Nova Scotia Guidelines for Acute Coronary Syndromes (2008) QUICK REFERENCE MARCH Supported by unrestricted educational grants from:

Transcription

1 Nva Sctia Guidelines fr Acute Crnary Syndrmes (2008) QUICK REFERENCE MARCH 2010 Supprted by unrestricted educatinal grants frm:

2 Critical Pathways STEMI in the Emergency department EVALUATION Vital Signs 12-lead ECG (within 10 minutes f arrival), then q 30 minutes x 3 IV x 2 Inserted Trpnin immediately and q 8 hurs x 2 CBC PT/aPTT 0 2 t maintain sats >95% Chemistry Panel Chest Xray Mnitred Bed Estimate CrCl (<30 ml/min is equivalent t severe renal insufficiency) Ideal bdy weight (IBW) (kg) = 0.9 (Ht [cm] -150) (+50, male; + 45, female) CrCl frmula (ml/min): Male: (140 - age) (IBW kg) (60) (Serum creatinine uml/l) (50) Female: 0.85 x male CrCl value Determine Eligibility fr Reperfusin Review Cntraindicatins and Timelines Primary PCI (dr t balln <90 minutes) Thrmblysis (dr t needle <30 minutes) u See Over t

3 Medicatin fr STEMI Aspirin u mg Clpidgrel u 300 mg p, (reduce dse t 75 mg if 75 and receiving TNK) Metprll u 5 mg IV q 5 min prn if HR >100 and SBP >110 and n heart failure Nitrates u mg SL q 5 min x3 until pain free r SBP 100 Mrphine u 2-4 mg IV r subcut q 30 min prn pain Fentanyl u mcg IV q 30 min prn pain Anticagulant (Chse ONE): Enxaparin u <75 years f age: administer a fixed 30 mg IV blus, fllwed by subcut injectin 1mg/kg (max 100mg/dse fr first 2 subcut injectins) twice daily (BID) u 75 years f age: Omit blus; reduce subcut injectin t 0.75 mg/kg BID (max 75 mg/dse fr first 2 subcut injectins) Unfractinated u IV lading dse f 60 IU/kg (max 4000 IU); subsequent Heparin (UFH) IV infusin f 12 IU/kg/hur (Max 1000 IU/hur). (use if CrCl adjust dse as per lcal nmgram. <30 ml/mins; r cncern re bleeding risk)

4 Abslute Cntraindicatins t Fibrinlysis Any prir intracranial hemrrhage (ICH) Knwn structural cerebral vascular lesin (ie., arterivenus malfrmatin) Knwn malignant intracranial neplasm (primary r metastatic) Ischemic strke within 3 mnths EXCEPT acute ischemic strke within 4 hurs Suspected artic dissectin Active bleeding r bleeding diathesis (excluding menses) Significant clsed-head r facial trauma within 3 mnths Adapted frm Antman EM, et al J Am Cll Cardil. 2004; 44:E1-E2111 u See Over t

5 Relative Cntraindicatins t Fibrinlysis Histry f chrnic, severe, prly cntrlled hypertensin Severe uncntrlled HTN n presentatin (SBP > 180 mm Hg r DBP >110 mm Hg) Histry f prir ischemic strke >3 mnths, dementia, r knwn intracranial pathlgy nt cvered in abslute cntraindicatins Traumatic r prlnged (>10 minutes) CPR r majr surgery (<3 weeks) Recent (within 2-4 weeks) internal bleeding Nncmpressible vascular punctures Fr streptkinase/anistreplase: prir expsure (>5 days ag) r prir allergic reactin t these agents Pregnancy Active peptic ulcer Current use f anticagulants: the higher the INR, the higher the risk f bleeding Adapted frm Antman EM, et al J Am Cll Cardil. 2004; 44:E1 - E2111

6 STEMI Wh shuld g fr cath? Risk Stratificatin and Triage fr Cardiac Catheterizatin Primary PCI Emergent Catheterizatin Lytic ineligible and < 12 hurs frm symptm nset Cardigenic shck Rescue PCI* Failure t reperfuse (<50% reslutin f ST 90 min) Recurrent ST elevatin fr min after successful lysis** High risk/cmplicated STEMI Mechanical cmplicatins - VSD, papillary muscle rupture Recurrent/ refractry ischemia Recurrent ventricular arrhythmias Refractry bradycardia Severe heart failure r persistent hyptensin - VAD (ventricular assist device team) shuld be ntified * symptm nset t balln time is predicted t be < 12 hurs ** cnsider repeat lysis if rescue nt available within min NON-Emergent Catheterizatin Patients with high risk STEMI (e.g. extensive MI invlving 2 territries [anterlateral, inferlateral, inferpsterir]) and wh have respnded well t the initial thrmblysis may be cnsidered fr cardiac catheterizatin during the current hspitalizatin withut underging nn-invasive risk stratificatin. Patients with lw risk STEMI (e.g. islated uncmplicated inferir infarctin) wh have respnded well t thrmblysis shuld underg a nninvasive risk stratificatin test, such as an exercise tlerance test, prir t discharge t determine the need fr cardiac catheterizatin. Cntact Telephne Numbers: Cath QEII (day): (902) r (902) Evening: Page the n-call Interventinal Cardilgist: (902) Ventricular Assist Device Team: (902)

