Download Plavix® Consultants Kit Blue

ACS*
Joseph G. Cacchione, M.D.
December 9, 2005
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
1
What is the pathophysiology of
arterial thrombosis?
2
Vascular Disease: A Generalized
and Progressive Disease
Plaque Rupture
Thrombosis
Unstable
angina
MI
Atherosclerosis
ACS
Ischemic
stroke
Critical leg
ischemia
Intermittent
claudication
CV death
Stable angina/intermittent claudication
Adapted from Libby P. Circulation. 2001;104:365-372.
3
Major Manifestations of Vascular
Disease and Arterial Thrombotic Events
Cerebrovascular
Disease (CVD)
• Ischemic Stroke
• Transient ischemic attack
Cardiovascular
Disease (CAD)
• Myocardial infarction
• Angina Pectoris
(stable & unstable)
Peripheral Arterial
Disease (PAD)
• Intermittent Claudication
• Critical Limb Ischemia, rest
pain, gangrene, necrosis
4
What are the risk factors
associated with ACS*?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
5
Identifying Those at Risk of Vascular
Disease and Thrombotic Events
Lifestyle
• Smoking
• Diet
• Lack of exercise
Genetic Traits
• Gender
• Age
Generalized
Disorders
• Obesity
• Diabetes
Arterial
Thrombosis
Manifestations
(MI, stroke, vascular death)
Inflammation
• Elevated CRP
• Prothrombotic factors
• Fibrinogen
• IL6 and others
CRP=C-reactive protein.
Yusuf S et al. Circulation. 2001;104:2746-2753.
Drouet L. Cerebrovasc Dis. 2002;13(suppl 1):1-6.
Systemic Conditions
• History of vascular
events
• Hypertension
• Hyperlipidemia
• Hypercoagulable states
• Homocysteinemia
Local Factors
• Blood flow patterns
• Shear stress
• Vessel diameter
• Arterial wall structure
• % arterial stenosis
6
What role does
“vulnerable plaque”
play in ACS*?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
7
Characteristics of Unstable
(Vulnerable) and Stable Plaques
Unstable
Stable
Inflammatory
Cells
Few
SMCs
Thin
Fibrous Cap
More
SMCs
Thick
Fibrous Cap
Lack of
Inflammatory
Cells
Intact
Endothelium
Eroded
Endothelium
Activated
Macrophages
SMC=smooth muscle cell.
Adapted from Libby P, et al. Circulation. 1995;91:2844-2850.
Naghavi M et al. Circulation. 2003;108:1664-1672.
Foam Cells
8
Vulnerable Plaque and Patient Risk
Vulnerable Patient
Vulnerable Blood
Vulnerable Plaque
• Hypercoagulability
• Increased platelet
activation and
aggregation
• Increased
coagulation factors
• Decreased
fibrinolysis
• Increased
thrombogenic factors
•
•
•
•
Active inflammation
Cap thickness
Lipid core size
Endothelial
denudation
• Injured plaque
Vulnerable Myocardium
• Myocardial ischemia
• Electrophysiological disorders
• Myocarditis
Adapted from Naghavi M et al. Circulation. 2003;108:1664-1672.
Naghavi M et al. Circulation. 2003;108:1772-1778.
9
What is the
epidemiology of ACS*?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
10
Arterial Thrombosis* Is a Leading
Cause of Death Worldwide1†
Leading Causes of Death Worldwide† ( % of All Deaths)1
AIDS
Pulmonary disease
Injuries
Cancer
Infectious disease
5.1%
6.0%
9.1%
12.6%
17.8%
Arterial thrombosis*
23%
Mortality (%)
* Ischemic heart disease and cerebrovascular disease.
† Worldwide defined as Member States by WHO Region (Africa, Americas, Eastern Mediterranean, European, South-East Asia
and Western Pacific).
1. The World Health Report, 2002, WHO Geneva.
11
Ongoing Risk of MI and Stroke
Over 10 Years
Post-MI
Increased risk
of MI*
Increased risk
of stroke*
5-7 
3-4 
greater
risk1
(includes death)
2-3 
Post-Stroke
greater risk2
(includes angina
and sudden death†)
4
PAD
greater risk4
(includes only fatal MI
and other CHD death)
greater risk2
(includes TIA)
9
greater risk3
2-3 
greater risk2
(includes TIA)
* Versus the general population except for stroke following stroke which measures subsequent risk per year.
