Download STEMI standing orders

ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
Patient ___________________________ ___________________________ _______
(LAST NAME)
(FIRST NAME)
(MI)
Age: ______
Weight: _________ Height: __________
 Male
 Female
Medication allergies: _______________________________________________
Initial Orders: Check all that apply
DIAGNOSTICS
 Stat ECG, obtain old ECG and medical record
 Stat ACS lab panel: complete metabolic panel, magnesium, CBC/diff., T/INR/aPTT,
CK+CK-MB, troponin-I, lipid profile
 Calculate creatinine clearance (CrCl) : ________________ mL/min
CrCl mL/min = (140 – age)  weight (kg)/(serum creatinine  72) multiply by 0.85 if female
 Stat portable CXR
 Cardiac monitor and SaO2 monitor
 Other _________________________________________________________

STEMI confirmed (check all that apply)
 Anterior
 Inferior
 Lateral
 Posterior
 LBBB
ANTI-ISCHEMIC THERAPY
 Oxygen 2 L/min nasal cannula (titrate to keep arterial saturation >90%)
 IV – D5W
 KVO _______mL/hr
 Opiate: ____________________________________ ______ mg IV (suggest morphine
sulfate)
Discontinue all NSAIDs except aspirin. Do not initiate during acute phase of
management.
1
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
MEDICATIONS
 Aspirin 162-325 mg po chewed
NITROGLYCERIN THERAPY
Hold if patient has taken a phosphodiesterase inhibitor for erectile dysfunction
in the last 24 hours (48 hours for tadalafil).
 Nitroglycerin 0.4 mg SL q5min x 3 prn chest pain; HOLD IF: SBP <100 mm Hg
 Nitroglycerin IV – start infusion at 10 µg/min, then titrate up by 10-20 µg/min every 5-10
min as needed to control pain, if BP permits
 Nitroglycerin, transdermal, 0.2 to 0.8 mg/h q12h, tolerance in 7 to 8 h
Oral -Blocker
 Metoprolol tartrate ____________ mg _____________________
IV -Blocker (optional; recommended if persistent ischemic symptoms, hypertension, or
tachycardia and no signs of hemodynamic instability)
 Drug: _____________________________
2
_______ mg IV for ____ doses every __ hrs
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
SELECT REPERFUSION STRATEGY
 Fibrinolytic Therapy:
Within 12 hours of symptom onset and primary PCI cannot
be achieved in <90 minutes of first medical contact OR
patient cannot be transferred to primary PCI center with
anticipated time from first medical contact to balloon to be
<90 minutes
 Fibrinolytic Therapy Orders (goal door to needle <30
min)
 Primary PCI:
Within 12 hours of symptom onset, with primary PCI facility
available, with anticipated first medical contact to balloon
time <90 minutes
 Primary PCI Orders (goal door to balloon <90 min)
 Medical Management:
Contraindications to reperfusion therapy
 Medical Management Strategy Orders
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ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
FIBRINOLYTIC THERAPY ORDERS (goal door to needle <30 min)
Indications: chest pain <12 hours, ECG ST elevations or new left bundle branch block
Assess for contraindications to fibrinolytic therapy:
Absolute contraindications:
 Any prior ICH
 Known structural cerebral vascular lesion (eg, AVM)
 Known malignant intracranial neoplasm (primary or metastatic)
 Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours
 Suspected aortic dissection
 Active bleeding or bleeding diathesis (excluding menses)
 Significant closed head or facial trauma within 3 months
Relative contraindications:
 Hx of chronic, severe, poorly controlled HTN
 Severe uncontrolled HTN on presentation (SBP >180 mm Hg or DBP >110 mm
Hg)
 Hx of prior ischemic stroke >3 months, dementia, or known intracranial pathology
not covered in contraindications
 Traumatic or prolonged (>10 min) CPR or major surgery (<3 wk)
 Recent (within 2-4 wk) internal bleeding
 Noncompressible vascular punctures
 For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic
reaction to these agents
 Pregnancy
 Active peptic ulcer
 Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

If fibrinolytic contraindicated, call STAT cardiology consult Dr. _________________
FIBRINOLYTIC THERAPY (choose one):

Reteplase 10 U IV over 2 minutes, repeat after 30 minutes
or

Tenecteplase 30-50 mg IV over 5 seconds, based on weight:
- 30 mg for weight <60 kg
- 35 mg for 60-69 kg
- 40 mg for 70-79 kg
- 45 mg for 80-89 kg
- 50 mg for ≥90 kg
or

