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THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 1 of 25 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 2 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 3 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 4 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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). THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 5 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 6 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 7 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE (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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 8 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE (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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 9 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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: THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 10 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 11 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE (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%) THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 12 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 13 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 14 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 15 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 16 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 17 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 18 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 19 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 20 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 21 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE Addendum 4: Chest Pain, NSTEMI, STEMI order sets Step 1: Select “Order Sets” Step 2: Select “Cardiology” THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 22 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE Step 3: Select appropriate order set (Card-Chest Pain, Card-NSTEMI, or Card-STEMI) Step 4: Select/Deselect desired orders THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 23 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 24 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO.: G-1.1 DATE: May 2011 PAGE: 25 of 25 UNIVERSITY OF ILLINOIS MEDICAL CENTER CLINICAL CARE GUIDELINE 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