NSTEMI: INITIAL MANAGEMENT ORDER TEMPLATE (Referenced Version) This template lists elements, drugs, doses, and strategies that should be highly considered when creating admission order sets based upon recent clinical practice guidelines, medication package inserts, and emerging evidence.
DEMOGRAPHICS Age ______years Weight ______kg
DIET ORDERS NPO Diabetic ______calorie ADA 2 gm sodium restricted/low cholesterol/low fat Other (specify) ______
ACTIVITY ORDERS Bed rest
NURSING1(pg e35) Continuous ECG monitoring Supplemental O2 to keep arterial saturation > 90% Nitroglycerin Protocol: PRN use of 0.4mg q5 min for chest pain
MEDICATION ALLERGIES Specify: ______Reaction (if known): ______
DIAGNOSTIC STUDIES 12-lead ECG NOW 12-lead ECG FOR RECURRENT CHEST PAIN 12-lead ECG IN AM (____/___/______:___ AM)
LABORATORY STUDIES CARDIAC MARKERS Troponin T/ Troponin I: NOW AND EVERY ______hours X ______times OR CK AND CK-MB: NOW AND EVERY ______hours X ______times ROUTINE LABS Chemistry panel: NOW DAILY IN AM Fasting lipid panel: IN AM CBC: NOW DAILY IN AM HbA1c: IN AM Calculate creatinine clearance (CrCl): ______ml/min CrCl ml/min = (140- age) X weight (kg)/(serum creatinine X 72) multiply by 0.85 if female
MEDICATIONS FOR ALL PATIENTS Aspirin: Loading dose (NOW) 162 mg to 325 mg chewed orally, then maintenance dose (DAILY) of 81 mg to 162 mg orally (or 162 mg to 325 mg DAILY after stent implantation). (If aspirin intolerant, give clopidogrel) 1
1Page 1 of 4 Loading dose: ______mg orally. Daily dose: ______mg orally.
Clopidogrel: Loading dose 300 -600 mg orally, then daily dose of 75 mg orally 2 (for patients who are aspirin intolerant, or in addition to aspirin in initial conservative strategy or as option with either clopidogrel or IV GP IIb/IIIa inhibitors prior to Cath)3 Loading dose: ______mg orally. Daily dose: ______mg orally
Statin: Drug: ______mg daily (regardless of LDL)4
ACE/ARB: (if LVEF<40%, CHF on exam, or pulmonary edema if SBP >100 mmHg)5 Drug: ______mg ______times day
BETA BLOCKERS (Hold if signs of heart failure, evidence of low-output state, high risk for cardiogenic shock* or contraindications to beta blocker therapy**)6 Oral Beta-blocker: Drug: ______mg _____ times day
IV Beta-Blockers (Optional; recommended if persistent ischemic symptoms, hypertension, or tachycardia and no signs of hemodynamic instability)7 Drug: ______mg IV for ____ doses every ___ minutes
*Risk factors for shock (greater number of risk factors, the greater the risk): age > 70 years, SBP < 120 mmHg, sinus tachycardia with HR > 110 bpm or < 60 mmHg, or increased time since onset of symptoms. **Contraindications for beta-blockers: PR interval > 0.24 sec, second or third degree AV block, active asthma, or reactive airway disease. Stop NSAIDS (except aspirin) GI Prophylaxis (with history of GI bleeding) Drug: ______mg ______times day
RISK STRATIFICATION High risk: Refractory angina, hemodynamic or electrical instability, elevated cardiac markers (TnT, TnI), new or presumably new ST segment depression, signs or symptoms of HF or new or worsening mitral regurgitation, high risk from noninvasive testing, reduced EF <40%, High risk score (eg. TIMI or GRACE) or PCI within 6 months or prior CABG.8 PREFER INITIAL INVASIVE STRATEGY (Diagnostic Angiography with intent to revascularize)
