHA step II diet.

2. Management and referral to appropriate care for co-morbid conditions (i.e., hypertension, diabetes, heart failure).

III. Discharge Education and Planning

A. Patients and family should be educated on all of the above targeted therapies and also monitoring of symptoms.

B. Education on warning signs of a heart attack and plan of action should be included.

Table 1: Biochemical cardiac markers for evaluation and management of patients with suspected ACS but without ST-Segment elevation on 12-Lead.

Marker

Advantages

Disadvantages

Clinical Recommendations

CK-MB

§ Rapid, cost-efficient, accurate assays.

§ Ability to detect early reinfarction.

§ Loss of specificity in setting of skeletal muscle disease or injury, including surgery.

§ Low sensitivity during early MI (6h after symptom onset); or

§ Later after symptom onset (36h) and for minor myocardial damage (detectable with troponins).

Prior standard and still acceptable diagnostic test in most clinical circumstances.

Normal lab values:

Male: 8 ng/ml

Female: 6 ng/ml

Cardiac Troponins

§ Powerful tool for risk stratification.

§ Greater sensitivity and specificity than CK-MB.

§ Detection of recent MI up to 2 weeks after onset.

§ Useful for selection of therapy.

§ Detection of reperfusion.

§ Low sensitivity in very early phase of MI (<6>

§ Limited ability to detect late minor reinfarction.

Useful as a single test to efficiently diagnose NSTEMI, with serial measurements. Know diagnostic “cutoffs”.

Normal lab values:

<2.0>

Table 2: Risk Stratification: Likelihood that signs and symptoms represent ACS secondary to CAD.

Feature

High Likelihood

Intermediate Likelihood

Low Likelihood

History

§ Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina.

§ Known history of CAD, including MI.

§ Chest or left arm pain or discomfort as chief symptom.

§ Age > 70 years.

§ Male sex.

§ Diabetes mellitus.

§ Probable ischemic symptoms in absence of any of the intermediate likelihood characteristics.

§ Recent cocaine use.

Examination

§ Transient MR.

§ Hypotension.

§ Diaphoresis.

§ Pulmonary edema.

§ Rales.

§ Extracardiac vascular disease.

§ Chest discomfort reproduced by palpation.

ECG

§ New, or presumably new transient ST-segment deviation (>0.05 mV); or

§ T-wave inversion (>0.2 mV) with symptoms.

§ Fixed Q waves.

§ Abnormal ST segment; or

§ T waves not documented to be new.

§ T-wave flattening; or

§ Inversion in leads with dominant R waves.

§ Normal ECG.

Cardiac Markers

§ Elevated cardiac TnI or CK-MB.

§ Normal.

§ Normal.

Table 3: Noninvasive Risk Stratification

Coronary Angiography

High risk (>3% annual mortality rate)

Severe resting LV dysfunction (LVEF <0.35)

High-risk treadmill score (score < -11)

Severe exercise LV dysfunction (exercise LVEF <0.35)

Stress-induced large perfusion defect (particularly if anterior)

Stress-induced multiple perfusion defects of moderate size

Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201)

Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium-201)

Echocardiographic wall motion abnormality

Stress echocardiographic evidence of extensive ischemia

Coronary Angiograph or Medical Management

Intermediate risk (1-3% annual mortality rate)

Mild/moderate resting LV dysfunction (LVEF 0.35-0.49)

Intermediate-risk treadmill score (-11<5)

Stress-induced moderate perfusion defect without LV dilation or increased lung intake (thallium-201)

Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving <>

Medical Management

Low risk (<>

Low risk-treadmill score (score > 5)

Normal or small myocardial perfusion defect at rest or with stress

Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress

Addenda

ST-Elevation MI (STEMI) Order Set

Suspected Unstable Angina/Non-ST-Elevation MI: (NSTEMI) Order Set

Glycoprotein IIB/ IIIA Inhibitors

((NOTE: IMPORTANT!!))

