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
NTG
Morphine
• As needed to keep
SaO2 > 90%
• 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
• IV if uncontrolled
ischemic chest pain
despite NTG (class
IIa)
Additional Anti-ischemic Therapy
Beta Blockers
Calcium Channel Blockers
• Oral within 24 hrs. as with
STEMI
• IV beta blocker for HTN if no
contraindications (class IIa)
• 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)
– Sign of HF
– Increased risk of cardiogenic
shock
– Relative contraindications of
beta-blockade
• PRI > .24 seconds
• 2nd or 3rd degree HB
• Active asthma or RAD
Anti-ischemic Therapy continued
ACEI
ARBs
Oral within 24 hours
If patient intolerant of ACEI
• If clinical or X-ray signs of HF
• LVEF ≤ 40%
• If pulmonary congestion or
LVEF ≤ 40%
• Class IIa recommendations
for all patients with
UA/NSTEMI
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
IIb/IIIa Inhibitor
• 600 mg
recommended
• Up to 900 mg has be
used
• 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
Medical Therapy
• Enoxaparin (lovenox) or
UFH
• Bivalirudin (Angiomax) or
fondaparinux (Arixtra) are
acceptable alternatives
• 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
Right 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)
• 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