Download NSTEMI standing orders

STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
Patient ___________________________ ______________________ _______
(LAST NAME)
Age: ___________ years
(FIRST NAME)
Weight: __________ kg
(MI)
 Male
 Female
Admit to: Cardiology
Condition:_______________________________________________________
Diagnosis:  Unstable angina
 NSTEMI
Medication allergies: ______________________________________________
________________________________________________________________
NURSING
Check/Initial/Date
 _____/_____
Activity: bed rest
 _____/_____
Cardiac monitor
 _____/_____
Vital signs q4h x 24 h then q8h
 _____/_____
Diet: house/no added salt/low saturated fat; low cholesterol
 _____/_____
Call house officer for T >101, SBP >190 mm Hg or SBP <90
mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10
 _____/_____
Guaiac ALL stools while on UFH, LMWH, GP IIb/IIIa inhibitor
 _____/_____
Supplemental O2 to keep arterial saturation >90%
Nasal prongs (cannula) 2 L/min
PLEASE CALL HOUSE OFFICER FOR O2 SAT <90%
 _____/_____
ORDER FOR RESPIRATORY CARE O2 SAT CHECK q8h
DIAGNOSTIC STUDIES
Check/Initial/Date
 _____/_____
ECG ON ADMISSION
 _____/_____
ECG for recurrent chest pain
1
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
LABORATORY STUDIES
Check/Initial/Date
CARDIAC MARKERS
 _____/_____
Troponin T/Troponin I: NOW AND EVERY _____hrs  ___
times
 _____/_____
CK-MB: NOW AND EVERY _____ hrs  ___ times
CHEMISTRY PANEL
 _____/_____
CBC, Lipid Profile, PTT, Chemistry (7) panel in AM – FASTING
MEDICATIONS
Check/Initial/Date
 _____/_____
 _____/_____
 _____/_____
Aspirin 162-325 (__________ insert dose) mg po chewed
(loading dose) now, then 75-162 mg/d po (or 162-325 mg/d
after stent implantation) daily maintenance dose
If aspirin intolerant, use clopidogrel 300-600 (_________
insert dose) mg po x 1(loading dose),b then 75 mg/d po
Stop all NSAIDs except aspirin
2
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
MEDICATIONS cont
Check/Initial/Date
-BLOCKER
Hold if signs of HF, evidence of a low-output state, increased
risk for cardiogenic shock (age >70 y, SBP <120 mm Hg, sinus
tachycardia >110 bpm or heart rate <60 bpm, increased time
since onset of UA/NSTEMI symptoms), or other relative
contraindications to β-blockade (PR interval >0.24 s, secondor third-degree heart block, active asthma, or reactive airway
disease).
Choose one:
IV -Blocker (optional; reserved for patients with refractory
tachycardia or refractory hypertension; otherwise, oral βblockade is sufficient)
 _____/_____
Drug: _____________________________
every ____ hrs
_______ mg IV
Oral -Blocker
 _____/_____
METOPROLOL TARTRATE 50-200 mg bid
 _____/_____
ATENOLOL 50-200 mg/d
 _____/_____
CARVEDILOL 6.25 mg bid, uptitrated to max. 25 mg bid
NITROGLYCERIN
 _____/_____
NITROGLYCERIN 1/150 (0.4 mg) 1 TAB SL q5min x 3 prn
chest pain; HOLD IF: SBP <100 mm Hg
 _____/_____
NITROGLYCERIN 5-200 µg/min IV in D5W continuous IV
 _____/_____
NITROGLYCERIN, transdermal, 0.2 to 0.8 mg/h q12h,
tolerance in 7 to 8 h
3
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
EARLY RISK STRATIFICATION
Check/Initial/Date
 _____/_____
 High risk
 Intermediate risk  Low risk
High risk: elevated cardiac biomarkers, ST depression,
transient ST elevation, >20 min of rest pain, hemodynamic
instability, signs of CHF  INITIAL INVASIVE STRATEGY
(Diagnostic angiography with intent to revascularize)
Intermediate risk: no high-risk features, prior MI, prior CABG,
T-wave inversions, rest angina <20 min relieved promptly with
nitroglycerin, age >70 years  EITHER INITIAL INVASIVE OR
INITIAL CONSERVATIVE STRATEGY
Low risk: No high- or moderate-risk features, progressive
angina without prolonged rest pain, normal cardiac markers,
normal ECG with pain  INITIAL CONSERVATIVE STRATEGY
 _____/_____
 Invasive strategy
 Conservative strategy
Selection of Initial Treatment Strategy: Patient Characteristics
Invasive Strategy Preferred
● Recurrent angina or ischemia at rest or with low-level activities
● Elevated cardiac biomarkers (TnT or TnI)
● New or presumably new ST-segment depression
● Signs or symptoms of HF or new or worsening mitral regurgitation
● High-risk findings from noninvasive testing
● Hemodynamic instability
● Sustained ventricular tachycardia
● PCI within 6 months
● Prior CABG
● High risk score (eg, TIMI, GRACE)
● Reduced LV function (LVEF <40%)
Conservative (Selectively Invasive) Strategy Preferred
● Low risk score
● Patient or physician preference in absence of high-risk features
It is reasonable for initially stabilized high-risk patients with UA/NSTEMI* (GRACE
risk score >140) to undergo an early invasive strategy within 12 to 24 hours of
admission. For patients not at high risk, an early invasive approach is also
reasonable (Class IIa, LOE: B).c
*Immediate catheterization/angiography is recommended for unstable patients.
