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Line 207: |
Line 207: |
| :❑ Discontinue [[bivalirudin]] (3 hours prior to CABG) and dose with UFH (I-B)</div> | | :❑ Discontinue [[bivalirudin]] (3 hours prior to CABG) and dose with UFH (I-B)</div> |
| |M04= }} | | |M04= }} |
| {{familytree/end}}
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|
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| ====Management Following Angiography====
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|
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| {{Family tree/start}}
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| {{familytree | | | | | | | | | | | A01 | | | | | | | | A01= '''Did the patient undergo angiography?'''}}
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| {{familytree | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | }}
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| {{familytree | | | | | B01 | | | | | | | | | | | B02 | B01= Yes| B02= No}}
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| {{familytree | | | | | |!| | | | | | | | | | | | |!| | }}
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| {{familytree | | | | | C01 | | | | | | | | | | | |!| | C01= <div style="float: left; text-align: left; width: 17em; padding:1em;">'''Does the [[angiography]] show coronary vessel obstruction ?'''</div> }}
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| {{familytree | | |,|-|-|^|-|-|.| | | | | | | | | |!| | | | }}
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| {{familytree | | D01 | | | | D02 | | | | | | | | |!| | | | D01= '''No'''| D02= '''Yes'''}}
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| {{familytree | | |!| | | |,|-|^|-|-|-|-|-|.| | | |!| | | }}
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| {{familytree | | |!| | | E01 | | E02 | | E03 | | |!| | E01=<div style="float: left; text-align: left; width: 17em; padding:1em;">❑ 1 or 2 vessel disease <br> ''[[CABG]] or medical therapy might also be considered'' </div>|E02=<div style="float: left; text-align: left; width: 17em; padding:1em;">❑ Left main coronary artery disease <br>❑ 3 vessel disease <br>❑ 2 vessel disease with proximal left anterior descending artery affection <br>❑ [[Left ventricular dysfunction]] <br> ❑Patient treated from [[diabetes]]</div>| E03= }}
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| {{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |}}
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| {{familytree | | L03 | | L01 | | L02 | | L03 | | L04 | | L01= '''[[PCI]]''' <br>
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| | L02= '''[[CABG]]''' <BR>
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| | L03= '''Medical treatment'''
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| |L04= }}
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| {{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | | }}
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| {{familytree | | M01 | | M02 | | M03 | | M04 | | M05 | | | M01= <div style="float: left; text-align: left; width: 17em; padding:1em;"> ❑ Continue [[aspirin]] <br>
| |
| ❑ Administer a loading dose of [[P2Y12]] receptor inhibitors (if not given before angiography)
| |
| :❑ [[Clopidogrel]] (600 mg), or <br>
| |
| :❑ [[Prasugrel]] (60 mg) <br>
| |
| ❑ Discontinue IV [[GP IIb/IIIa]] inhibitors if started <br>
| |
| ❑ Manage [[antithrombotic]] therapy if given before angiography:
| |
| :❑ Continue IV [[UFH]] for 48 hours or until discharge
| |
| :❑ Continue [[enoxaparin]] for entire hospital stay, up to 8 days
| |
| :❑ Continue [[fondaparinux]] for entire hospital stay, up to 8 days
| |
| :❑ Discontinue [[bivalirudin]] or continue, 0.25 mg/kg/hour for up to 72 hours</div> |M02= <div style="float: left; text-align: left; width: 17em; padding:1em;"> ❑ Administer [[aspirin]] for life <br>
| |
| ❑ Administer a loading dose of [[P2Y12]] receptor inhibitor (if not initially started)<br>
| |
| :❑ [[Clopidogrel]] 600 mg<br>
| |
| :❑ [[Ticagrelor]] 180 mg<br>
| |
| :❑ [[Prasugrel]] 60 mg<br>
| |
| ❑ Discontinue anticoagulant therapy following PCI in uncomplicated cases (I-B)</div>
| |
| | M03=<div style="float: left; text-align: left; width: 17em; padding:1em;">
| |
| ❑ Continue [[aspirin]] (I-A)<br>
| |
| ❑ Discontinue IV [[GP IIb/IIIa]] inhibitors (4 hours before CABG) (I-B)<br>
| |
| ❑ Manage the P2Y12 receptor inhibitor therapy as follows ''if CABG can be delayed'' (depending on whether benefits of CABG outweigh the risk of bleeding) (I-B):<br>
| |
| :❑ Discontinue clopidogrel (5 days prior to CABG) (I-B)<br>
| |
| :❑ Discontinue ticagrelor (5 days prior to CABG) (I-C)<br>
| |
| :❑ Discontinue prasugrel (7 days prior to CABG) (I-C)<br>
| |
| ❑ Manage the [[anticoagulation]] therapy <br>
| |
| :❑ Continue [[UFH]] (I-B)
| |
| :❑ Discontinue [[enoxaparin]] (12-24 hours prior to CABG) and dose with UFH (I-B)<br>
| |
| :❑ Discontinue [[fondaparinux]] (24 hours prior to CABG) and dose with UFH (I-B)<br>
| |
| :❑ Discontinue [[bivalirudin]] (3 hours prior to CABG) and dose with UFH (I-B)</div>
| |
| |M04=
| |
| |M05= }}
| |
| {{familytree/end}} | | {{familytree/end}} |
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention based on the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction.[1]
Boxes in the red color signify that an urgent management is needed.
