Download NSTEMI standing orders

STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Patient ___________________________ ______________________ _______
(LAST NAME)
Age: ___________ years
(FIRST NAME)
Weight: __________ kg
(MI)
Male
Female
Admit to: Cardiology
Condition:_______________________________________________________
Diagnosis:
Unstable angina
NSTEMI
Check/Initial/Date
_____/_____
Allergies: ________________________________________
________________________________________________
_____/_____
EARLY RISK STRATIFICATION
High risk
Intermediate risk
Low risk
High risk: elevated cardiac biomarkers, ST depression,
transient ST elevation, >20 min of rest pain, hemodynamic
instability, signs of CHF → EARLY INVASIVE STRATEGY
Intermediate risk: no high-risk features, prior MI, prior
CABG, T-wave inversions, rest angina <20 min relieved
promptly with nitroglycerin, age >70 years → EITHER
EARLY INVASIVE OR EARLY CONSERVATIVE
STRATEGY
Low risk: No high- or moderate-risk features, progressive
angina without prolonged rest pain, normal cardiac markers,
normal ECG with pain → EARLY CONSERVATIVE
STRATEGY
ACC/AHA Class I A rapid clinical determination of the likelihood risk of
Recommendation obstructive CAD (ie, high, intermediate, or low) should
be made in all patients with chest discomfort or other
symptoms suggestive of an ACS and considered in
patient management [Level of Evidence: C]. Patients
who present with chest discomfort or other ischemic
symptoms should undergo early risk stratification for
the risk of cardiovascular events (eg, death or [re]MI)
that focuses on history, including anginal symptoms,
physical findings, ECG findings, and biomarkers of
cardiac injury, and results should be considered in
patient management [Level of Evidence: C].
1
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date
NURSING
_____/_____
Activity – Bed rest
_____/_____
Cardiac monitor
ACC/AHA Class I Bed/chair rest with continuous ECG monitoring is
Recommendation recommended for all patients during the early hospital
phase [Level of Evidence: C].
_____/_____
Vital signs q4h x 24 h then q8h
_____/_____
Diet: house/no added salt/low saturated fat; low cholesterol
_____/_____
Call house officer for T >101°, SBP >190 mm Hg or SBP <90
mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10
_____/_____
Guaiac ALL stools while on heparin, LMWH, IIb/IIIa inhibitor
_____/_____
O2: Nasal prongs (cannula) 2 L/min
PLEASE CALL HOUSE OFFICER FOR O2 SAT <90%
_____/_____
ORDER FOR RESPIRATORY CARE O2 SAT CHECK q8h
ACC/AHA Class I Supplemental oxygen should be administered to
Recommendation patients with an arterial saturation less than 90%,
respiratory distress, or other high-risk features for
hypoxemia [Level of Evidence: B].
2
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date
DIAGNOSTIC STUDIES
_____/_____
ECG ON ADMISSION
_____/_____
ECG for recurrent chest pain
ACC/AHA Class I A 12-lead ECG should be performed and shown to an
Recommendation experienced emergency physician as soon as possible
after ED arrival, with a goal of within 10 min of ED arrival
for all patients with chest discomfort (or anginal
equivalent) or other symptoms suggestive of ACS. If the
initial ECG is not diagnostic but the patient remains
symptomatic and there is high clinical suspicion for
ACS, serial ECGs, initially at 15- to 30-min intervals,
should be performed to detect the potential for
development of ST-segment elevation or depression
[Level of Evidence: B].
LABORATORY STUDIES
CARDIAC MARKERS
_____/_____
Troponin T/Troponin I: NOW AND EVERY _____hrs × ___
times
_____/_____
CK-MB: NOW AND EVERY _____ hrs × ___ times
ACC/AHA Class I Cardiac biomarkers should be measured in all patients
Recommendation who present with chest discomfort consistent with ACS.
A cardiac-specific troponin is the preferred marker, and,
if available, it should be measured in all patients who
present with chest discomfort consistent with ACS.
