Download G1.1 Acute Coronary Syndrome (ACS) and Suspected ACS

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University of Illinois Medical Center
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NO.: G-1.1
DATE: May 2011
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UNIVERSITY OF ILLINOIS MEDICAL CENTER
CLINICAL CARE GUIDELINE
ACUTE CORONARY SYNDROME (ACS) AND
SUSPECTED ACS
May 2011
Key Content Expert:
Dr. George Kondos, Professor of Medicine, Cardiology*
Carolyn Dickens MSN APN*
Dr. Robert DiDomenico, Clinical Associate Professor of Pharmacy
*Co-Chairs, Cardiovascular Quality Improvement Committee
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.
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NO: G-1.1
DATE: May 6, 2011
SUBJECT: Acute Coronary Syndromes and Suspected ACS
OBJECTIVE
The goal of these guidelines is to improve the quality and efficiency of management of adult
patients with acute coronary syndromes (ACS) in accordance with the ACC/AHA clinical
practice guidelines. Specifically:
1. Provide management and diagnostic guidelines for patients assigned to these categories:
unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and STsegment elevation myocardial infarction (STEMI). NOTE: the intent of this document is not
to guide diagnostic and therapeutic decision-making in low-risk patients with suspected
noncardiac chest pain.
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 90 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.
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Non ST-Segment-Elevation 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-Elevation 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/Inpatient Care
I.
Assessment/Diagnosis (Early Risk Stratification)
A. History (likelihood of ischemia due to CAD)
1. Nature of angina 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.
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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 Addendum 1)
1. For initial MI rule out, Cardiac labs (CK-MB, Troponin I, and total CPK).
2. Labs to be drawn q4 hours x 3, and then at physician’s discretion.
E. Conclusion of Initial Evaluation with Documentation Using Risk Stratification Guideline
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. Likelihood of ACS related to coronary artery disease (Addendum 2)
(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.
b. Risk of major adverse cardiac events (patients with unstable angina/non-STelevation MI)
(a) Calculate TIMI Risk Score (Addendum 3)
(i) Low risk: TIMI score 0 – 2
(ii) Intermediate risk: TIMI score 3 – 4
(iii) High risk: TIMI score 5 – 7
F. Low risk patients with possible ACS
1. Patients will be observed in the ED with continuous cardiac monitoring.
2. Low risk patients and those with atypical symptoms 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. These patients may proceed with a more rapid (e.g., 2 hour)
chest pain evaluation based on an American College of Emergency Physicians
Clinical Policy (Ann Emerg Med 2006;48:270-301).
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a. Vital signs every 2 hours.
b. Serial ECG and cardiac markers at baseline (time 0) and 2 hours.
3. Patient Disposition
a. Patients should be scheduled for a stress test or may be discharged from the ED
and return for stress test as outpatient within 72 hours provided the following
conditions are met at 2 hour follow up period:
(a) No interval change in ECG
(b) No recurrence of chest pain symptoms
(c) No change in delta CK-MB and troponin-I
(d) Patients should be instructed to call their primary care physician to arrange a
follow-up appointment within 72 hours of discharge.
b. Patients should be admitted for further cardiovascular work up and treatment
(e.g., intermediate-high risk) if any of the following occur during the 2-hour follow
up period:
(a) An increase in CK-MB level of ≥1.5 ng/mL, or cardiac troponin I level of
≥0.2ng/mL .
(b) Recurrence of chest pain during observation
(c) New ECG changes consistent with ischemia.
4. 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.
G. Intermediate-high risk patients
1. The CCU fellow and the cardiology team shall determine whether patient will be
monitored on 6WSD or CCU based on risk stratification.
2. Nursing staff shall notify the CCU resident of patient’s arrival on the unit, tele-monitor
assigned, and nursing admission database to be completed.
3. 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 (see Addendum 4)
A. General Care
1. Patients should remain on continuous ECG monitoring for ischemia and arrhythmia
detection.
2. Maintain pulse oximeter saturation > 90%, monitor patients for signs of respiratory
distress, supplemental oxygen as needed.
3. Patients should be placed on bed rest during initial phase of management.
4. Patients should remain NPO except meds until clinical stability is demonstrated and
cardiac catheterization need and timing is determined.