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STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
INITIAL INVASIVE STRATEGY (High- or Intermediate-Risk Patients)
Check/Initial/Date
Initiate at least one (Class I, LOE: A) or both (Class IIa, LOE: B) of the following:
 _____/_____
Clopidogrel 300-600 (__________ insert dose) mg po x 1
(loading dose),b then 75 mg/d po. Withhold for 5 days if CABG is
planned.
OR
 _____/_____
Prasugrel (at the time of PCI) 60 mg po x 1 (loading dose),c then 10
mg/d po. Do not use prasugrel in patients with active pathological
bleeding or a history of TIA or stroke. In patients ≥75 years of age,
prasugrel is generally not recommended because of the increased
risk of fatal and intracranial bleeding and uncertain benefit, except in
high-risk situations (patients with diabetes or a history of prior MI) for
which its effect appears to be greater and its use may be
considered. Do not start prasugrel in patients likely to undergo
urgent CABG. When possible, discontinue prasugrel at least 7 days
before any surgery.
AND/OR
 _____/_____
GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY (choose one):
Eptifibatide 180 µg/kg IV bolus x 2, 10 min apart, followed by IV
infusion of 2.0 µg/kg/min, reduce to 1.0 µg/kg/min if CrCl <50
mL/min. Continue for 18 to 24 hours post-PCI.
OR
 _____/_____
Tirofiban IV infusion of 0.4 µg/kg/min for 30 min, reduce to 0.2
µg/kg/min for CrCl <30 mL/min, followed by IV infusion of 0.1
µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min. Continue
for 18 to 24 hours post-PCI.
OR
 _____/_____
Abciximab 0.25 mg/kg IV bolus administered 10-60 min before
the start of PCI, followed by IV infusion of 0.125 µg/kg/min (to a
maximum of 10 μg/min). Continue for 12 hours post-PCI. Indicated
only if there is no appreciable delay to angiography and PCI is
likely to be performed. Reserve only for patients with planned PCI
within 24 hours.
5
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
INITIAL INVASIVE STRATEGY (High- or Intermediate-Risk Patients) cont
Either an IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban; Class I, LOE: A) or
clopidogrel (loading dose followed by daily maintenance dose; Class I, LOE: A)
should be added to aspirin and anticoagulant therapy before diagnostic
angiography.
For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is
reasonable to initiate antiplatelet therapy with both clopidogrel (loading dose followed
by daily maintenance dose) and a GP IIb/IIIa inhibitor (Class IIa, LOE: B).
Factors favoring administration of both clopidogrel and a GP IIb/IIIa inhibitor include
delay to angiography, high-risk features, and early recurrent ischemic discomfort.
Check/Initial/Date
ANTICOAGULANT THERAPY (choose one):
(A) or (B) denotes level of evidence designation.
 _____/_____
Unfractionated Heparin (A) (for 48 hours) 60 U/kg IV bolus
(not to exceed 4000 U), followed by IV infusion of 12 U/kg/h
(not to exceed 1000 U/h) to achieve goal aPTT 1.5 to 2.0 times
control (approximately 50 to 70 s); check aPTT in 6 h and
adjust heparin as indicated (see appendix for titration
nomogram)
OR
 _____/_____
Enoxaparind (A) 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1
mg/kg every 24 h). Continue for the duration of hospitalization,
8 days, or until PCI or CABG is performed.
