Protocols for the Management of Cardiac Conditions By Pam Bayles, RN, BSN
Deaths in Thousands 1,000 800 600 400 200 0 00 10 20 30 40 50 60 70 80 90 00 06 Years Deaths from diseases of the heart (United States: 1900 2006) Note: See Glossary for an explanation of Diseases of the Heart. Source: NCHS and NHLBI. 2
Guidelines/Standards In 2009, over ½ million people will have their first MI. Within 1 yr. of a recognized MI 25% of men and 38% of women will die 18% of men and 35% of women will have another MI within 6 years of their first event. Over 450,000 people suffer from recurrent coronary attacks each year 50% of all case of AMI are clinically silent or unremarkable 33% report symptoms other than CP, esp. women, older adults, diabetics and pts. With HF
STEMI guidelines Reperfusion within 90 minutes with primary PCI Get artery open ASAP! Clopidogrel Loading dose of 300-600 mg prior to PCI If pt. has received fibrinolytic therapy within 12-24 hrs. of PCI, consider 300 mg loading dose Anticoagulants Fibrinolytics minimum of 48 hours UFH, enoxaparin (Lovenox), fondaparinux (Arixtra) Heparin or bivalirudin (Angiomax) Fibrinolytics ARB within 24 hrs. of symptom onset Statin therapy
Medical Management of STEMI 2007 Update: Class I Recommendations Initial Management O2 to keep Sat > 90% ASA 162 325 mg ASAP NTG 0.4 mg SL q 5 min x 3, then decide on IV NTG ( if persistent ischemia, HF or HTN) Morphine 2-4 mg IV q 5-15 minutes for pain Discontinue NSAIDS except ASA Oral beta blocker within 24 hours
ACE Inhibitors in STEMI Should be started within 24 hrs. and continued indefinitely in all pts. With EF 40% With HTN, diabetes, or chronic kidney disease Who are not low risk pts. It is reasonable to give ACEI to all patients recovering from STEMI unless contraindications exist (class IIa) Should not be given if hypotensive: SBP < 100 mm Hg or 30 mm Hg below baseline
At least 10% of STEMI don t develop myocardial necrosis and subsequent Q waves on EKG after reperfusion therapy Successful restoration of flow is called aborting of MI If treated within the hour, about 25% of STEMI can be aborted Effectiveness of thrombolysis is highest within first 2 hours. After 12 hours, risk outweighs benefit Irreversible injury occurs within 2-4 hours of infarction Limited time for reperfusion
UA/NSTEMI guidelines
Anti-ischemic Therapy for NSTEMI O2 As needed to keep SaO2 > 90% NTG 0.4 mg SL every 5 minutes for 3 doses if ongoing ischemia IV NTG is indicated in first 48 hrs. for treatment of persistent ischemia, HF, or HTN Morphine IV if uncontrolled ischemic chest pain despite NTG (class IIa)
Additional Anti-ischemic Therapy Beta Blockers Oral within 24 hrs. as with STEMI IV beta blocker for HTN if no contraindications (class IIa) Sign of HF Increased risk of cardiogenic shock Relative contraindications of beta-blockade PRI >.24 seconds 2 nd or 3 rd degree HB Active asthma or RAD Calcium Channel Blockers If continuing of frequently recurring ischemia and can t take beta blocker Verapamil or diltiazem preferred if no LV dysfunction or other contraindications Oral long acting verapamil or diltiazem for recurrent ischemia if beta blockers and nitrates have been full used (class IIa) Avoid short acting dihydropyridines (nifedipine, nicardipine)
Anti-ischemic Therapy continued ACEI Oral within 24 hours If pulmonary congestion or LVEF 40% Class IIa recommendations for all patients with UA/NSTEMI ARBs If patient intolerant of ACEI If clinical or X-ray signs of HF LVEF 40%
Anti-platelet Therapy for UA/NSTEMI Aspirin ASAP and indefinitely 162 325 mg Plavix 300 mg (or higher) if patient unable to take ASA 75 mg daily for at least 1 month and ideally up to 1 year
If Invasive Therapy is Planned: Prior to Cath Lab Plavix 600 mg recommended Up to 900 mg has be used IIb/IIIa Inhibitor Eptifibatide (Integrilin) or Tirofiban (Aggrastat) preferred Abciximab (ReoPro) only if there is no delay to angiography and PCI is planned for sure
Anticoagulant Therapy Should be added to antiplatelet therapy ASAP Invasive Therapy Enoxaparin (lovenox) or UFH Bivalirudin (Angiomax) or fondaparinux (Arixtra) are acceptable alternatives Medical Therapy Enoxaparin or fondaparinux are preferable to UFH unless CABG planned within 24 hours Fondaparinux is preferred if patient at increased risk of bleeding
Long-term Therapy & Secondary Prevention
Additional long-term therapy & Prevention Prevention Calcium Channel Blockers For ischemic symptoms when beta blockers not effective or not tolerated Lipid Management New LDL-C goal is < 100 mg/dl (< 70 reasonable) Statin if baseline LDL-C is 100 mg/dl ( use highest dose immediately)
Discharge Medications Following ACS ACEI ASA Plavix Beta Blocker ARB if ACEI intolerant Statin
As part of other AHA guidelines, must also monitor/assess Smoking Cessation Weight Management Diabetes Management HbA1c < 7% Lipid Management LDL should be < 100 mg/dl and further reduction to < 70 mg/dl is reasonable Blood Pressure Control < 140/90 mmhg or < 130/80 if pt. has DM or chronic kidney disease Physical Activity Influenza Vaccination Projections have shown that implementation of secondary guidelines could result in saving more than 80,000 lives each year
Insulin drip control The presence of hyperglycemia in critically ill pts. Has been linked to adverse effects including multiple organ failure and death The Portland Diabetic Project was the first study to show the relationship between high blood glucose levels and increased risk of death, infection and length of hospital stay in cardiac surgery pts. Also showed that the use of an IV insulin infusion eradicated some of these complications Created the Portland Protocol that has been used since 1992 for tight glucose control Target 70-110