5. Consider and initiate consultations as needed: cardiac rehab, dietitian, social worker,
and chaplain.
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B. Low Risk Patients with possible ACS
1. Patients admitted with diagnosis of chest pain should be placed on R/O MI protocol:
a. EKG and cardiac markers (CPK, CK-MB, Troponin I) every 4 hours x 3.
b. The CCU resident or fellow should be notified with every EKG readings and any
abnormal lab values.
2. All patients should receive 162 – 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.
C. Intermediate-High Risk Patients (Possible/Likely ACS)
1. Reperfusion, Angiography, and Antithrombotic Therapy
a. ST-Segment Elevation Myocardial Infarction (STEMI)
(a) Goal: rapid initiation of therapy aimed at reperfusion, time from door to
percutaneous coronary intervention (PCI) of 90 minutes.
(b) Reperfusion therapy
(i) Activate the cath lab team immediately. DO NOT page the cardiology
fellow or cardiology team prior to activating the cath lab team
(ii) In rare instances (e.g., severe weather) when primary PCI is not available
or not possible within the 90 minute window, thrombolysis with alteplase
should be considered
1. Note: Decision should be made jointly between interventional
cardiologist on-call and the emergency department attending
physician.
2. Indications:
a. ST elevation ≥ 1mm in 2 contiguous leads or new left bundle
branch block AND
b. Persistent angina symptoms with an onset < 12 hours
3. Contraindications:
a. Active bleeding
b. History of stroke
c. Recent intracranial or intraspinal surgery
d. Known intracranial neoplasm
e. Arteriovenous malformation or aneurysm
f. Known bleeding diathesis
g. Severe uncontrolled hypertension
h. Suspected aortic dissection
4. Alteplase Dose (maximum total dose = 100mg)
a. 15mg Intravenous (IV) push, THEN
b. 0.75mg/kg (maximum 50mg) over 30 minutes, THEN
c. 0.5mg/kg (maximum 35mg) over 60 minutes
d. Note: Patients should also receive concomitant aspirin and IV
heparin as described below.
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(c) Antithrombotic therapy recommendations (STEMI)
(i) All patients should receive regular aspirin (ASA) 162 – 325mg as soon as
possible.
1. Contraindications:
a. Evidence of life-threatening hemorrhage
b. History of severe hypersensitivity to ASA.
(ii) All patients should be considered for adjunctive thienopyridine therapy,
particularly those undergoing primary PCI
1. Clopidogrel: loading dose: 300 – 600mg po x 1, then 75mg daily for
up to 1 year
2. Prasugrel: 60mg po x 1, then 10mg daily for up to 1 year
a. Prasugrel is only indicated in patients with ACS undergoing PCI.
b. Prasugrel is CONTRAINDICATED in the following patients due to
increased risk of potentially fatal intracranial hemorrhage
i. Prior thrombolytic therapy
ii. Age > 75 years
iii. Previous stroke
iv. Weight < 60kg
(iii) All patients should be started on a parenteral anticoagulant drug. Options
include:
1. IV heparin: 60 units/kg bolus (maximum bolus = 4000 units), then 12
units/kg/hr continuous infusion (maximum infusion rate = 1000
units/hr) titrated to aPTT of 60 – 80 seconds.
a. Note: the maximum doses are lower than the UIMCC heparin
dosing guidelines due to the risk of bleeding from combination
antithrombotic therapy and interventional strategies as
recommended by the ACC/AHA.
b. Contraindications
i. Acute pericarditis
ii. Aortic dissection
iii. Heparin allergy
iv. Major life threatening hemorrhage.
2. Bivalirudin: 0.75mg/kg IV bolus, then 1.75mg/kg/hr
a. Note: bivalirudin is only indicated for patients in whom primary PCI
is planned. Bivalirudin should not be used in medically managed
patients.