OR
 _____/_____
Fondaparinux (B) 2.5 mg SC once daily (avoid if CrCl <30
mL/min). Continue for the duration of hospitalization, 8 days, or
until PCI or CABG is performed. UFH, per institutional practice,
should be administered for any PCI procedure.
OR
 _____/_____
Bivalirudin (B) 0.1 mg/kg IV bolus, then IV infusion of 0.25
mg/kg/h (use with caution if CrCl <30 mL/min). Continue until
PCI is performed or for up to 4 h post-PCI. Discontinue 3 h
before CABG and dose with UFH per institutional practice.
6
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
INITIAL CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients)
Check/Initial/Date
 _____/_____
Clopidogrel 300 mg po x 1 (loading dose), b then 75 mg/d po
ANTICOAGULANT THERAPY (choose one):
(A) or (B) denotes level of evidence designation.
 _____/_____
Unfractionated Heparin (A) (for 48 hours) 60 U/kg IV bolus
(not to exceed 4000 U), followed by IV infusion of 12 U/kg/h
(not to exceed 1000 U/h) to achieve goal aPTT 1.5 to 2.0 times
control (approximately 50 to 70 s); check aPTT in 6 h and
adjust heparin as indicated.
OR
 _____/_____
 _____/_____
Enoxaparinc (A) 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1
mg/kg every 24 h)
OR
Fondaparinux (B) 2.5 mg SC once daily (avoid if CrCl <30
mL/min). Preferred if high risk of bleeding.
Continue IV UFH for at least 48 h (Class I, LOE: A) or enoxaparin or fondaparinux for
the duration of the hospitalization (Class I, LOE: A). Enoxaparin or fondaparinux is
preferable to UFH as anticoagulant therapy, unless CABG is planned within 24 h
(Class IIa, LOE: B).
For UFH, consult Unfractionated Heparin Dosing Chart.
 _____/_____
Schedule assessment of LVEF
 _____/_____
Schedule stress test
 _____/_____
Start early invasive strategy if patient has recurrent
symptoms/ischemia, HF, arrhythmias, positive cardiac
biomarkers, or positive stress test
7
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
INITIAL CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients) cont
GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY
For UA/NSTEMI patients in whom an initial conservative (ie, noninvasive) strategy is
selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and
oral antiplatelet therapy (Class IIb, LOE: B).
 _____/_____
Eptifibatide 180 µg/kg IV bolus, followed by IV infusion of 2.0
µg/kg/min (reduce to 1.0 µg/kg/min if CrCl <50 mL/min)
OR
 _____/_____
Tirofiban IV infusion of 0.4 µg/kg/min for 30 min, reduce to 0.2
µg/kg/min for CrCl <30 mL/min, followed by IV infusion of 0.1
µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min
8
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
AS-NEEDED MEDICATIONS
Check/Initial/Date
 _____/_____
DOCUSATE SODIUM 100 mg po bid
 _____/_____
MAALOX PLUS EX STR 15 mL po q6h prn indigestion
 _____/_____
OXAZEPAM 15-30 mg po qhs prn insomnia
 _____/_____
ACETAMINOPHEN 650 mg po q4h prn headache
 _____/_____
MAGNESIUM HYDROXIDE 30 mL po daily prn constipation
 _____/_____
MAGNESIUM SULFATE Sliding Scale IV daily
Call house officer if serum Mg <1.2; hold order for creatinine >1.9
If serum Mg <1.4 give 5 g MgSO4 IV
If serum Mg <1.6 give 4 g MgSO4 IV
If serum Mg <1.8 give 3 g MgSO4 IV
If serum Mg <2.0 give 2 g MgSO4 IV
 _____/_____
 _____/_____
LAB, MG, K daily
KCL IMMEDIATE REL Sliding Scale Target K >4.5 mg/dL po daily
Call house officer if K <3.4; hold order for creatinine >1.9
If K <3.7 give 60 mEq
If K <4.1 give 40 mEq
If K <4.6 give 20 mEq
Additional Orders:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
9
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
 _____/_____
CHEST PAIN PROTOCOL
 _____/_____
ECG x 1 prn chest pain
 _____/_____
For CP: check VS, call house officer
 _____/_____
Mark if cardiac cath is planned: Time _________________
 _____/_____
NPO except meds
 _____/_____
LAB, TYPE AND HOLD NEXT AVAILABLE
 _____/_____
NUTRITION CONSULT
Patient admitted to cardiology ischemia pathway with known or
suspected CAD. Please facilitate outpatient education in lowcholesterol, low-salt diet
 _____/_____
SOCIAL SERVICE CONSULT
Patient admitted to cardiology ischemia pathway with known
or suspected CAD. Please assess and assist in need for
outpatient support (including VNA) services
 Now
10
 After midnight
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
DAY 2 OR LATER: REMINDERS
Check/Initial/Date
 _____/_____
If on UFH (consult Unfractionated Heparin Dosing Chart)
_____________________________________________
 _____/_____
Calcium channel blocker (if β-blocker contraindicated)