Low risk: Low risk score (eg. TIMI or GRACE) and absence of above high risk features9 PREFER INITIAL CONSERVATIVE STRATEGY (especially if female or based on patient preference)
INITIAL INVASIVE STRATEGY (Higher Risk) ANTICOAGULANT THERAPY (Choose one): Unfractionated heparinA (continue for 48 hrs) Bolus: 60 U/kg IV, not to exceed 4000 U Infusion: 12 U/kg/hr IV, not to exceed 1000 U/hr, to achieve goal PTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as indicated10 OR EnoxaparinA 1 mg/kg subcutaneous every 12 hours (if CrCl < 30 mL/min, give 1mg/kg every 24 hours)11 OR BivalirudinB Bolus: 0.1 mg/kg IV Infusion: 0.25 mg/kg/hr IV (Use with caution if CrCl < 30 mL/min)12
2Page 2 of 4 OR FondaparinuxB 2.5 mg subcutaneously once daily (Avoid if CrCl< 30 mL/min)13
*Continue for the shorter of the duration of hospitalization, 8 days, or until determined by management during PCI. ALevel of evidence A with data from multiple trials. BLevel of evidence B with data from a single trial. Schedule for catheterization and revascularization if appropriate
GLYCOPROTEIN IIB/IIIA THERAPY (Choose one or use clopidogrel as above) Abciximab (if no delay to cath) Loading: 0.25 mcg/kg IV bolus Infusion 0.125 mcg/kg/min IV (Reserve for patients with planned PCI within 12 hours)14 OR Eptifibatide Loading: 180 mcg/kg IV bolus Infusion: 2.0 mcg/kg/min (Reduce to 1.0 mcg/kg/min if CrCl < 50mL/min)15 OR Tirofiban Loading: 0.4 mcg/kg/min for 30 min (Reduce to 0.2 mcg/kg/min for CrCl ≤ 30 mL/min) Infusion: 0.1 mcg/kg/min (Reduce to 0.05 mcg/kg/min if CrCl ≤ 30 mL/min)16
*Can be started prior to or in cardiac catheterization lab.
INITIAL CONSERVATIVE STRATEGY (Lower Risk)
ANTICOAGULANT THERAPY (Choose one): Unfractionated heparinA (for 48 hours) Bolus: 60 U/kg IV (not to exceed 4000 U) Infusion: 12 U/kg/hr IV (not to exceed 1000U/hr) to goal PTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as indicated.17 OR EnoxaparinA 1 mg/kg subcutaneous every 12 hours (if CrCl < 30mL/min, give 1 mg/kg every 24 hours)18 OR FondaparinuxB 2.5 mg subcutaneously once daily (avoid if CrCl<30mL/min; Preferred if high risk of bleeding)19
*Continue for the shorter of the duration of hospitalization, 8 days, or until PCI. ALevel of evidence A with data from multiple trials. BLevel of evidence B with data from a single trial. Schedule assessment of LVEF Schedule for stress test Revert to invasive protocol if recurrent symptoms/ischemia, or develops high risk features such as heart failure, arrhythmias, or positive cardiac biomarkers.
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Endnote:
1 Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1-e157.
Anderson et al, 2007, p 37.
3 Anderson et al, 2007, p45
4 Anderson et al, 2007, p 92.
5 Anderson et al, 2007, p 35.
6 Anderson et al, 2007, p 35
7 Anderson et al, 2007, p 36
8 Anderson et al, 2007, p 34.
9 Anderson et al, 2007, p 34.
10 Anderson et al, 2007, p 37.
11 Anderson et al, 2007, p 37.
12 Anderson et al, 2007, p 37
13 Anderson et al, 2007, p 37.
14 Anderson et al, 2007, p 37.
15 Anderson et al, 2007, p 38.
16 Anderson et al, 2007, p 38.
17 Anderson et al, 2007, p 37.
18 Anderson et al, 2007, p 37.
19 Anderson et al, 2007, p 37.