Patients with negative cardiac biomarkers within 6 h of
the onset of symptoms consistent with ACS should
have biomarkers remeasured in the time frame of 8 to 12
h after symptom onset. (The exact timing of serum
marker measurement should take into account the
uncertainties often present with the exact timing of
onset of pain and the sensitivity, precision, and
institutional norms of the assay being utilized as well as
the release kinetics of the marker being measured.)
[Level of Evidence: B].
CHEMISTRY PANEL
_____/_____
CBC, LIPID PROFILE, PTT, Chemistry (7) panel IN AM –
FASTING
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STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date
MEDICATIONS
_____/_____
ASPIRIN 162-325 (__________ insert dose) mg po chewed
(loading dose) now, then 162-325 mg/d po (daily
maintenance dose)
ACC/AHA Class I Aspirin should be administered to patients as soon as
Recommendation possible after hospital presentation and continued
indefinitely in patients not known to be intolerant of that
medication [Level of Evidence: A].
OR
_____/_____
ACC/AHA Class I
Recommendation
_____/_____
CLOPIDOGREL 300 mg po x 1, then 75 mg/d po if
aspirin intolerant
Clopidogrel (loading dose followed by daily
maintenance dose)† should be administered to
patients who are unable to take ASA because of
hypersensitivity or major GI intolerance [Level of
Evidence: A].
Stop all NSAIDs except aspirin
β-BLOCKER (choose one):
IV β-BLOCKER
_____/_____
Drug: _____________________________
every ____ hrs
_______ mg IV
ORAL β-BLOCKER
_____/_____
METOPROLOL TARTRATE 50-200 mg bid
_____/_____
ATENOLOL 50-200 mg/d
_____/_____
CARVEDILOL 6.25 mg bid, uptitrated to max. 25 mg bid
ACC/AHA Class I Oral β-blocker therapy should be initiated within the first
Recommendation 24 h for patients who do not have ≥1 of the following: 1)
signs of HF, 2) evidence of a low-output state, 3)
increased risk‡ for cardiogenic shock, or 4) other relative
contraindications to β-blockade (PR interval >0.24 s,
second- or third-degree heart block, active asthma, or
reactive airway disease) [Level of Evidence: B].
4
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
_____/_____
NITROGLYCERIN PASTE 2% Sliding Scale TP q4h. For
SBP <100 mm Hg, remove nitropaste; for SBP 100-120 mm
Hg, give 1” nitropaste; for SBP 121-140 mm Hg, give 2”
nitropaste; for SBP >140 mm Hg, give 3” nitropaste
_____/_____
NITROGLYCERIN 1/150 (0.4 mg) 1 TAB SL q5min x 3 prn
chest pain; HOLD IF: SBP <100 mm Hg
_____/_____
NITROGLYCERIN 5-200 µg/min IV in D5W continuous IV
ACC/AHA Class I Patients with ongoing ischemic discomfort should
Recommendation receive sublingual NTG (0.4 mg) every 5 min for a total
of 3 doses, after which assessment should be made
about the need for IV NTG, if not contraindicated. [Level
of Evidence: C]. IV NTG is indicated in the first 48 h after
UA/NSTEMI for treatment of persistent ischemia, HF, or
hypertension. The decision to administer IV NTG and the
dose used should not preclude therapy with other
proven mortality-reducing interventions such as βblockers or ACE inhibitors [Level of Evidence: B].
5
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
EARLY INVASIVE STRATEGY (High- or Intermediate-Risk Patients)
Check/Initial/Date
_____/_____
CLOPIDOGREL 300-600 (__________ insert dose) mg po x
1, then 75 mg/d po (Add once decision to proceed with PCI
is confirmed. Withhold for 5 days if CABG is planned.)
ACC/AHA Class I In patients with a history of GI bleeding, when ASA and
Recommendation clopidogrel are administered alone or in combination,
drugs to minimize the risk of recurrent GI bleeding (eg,
proton-pump inhibitors) should be prescribed
concomitantly [Level of Evidence: B].
