Unstable Angina /Non-ST Elevation Myocardial Infarction

Critical Pathway Toolkit

Adapted from Dr Chris CannonSTRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines - 2007

Anticoagulants

Enoxaparin more effective in preventing combined end point of death or MI vs Unfractionated heparin (UFH).

Avoid cross-over during PCILast SC dose >8 hrs, 0.3 mg/kg of

iv.Last SC dose <8 hours, no

additional enoxaparin.

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.

Lipid Management

Fasting lipid profile workup within 24h [Class I, LOE: C]

Statin regardless of LDL-C [Class I, LOE: A]

Beta-blockers

Ellis K, et al. 6-month mortality in ACS pts undergoing PCI1.7% Beta-blockers vs 3.7% without beta-blockers.

(Pooled results from EPIC, EPILOG, RAPPORT, CAPTURE and EPISTENT J Interv Cardiol 2003;16:299–305.)

Beta-blockers

ACC/AHA 2007 Class 1 (LOE B)#Oral therapy initiated ≤24 h if NOHeart failure Low-output stateIncreased risk for cardiogenic shockRelative contraindications PR ›0.24 s2nd or 3rd degree heart blockReactive airway disease

Angiotensin-aldosterone inhibitorsPulmonary 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.

Optimal Discharge PlanningOptimal 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-up2-6 weeks in low risk, medically treated, revascularized,

14 days high risk [ Class I, LOE: C]

Cardiac Admission Checklist

Cardiac Admission Checklist

Cardiac Discharge Prescription

Adapted by

Kamelia Emamian M.D. and Thao Huynh, MD, MSC.