Streptokinase 1.5 MU IV over 30-60 minutes
4
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
FIBRINOLYTIC THERAPY ORDERS continued
ANTICOAGULANT THERAPY (choose one with fibrinolytics):
 Unfractionated Heparin: 60 U/kg IV bolus (maximum 4000 U), followed by IV infusion of
12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain goal aPTT 1.5 to 2.0 times
control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as indicated.
When using a fibrinolytic, use Unfractionated Heparin Dosing Chart. Note: Regimens
other than UFH are recommended if anticoagulant therapy is given for more than 48
hours because of the risk of heparin-induced thrombocytopenia with prolonged
UFH treatment (see appendix for titration nomogram)
or
 Enoxaparin (provided the serum creatinine is <2.5 mg/dL in men and 2.0 mg/dL in women):
- Patients <75 years of age: 30 mg IV bolus, followed 15 min later by 1 mg/kg SC q12h
(if CrCl <30 mL/min, give 1 mg/kg every 24 h). Continue for at least 48 hours, and
preferably for the duration of hospitalization, up to 8 days.
- Patients ≥75 years of age: No bolus; 0.75 mg/kg SC q12h. Continue for at least 48
hours, and preferably for the duration of hospitalization, up to 8 days.
or

Fondaparinux 2.5 mg IV initially, followed by 2.5 mg SC once daily (avoid if CrCl <30
mL/min). Continue for at least 48 hours, and preferably for the duration of
hospitalization, up to 8 days.
For patients treated initially with fondaparinux who later undergo PCI, administer
additional IV treatment with an anticoagulant possessing anti-IIa activity (such as
UFH or bivalirudin), taking into account whether GP IIb/IIIa inhibitors have been
administered. Note: Because of the risk of catheter thrombosis, fondaparinux
should not be used as the sole anticoagulant to support PCI.
ANTIPLATELET THERAPY
 Clopidogrel 300 mg po loading dose if age <75 years
(75 mg po loading dose if age ≥75 years)
ASSESS FOR REPERFUSION

ECG 60 minutes after initial bolus of fibrinolytic.
Assess for reperfusion based on angina intensity, ST resolution on 60-minute ECG and/or
hypotension.

Cardiology consultation, if possible reperfusion failure
Call Dr. __________________________________________________________________
Physician/NP/PA Signature: _________________________ Date: _______ Time: _______
5
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
RISK STRATIFICATION (non–PCI-capable facility)
 High risk (recommend early transfer <6 hours for PCI)
 Low risk (recommend admission to CCU; monitor for ischemia)
If high risk:
 Transfer for PCI
 Initiate preparatory antithrombotic (anticoagulant plus antiplatelet)
 Anticoagulant: _________________________ at _______________________
 Antiplatelet: __________________________ at _______________________
It is reasonable for high-risk patients who receive fibrinolytic therapy as primary
reperfusion therapy at a non–PCI-capable facility to be transferred as soon as possible to
a PCI-capable facility where PCI can be performed either when needed or as a
pharmacoinvasive strategy. Consideration should be given to initiating a preparatory
antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer
to the catheterization laboratory (Class IIa, LOE: B).b
Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion
therapy at a non–PCI-capable facility may be considered for transfer as soon as possible
to a PCI-capable facility where PCI can be performed either when needed or as a
pharmacoinvasive strategy. Consideration should be given to initiating a preparatory
antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer
to the catheterization laboratory (Class IIb, LOE: C).b
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ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
Triage and Transfer for PCIb
Adapted with permission from Kushner FG, et al. J Am Coll Cardiol. 2009;54(23):2205-2241.
Note: A planned perfusion strategy using full-dose fibrinolytic therapy followed by
immediate PCI may be harmful and is not recommended.
7
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
PRIMARY PCI STRATEGY ORDERS (goal door to balloon <90 min)
ANTIPLATELET THERAPY (choose one):
 Clopidogrel 300-600 mg po loading dose
or
 Prasugrel 60 mg po loading doseb,c
and/or
 GP IIb/IIIa inhibitor
GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY (choose one):
 Abciximab 0.25 mg/kg IV bolus, followed by IV infusion of 0.125 µg/kg/min (to a
maximum of 10 μg/min). Continue for 12 hours.
or
 Tirofiban 25 µg/kg IV bolus, followed by IV infusion at 0.15 µg/kg/min. Continue for
18 to 24 hours.
or
 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. Continue until hospital
discharge or for 12 to 18 hours.
It is reasonable to start treatment with glycoprotein IIb/IIIa receptor antagonists
(abciximab [Class IIa, LOE: A], tirofiban [Class IIa, LOE: B], or eptifibatide [Class IIa,
LOE: B]) at the time of primary PCI (with or without stenting) in selected patients with
STEMI.b
8
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
PRIMARY PCI STRATEGY ORDERS continued
ANTICOAGULANT THERAPY (choose one):