AND/OR
_____/_____
GLYCOPROTEIN IIB/IIIA THERAPY (choose one [can be
started upstream or in cardiac catheterization lab]):
EPTIFIBATIDE 180 µg/kg IV bolus x 2, 10 min apart,
followed by IV infusion of 2.0 µg/kg/min, reduce to 1.0
µg/kg/min if CrCl <50 mL/min
OR
_____/_____
TIROFIBAN IV infusion of 0.4 µg/kg/min for 30 min, reduce to
0.2 µg/kg/min for CrCl <30 mL/min, followed by IV infusion of
0.1 µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min
OR
_____/_____
ABCIXIMAB 0.25 mg/kg IV bolus, followed by IV infusion of
0.125 µg/kg/min [reserve only for patients with planned PCI
within 12 hours]
ACC/AHA Class I For patients in whom an initial invasive strategy is
Recommendation selected, antiplatelet therapy in addition to aspirin
should be initiated before diagnostic angiography
(upstream) with either clopidogrel (loading dose
followed by daily maintenance dose)† or an IV GP IIb/IIIa
inhibitor [Level of Evidence: A]. Abciximab as the choice
for upstream GP IIb/IIIa therapy is indicated only if there
is no appreciable delay to angiography and PCI is likely
to be performed; otherwise, IV eptifibatide or tirofiban is
the preferred choice of GP IIb/IIIa inhibitor [Level of
Evidence: B].
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STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
EARLY INVASIVE STRATEGY (High- or Intermediate-Risk Patients)
Continued
Check/Initial/Date
_____/_____
ANTICOAGULANT THERAPY (choose one):
ENOXAPARIN 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1
mg/kg every 24 h) [continue for the duration of
hospitalization, 8 days, or until PCI or CABG is performed]
OR
_____/_____
UNFRACTIONATED HEPARIN (for 48 hours) 60 U/kg IV
bolus (not to exceed 4000 U), followed by IV infusion of 12
U/kg/h (not to exceed 1000 U/h) to goal aPTT 50-70 sec;
check aPTT in 6 h and adjust as indicated
OR
_____/_____
FONDAPARINUX 2.5 mg SC once daily (avoid if CrCl <30
mL/min [continue for the duration of hospitalization, 8 days,
or until PCI or CABG is performed]). UFH, per institutional
practice, should be administered for any PCI procedure
OR
_____/_____
BIVALIRUDIN 0.1 mg/kg IV bolus, then IV infusion of 0.25
mg/kg/h [continue for the duration of hospitalization, 8 days,
or until PCI or CABG is performed]
ACC/AHA Class I Anticoagulant therapy should be added to antiplatelet
Recommendation therapy as soon as possible after presentation. For
patients in whom an invasive strategy is selected,
regimens with established efficacy at a Level of
Evidence: A include enoxaparin and UFH, and those
with established efficacy at a Level of Evidence: B
include bivalirudin and fondaparinux.
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STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
EARLY CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients)
Check/Initial/Date
_____/_____
CLOPIDOGREL 300-600 (__________ insert dose) mg po x
1, then 75 mg/d po
ACC/AHA Class I For patients in whom an initial conservative (ie,
Recommendation noninvasive) strategy is selected, clopidogrel (loading
dose followed by daily maintenance dose)† should be
added to ASA and anticoagulant therapy as soon as
possible after admission and administered for at least 1
month [Level of Evidence: A] and ideally up to 1 year
[Level of Evidence: B]. In patients with a history of GI
bleeding, when ASA and clopidogrel are administered
alone or in combination, drugs to minimize the risk of
recurrent GI bleeding (eg, proton-pump inhibitors)
should be prescribed concomitantly [Level of Evidence:
B].
ANTICOAGULANT THERAPY (choose one):
_____/_____
ENOXAPARIN 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1
mg/kg every 24 h) [continue for the duration of
hospitalization, 8 days, or until PCI]
OR
_____/_____
UNFRACTIONATED HEPARIN (for 48 hours) 60 U/kg IV
bolus (not to exceed 4000 U), followed by IV infusion of 12
U/kg/h (not to exceed 1000 U/h) to goal aPTT 50-70 sec;
check aPTT in 6 h and adjust as indicated
OR
_____/_____
FONDAPARINUX 2.5 mg SC once daily (avoid if CrCl <30
mL/min [continue for the duration of hospitalization, 8 days,
or until PCI]). UFH, per institutional practice, should be
administered for any PCI procedure
ACC/AHA Class I Anticoagulant therapy should be added to antiplatelet
Recommendation therapy as soon as possible after presentation.