† Sudden death defined as death documented within 1 hour and attributed to coronary heart disease.
1. Adult Treatment Panel II. Circulation. 1994;89:1333-1435.
2. Kannel WB. J Cardiovasc Risk. 1994;1:333-339.
3. Wilterdink JI, Easton JD. Arch Neurol. 1992;49:857-863.
4. Criqui MH, et al. N Engl J Med. 1992;326:381-386.
12
Hospital Discharges for ACS:
UA/NSTEMI vs STEMI
ACS
1.67 Million Hospital Discharges
ACS
UA*
MI
700,000
973,000
UA/NSTEMI
NSTEMI†
STEMI**
652,000
Discharges per Year
321,000‡
Discharges per Year
1.352 Million
Discharges per Year
* UA=unstable angina.
† NSTEMI=nonST-segment elevation myocardial infarction (also known as non–Q-wave MI).
**STEMI=ST-segment elevation MI (also known as Q-wave MI).
American Heart Association. Heart Disease and Stroke Statistics—2005 Update. 2004.
13
What are the goals of
ACS* management?
• Acute management?
• Long-term management?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
14
What are the goals of
ACS* management?
• Acute management?
• Long-term management?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
15
Brigham and Women’s Hospital
Critical Pathway 2002: UA/NSTEMI
Aspirin, Clopidogrel, UFH or LMWH
Beta-blocker, Nitrates
Low Risk
High Risk
– ECG, – Markers
TIMI Risk Score <3
ST s, +Troponin/CK-MB,
or TIMI Risk Score >3
No Cath Planned
Cath
GP IIb/IIIa Inhibitor
ETT
Cath/PCI
(on GP IIb/IIIa )
Cath
GP IIb/IIIa for PCI
D/C Day 1 or 2
D/C Day 2
D/C Day 2
ETT=exercise tolerance test.
Modified from Cannon CP. Crit Path Cardiol. 2002;1:12-21 with permission of the author.
16
What are the goals of
ACS* management?
• Acute management?
• Long-term management?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
17
Distribution of Multiple Plaques in
Patients with Acute Coronary Syndromes
80% of patients with >1 plaque
N=24
30
Patients (%)
25
20
15
10
5
0
0
1
2
3
4
5
Number of ruptured plaques in addition to culprit lesion
Rioufol G et al. Circulation. 2002;106:804-808.
18
An Integrated Approach to Managing
Patients With Acute Coronary Syndrome*
• Focal interventional treatment
to stabilize ruptured plaque
– PCI with stent
• Systemic medical therapy
intended to stabilize plaque
and inhibit clot formation,
thus helping to reduce the
risk of thrombotic events
(MI, stroke, or death) due to
diffuse atherosclerosis
– aspirin, clopidogrel, lipid-lowering
therapy, ACE inhibitors, beta-blockers
* ACS=unstable angina/non–Q-wave MI.
Ambrose JA. Circulation. 2002;105:2000-2004.
19
What evidence is there
to support the use
of clopidogrel in ACS*?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
20
Mechanisms of Action of
Oral Antiplatelet Therapies
ADP
clopidogrel bisulfate
ticlopidine HCl
dipyridamole
ADP
phosphodiesterase
ADP
cAMP
Activation
GP IIb/IIIa
(fibrinogen
receptor)
collagen
thrombin
TXA2
COX
TXA2
aspirin
ADP=adenosine diphosphate, TXA2=thromboxane A2, COX=cyclooxygenase.
Schafer AI. Am J Med. 1996;101:199-209.
21
Plavix® (clopidogrel bisulfate) Inhibits a
Key Step in Thrombus Formation
Adapted from Libby P. Circulation. 2001;104:365-372; Frishman WH et. al. Am J Cardiol. 1990;66:66G-70G.