| | | Identify cardinal findings of unstable angina/ NSTEMI :
❑ Chest pain or chest discomfort
- ❑ Sudden onset
- ❑ Sensation of heaviness, tightness, pressure, or squeezing
- ❑ Duration> 20 minutes (but usually less than half an hour)
- ❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium
- ❑ No relief with medications
- ❑ No relief with rest
- ❑ Worse with time
- ❑ Worse with exertion
- ❑ Associated symptoms of palpitations, nausea, vomiting, sweating, dyspnea, and lightheadedness
❑ Characteristic ECG changes consistent with unstable angina/ NSTEMI
- ❑ No changes
- ❑ Non specific ST / T wave changes
- ❑ Flipped or inverted T waves
- ❑ ST depression (carries the poorest prognosis)
❑ Increase in >99th percentile of upper limit of normal of troponin and / or CK MB , which is consistent with NSTEMI | |
| | | | | | | | |
| | | Rule out life threatening alternative diagnoses:
❑ Aortic dissection (suggestive findings: back pain, interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms)
❑ Pulmonary embolism (suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT)
❑ Cardiac tamponade (suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus)
❑ Tension pneumothorax (suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound)
❑ Esophageal rupture (suggestive findings: vomiting, subcutaneous emphysema) |
| | | | | | | | |
| | | Begin initial treatment: ❑ Administer aspirin (I-A)
- ❑ 162 to 325 mg of non enteric aspirin,orally, crushed or chewed, THEN
- ❑ 75 to 325 mg/day
- Among patients with either GI intolerance or hypersensitivity to aspirin, administer a loading dose followed by maintenance dose of either clopidogrel (I-B), or prasugrel in PCI patients (I-C), or ticagrelor (I-C)
❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90%
- ❑ Caution in COPD patients: maintain an oxygen saturation between 88% and 92%
❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure
Contraindicated in heart failure , prolonged or high degree AV block , reactive airway disease , high risk of cardiogenic shock and low cardiac output state
- ❑ Metoprolol IV, 5 mg every 5 min, up to 3 doses, then 25 to 50 mg orally every 6 hours
- ❑ Carvedilol IV, 25 mg, two times a day
❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
Contraindicated in suspected right ventricular MI , recent use of phosphodiesterase inhibitors , decreased blood pressure 30 mmHg below baseline
❑ Administer IV morphine if persistent symptoms or pulmonary edema
- ❑ Initial dose 4-8 mg
- ❑ 2-8 mg every 5 to 15 minutes, as needed
❑ Administer 80 mg atorvastatin
❑ Monitor with a 12-lead ECG all the time
| | | | |
| | | | | | | | |
| | | TRIAGE FOR IMMEDIATE INTERVENTION Does the patient have any of the following indications that require immediate angiography and revascularization ?
❑ Hemodynamic instability or cardiogenic shock
❑ Severe left ventricular dysfunction or heart failure
❑ Recurrent or persistent rest angina despite intensive medical therapy
❑ New or worsening mitral regurgitation or new VSD
❑ Sustained VT or VF
❑ Prior PCI within past 6 months or CABG |
| | | | | | | | | | | | |
| | | | | | | |
YES | | | | NO | | |
| | | | | | | | | | | | | |
| | | | | | | Does the patient have negative ECG findings AND negative biomarkers? | | |
| | | | | | | | | | | | | | | |
| | | | | |
| | | | | Yes | | No |
| | | | | | | | | | | | | | |
| | | | | Repeat ECG and biomarkers within next 6 hours and 12 hours | | | | | |
| | | | | | | | | | | | | | | |
| | | | | |
| | | ECG and biomarkers are both negative | | At least one (ECG or biomarkers) is positive | | |
| | | | | | | | | | | | | | |
| | | | | | | | |
| | | | | | | | | | | | | | | |
| | | | | |
| | | | | Intermediate or high risk | | Low risk |
| | | | | | | | | | | | | | |
IMMEDIATE initial invasive strategy
| | Initial invasive strategy (4 to 48 hours) | | Initial conservative strategy | |
| | | | | | | | | | | | | | |
| | Initiate ONE of the following anticoagulant therapy (I-A)
❑ Enoxaparin (I-A), OR
