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Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit

Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit. Adapted from Dr Chris Cannon STRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines - 2007. Anticoagulants.

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Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit

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  1. Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit Adapted from Dr Chris Cannon STRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines - 2007

  2. Anticoagulants • Enoxaparinmore effective in preventing combined end point of death or MI vsUnfractionated heparin (UFH). • Avoid cross-over during PCI Last SC dose >8 hrs, 0.3 mg/kg of iv. Last SC dose <8 hours, no additional enoxaparin.

  3. Anticoagulants • Bivalirudin (single therapy) lower risk of bleeding compared to Enoxaparin and UFH. Approved only for early PCI. • Fondaparinux Lower risk of bleed but increased risk of catheter-related thrombi, to switch to UFH in Cath Lab.

  4. Lipid Management • Fasting lipid profile workup within 24h [Class I, LOE: C] • Statin regardless of LDL-C [Class I, LOE: A]

  5. Beta-blockers Ellis K, et al. 6-month mortality in ACS pts undergoing PCI 1.7% Beta-blockers vs 3.7% without beta-blockers. (Pooled results from EPIC, EPILOG, RAPPORT, CAPTURE and EPISTENT J Interv Cardiol 2003;16:299–305.)

  6. Beta-blockers ACC/AHA 2007 Class 1 (LOE B)# Oral therapy initiated ≤24 h if NO • Heart failure • Low-output state • Increased risk for cardiogenic shock • Relative contraindications • PR ›0.24 s • 2nd or 3rd degree heart block • Reactive airway disease

  7. Angiotensin-aldosterone inhibitors • Pulmonary congestion or LVEF ≤ 40% - ACEI within 24h or ARB if intolerant. • LV dysfunction, hypertension or diabetes – Long-term ACEI or ARB. • LVEF ≤ 40% and symptomatic heart failure or diabetes (without renal dysfunction/hyperkalemia) Aldosterone-receptor blockade in addition to ACEI.

  8. Optimal Discharge Planning • Optimal blood pressure <140/90 mm Hg [Class I, LOE: A] <130/80 in diabetes or chronic kidney disease mm Hg [Class I, LOE: A] • Discharge education Medication use, cardiac rehabilitation, lifestyle modification (diet, exercise & smoking cessation) [Class I, LOE: C] • Follow-up 2-6 weeks in low risk, medically treated, revascularized, 14 days high risk [ Class I, LOE: C]

  9. GET WITh the GUIDELINES TOOL KIT

  10. Early invasive strategy

  11. Early conservative strategy

  12. Cardiac Admission Checklist

  13. Cardiac Admission Checklist

  14. Cardiac Discharge Prescription

  15. Adapted byKamelia Emamian M.D. and Thao Huynh, MD, MSC.

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