Addendum #1:
ST-Elevation MI (STEMI) Order
Set

Initial Orders

DIAGNOSTICS

¨ Stat ECG, obtain old ECG record

¨ Labs to be drawn stat: CMP, CBC/diff, PT/PTT/INR, CK and CK-MB (site specific), Troponin-I

¨ Lipid panel

¨ Stat portable CXR

¨ Cardiac monitor and SaO2 monitors

¨ Other_____________________________________________________

ANTI-ISCHEMIC THERAPY

¨ Oxygen 2L/min Nasal Cannula (titrate to keep pulse oximetry saturations >94%)

¨ IV 0.9NS _____ml/hr

¨ Morphine Sulfate

NITROGLYCERIN THERAPY (Hold if patient has taken Sildenafil (Viagara) within 24 hours)

¨ Nitroglycerin 0.4mg SL q5 min x 3 doses or until pain relief or SBP <>

¨ Nitroglycerin paste _____ inch(es) topically x 1

¨ IV – start Nitroglycerin infusion at 10mcg/min, then titrate to chest pain relief

B-BLOCKER THERAPY

¨ Metoprolol (Lopressor) 5mg IV q 5min x 3 doses (Hold for SBP <90),> 1st degree, decompensated CHF, severe COPD/Asthma)

ANTI-THROMBOTIC THERAPY

¨ Aspirin 162 mg po (2 chewable 81 mg tablets)

FIBRINOLYTIC THERAPY (Per discretion of Interventional Attending)

Indications: chest pain <>

1. History of hemorrhagic stroke at any time; other stroke or cerebrovascular event within 1 year.

2. Known intra-cranial neoplasm.

3. Active internal bleeding.

4. Suspected aortic dissection (consider CT of chest).

TPA (Per interventional attending)

¨ Full dose:15mg IVP, then 0.75mg/kg (maximum 50mg) over 30 min, then 0.5mg/kg (maximum 35mg) over 60 min

¨ Facilitated PCI (per interventional attending discretion)- Alteplase plus Eptifibatide

¨ Patient eligibility- <75yo>

¨ Serum Creatinine <2.0>

All Patients shall receive:

¨ ASA 160mg –325mg STAT

¨ Heparin - 60Units/KG (max 4000 Units) followed by 12/units/kg/hr (max 800units/hr titrated to aPTT 50-70)

¨ Alteplase Dose (should precede GPIIb IIIa inhibitors) - 15mg IVP followed by .75mg/kg (max 35mg) over 60 minutes

¨ Eptifibatide Dose - 180mcg/kg IVP, followed by 2mcg/kg/mininfusion. Second bolus -90mcg/kg IVP thirty minutes after first bolus. Infusion continues x 18-24 hours post PCI or max of 48 hours

HEPARIN THERAPY

May be administered simultaneously with TPA or given alone

¨ Unfractionated heparin: 5000 units IV bolus or 60 units/kg bolus (1000units/ml), then 1000 units/hr IV or 12units/kg/hr IV

¨ Follow Heparin Normogram per hospital protocol

¨ Goal of PTT 60-80

Addendum # 2:
Suspected Unstable Angina/Non-ST- Elevation MI: (NSTEMI) Order Set

Initial Orders

DIAGNOSTICS

¨ Stat ECG, obtain old ECG record

¨ Stat labs: CMP, CBC/diff, PT/PTT/INR, CK and CK-MB (site specific), Troponin I

¨ Lipid Panel

¨ Stat portable CXR

¨ Cardiac monitor and SaO2 monitors

¨ Other ___________________________________________________________

ANTI-ISCHEMIC THERAPY

¨ Oxygen 2L/min Nasal Cannula (titrate to keep pulse oximetry saturations >94%)

¨ IV 0.9NS _____ml/hr

¨ Morphine Sulfate

NITROGLYCERIN THERAPY

¨ Hold if patient has taken Sildenfil (Viagara) within 24 hours

¨ Nitroglycerin 0.4mg SL q 5min x 3 doses or until pain relief or SBP <>

¨ Nitroglycerin paste ____ inch(es) topically x 1

¨ Start IV infusion of Nitroglycerin at 10mcg/min, then titrate for pain relief

B-BLOCKER THERAPY

¨ Metoprolol (Lopressor) 5mg IV q 5 min x 3 (Hold SBP <90,> 1st degree, decompensated CHF, severe COPD/Asthma)

ACS ANTI-THROMBOTIC TREATMENT GUIDE

Possible ACS:

¨ Aspirin 162 mg (2 chewable 81 mg tablets)

Likely/Definite ACS (without continuing ischemic pain or high risk features)

