unstable angina /non-st elevation myocardial infarction critical pathway toolkit
DESCRIPTION
Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit. Adapted from Dr Chris Cannon STRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines - 2007. Anticoagulants. - PowerPoint PPT PresentationTRANSCRIPT
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Unstable Angina /Non-ST Elevation Myocardial Infarction
Critical Pathway Toolkit
Adapted from Dr Chris CannonSTRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines - 2007
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Anticoagulants
Enoxaparin more effective in preventing combined end point of death or MI vs Unfractionated heparin (UFH).
Avoid cross-over during PCILast SC dose >8 hrs, 0.3 mg/kg of
iv.Last SC dose <8 hours, no
additional enoxaparin.
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Anticoagulants Bivalirudin (single therapy) lower risk of
bleeding compared to Enoxaparin and UFH. Approved only for early PCI.
Fondaparinux Lower risk of bleed but increased risk of catheter-related thrombi, to switch to UFH in Cath Lab.
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Lipid Management
Fasting lipid profile workup within 24h [Class I, LOE: C]
Statin regardless of LDL-C [Class I, LOE: A]
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Beta-blockers
Ellis K, et al. 6-month mortality in ACS pts undergoing PCI1.7% Beta-blockers vs 3.7% without beta-blockers.
(Pooled results from EPIC, EPILOG, RAPPORT, CAPTURE and EPISTENT J Interv Cardiol 2003;16:299–305.)
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Beta-blockers
ACC/AHA 2007 Class 1 (LOE B)#Oral therapy initiated ≤24 h if NOHeart failure Low-output stateIncreased risk for cardiogenic shockRelative contraindications PR ›0.24 s2nd or 3rd degree heart blockReactive airway disease
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Angiotensin-aldosterone inhibitorsPulmonary congestion or LVEF ≤ 40% -
ACEI within 24h or ARB if intolerant.
LV dysfunction, hypertension or diabetes – Long-term ACEI or ARB.
LVEF ≤ 40% and symptomatic heart failure or diabetes
(without renal dysfunction/hyperkalemia)Aldosterone-receptor blockade in addition to ACEI.
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Optimal Discharge PlanningOptimal blood pressure <140/90 mm Hg [Class I, LOE: A]
<130/80 in diabetes or chronic kidney disease mm Hg [Class I, LOE: A]
Discharge education Medication use, cardiac rehabilitation, lifestyle modification (diet, exercise & smoking cessation) [Class I, LOE: C]
Follow-up2-6 weeks in low risk, medically treated, revascularized,
14 days high risk [ Class I, LOE: C]
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Cardiac Admission Checklist
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Cardiac Admission Checklist
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Cardiac Discharge Prescription
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Adapted by
Kamelia Emamian M.D. and Thao Huynh, MD, MSC.