For patients in whom a conservative strategy is
selected, regimens using either enoxaparin§ or UFH
[Level of Evidence: A] or fondaparinux [Level of
Evidence: B] have established efficacy. In patients in
whom a conservative strategy is selected and who have
an increased risk of bleeding, fondaparinux is preferable
[Level of Evidence: B].
8
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
EARLY CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients)
Continued
Check/Initial/Date
_____/_____
Schedule assessment of LVEF
_____/_____
Schedule stress test
ACC/AHA Class I For patients in whom an initial conservative strategy is
Recommendation selected and no subsequent features appear that would
necessitate diagnostic angiography (recurrent
symptoms/ischemia, HF, or serious arrhythmias), a
stress test should be performed [Level of Evidence: B].
_____/_____
_____/_____
Start early invasive strategy if patient has recurrent
symptoms/ischemia, HF, arrhythmias, or positive cardiac
biomarkers
GLYCOPROTEIN IIB/IIIA THERAPY
EPTIFIBATIDE 180 µg/kg IV bolus x 2, 10 min apart,
followed by IV infusion of 2.0 µg/kg/min, reduce to 1.0
µg/kg/min if CrCl <50 mL/min
OR
_____/_____
TIROFIBAN IV infusion of 0.4 µg/kg/min for 30 min, reduce to
0.2 µg/kg/min for CrCl <30 mL/min, followed by IV infusion of
0.1 µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min
ACC/AHA Class I For patients in whom an initial conservative strategy is
Recommendation selected, if recurrent symptoms/ischemia, HF, or serious
arrhythmias subsequently appear, then diagnostic
angiography should be performed. Either an IV GP
IIb/IIIa inhibitor (eptifibatide or tirofiban) or clopidogrel
(loading dose followed by daily maintenance dose)†
[Level of Evidence: A] should be added to ASA and
anticoagulant therapy before diagnostic angiography
(upstream) [Level of Evidence: C].
9
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date
AS-NEEDED MEDICATIONS
_____/_____
Colace 100 mg po bid
_____/_____
MAALOX PLUS EX STR 15 mL po q6h prn indigestion
_____/_____
OXAZEPAM 15-30 mg po qhs prn insomnia
_____/_____
ACETAMINOPHEN 650 mg po q4h prn headache
_____/_____
MAGNESIUM HYDROXIDE 30 mL po qd prn constipation
_____/_____
MAGNESIUM SULFATE Sliding Scale IV qd
Call house officer if serum Mg <1.2
Hold order for creatinine >1.9
If serum Mg <1.4 give 5 g MgSO4 IV
If serum Mg <1.6 give 4 g MgSO4 IV
If serum Mg <1.8 give 3 g MgSO4 IV
If serum Mg <2.0 give 2 g MgSO4 IV
_____/_____
LAB, MG, K qd
_____/_____
KCL IMMEDIATE REL Sliding Scale Target K >4.5 po qd
Call house officer if K <3.4
If K <3.7 give 60 mEq
If K <4.1 give 40 mEq
If K <4.6 give 20 mEq
_____/_____
CHEST PAIN PROTOCOL
_____/_____
ECG x 1 prn chest pain
_____/_____
For CP: check VS, call house officer
_____/_____
Mark if cardiac cath is planned: Time _________________
_____/_____
NPO except meds
_____/_____
LAB, TYPE AND HOLD NEXT AVAILABLE
_____/_____
NUTRITION CONSULT
Patient admitted to cardiology ischemia pathway with known
or suspected CAD. Please facilitate outpatient education in
low-cholesterol, low-salt diet
_____/_____
SOCIAL SERVICE CONSULT
Patient admitted to cardiology ischemia pathway with known
or suspected CAD. Please assess and assist in need for
outpatient support (including VNA) services
10
Now
After midnight
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date DAY 2 or Later: REMINDERS
_____/_____
Calcium channel blocker (if β-blocker contraindicated)
Drug: _______________________ ___mg ____times/d
ACC/AHA Class I In patients with continuing or frequently recurring
Recommendation ischemia and in whom β-blockers are contraindicated, a
nondihydropyridine calcium channel blocker (eg,
verapamil or diltiazem) should be given as initial therapy
in the absence of clinically significant LV dysfunction or
other contraindications [Level of Evidence: B].