b. Contraindications
i. Active major bleeding
ii. Suspected aortic aneurysm
iii. Acute pericarditis
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(iv) The use of glycoprotein IIb/IIIa inhibitors may also be considered in the
following patients (often initiated in the cath lab at interventional
cardiologist’s discretion): (Addendum 5)
1. Patients undergoing primary PCI treated with IV heparin.
a. Should NOT be used routinely in patients treated with bivalirudin
as the anticoagulant
b. Options include:
i. Abciximab: 0.25mg/kg IV bolus, then 0.125mcg/kg/min (max
10mcg/min) continuous infusion x 12 hours
ii. Eptifibatide: 180mcg/kg IV bolus x 2 separated by 10 minutes,
then 2mcg/kg/min x 18 – 24 hours
iii. For creatinine clearance (CrCl) < 50ml/min: 1mcg/kg/min
2. Contraindications
a. Active or recent (< 6 weeks) internal bleeding/hemorrhage
b. Clinically significant GI bleed
c. History of stroke within previous 2 years or with persistent
neurological deficit
d. Bleeding diathesis
e. Thrombocytopenia
f. Recent (< 6 weeks) major surgery
g. AV malformation or aneurysm
h. Intracranial tumor
i. Severe uncontrolled hypertension
b. Unstable Angina/Non-ST Elevation MI (NSTEMI)
(a) Goal: medical therapy or revascularization to prevent the evolution to MI and
diagnostic testing (coronary angiography or physiologic stress testing) to
assess coronary risk.
(i) Treatment Strategies (Addendum 6)
1. 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.
2. 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, hemodynamic instability, sustained
ventricular arrhythmias, prior PCI (within 6 months), and prior CABG.
(b) Antithrombotic therapy recommendations (Unstable Angina/NSTEMI)
(i) All patients should receive regular ASA 162 – 325mg as soon as
possible.
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1. Contraindications:
a. Evidence of life-threatening hemorrhage
b. History of severe hypersensitivity to ASA.
(ii) All patients deemed to be intermediate-high risk (e.g., TIMI score ≥ 3)
should be considered for adjunctive thienopyridine therapy, particularly
those undergoing PCI
1. Clopidogrel: loading dose: 300 – 600mg po x 1, then 75mg daily for
up to 1 year
2. Prasugrel: 60mg po x 1, then 10mg daily for up to 1 year
a. Prasugrel is only indicated in patients with ACS undergoing PCI.
b. Prasugrel is CONTRAINDICATED in the following patients due to
increased risk of potentially fatal intracranial hemorrhage
i. Prior thrombolytic therapy
ii. Age > 75 years
iii. Previous stroke
iv. Weight < 60kg
(iii) All patients should be started one of the following parenteral
anticoagulant drugs:
1. Intravenous (IV) heparin: 60 units/kg bolus (maximum bolus = 4000
units), then 12 units/kg/hr continuous infusion (maximum infusion rate
= 1000 units/hr).
a. Note: the maximum doses are lower than the UIMCC heparin
dosing guidelines due to the risk of bleeding from combination
antithrombotic therapy and interventional strategies as
recommended by the ACC/AHA.
b. Contraindications
i. Acute pericarditis
ii. Aortic dissection
iii. Heparin allergy
iv. Major life threatening hemorrhage.
2. Bivalirudin:
a. Dose:
i. Initiation prior to angiography: 0.1mg/kg IV bolus, then 0.25
mg/kg/hr
ii. Once PCI is determined to be necessary: additional 0.5mg/kg
IV bolus, increase infusion to 1.75 mg/kg/hr
iii. Initiation during angiography/PCI: 0.75mg/kg IV bolus, then
1.75mg/kg/hr
b. Note: bivalirudin is only indicated for patients in whom PCI is
planned. Bivalirudin should not be used in medically managed
patients.
c. Contraindications:
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i.
Active major bleeding
3. Fondaparinux 2.5mg subcutaneously once daily until hospital
discharge (maximum duration = 8 days)
a. Note: Fondaparinux may be considered in patients for whom the
plan is conservative, noninvasive management due to similar
efficacy and improved safety compared to heparin and lowmolecular-weight heparins
b. Contraindications:
i. CrCl < 30ml/min or serum creatinine > 3mg/dl
ii. Active major bleeding
iii. Bacterial endocarditis
(iv) The use of glycoprotein IIb/IIIa inhibitors may also be considered in the
following patients (often initiated in the cath lab at interventional
cardiologist’s discretion):
1. Patients undergoing angiography & possible PCI treated with IV
heparin who did not receive a thienopyridine (e.g., clopidogrel or
prasugrel).
a. Should NOT be used routinely in patients treated with bivalirudin
as the anticoagulant.
b. Options include:
i. Eptifibatide: 180mcg/kg IV bolus x 2 separated by 10 minutes,
then 2mcg/kg/min x 18 – 24 hours
ii. For creatinine clearance (CrCl) < 50ml/min: 1mcg/kg/min
iii. Abciximab: 0.25mg/kg IV bolus, then 0.125mcg/kg/min (max
10mcg/min) continuous infusion x 12 hours
2. Antianginal therapy during 1st 24 hours (consider in ALL patients)
a. All patients with ongoing chest pain should be considered for nitroglycerin (NTG)
therapy.