22
Antithrombotic Trialists’ Collaboration
Efficacy of Aspirin Doses on
Vascular Events in High-Risk Patients
Aspirin Dose
# Trials
500–1500 mg
34
19
160–325 mg
19
26
75–150 mg
12
32
3
13
65
23
<75 mg
Any aspirin
Odds Ratio
OR* (%)
0
0.5
Antiplatelet Better
1.0
1.5
2.0
Antiplatelet Worse
* Odds reduction.
Treatment effect P<0.0001.
Adapted with permission from the BMJ Publishing Group. Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.
23
CURE
CURE: Clopidogrel in Unstable Angina
to Prevent Recurrent Events
Loading dose
Maintenance dose
clopidogrel 300 mg
+ ASA 75–325 mg
clopidogrel 75 mg
+ ASA 75–325 mg
placebo
+ ASA 75–325 mg
placebo
+ ASA 75–325 mg
N=12,562
n=6,259
Patient Population
• Patients with ACS
presenting within
24 hours
n=6,303
Primary End Point
• Composite of death from cardiovascular causes,
nonfatal MI, or stroke
CURE Trial Investigators. N Engl J Med. 2001;345:494-502.
482 centers
28 countries
24
CURE
Primary End Point: MI/Stroke/CV Death
0.14
0.12
Cumulative Hazard Rate
20%
Placebo
+ ASA*
Relative Risk
Reduction
0.10
P=0.00009†
N=12,562
0.08
Clopidogrel
+ ASA*
0.06
The primary outcome occurred in
9.3% of patients in the clopidogrel
+ ASA group and 11.4% in the
placebo + ASA group.
0.04
0.02
0.00
0
3
6
9
12
Months of Follow-Up
* Other standard therapies were used as appropriate.
† PLAVIX Prescribing Information.
Adapted with permission (2002) from the Massachusetts Medical Society. The CURE Trial Investigators. N Engl J Med.
2001;345:494-502.
25
CURE
Patients Treated with Medical Therapy
Cumulative Hazard Rate
0.20
Without PCI* and/or CABG
0.15
Placebo +
ASA†
(10.0%)
20%
Relative Risk
Reduction
0.10
Clopidogrel
+ ASA†
0.05
(P=0.0025‡)
(8.1%)
0.00
0
100
200
300
Days of Follow-Up
* PCI was also referred to as PTCA.
† Other standard therapies were used as appropriate.
‡ In the combined end point of MI, stroke, or CV death. Only first events after randomization were counted in the composite end point.
Data on file, Sanofi-Synthelabo Inc.
26
CURE
Patients Treated with PCI* and/or CABG
Placebo
+ ASA†
0.20
18%
Relative Risk
Reduction
Cumulative Hazard Rate
(13.8%)
0.15
(P=0.015‡)
Clopidogrel
+ ASA†
0.10
(11.4%)
0.05
0.00
0
100
200
300
Days of Follow-Up
* PCI was also referred to as PTCA.
† Other standard therapies were used as appropriate.
‡ In the combined end point of MI, stroke, or CV death. Only first events after randomization were counted in the composite end point.
Data on file, Sanofi-Synthelabo Inc.
27
CURE
Main Efficacy Results:
Combined Co-primary End Points
Outcome
Clopidogrel
+ ASA*
Placebo
+ ASA*
(n=6,259)
(n=6,303)
Primary outcome
Relative
Risk
Reduction
P value
9.3%
11.4%
20%
0.00009
16.5%
18.8%
14%
0.0005
5.2%
6.6%
23%
1.2%
1.4%
14%
5.1%
5.5%
7%
8.7%
9.3%
7%
(MI, stroke, CV death)
Co-primary outcome†
All individual outcome events‡:
MI
Stroke
CV death
Refractory ischemia
* Other standard therapies were used as appropriate.
† MI, stroke, CV death, or refractory ischemia.
‡ The individual components represent the total number of subjects experiencing an event during the course of the study.
PLAVIX Prescribing Information.
