Transcript STRIVE Lecture 1 - Clinical Trial Results

EMS Reperfusion Checklist: Evaluation of the STEMI Patient
Step 1:
Has patient experienced chest discomfort for > 15 min and < 12 h?
YES
Step 2:
STOP
NO
Are there contraindications to fibrinolysis? If ANY of the following are
CHECKED, fibrinolysis MAY be contraindicated.
Systolic BP greater than 180 mm Hg
Diastolic BP greater than 110 mm Hg
Right vs left arm systolic BP difference greater than 15 mm Hg
History of structural central nervous system disease
Significant closed head/facial trauma within the previous 3 months
Recent (< 6 wk) major trauma, surgery (including laser eye surgery), GI/GU bleed
Bleeding or clotting problem or on blood thinners
CPR greater than 10 min
Pregnant female
Serious systemic disease
(eg, advanced/terminal cancer, severe liver or kidney disease)
Step 3:
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Is patient at high risk such that PCI is preferable?
Heart rate greater than or equal to 100 bpm
Pulmonary edema (rales greater than halfway up)
Systolic BP less than 100 mm Hg
Systemic hypoperfusion (cool, clammy)
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Adapted from Antman
EM, et al. Available
at:
http://www.acc.org/cli
nical/guidelines/stemi/
index.pdf.
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STEMI Critical Pathways
ST-ELEVATION MI (STEMI): EMERGENCY DEPARTMENT ORDERS
ALLERGIES
 Actual
 Estimated
 Actual
 Estimated
WEIGHT____________  kg
 lbs
HEIGHT ____________  cm
 ft
DO NOT USE THESE UNSAFE ABBREVIATIONS
“U” and “IU” should be unit, “Ug” should be mcg. “QD” should be daily. “QOD” should be every other day. “BIW” should be
two times a week. “TIW” should be three times a week, “AU”, “AS”, “OS”, and “OD” should be written out in full. Correct
Use of Leading and Trailing Zeros – Always Leading Never Trailing. .1 should be 0.1 and 1.0 should be 1
Initial Orders
Check all that apply
DIAGNOSTICS
 Stat EKG, obtain old EKG record  Repeat stat EKG 60 minutes after initial bolus of Retavase
 Start Acute Coronary Syndrome Lab Panel: CMP, CBC/diff, PT/INR/aPTT, CK + CK-MB (site specific),
Troponin-I, Magnesium, hs-CRP, lipid profile (routine)
 Stat portable CXR  Cardiac monitor and SaO2 monitors  Other ______________________________________
ANTI-ISCHEMIC THERAPY
 Oxygen 2L/minute Nasal Cannula (titrate to keep pulse oximetry saturations > 94%)
 IV – 0.9 NS:  Intermittent Infusion Device  KVO ____ ml/hour
 Opiate: __________________________________ mg IV (suggest Morphine Sulfate)
Nitroglycerin Therapy (Hold if patient has taken Sildenafil (Viagra) within 24 hours)
 NTG 0.4mg SL every 5 minutes X 3 doses or until pain relief or systolic BP < 100 mm Hg
 NTG paste _______________________inch(es) topically X 1
 IV- start NTG infusion at 10 mcg/minute, then titrate as per pharmacy protocol (use 100mg in 250 ml D 5W)
ANTI-THROMBOTIC THERAPY
 Aspirin 162 mg po (2 chewable 81 mg tablets)
Corbelli J, et al. Critical Pathways in Cardiology. 2003;2:71-87.
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STEMI Critical Pathways
Reperfusion Therapy
Indications: Chest pain <12 hours, EKG ST-elevations or new left bundle branch block
Fibrinolysis Indications



3-hr symptom onset
Delay in PCI (door-to-balloon >90 min)
Contraindications to PCI: poor arterial access, renal failure, dye allergy
Assess for contraindications for fibrinolytic therapy:
1. History of hemorrhagic stroke at any time; other stroke or cerebrovascular event within 1 year
2. Known intracranial neoplasm
3. Active internal bleeding
4. Suspected aortic dissection (consider CT of chest)
 Reteplase (Retavase) 10 units IV bolus, repeat 10 units IV bolus at 30 minutes
HEPARIN THERAPY: (administer simultaneously with Retavase):
 Unfractionated heparin: ___units IV bolus (1000 units/ml), then ___units/hour IV infusion
Note: When using a fibrinolytic (eg, reteplase): Use Cardiac Unfractionated Heparin Nomogram on back of form
Primary PCI Indications



>3-hr symptom onset
Presence of cardiogenic shock, CHF, contraindications to fibrinolysis
 Stat cardiology consult/catheterization lab page
 Eptifibatide (Integrilin) _____ml IV bolus, then ____ml/hr IV infusion (dosing nomogram on back of form)
(Dose adjustment based on serum creatinine may be required.)
 Unfractionated heparin _____ units IV bolus (1000 units/ml), then ______units/hour IV infusion
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Sample Critical Pathways Grid: UA/NSTEMI
STRIVE Scientific Committee
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Sample Pocket Card (front)
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Sample Pocket Card (back)
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Smooth Transition From Acute
to Long-Term Management
Cardiology
Acute Care
Guidelines
•
•
•
•
Primary Care
Secondary
Prevention
Follow guidelines
Improve communications
Ensure compliance
Improve quality of care
and outcomes
Adapted from the American Heart Association. Get With The Guidelines. 2001.
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Discharge Protocols

Enhance communication with
patient and between specialist(s)
and primary care physicians1

Medications: aspirin, clopidogrel,
ACE inhibitor, β-blocker, statin1

Diet, exercise, smoking
cessation recommendations1

Patient symptom awareness,
“Act in Time” protocol2

Wallet-/purse-sized copy of ECG3

Follow-up appointments1
1. American Heart Association Web site. Get With The Guidelines. Available at:
http://www.americanheart.org/presenter.jhtml?identifier=1165.
2. Act in Time to Heart Attack Signs Campaign. Available at:
http://www.nhlbi.nih.gov/actintime/index.htm.
3. Greenberg DI, et al. J Cardiovasc Manag. 2004;15:16-18.
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Sample Cardiac Discharge Checklist UA/NSTEMI
STRIVE Scientific Committee
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Sample Letter to Patient’s PCP at Discharge for UA/NSTEMI
Dear Dr. ________________:
Your patient, (name), has been discharged on (date) following treatment for ____ days with a
diagnosis of acute coronary syndromes (unstable angina ___ or non-ST-segment elevation
myocardial infarction ___). Risk stratification at discharge was _______________________.
The patient underwent the following procedures: PCI _____ CABG _____
The following medications have been prescribed post-discharge:
Aspirin + clopidogrel:
Aspirin at a dose of _____ mg/d
Clopidogrel at a dose of 75 mg/d
Nitrates (________________) at a dose of ______ mg/d
Beta-blocker (________________) at a dose of ______ mg/d
ACE inhibitor (________________) at a dose of ______ mg/d
Calcium channel blocker (________________) at a dose of ______ mg/d
Lipid-lowering agent(s)(__________________) at a dose of ______ mg/d
Other: ________________________________________________________________
The following counseling concerning risk modification was
provided:______________________
Follow-up is strongly recommended in these areas:
___________________________________
If you have questions, please contact me at: telephone_______________
voice mail ____________ email_______________________________
Sincerely,
(Hospital discharge report attached)
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