NICE - SUGAR Study was a multi-center, international controlled study with patients recruited from Intensive Care Units throughout Australia, New Zealand, Canada and the USA Treatment groups assigned either target blood glucose of 81-108 or 144-180 Found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less resulted in lower mortality than did a target of 81 to 108 Severe hypoglycemia in intensive control group
DVT Prophylaxis Up to 2 million Americans suffer from DVT blood clots annually Approximately 300,000 patients die annually from pulmonary embolism; the majority of which result from DVT Complications from DVT will kill more Americans than AIDS and breast cancer combines Approximately 10% of all hospital deaths are directly attributed to PE DVT is the #1 cause of preventable hospital deaths
To meet National Patient Safety Goals, all patients are assessed upon admission for their risk of DVT The risk assessment tool looks at: Recent hip/joint surgery, fractures, trauma or spinal cord injury with resulting paralysis within the prior month History of DVT/PE of family history of clots/blood-clotting disorders Cancer, recent surgery lasting > 45 minutes, Limited mobility secondary to plaster cast, recently confined to bed > 72 hrs, central venous access Varicose veins, IBS/crohn s disease/ulcerative colitis, overweight/obese, MI, CHF, lung disease, serious infection Age Use of birth control or Hormone replacement therapy Pregnant or gave birth within last month
Lovenox Low molecular weight heparin Indicated for: Prophylaxis of DVT in abdominal surgery, hip replacement surgery, knee replacement surgery or medical patients with severely restricted mobility during acute illness Hip/Knee: 30 mg q12 hrs SC provided hemostasis established Hip: 40 mg SC 12 hrs. prior to OR the daily for 3 weeks Inpatient treatment of acute DVT with or without pulmonary embolism 1mg/kg q12 hrs. SC or 1.5mg/kg daily SC
Outpatient treatment of acute DVT without pulmonary embolism 1 mg/kg q12 hours SC Prophylaxis of ischemic complications of unstable angina and non-q wave MI 1 mg/kg SC q12 hours with ASA PO 100 325 mg daily Treatment of acute STEMI managed medically or with subsequent percutaneous coronary intervention IV bolus of 30 mg plus a 1 mg/kg SC dose followed by a 1 mg/kg SC q 12hours
Heart Failure Complex clinical syndrome resulting from any structural or functional disorder impairing the ability of the ventricle to either fill or eject Affects 5 million in US Majority of pts. Have impaired left ventricular function Causes impaired functional capacity and quality of life Clinical syndrome resulting in Dyspnea and fatigue And/or fluid overload
Systolic Dysfunction
Diastolic Dysfunction
Left-sided Heart Failure Decrease in CO/stroke volume Pressure rises in the LV, LA, and pulmonary vasculature Hydrostatic forces can cause intracellular fluid to accumulate in the pulmonary capillary bed (pulmonary congestion) Signs/symptoms result from elevated pulmonary pressures (SOB/paroxysmal nocturnal dyspnea) Right sided Heart Failure Typically follows left-sided failure Isolated RV failure (COPD, pulmonary HTN) Pressure increases in the right side of heart Hydrostatic pressures force more blood into the systemic venous circulation Causing neck vein distention, peripheral edema, weight gain, engorgement of hepatic and gastric vessels
Heart Failure as Progress Disorder
Ace-Inhibitors Definitive evidence of mortality/morbidity reduction Interferes with ventricular remodeling Slows disease progression Used for mortality benefit not symptom relief May need to adjust diuretic dose and monitor K+ Suffix: pril Angiotensin Receptor Blockers (ARBs) Remain first choice for inhibition of RAAS Reasonable alternative to ACE inhibitor if intolerant due to cough or angioedema Combination of ACE-I and ARB not considered appropriate Suffix: sartan
Beta-blockers Decrease mortality/hospitalization Even better in combination with ACE-I Enhances overall well-being Slows disease progression Inhibits ventricular remodeling and apoptosis Decrease myocardial oxygen consumption Suffix: olol Diuretics Goal is to decrease congestive symptoms Loop diuretics preferred Keep K+ <4 and Mg >2
Digoxin For pts. With persistent symptoms already on ACE-I, Betablockers and diuretic Weak Positive inotropic effect Improved symptoms, exercise tolerance and quality of life Aldosterone Antagonists Pts. Already on ACE-I, Beta-Blocker, Diuretics, Digoxin Reduces death and rehospitalizations Spironolactone (RALES Trial) Survival benefit in NYHA Functional Class 3 or 4 HF High risk for hyperkalemia Don t initiate in pts. With elevated creatinine or elevated potassium
Warfarin recommended if has HF and A. Fib Antiarrhythmics ICD if had VF or unstable VT Amiodarone Medications for Diastolic Dysfunction are essentially the same Add Calcium Channel Blockers to control BP, decrease HR Suffix: pine Worsen systolic dysfunction
Left Ventricular Assist Device
New treatment of HF directed toward molecular cardiology The mapping of the human genome has opened up studies to look at the actual biochemical pathways of human health, disease and development As far as cardiovascular medicine, it has been realized into two pathways: Predictive diagnosis Pharmaceuticals Stem cell therapy to build new blood vessels and heart muscle