Unfractionated Heparin (for at least 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 achieve goal aPTT
1.5 to 2.0 times control (approximately 50 to 70 s). Target ACT in catheterization lab:
200-250 sec if concomitant GP IIb/IIIa inhibitor therapy, 250-300 sec if no concomitant
GP IIb/IIIa inhibitor therapy; administer additional boluses to achieve target ACT if
measured values below recommended ranges (see appendix for dosing)
or

Enoxaparin 30 mg IV, followed by 1 mg/kg SC q12h, first dose 15 minutes after bolus
(if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min,
give 1 mg/kg every 24 h after bolus). If the last SC dose was given less than 8 hours
prior to PCI, no additional enoxaparin required; if last SC was given 8 to 12 hours
earlier or never given, an IV dose of 0.3 mg/kg of enoxaparin should be given.
Discontinue after completion of the PCI procedure, unless continued anticoagulation is
indicated. Enoxaparin can be used to support PCI after fibrinolysis; no additional
anticoagulant is needed.
or

Bivalirudin 0.75 mg/kg IV bolus, followed by infusion of 1.75 mg/kg/h. If UFH was
given previously, start bivalirudin 30 minutes later but before PCI.
For patients proceeding to primary PCI who have been treated with ASA and a
thienopyridine, recommended supportive anticoagulant regimens include the following:
a. For prior treatment with UFH, additional boluses of UFH should be administered as
needed to maintain therapeutic activated clotting time levels, taking into account
whether GP IIb/IIIa receptor antagonists have been administered (Class I, LOE: C).b
b. Bivalirudin is useful as a supportive measure for primary PCI with or without prior
treatment with UFH (Class I, LOE: B).b
In STEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin
anticoagulation is reasonable (Class IIa, LOE: B).b
For prior treatment with fondaparinux, administer additional intravenous treatment
with an anticoagulant possessing anti-IIa activity (such as UFH or bivalirudin),
taking into account whether GP IIb/IIIa inhibitors have been administered. Note:
Because of the risk of catheter thrombosis, fondaparinux should not be used as the
sole anticoagulant to support PCI.
9
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
PCI PROCEDURES: THROMBUS ASPIRATION AND USE OF STENTS
PCI PROCEDURES (check if applicable)
 Aspiration thrombectomy
Aspiration thrombectomy is reasonable for patients undergoing primary PCI (Class IIa,
LOE: B).b
Stent Use (check one if applicable):
 DES
 BMS
It is reasonable to use a drug-eluting stent (DES) as an alternative to a bare-metal stent
(BMS) for primary PCI in STEMI (Class IIa, LOE: B). b
A DES may be considered for clinical and anatomic settings in which the efficacy/safety
profile appears favorable (Class IIb, LOE: B).b
10
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
MEDICAL MANAGEMENT STRATEGY ORDERS (NO REPERFUSION)
ANTICOAGULANT THERAPY (choose one):

Unfractionated Heparin: 60 U/kg IV bolus (maximum 4000 U), followed by IV infusion
of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain goal aPTT 1.5 to 2.0
times control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as
indicated. When using a fibrinolytic, use Unfractionated Heparin Dosing Chart. Note:
Regimens other than UFH are recommended if anticoagulant therapy is given for
more than 48 hours because of the risk of heparin-induced thrombocytopenia
with prolonged UFH treatment.
or

Enoxaparin 30 mg IV, followed by 1 mg/kg SC q12h, first dose 30 minutes after bolus
(if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min,
give 1 mg/kg every 24 h after bolus). Continue for at least 48 hours, and preferably for
the duration of hospitalization, up to 8 days in patients with no contraindications to
anticoagulation.
or