28
CURE
Beneficial Outcomes with Clopidogrel
in Various Subgroups
Percentage of Patients With Event
Characteristic
Overall
No. of
Patients
Clopidogrel
+ ASA*
Placebo
+ ASA*
12562
9.3
11.4
Male sex
Female sex
7726
4836
9.1
9.5
11.9
10.7
< 65 yr old
> 65 yr old
6354
6208
5.4
13.3
7.6
15.3
ST-segment deviation
No ST-segment deviation
6275
6287
11.5
7.0
14.3
8.6
Diabetes
No diabetes
2840
9722
14.2
7.9
16.7
9.9
0.4
0.6
0.8
1.0
1.2
Clopidogrel Better Placebo Better
Relative Risk (95% CI)
* In addition to other standard therapies.
The CURE Trial Investigators. N Engl J Med. 2001;345:494-502.
29
CURE
Outcomes With Clopidogrel in
Addition to Standard Therapy
Concomitant
Medication
Heparin/LMWH
No
Yes
Aspirin
N
Clopidogrel
+ ASA*
Placebo
+ASA*
951
11611
4.9
9.7
7.7
11.7
<100 mg
100-200 mg
1927
7428
8.5
9.2
9.7
10.9
>200 mg
3201
9.9
13.7
IV GP IIb/IIIa†
No
Yes
11739
823
8.9
15.7
10.8
19.2
Beta-blockers
No
Yes
2032
10530
9.9
9.2
12.0
11.3
ACE Inhibitors
No
Yes
4813
7749
6.3
11.2
8.1
13.5
Lipid-lowering
No
Yes
4461
8101
10.9
8.4
13.1
10.5
PTCA/CABG
No
Yes
7977
4585
8.1
11.4
10.0
13.8
0.4
* Other standard therapies were used as appropriate.
† Use not permitted within 3 days prior to randomization.
PLAVIX Prescribing Information.
0.6
1.2
0.8
1.0
Clopidogrel
Placebo
Better
Better
Relative Risk (95% CI)
30
CURE
Bleeding Results
Clopidogrel
+ ASA*
Placebo
+ ASA*
(n=6,259)
(n=6,303)
P value
3.7%
2.7%
0.001
Life-threatening
bleeding
2.2%
1.8%
0.13
Other major
bleeding
1.6%
1.0%
0.005
Minor bleeding
5.1%
2.4%
<0.001
Event
Major bleeding†
* Other standard therapies were used as appropriate.
† Life-threatening and other major bleeding.
PLAVIX Prescribing Information.
31
CURE
Major Bleeding by ASA Dose
ASA Dose
Clopidogrel
+ ASA*
Placebo
+ ASA*
<100 mg
2.6%
2.0%
100–200 mg
3.5%
2.3%
>200 mg
4.9%
4.0%
* Other standard therapies were used as appropriate.
PLAVIX Prescribing Information.
32
What are the 2002 ACC/AHA
UA/NSTEMI* guideline
recommendations for
clopidogrel therapy?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
33
2002 ACC/AHA UA/NSTEMI* Guideline Update:
Recommendations for Long-Term Medical Therapy
Class I
 Aspirin 75 to 325 mg/day (level of evidence: A)
 Clopidogrel 75 mg daily (in the absence of contraindications) when ASA
is not tolerated because of hypersensitivity or gastrointestinal intolerance
(level of evidence: A)
 The combination of ASA and clopidogrel for 9 months after UA/NSTEMI
(level of evidence: B)
 Beta-blockers in the absence of contraindications (level of evidence: B)
 Lipid-lowering agents and diet in post-ACS and post-revascularization patients
with LDL cholesterol >130 mg/dL (level of evidence: A)
 Lipid-lowering agents if LDL cholesterol level after diet is >100 mg/dL
(level of evidence: C)
 ACE inhibitors for patients with CHF, LV dysfunction (EF <0.40), hypertension,
or diabetes (level of evidence: A)
* Also known as non–Q-wave MI.
Braunwald E, et al. Available at: www.acc.org. Accessed February 18, 2004.
34
2002 ACC/AHA UA/NSTEMI* Guidelines Update:
Key Recommendations for Clopidogrel Therapy
Class I

In patients in whom an early noninterventional approach is planned, clopidogrel
should be added to ASA as soon as possible on admission and administered for
at least 1 month (A) and for up to 9 months (B)

In patients in whom a PCI is planned, clopidogrel should be started and
continued for at least 1 month (A) and up to 9 months in patients who are not at
high risk for bleeding (B)

For long-term medical therapy, the combination of ASA and clopidogrel is
recommended for 9 months after UA/NSTEMI (B)

In patients taking clopidogrel in whom elective CABG is planned, the drug should
be withheld for 5 to 7 days (B)
* Also known as non–Q-wave MI.