Drug: _______________________ ___mg ____times/d
 _____/_____
ACE inhibitor or ARB; recommended if diabetic
Drug: _______________________ ___mg ____times/d
 _____/_____
Lipid-lowering therapy (statins) regardless of LDL; dose target
to LDL <100 mg/dL (further reduction to <70 mg/dL
reasonable)
Drug: ____________________________ ___mg once daily
 _____/_____
Echocardiography. FIRST 24 HR if evidence of CHF,
hemodynamic instability, mechanical complication
 _____/_____
Warfarin: RECOMMENDED if LV thrombus, extensive wall
dyskinesis, LVEF <20%-30%
11
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
PRIOR TO DISCHARGE
Check/Initial/Date
 _____/_____
 _____/_____
Patient had stent implanted
OR
Patient had medical therapy without stenting
MEDICATIONS
 _____/_____
Aspirin ________ mg/d for ___________________________
 _____/_____
Clopidogrel _________ mg/d for _______________________
OR
Prasugrel 10 mg/d for ______________________________
 _____/_____
 _____/_____
-blocker
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
ACE inhibitor or ARB
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
Aldosterone receptor blocker
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
Calcium channel blocker
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Statin
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Nitroglycerin
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Drug: ___________________________________________
Dosage: _________________________________________
12
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
PRIOR TO DISCHARGE cont
PATIENT/FAMILY EDUCATION AND FOLLOW-UP
INSTRUCTIONS
Check/Initial/Date
 _____/_____
Medication instructions/disease education
 _____/_____
Smoking cessation
 _____/_____
Diabetes management
 _____/_____
Nutrition, weight, and blood pressure management
 _____/_____
Exercise program
 _____/_____
Referral to cardiac rehab
Time: ______ Date: ______ Signature: ____________________________________
a 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(7):e1-e157.
b Some
uncertainty exists about optimum dosing of clopidogrel. Randomized trials establishing its
efficacy and providing data on bleeding risks used a loading dose of 300 mg orally followed by a
daily oral maintenance dose of 75 mg. Higher oral loading doses such as 600 or 900 mg of
clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of
inhibition of platelet aggregation, but the additive clinical efficacy and the safety of higher oral
loading doses have not been rigorously established.
c Kushner
FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the
management of patients with ST-elevation myocardial infarction (updating the 2004 guideline
and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention
(updating the 2005 guideline and 2007 focused update): a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2009;54(23):2205-2241.
d Limited
data are available for the use of other LMWHs in UA/NSTEMI.
13
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
14
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
Based on ACC/AHA 2007 Class I Recommendationsa
Heparin Adjustment Nomogram for Standard Laboratory Reagents
With a Mean Control aPTT of 26-36 s
aPTT (s)
Bolus Dose
(U)
Stop Infusion
(min)
Rate Change
(mL/h)
Repeat aPTT
3000
0
+2
6h
40-49
0
0
+1
6h
50-75
0
0
0 (no change)
Next AM
76-85
0
0
–1
Next AM
86-100
0
30
–2
6h
101-150
0
60
–3
6h
>150
0
60
–6
6h
<40
aPTT indicates activated partial thromboplastin time. Heparin infusion concentration = 50 U/mL.
Target aPTT = 50-75 s.
For aPTTs obtained before 12 h after initiation of thrombolytic therapy:
1. Do not discontinue or decrease infusion unless significant bleeding or aPTT >150 s.
2. Adjust infusion upward if aPTT <50 s. For aPTTs obtained 12 h after initiation of
thrombolytic therapy, use entire nomogram: Deliver bolus, stop infusion, and/or change rate
of infusion based on aPTT, as noted on appropriate line of nomogram.
Adapted with permission from Hirsh J, Raschke R, Warkentin TE, Dalen JE, Deykin D, Poller L.
Heparin: mechanism of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and
safety. Chest. 1995;108(4 suppl):258S-275S.
Reprinted with permission from Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for
the management of patients with acute myocardial infarction. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1996;28(5):1328-1428.
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