Fondaparinux 2.5 mg IV initially, followed by 2.5 mg SC once daily (avoid if CrCl <30
mL/min). Continue for at least 48 hours, and preferably for the duration of
hospitalization, up to 8 days in patients with no contraindications to anticoagulation.
11
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
AS-NEEDED MEDICATIONS
Check/Initial/Date
 _____/_____
DOCUSATE SODIUM 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 daily prn constipation
 _____/_____
MAGNESIUM SULFATE Sliding Scale IV daily
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 daily
KCL IMMEDIATE REL Sliding Scale Target K >4.5 mg/dL po daily
Call house officer if K <3.4; hold order for creatinine >1.9
If K <3.7 give 60 mEq
If K <4.1 give 40 mEq
If K <4.6 give 20 mEq
Additional Orders:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
 _____/_____
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
 Now
13
 After midnight
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
DAY 2 OR LATER: REMINDERS
Check/Initial/Date
 _____/_____
If on UFH (consult Unfractionated Heparin Dosing Chart)
_____________________________________________
 _____/_____
Calcium channel blocker (if β-blocker contraindicated)
Drug: _______________________ ___mg ____times/d
 _____/_____
ACE inhibitor or ARB; recommended if diabetic
Drug: _______________________ ___mg ____times/d
 _____/_____
Lipid-lowering therapy (statins) regardless of LDL; dose target
to LDL <100 mg/dL (further reduction to <70 mg/dL
reasonable)
Drug: ____________________________ ___mg once daily
 _____/_____
Echocardiography. FIRST 24 HR if evidence of CHF,
hemodynamic instability, mechanical complication
 _____/_____
Warfarin: RECOMMENDED if LV thrombus, extensive wall
dyskinesis, LVEF <20%-30%
14
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
PRIOR TO DISCHARGE
Check/Initial/Date
 _____/_____
 _____/_____
Patient had stent implanted
OR
Patient had medical therapy without stenting
MEDICATIONS
 _____/_____
Aspirin ________ mg/d for _________________________
 _____/_____
Clopidogrel _________ mg/d for ______________________
OR
Prasugrel 10 mg/d for ______________________________
 _____/_____
 _____/_____
-blocker
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
ACE inhibitor or ARB
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
Aldosterone receptor blocker
Drug: __________________________________________
Dosage: ________________________________________
 _____/_____
Calcium channel blocker
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Statin
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Nitroglycerin
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Drug: ___________________________________________
Dosage: _________________________________________
 _____/_____
Drug: ___________________________________________
Dosage: _________________________________________
15
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
PRIOR TO DISCHARGE cont
PATIENT/FAMILY EDUCATION AND FOLLOW-UP
INSTRUCTIONS
Check/Initial/Date
 _____/_____
Medication instructions/disease education
 _____/_____
Smoking cessation
 _____/_____
Diabetes management
 _____/_____
Nutrition, weight, and blood pressure management
 _____/_____
Exercise program
 _____/_____
Referral to cardiac rehab
Time: ______ Date: ______ Signature: ____________________________________
a
Canadian Cardiovascular Society; American Academy of Family Physicians; American College
of Cardiology; American Heart Association, Antman EM, Hand M, Armstrong PW, et al. 2007
focused update of the ACC/AHA 2004 guidelines for the management of patients with STelevation myocardial infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51(2):210-247.
b 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 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(23):2205-2241.
c In
STEMI patients with a prior history of stroke and transient ischemic attack for whom primary PCI
is planned, prasugrel is not recommended as part of a dual-antiplatelet therapy regimen.
16
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
17
ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
Heparin Adjustment Nomogram for Standard Laboratory Reagents
With a Mean Control aPTT of 26-36 s
aPTT (s)
Bolus Dose
(U)
Stop Infusion
(min)
Rate Change
(mL/h)
Repeat aPTT
3000
0
+2
6h
40-49
0
0
+1
6h
50-75
0
0
0 (no change)
Next AM
76-85
0
0
–1
Next AM
86-100
0
30
–2
6h
101-150
0
60
–3
6h
>150
0
60
–6
6h
<40
aPTT indicates activated partial thromboplastin time. Heparin infusion concentration = 50 U/mL.
Target aPTT = 50-75 s.
For aPTTs obtained before 12 h after initiation of thrombolytic therapy:
1. Do not discontinue or decrease infusion unless significant bleeding or aPTT >150 s.
2. Adjust infusion upward if aPTT <50 s. For aPTTs obtained 12 h after initiation of
thrombolytic therapy, use entire nomogram: Deliver bolus, stop infusion, and/or change rate
of infusion based on aPTT, as noted on appropriate line of nomogram.
Adapted with permission from Hirsh J, Raschke R, Warkentin TE, Dalen JE, Deykin D, Poller L.
Heparin: mechanism of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and
safety. Chest. 1995;108(4 suppl):258S-275S.
Reprinted with permission from Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for
the management of patients with acute myocardial infarction. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1996;28(5):1328-1428.
18