Braunwald E, et al. Available at: http://www.acc.org. Accessed February 18, 2004.
35
2002 ACC/AHA UA/NSTEMI* Guidelines
Update: Recommendations for Clopidogrel
in Long-term Medical Therapy
PATIENT TYPE
RECOMMENDED
THERAPY
For patients not
receiving PCI
Clopidogrel bisulfate with
aspirin as soon as
possible on admission
LENGTH OF THERAPY
Administer for at least 1 month
CLASS/LEVEL
OF EVIDENCE
Class I
Level A
May be administered for up to 9 months
Class I
Level B
For patients
receiving PCI
with or without
stent
Clopidogrel bisulfate with
aspirin
Administer for at least 1 month
May be administered for
up to 9 months in patients who are not
at high risk of bleeding
Class I
Level A
Class I
Level B
In patients taking clopidogrel bisulfate in whom elective CABG is planned, the drug should be withheld
for 5 to 7 days (Level of Evidence: B)
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
Braunwald E, et al. Available at: www.acc.org. Accessed February 10, 2005.
36
ACC/AHA Treatment Recommendations
for the Long-term Management of ACS*
ACS
(UA/NSTEMI* patients)
Medical
Management
Cath lab
Medical
Management
(no intervention
required)
PCI
(with or
without stent)
CABG†
Long-term management
1.
2.
3.
4.
5.
Clopidogrel
ASA
ß-blocker
ACE Inhibitor
Statin
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
† If possible, withhold clopidogrel 5 to 7 days prior to the procedure.
Braunwald E, et al. Available at: www.acc.org. Accessed February 10, 2005.
37
What quality of care programs
exist for ACS*?
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
38
Overview of CRUSADE
Quality Improvement Program
CRUSADE Quality Improvement Program
1. Implement quality improvement initiatives to promote
ACC/AHA NSTE ACS Guidelines recommendations
Objectives
2. Improve clinical outcomes for NSTE ACS patients via early
risk stratification and implementation of evidence-based
care, both in-hospital and post-discharge
Up to 600 participating hospitals—a collaborative effort
between Emergency Medicine, Cardiology, Hospital QI,
Academia, and Industry
Participants
Methods
–
Collect data regarding patient management practice
patterns in the US
–
Use those data to target educational interventions designed
to promote adherence to the revised ACC/AHA NSTE ACS
guidelines recommendations
CRUSADE Overview. Available at: http://www.crusadeqi.com. Accessed March 13, 2005.
CRUSADE is funded by Millennium Pharmaceuticals, Inc., Schering Corporation, and the Bristol-Myers Squibb/Sanofi
Pharmaceuticals Partnership.
39
CRUSADE
Acute and Discharge Clopidogrel Use
by Treatment Approach
96
Utilization of Therapies (%)
100
75
57
45
50
33
26
25
0
Early Cath
No Early Cath
PCI
Acute Therapy
Medical Rx
CABG
Discharge Therapy
(clopidodegrel given within
24 hrs of admission)
Q4 2004 CRUSADE data. Adapted with permission from CRUSADE Web site.
Available at: http://www.crusadeqi.com. Accessed March 11, 2005.
40
CRUSADE
Discharge Medication Use – Last 12 Months
(In patients without contraindications)
100%
93%
89%
86%
Utilization of Therapies (%)
80%
69%
64%
60%
40%
20%
0%
ASA
Beta
Blockers
ACEInhibitors*
Any LipidLowering
Agent†
Clopidogrel
* LVEF <40%, CHF, DM, HTN.
† Known hyperlipidemia,  TC,  LDL.
CRUSADE data October 1, 2003-September 30, 2004 (n=40,386) Adapted with permission from CRUSADE Web site.
Available at: http://www.crusadeqi.com. Accessed March 11, 2005.