§ Chief symptom: chest or left arm discomfort

§ Prior MI, History of CAD, extra-cardiac vascular disease, age >70 years

§ ECG: fixed Q waves, presumed old abnormal ST segments or T waves

¨ Aspirin 162 mg po (2 chewable 81 mg tablets)

¨ Noxaparin (Lovenox) ___mg SQ x 1 (1mg/kg dose) or

¨ Unfractionated heparin ____ units IV bolus (1000units/ml), followed by ______ units/hr (Follow Heparin Normogram per hospital protocol)

Definite ACS with any of the following features:

§ Continuing ischemic pain (despite ASA, clopidigrel, IV NTG, heparin)

§ High-risk (of death or non-fatal MI) features: positive cardiac enzymes, new or transient ST-segment changes, chest pain at rest >20minutes, diabetes, pulmonary edema, recent MI, age >75 years, hypotension

§ Planned intervention

¨ Aspirin 162mg (2 chewable 81 mg tablets)

¨ Eptifibatide (Integrillin) - See Micromedex for details

______180mcg/kg Eptifibatide IV bolus

______2.0mcg/kg/min Eptifibatide IV infusion

§ (NOTE: Half infusion rate if serum creatinine is between 2-4 mg/dl, hold if patient is on hemodialysis)

¨ Unfractionated heparin _____ units IV bolus (1000units/ml), then ____units/hr IV infusion (Follow Heparin Normogram per hospital protocol)

Addendum #3:
Glycoprotein IIB/ IIIA Inhibitors

Medication Pharmacokinetics/Pharmacodynamics

Eptifibatide

Abciximab

Mechanism of Action

Reversible inhibitor of receptor

Monoclonal antibody that irreversibly inhibits receptor

Half life

1.5 – 2.5 hours

a: <>

b: 30 minutes *

Duration of Action

§ Platelet aggregation

§ Bleeding time

2 – 4 hours

15 – 30 minutes

~ 48 hours

~ 24 hours

*NOTE: Half-life is deceiving. Applies to free drug in serum, drug still bound to receptor at 15 days.

Dosing (eptifibatide used in most cases, abciximab is used sparingly in Cath lab):

Eptifibatide

(Dosing charts available in pharmacy, cath lab, and CCU)

Abciximab

Acute Coronary Syndrome

180 mcg/kg IVP, plus 2 mcg/kg/min [generally continued x 24 hrs after PCI (if performed), may give up to 96 hrs total]

**For pt’s with SCr 2.0 - 4.0mg/dl, reduce maintenance infusion rate to 1.0 mcg/kg/min**

0.25 mg/kg IVP, then 0.125 mcg/kg/min (max 10 mcg/min)

x 18 – 24 hrs (for pts undergoing PCI w/in 24hrs)

Percutaneous Coronary Intervention

180 mcg/kg IVP x 2 (10 minutes apart), plus

2 mcg/kg/min x 20 – 24 hrs

**For pt’s with SCr 2.0 - 4.0mg/dl, reduce maintenance infusion rate to 1.0 mcg/kg/min**

0.25 mg/kg IVP, then 0.125 mcg/kg/min (max 10 mcg/min)

x 12 hrs

Adverse Drug Reactions/Monitoring Parameters:

§ Bleeding [vascular access site (usually groin) most common].

§ CBC baseline, QD, and if bleed suspected.

§ PTT as appropriate (in most cases due to concomitant heparin therapy).

§ 50 – 70 seconds [goal may be higher (60 – 80 seconds) if PCI performed].

§ For PCI, may use activated clotting time (ACT) with goal of 200 – 300 seconds.

§ Thrombocytopenia (primarily with abciximab, rare with eptifibatide).

§ May be given concomitantly with IV heparin and ASA.

University of Illinois Medical Center at Chicago Procedures for Integrilin™ Use

I. Requires cardiology approval.

II. Screen for appropriate use and contraindications.

III. Verify patient weight.

IV. Patient selection.

A. Ischemic chest pain at rest > 10 minutes within last 12 hours.

AND

B.

ECG changes consistent with ischemia.

1. ST depression.

2. T wave inversion.

3. Normalization of previously abnormal T waves.

OR

C. Positive Troponin I or CPK-MB.

OR

D. Recurrent chest pain on medical therapy (ASA, heparin, nitrates, beta-blocker).



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