(a) NTG sublingual (SL): 0.4mg SL q5 minutes for a total of up to 3 doses.
(b) NTG IV: 10mcg/min titrated q5 – 15 minutes to relief of chest pain and
systolic BP > 90 – 100mmHg.
(i) For patients with persistent angina symptoms despite NTG SL.
(c) Contraindications:
(i) Systolic BP < 90mmHg
(ii) Severe bradycardia (HR < 50bpm)
(iii) Suspected right ventricular infarction.
(iv) Patients who have received a phosphodiesterase inhibitor
1. Sildenafil, vardenafil: within 24 hours
2. Tadalafil: within 48 hours
b. All patients should be considered for beta-blocker therapy.
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(a) Oral beta-blockers: All patients within 24 hours of hospitalization.
(i) Avoid EARLY initiation of beta-blockers if the following are present:
1. Signs of heart failure
2. Evidence of low cardiac output state
3. Presence of cardiogenic shock or risk factors for its development:
a. Age > 70 years
b. Systolic BP < 120mmHg
c. Sinus tachycardia (HR > 110bpm)
d. Sinus bradycardia (HR < 60bpm)
e. Increased time from symptom onset
4. Hypotension
5. 1st or 2nd degree AV block
6. Severe, active COPD/asthma
(ii) Commonly used formulary agents: metoprolol, carvedilol, labetalol
(b) Intravenous beta-blockers may be considered ONLY in patients with
uncontrolled hypertension in the absence of the risk factors for adverse
events due to beta-blockers listed above (II. A. 1. f. (a). (i) above).
(i) Commonly used formulary agents: metoprolol, esmolol, labetalol
c. Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) may be
considered as alternatives to beta-blockers in patients with persistent angina
symptoms, contraindications for beta-blockers or history of recent cocaine use.
(a) Contraindications:
1. Signs of heart failure
2. Evidence of low cardiac output state
3. Presence of cardiogenic shock or risk factors for its development:
a. Age > 70 years
b. Systolic BP < 120mmHg
c. Sinus tachycardia (HR > 110bpm)
d. Sinus bradycardia (HR < 60bpm)
e. Increased time from symptom onset
4. Hypotension
5. 1st or 2nd degree AV block
d. Morphine sulfate may be considered as an analgesic in patients with ongoing
pain in the absence of contraindications.
(a) Dose: 2 – 4mg IV push q5 – 15 minutes
(b) Contraindications:
(i) Hypersensitivity to morphine or other opiates
(ii) Severe respiratory depression
(iii) Acute or severe asthma
e. Supplemental oxygen is indicated in patients with evidence of hypoxia (SaO2 <
90%)
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3. Sub-acute Therapy
a. Patients should be continuously monitored on ECG for 48-72 hours in
uncomplicated myocardial infarction (MI).
b. Consultations ordered for cardiac rehab, social worker, dietitian, or chaplain.
c. Initially bed rest is recommended followed by an advance with ambulation on day
2 or 3.
d. Patients should be placed on a cardiac diet
e. Medications to be considered
(a) ASA
(i) Continue 81 – 325mg po daily on all patients unless contraindicated.
(b) Beta-blocker
(i) Continue or initiate in all patients unless contraindicated.
(ii) Commonly used formulary agents include metoprolol, carvedilol, labetalol.
(c) ACE inhibitors
(i) Initiate in ALL patients with LV dysfunction (LV function < 40% or
described as moderate to severe) unless contraindicated.
(ii) Consider in all MI patients without contraindications within two weeks of
MI onset, even if blood pressure and ejection fraction are normal.
(iii) Formulary agents include enalapril, lisinopril, and captopril
(d) Angiotensin Receptor Blocker (ARB)
(i) Where an ACE inhibitor is indicated but not tolerated (e.g., ACE inhibitorinduced cough, mild-moderate ACE-inhibitor induced angioedema),
consider an ARB.