7 Critical Pathways UA/NSTEMI in the Emergency department EVALUATION Vital Signs 12-lead ECG (within 10 minutes f arrival), then 1 hur x 3 IV x 2 Inserted Trpnin immediately and q 8 hurs x 2 CBC PT/aPTT 0 2 t maintain sats >95% Chemistry Panel Chest Xray Mnitred Bed Estimate CrCl (<30 ml/min is equivalent t severe renal insufficiency) Ideal bdy weight (IBW) (kg) = 0.9 (Ht [cm] -150) (+50, male; + 45, female) CrCl frmula (ml/min): Male: (140 - age) (IBW kg) (60) (Serum creatinine uml/l) (50) Female: 0.85 x male CrCl value u See Over t

8 Medicatin & Cnsultatin fr UA/NSTEMI Aspirin* u mg p Clpidgrel* u 300 mg p, then 75 mg daily Metprll u 5 mg IV q 5 min prn IF HR >100 and SBP >110 and n heart failure Nitrates u Nitr mg SL q 5 min x3 until pain free r SBP 100 Mrphine u 2-4 mg IV r subcut q 30 min prn pain Fentanyl u mcg IV q 30 min prn pain Anticagulant (Chse ONE): Fndaparinux u 2.5 mg subcut nce daily u If cntraindicated (CrCl<30 ml/min, prsthetic heart valve r if ging t the Cath lab), use UFH Unfractinated u 60 IU/kg blus (max 4000 IU) + 12 IU/kg/hr IV infusin Heparin (UFH) (max 1000 IU/hr); target aptt: sec Cnsult n call internist/cardilgist Triage fr cardiac u Priritized accrding t risk. Generally at higher risk, catheterizatin and therefre, the majrity shuld be cnsidered fr revascularizatin early cardiac catheterizatin, prvided the benefits f invasive assessment & revascularizatin are felt t utweigh the risks. *Administer in cmbinatin unless patient is intlerant t aspirin, r has taken previusly

9 TIMI Risk Scre One pint each fr: 65 years f age At least 3 risk factrs fr CAD (a) Significant crnary stensis (b) Severe anginal symptms (c) ST deviatin n presentatin Use f ASA in last 7 days Elevated serum cardiac markers (d) Ttal: Pints: Ttal number f pints = TIMI risk scre CCS risk Categry TIMI risk scre Recmmended timing f cardiac catheterizatin Lw risk u 1-2 u 5-7 days Intermediate risk u 3-4 u 3-4 days High risk u 5-7 u hurs (a) family histry f crnary disease, hypertensin, dyslipidemia, diabetes r current smking (b) prir crnary stensis 50% (c) 2 anginal episdes in last 24 hurs (d) trpnin r creatine kinase MB u See Over t

10 UA/NSTEMI Wh shuld g fr cath? Risk Stratificatin and Triage fr Cardiac Catheterizatin High Risk Cath ± PCI within hurs Hyptensin (a) r definite evidence f heart failure Recurrent ventricular arrhythmias Transient ST elevatin New ST depressin 2mm in 3 leads Recurrent r refractry ischemia despite initial therapy (b) TIMI risk scre 5-7 Intermediate Risk Cath ± PCI within 3-5 days NSTEMI withut high risk features but LVEF <40% TIMI risk scre 3-4 Lw Risk Cath ± PCI within 5-7 days NSTEMI with n high- r intermediate-risk features (c) suspected unstable angina with recurrent symptms but n ECG changes unstable angina with easily inducible (<3 METs) r widespread ischemia n nn-invasive testing, r sme ther marker f increased risk (d) TIMI risk scre 1-2 (e) Cntact Telephne Numbers: Day: Call the QEII Cardilgy Bed Manager (902) Evenings/Weekends/Hlidays: Page Triage Cardilgist n call (902) Fax: Request fr cardiac cath PCI r ther interventin (Frm # CD0720) (902) (a) with ther supprtive evidence f ischemia (b) definite new r dynamic ST segment changes required t justify urgent status in patients with unstable angina (nrmal trpnin level) (c) lw-risk NSTEMI patients can have invasive assessment deferred t an early utpatient setting (<2 weeks) prvided that nn-invasive testing des nt indicate easily inducible (<3METs) r widespread ischemia r sme ther marker f increased risk (d) (d) e.g. hyptensive respnse, sustained ST depressin, exercise-induced ventricular tachycardia, large territry f reversible ischemia, multiple perfusin defects, lw LVEF <40% (e) lw-risk unstable angina patients with a TIMI risk scre f 1-2 need nt necessarily underg early invasive assessment if nn-invasive testing rules ut easily inducible r widespread ischemia

11

12 Supprted by unrestricted educatinal grants frm: Cardivascular Health Nva Sctia Rm 539, Bethune Bldg Suth Park Street, Halifax NS B3H 2Y (T); (F) Visit ur website at