_____/_____
ACE inhibitor or ARB; recommended if diabetic
Drug: _______________________ ___mg ____times/d
ACC/AHA Class I An ACE inhibitor should be administered orally within
Recommendation the first 24 h to patients with pulmonary congestion or
LVEF ≤0.40, in the absence of hypotension (SBP <100
mm Hg or <30 mm Hg below baseline) or known
contraindications to that class of medications. An ARB
should be administered to patients who are intolerant of
ACE inhibitors and have either clinical or radiologic
signs of HF or LVEF ≤0.40 [Level of Evidence: A].
_____/_____
Lipid-lowering therapy (statins) regardless of LDL; dose
target to LDL <100 mg/dL
Drug: ____________________________ ___mg once daily
ACC/AHA Class I Hydroxymethyl glutaryl-coenzyme A reductase
Recommendation inhibitors (statins), in the absence of contraindications,
regardless of baseline LDL-C and diet modification,
should be given to post-UA/NSTEMI patients, including
postrevascularization patients. For patients with
elevated LDL-C (≥100 mg/dL), cholesterol-lowering
therapy should be initiated or intensified to achieve an
LDL-C <100 mg/dL [Level of Evidence: A].
_____/_____
Echocardiography. FIRST 24 HR if evidence of CHF,
hemodynamic instability, mechanical complication
_____/_____
Warfarin: RECOMMENDED if LV thrombus, extensive wall
dyskinesis, LVEF <20%-30%
11
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date PRIOR TO DISCHARGE
_____/_____
_____/_____
Patient had stent implanted
OR
Patient had medical therapy without stenting
MEDICATIONS
_____/_____
Aspirin ________ mg/d for _________________________
________________________________________________
ACC/AHA Class I For patients treated medically without stenting, aspirin
Recommendation (75 to 162 mg/d) should be prescribed indefinitely [Level
of Evidence: A].
For patients treated with bare-metal stents, aspirin 162
to 325 mg/d should be prescribed for at least 1 month
[Level of Evidence: B], then continued indefinitely at a
dose of 75 to 162 mg/d [Level of Evidence: A].
For patients treated with DES, aspirin 162 to 325 mg/d
should be prescribed for at least 3 months after
sirolimus-eluting stent implantation and 6 months after
paclitaxel-eluting stent implantation, then continued
indefinitely at a dose of 75 to 162 mg/d [Level of
Evidence: B]
_____/_____
Clopidogrel 75 mg/d for ____________________________
_______________________________________________
ACC/AHA Class I For patients treated medically without stenting,
Recommendation clopidogrel (75 mg/d) should be prescribed for at least 1
month [Level of Evidence: A] and ideally for up to 1 year
[Level of Evidence: B].
For patients treated with bare-metal stents, clopidogrel
should be prescribed at a dose of 75 mg/d for a
minimum of 1 month and ideally up to 1 year (unless the
patient is at increased risk of bleeding; then it should be
given for a minimum of 2 weeks [Level of Evidence: B].
For patients treated with DES, clopidogrel 75 mg/d
should be given for at least 12 months to all post-PCI
patients receiving DES [Level of Evidence: B].
12
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date PRIOR TO DISCHARGE (Continued)
MEDICATIONS (Continued)
_____/_____
β-blocker
Drug: _______________________________________
Dosage: _____________________________________
ACC/AHA Class I β-blockers are indicated for all patients recovering from
Recommendation UA/NSTEMI unless contraindicated. Treatment should
begin within a few days of the event, if not initiated
acutely, and should be continued indefinitely [Level of
Evidence: B].