41
CRUSADE
Paradoxical Discharge Care Patterns
Patients Treated (%)
100
92 91.9
Low-Risk
Moderate-Risk
High-Risk
87.9
n=74,217
84 84.1 82.8
70.3 68.7
75
61.7
60.3 59.6 61
58.5
56.6
47.4
50
25
0
ASA
Clopidogrel
Beta Blocker
Adapted with permission from CRUSADE Web site.
Available at: http://www.crusadeqi.com. Accessed March 11, 2005.
ACE-I
Statin
42
CRUSADE
Trends in Discharge Therapy Adherence
100%
91%
93%
86%
Q4-03
Q1-04
Q2-04
Q3-04
89%
86%
81%
75%
69%
59%
63%
64%
50%
25%
0%
Aspirin
Clopidogrel
Beta blocker ACE Inhibitor
CRUSADE data Quarter 4, 2003 through Quarter 3, 2004. Adapted with permission from CRUSADE Web site.
Available at: http://www.crusadeqi.com. Accessed March 11, 2005.
Lipidlowering
Agent
43
CRUSADE
Relationship Between Guidelines Adherence
and In-Hospital Mortality
Improved Hospital Adherence
7
In-Hospital Mortality (%)*
6
6.0%
5.2%
5
5.0%
4.2%
4
3
2
1
0
≤25%
25–50%
50–75%
≥75%
Hospital Composite Adherence Quartiles
* Adjusted figure.
Cumulative CRUSADE data (adjusted) through September 2004. Adapted with permission from CRUSADE Web site.
Available at: http://www.crusadeqi.com. Accessed February 10, 2005.
44
Summary
• The American Heart Association estimates that 1.4 million
patients are diagnosed with ACS each year
• Patients with ACS are at risk for other types of arterial
thrombosis, including stroke and PAD
• The CURE study showed a 20% relative risk reduction in
clopidogrel plus aspirin vs aspirin alone in the combined
end point of MI, stroke, or vascular death
• The 2002 ACC/AHA UA/NSTEMI* Guidelines for Long-term
Management of ACS recommend that clopidogrel may be
given daily for up to 9 months
• Quality improvement programs increase adherence
to guideline-recommended therapies and reduce
in-hospital mortality
* UA/NSTEMI=unstable angina/non–ST-segment elevation myocardial infarction (also known as non–Q-wave MI).
45
Case: Mrs. Charlotte Purdue*
• 72-year-old female who presents to clinic with
complaints of episodic chest discomfort
– PMH of MI 3 years ago and HTN controlled
with a diuretic
– She describes the pain as epigastric, sometimes
on her left side, and has lasted for 7 days
– The pain lasted 2 hours this morning, but she is
currently pain-free
• Plan: direct admit to the hospital for rule out of ACS†
and observation
* Patients’ names are fictitious.
† UA/NSTEMI=unstable angina/non-ST-segment elevation myocardial infarction (also known as non-Q-wave MI).
46
Case: Mrs. Charlotte Purdue
Past Medical History
• MI (3 years ago)
• Hypertension
Medications
– Aspirin 81 mg
– Diuretic
– Statin
Physical Examination
•
•
•
•
•
•
•
WT: 165 lb
BP: 158/88 mm Hg
P: 80 bpm
RR: 18
Lung sounds: clear
Cardiac exam: nl S1, S2, +S4
Distal pulses: normal
47
Case: Mrs. Charlotte Purdue
• Mrs. Purdue is admitted to the telemetry floor
• Her initial ECG shows small T wave inversions in leads
II and III, and initial cardiac markers are negative. These
are new findings when compared to an old ECG
• Working diagnosis: unstable angina
Nursing Orders
1. Rule out with cardiac
markers Q8
2. Serial ECGs
Medication Orders
•
•
•
•
•
•
Clopidogrel 300 mg
ASA 325 mg
Heparin IV
β-Blocker
Statin
Sublingual NTG prn
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Case: Mrs. Charlotte Purdue
• The next morning, Mrs. Purdue continues to be
chest pain free. There were no elevations in
cardiac markers, and her ECG findings resolve
• She is sent to the stress lab for a stress
myocardial perfusion scan
– Findings: small fixed defect with mild
inferolateral ischemia
– Normal LVEF (55%)
Final diagnosis: unstable angina
49