(ii) Formulary agents include valsartan, telmisartan
(e) Aldosterone Receptor Antagonist (spironolactone or eplerenone)
(i) Consider for patients with MI and an EF <40%
(ii) Contraindications:
1. Creatinine >2.0
2. Potassium > 5.0
(f) High-dose statin
(i) Unless contraindicated, statin therapy should be started on all patients
with a goal LDL cholesterol of < 70mg/dl.
(ii) Formulary agents: atorvastatin, pravastatin, and simvastatin (AVOID
simvastatin 80mg dose)
(g) Anticoagulation
(i) Warfarin is indicated for atrial fibrillation or LV thrombus post myocardial
infarction.
(ii) Dabigatran may also be considered in patients with atrial fibrillation with
preserved renal function.
(h) Immunizations/vaccinations
(i) Influenza & H1N1 (based on season)
(ii) Pneumococcus, if appropriate.
III. Discharge Education and Planning
A. Medications
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1. All patients should be considered for the following medications at discharge:
a. Aspirin 81 – 325mg daily indefinitely
(a) If aspirin not prescribed at discharge (for MI patients), explicitly state in the
discharge summary the reason/contraindication for use.
b. Thienopyridine (e.g., clopidogrel or prasugrel) especially in the following patients
(a) Post-stent:
(i) Minimum duration:
1. Bare metal stent (BMS): 1 month
2. Drug-eluting stent (DES): 12 months
(ii) Ideal duration: 12 months, indefinitely in patients at low-risk for bleeding
(b) Intolerance/allergy to aspirin
(c) Post-MI
c. Statin: targeting LDL < 70mg/dl
d. Beta-blocker, especially in the following patients:
(a) Post-MI
(b) LV dysfunction (LVEF < 40%)
(c) Hypertension
(d) If beta-blocker not prescribed at discharge (for MI patients), explicitly state in
the discharge summary the reason/contraindication for use.
e. ACE inhibitor, especially in the following patients:
(a) Post-MI
(b) LV dysfunction (LVEF < 40%)
(c) Hypertension
(d) Diabetes mellitus with chronic kidney disease
(e) Non-cardiac atherosclerotic vascular disease (e.g., cerebrovascular disease,
peripheral arterial disease)
(f) If ACE inhibitor not prescribed at discharge (for MI patients), explicitly state in
the discharge summary the reason/contraindication for use.
f. Short-acting nitrate for PRN use
(a) Nitroglycerin SL tablets
(b) Nitroglycerin spray
2. The following medications may be considered in certain patients:
a. ARB for patients with ACE-inhibitor indication but history of intolerance (e.g.,
cough, mild-moderate angioedema)
(a) If neither ACE inhibitor nor ARB prescribed at discharge (for MI patients),
explicitly state in the discharge summary the reason/contraindication for use.
b. Aldosterone antagonist (eplerenone, spironolactone) in post-MI patients with LV
dysfunction (LVEF < 40%)
c. Nondihydropyridine calcium channel blocker (diltiazem or verapamil) in patients
with preserved LV function and indication for beta-blocker but intolerance or
contraindication for beta-blockade.
d. Pharmacotherapy to aid in smoking cessation (with appropriate consultation):
(a) Nicotine replacement therapy
(b) Buproprion or varenicline
B. Discharge education for patients hospitalized and treated for unstable angina or MI
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1. Patients and family should receive education throughout the hospitalization course
on all the above treatment plans, monitoring of symptoms and follow up.
2. Physical activity
a. 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.
3. Smoking cessation
a. Patients with current tobacco use who are ready to quit should be referred to
smoking cessation clinic, and this should be clearly documented.
4. Diet
a. Patients should receive dietary counseling on the National Cholesterol Education
Program Step 2 Diet during hospitalization (refer to dietitian as need).
5. Patients should be given written discharge instructions that reviews the above
content as well as treatments and symptoms that would require contact of their
physician.
a. Educational content for MI or angina from the Depart tool should be included in
the discharge instructions
C. Disposition and follow-up
1. 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
2. All patients should have a follow up appointment with their Primary Care Physician
(PCP) within 2 weeks
3. Patients hospitalized and treated for unstable angina or MI should have a follow up
appointment with the Cardiologist in 1-2 weeks.