_____/_____
ACE inhibitor or ARB
Drug: _______________________________________
Dosage: _____________________________________
_____/_____
Aldosterone receptor blocker
Drug: _______________________________________
Dosage: _____________________________________
ACC/AHA Class I Angiotensin-converting enzyme inhibitors should be
Recommendation given and continued indefinitely for patients recovering
from UA/NSTEMI with HF, LV dysfunction (LVEF <0.40),
hypertension, or diabetes mellitus, unless
contraindicated [Level of Evidence: A]. An angiotensin
receptor blocker should be prescribed at discharge to
those UA/NSTEMI patients who are intolerant of an ACE
inhibitor and who have either clinical or radiological
signs of HF and LVEF <0.40 [Level of Evidence: A].
Long-term aldosterone receptor blockade should be
prescribed for UA/NSTEMI patients without significant
renal dysfunction (estimated creatinine clearance
should be >30 mL/min) or hyperkalemia (potassium
should be ≤5 mEq/L) who are already receiving
therapeutic doses of an ACE inhibitor, have an LVEF
≤0.40, and have either symptomatic HF or diabetes
mellitus [Level of Evidence: A].
13
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date PRIOR TO DISCHARGE (Continued)
MEDICATIONS (Continued)
_____/_____
Calcium channel blocker
Drug: ________________________________________
Dosage: ______________________________________
ACC/AHA Class I Calcium channel blockers are recommended for
Recommendation ischemic symptoms when β-blockers are not successful
[Level of Evidence: B]. Calcium channel blockers are
recommended for ischemic symptoms when β-blockers
are contraindicated or cause unacceptable side effects
[Level of Evidence: C].
_____/_____
Statin
Drug: ________________________________________
Dosage: ______________________________________
ACC/AHA Class I For hospitalized patients, lipid-lowering medications
Recommendation should be initiated before discharge [Level of Evidence:
A].
_____/_____
Nitroglycerin
Drug: ________________________________________
Dosage: ______________________________________
ACC/AHA Class I Nitroglycerin to treat ischemic symptoms is
Recommendation recommended [Level of Evidence: C].
14
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
Check/Initial/Date PRIOR TO DISCHARGE (Continued)
PATIENT/FAMILY EDUCATION AND FOLLOW-UP
INSTRUCTIONS
_____/_____
Medication instructions/disease education
_____/_____
Smoking cessation
_____/_____
Diabetes management
_____/_____
Nutrition, weight, and blood pressure management
_____/_____
Exercise program
ACC/AHA Class I Before hospital discharge, patients and/or designated
Recommendation responsible caregivers should be provided with
supportable, easily understood, and culturally sensitive
instructions with respect to medication type, purpose,
dose, frequency, and pertinent side effects. If the pattern
or severity of anginal symptoms changes, which
suggests worsening myocardial ischemia (eg, pain is
more frequent or severe or is precipitated by less effort
or now occurs at rest), the patient should contact his or
her physician without delay to assess the need for
additional treatment or testing [Level of Evidence: C].
Specific instruction should be given on the following:
smoking cessation and achievement of optimal weight,
daily exercise, and diet [Level of Evidence: B];
hypertension control to a blood pressure <140/90 mm
Hg or <130/80 mm Hg in patients with diabetes or
chronic kidney disease [Level of Evidence: A]; and
lifestyle and pharmacotherapy measures in patients with
diabetes to achieve a near-normal A1c level of <7%
[Level of Evidence: B].
*Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of
patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable
Angina/Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2007;50:e1-e157.
†
Some uncertainty exists about optimum dosing of clopidogrel. Randomized trials establishing its
efficacy and providing data on bleeding risks used a loading dose of 300 mg orally followed by a
daily oral maintenance dose of 75 mg. Higher oral loading doses such as 600 or 900 mg of
clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of
15
STANDING ORDERS
ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)
ACC/AHA Class I Recommendations* in Bold
inhibition of platelet aggregation, but the additive clinical efficacy and the safety of higher oral
loading doses have not been rigorously established.
‡
Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the
risk of developing cardiogenic shock): age >70 years, SBP <120 mm Hg, sinus tachycardia >110
or heart rate <60, increased time since onset of symptoms of UA/NSTEMI.
§
Limited data are available for the use of other LMWHs in UA/NSTEMI.
16