Download NSTEMI: INITIAL MANAGEMENT ORDER TEMPLATE (Referenced

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