4. Patients should be instructed to bring their ACS discharge instructions, including
medication list, to their first follow up appointments with their PCP and/or
Cardiologist, if appropriate.
5. 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 angina 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.
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3. Patients with positive stress testing should be referred for cardiac catheterization.
B. Unstable Angina/MI
1. Aggressive risk factor modifications and reinforcement of lifestyle changes, including
AHA step II diet, exercise program or cardiac rehab, smoking cessation.
2. Continue targeted therapy as outline in Cardiovascular Hospitalization
Atherosclerosis Management Program (CHAMP).
a. Medications
(a) All patients should be considered for the following medications at discharge:
(i) Aspirin 81 – 325mg daily indefinitely
(ii) Thienopyridine (e.g., clopidogrel or prasugrel), if appropriate
(iii) Statin: targeting LDL < 70mg/dl
(iv) Beta-blocker
(v) ACE-inhibitor or ARB
(vi) Short-acting nitrate for PRN use
(b) The following medications may be considered in certain patients:
(i) Aldosterone antagonist (eplerenone, spironolactone), if appropriate
(ii) Calcium channel blocker
(iii) Pharmacotherapy to aid in smoking cessation (with appropriate
consultation)
b. Lifestyle modifications
(a) Physical activity
(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.
(b) Smoking cessation
(i) Patients with current tobacco use who are ready to quit should be
referred to smoking cessation clinic, and this should be clearly
documented.
(c) Diet
(i) Patients should receive dietary counseling on the National Cholesterol
Education Program Step 2 Diet during hospitalization (refer to dietitian as
need).
3. 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.
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NO.: G-1.1
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Addenda
Addendum 1: Biochemical cardiac markers for evaluation and management of patients
with suspected ACS but without ST-Segment elevation on 12-Lead
Addendum 2: Risk Stratification: Likelihood that signs and symptoms represent ACS
secondary to CAD
Addendum 3: TIMI Risk Score for Unstable Angina and Non-ST-Elevation MI and
Associated Risk of Major Adverse Cardiac Events at 14 days
Addendum 4: Order Sets for chest pain, NSTEMI, & STEMI
Addendum 5: Glycoprotein IIb/ IIIa Inhibitors
Addendum 6: Noninvasive Risk Stratification
References
STEMI guidelines
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 the 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;54:2205-41.
Available at: http://content.onlinejacc.org/cgi/reprint/54/23/2205.pdf
Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS,
Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr. 2007 focused update
of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial
Infarction: a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004
Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). Circulation.
2008;117:XXX–XXX. Available at: http://content.onlinejacc.org/cgi/reprint/51/2/210.pdf
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients
with ST-elevation myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines
for the Management of Patients with Acute Myocardial Infarction). 2004. Available at:
http://www.acc.org/qualityandscience/clinical/guidelines/stemi/STEMI%20Full%20Text.pdf
NSTEMI/Unstable angina guidelines
Anderson JL, et al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/non-st-segment elevation myocardial infarction: executive summary: a report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to revise the 2002 guideline for the management of patients with unstable
angina/non-st-segment elevation myocardial infarction): developed in collaboration with the
American College of Emergency Physicians, American College of Physicians, Society for
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Academic Emergency Physicians, Society for Cardiovascular Angiography and Interventions, and
Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:e1-157.
Available at: http://content.onlinejacc.org/cgi/reprint/50/7/e1.pdf
TIMI Score
Sabatine MS, Antman EM. The thrombolysis in myocardial infarction risk score in ustable
angina/non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 2003;41:89S-95S.
Miscellaneous
University of Illinois Medical Center at Chicago protocols on Heparin Nomogram, GPIIb/IIIa
Inhibitors
The Erlanger Chest Pain Evaluation Protocol: A One Year Experience with Serial 12-Lead ECG
Monitoring, Two-Hour Delta Serum Marker Measurements, and Selective Nuclear Stress testing
to identify and exclude Acute Coronary Syndromes. Authors: Francis Fesmire, Allen Hughes, et.
al.
Rescission
April 2008
May 2005
March 2004
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NO.: G-1.1
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Addendum 1: Biochemical cardiac markers for evaluation and management of patients
with suspected ACS but without ST-Segment elevation on 12-Lead
Marker
CK-MB
Advantages
 Rapid, cost-
Disadvantages
 Loss of
efficient,
accurate assays.
 Ability to detect
early reinfarction.


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.


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).
Low sensitivity in
very early phase
of MI (<6 h after
symptom onset)
and requires
repeat
measurement at
8-12 h, if
negative.
Limited ability to
detect late minor
reinfarction.
Clinical
Recommendations
Prior standard and still
acceptable diagnostic
test in most clinical
circumstances.
Normal lab values:
Male: 8 ng/ml
Female: 6 ng/ml
Useful as a single test
to efficiently diagnose
NSTEMI, with serial
measurements. Know
diagnostic “cutoffs”.
Normal lab values:
<2.0 ng/ml
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NO.: G-1.1
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Addendum 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.
 Transient MR.
 Hypotension.
 Diaphoresis.
 Pulmonary edema.
 Rales.
 New, or
presumably new
transient STsegment deviation
(>0.05 mV); or
 T-wave inversion
(>0.2 mV) with
symptoms.
 Elevated cardiac
TnI or CK-MB.
 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.
 Chest discomfort
reproduced by
palpation.
Examination
ECG
Cardiac Markers
 Extracardiac
vascular disease.
 Fixed Q waves.
 Abnormal ST
segment; or
 T waves not
documented to
be new.
 Normal.
 T-wave flattening;
or
 Inversion in leads
with dominant R
waves.
 Normal ECG.
 Normal.
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Addendum 3: TIMI Risk Score for Unstable Angina and Non-ST-Elevation MI and
Associated Risk of Major Adverse Cardiac Events at 14 days
Calculation of the TIMI Risk Score
Clinical Feature(s)
TIMI Score Points
Historical features
Age > 65 years
1
≥ 3 CAD risk factors
Hypertension
Dyslipidemia
Diabetes
Family history of CAD
Active smoker
Known CAD (stenosis ≥ 50%)
1
1
Aspirin use in past 7 days
1
Presenting features
≥ 2 angina episodes in past 24 hours
1
ST-segment deviation ≥ 0.5mm
1
Elevated cardiac biomarkers (e.g., TnI)
1
Risk Score = Total Points
(0 – 7)
TIMI Risk Score
All-cause mortality; new/recurrent MI; or severe,
recurrent ischemia requiring urgent revascularization (%)
Low Risk
0–1
4.7
2
8.3
Intermediate Risk
3
13.2
4
19.9
High Risk
5
26.2
6–7
40.9
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UNIVERSITY OF ILLINOIS MEDICAL CENTER
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Addendum 4: Chest Pain, NSTEMI, STEMI order sets
Step 1: Select “Order Sets”
Step 2: Select “Cardiology”
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NO.: G-1.1
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Step 3: Select appropriate
order set (Card-Chest Pain,
Card-NSTEMI, or Card-STEMI)
Step 4: Select/Deselect desired
orders
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Addendum 5: University of Illinois Medical Center Procedures for Glycoprotein IIB/ IIIA
Inhibitors
I.
II.
III.
IV.
Requires cardiology approval.
Screen for appropriate use and contraindications.
Verify patient weight.
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).
Medication Pharmacokinetics/Pharmacodynamics
Eptifibatide
Mechanism of Action
Reversible inhibitor of
receptor
Half life
1.5 – 2.5 hours
Abciximab
Monoclonal antibody that
irreversibly inhibits receptor
: < 10 minutes *
: 30 minutes *
Duration of Action
 Platelet aggregation
2 – 4 hours
~ 48 hours
 Bleeding time
15 – 30 minutes
~ 24 hours
*NOTE: Half-life is deceiving. Applies to free drug in serum, drug still bound to receptor at 15
days.
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NO.: G-1.1
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Glycoprotein IIB/ IIIA Inhibitor Dosing:
(eptifibatide used in most cases, abciximab is used sparingly in Cath lab)
Acute
Coronary
Syndrome
Percutaneous
Coronary
Intervention
Eptifibatide
(Dosing charts available in pharmacy,
cath lab, and CCU)
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**
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**
Abciximab
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)
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.
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Addendum 6: 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<score<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 < 2 segments
Medical Management
Low risk (< 1% annual mortality rate)
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