❑ Unfractionated heparin
- ♦ If GP IIb/IIIa receptor antagonist is planned
- ❑ 50- to 70-U/kg IV bolus
- ♦ If no GP IIb/IIIa receptor antagonist is planned
- ❑ 70- to 100-U/kg bolus
, OR
❑ Bivalirudin (I-B)
- ❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion
- ❑ Additional bolus of 0.3 mg/kg if needed
- ❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min, OR
❑ Fondaparinux (I-B), OR
Administer ONE of the following antiplatelet agents (before OR at the time of PCI) (I-A)
Before PCI
❑ Loading dose of P2Y12 receptor inhibitors
- ❑ Clopidogrel (600 mg) (I-B), OR
- ❑ Ticagrelor (180 mg) (I-B)
OR
❑ IV GP IIb/IIIa inhibitors (I-A)
- ❑ Eptifibatide
- ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
- ❑ Maintenance dose 2 mcg/kg/min, OR
- ❑ Tirofiban
- ❑ Loading dose 25 mcg/kg
- ❑ Maintenance dose 0.15 mcg/kg/min
OR
At the time of PCI
❑ Loading dose of P2Y12 receptor inhibitors
- ❑ Clopidogrel (600 mg) (I-A), OR
- ❑ Ticagrelor (180 mg) (I-B), OR
- ❑ Prasugrel (60 mg) (I-B)
Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
OR
❑ IV GP IIb/IIIa inhibitors (I-A)
- ❑ Eptifibatide
- ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
- ❑ Maintenance dose 2 mcg/kg/min, OR
- ❑ Tirofiban
- ❑ Loading dose 25 mcg/kg
- ❑ Maintenance dose 0.15 mcg/kg/min
| | | | Initiate ONE of the following anticoagulant therapy (I-A)
❑ Enoxaparin (I-A), OR
❑ UFH (I-A), OR
❑ Fondaparinux (I-B), OR
- Enoxaparin or fondaparinux preferred over UFH (II-B)
Administer ONE of the following antiplatelet agents (I-B):
❑ Clopidogrel (I-B)
- ❑ Loading dose (300 mg)
- ❑ Maintenance dose for up to 12 months (75 mg)
❑ Ticagrelor (I-B)
- ❑ Loading dose (180 mg)
- ❑ Maintenance dose for up to 12 months (90 mg twice daily)
| |
| | | | | | | | | | | | | |
| | | | | | | | | TRIAGE FOR NEED OF INVASIVE THERAPY Does the patient experience any of the following?
❑ Recurrence of symptoms
❑ Heart failure
❑ Serious arrhythmia
❑ Subsequent ischemia | |
| | | | | | | | | | | | | | | |
| | | | | | |
| | | | | Yes | | No |
| | | | | | | | | | | | | |
| | | | | ❑ Perform diagnostic angiography (I-A)
Administer upstream antiplatelet agent:
❑ P2Y12 receptor inhibitors
- ❑ Clopidogrel
- ❑ Loading dose (600 mg)
- ❑ Maintenance dose (75 mg), or
- ❑ Ticagrelor
- ❑ Loading dose (180 mg)
- ❑ Maintenance dose (90 mg twice daily), or
❑ IV GP IIb/IIIa inhibitors
- ❑ Eptifibatide
- ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
- ❑ Maintenance dose 2 mcg/kg/min, or
- ❑ Tirofiban
- ❑ Loading dose 25 mcg/kg
- ❑ Maintenance dose 0.15 mcg/kg/min
| | TRIAGE PATIENTS BY RISK ON STRESS TEST ❑ Perform a stress test (I-B) |
| | | | | | | | | | | | | | | | |
| | | | | |
| | | | | | | High risk on stress test | | Low risk on stress test |
| | | | | | | | | | | | | | | | |
| | | | | | | | | | | | |
| | | | | | | | | | | | |
| | | | | | | | | | | | | | |
| | | TRIAGE FOR SUBSEQUENT THERAPY PLAN FOLLOWING ANGIOGRAPHY Does the angiography show coronary vessel obstruction ? | | | | | | | |
| | | | | | | | | | | | | | | |
| | | | | | |
| No | | | | Yes | | | |
| | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | |
| | | | | | ❑ 1 or 2 vessel disease CABG or medical therapy might also be considered | | ❑ Left main coronary artery disease ❑ 3 vessel disease ❑ 2 vessel disease with proximal left anterior descending artery affection ❑ Left ventricular dysfunction ❑Patient treated from diabetes | | | |
| | | | | | | | | | | | | | | | | | | | | |
| Medical treatment | | PCI
| | CABG
| | Medical treatment | |
| | | | | | | | | | | | | | | | | | | | | |
| ❑ Continue aspirin
❑ Administer a loading dose of P2Y12 receptor inhibitors (if not given before angiography)
- ❑ Clopidogrel (600 mg), or
- ❑ Prasugrel (60 mg)
❑ Discontinue IV GP IIb/IIIa inhibitors if started
❑ Manage antithrombotic therapy if given before angiography:
- ❑ Continue IV UFH for 48 hours or until discharge
- ❑ Continue enoxaparin for entire hospital stay, up to 8 days
- ❑ Continue fondaparinux for entire hospital stay, up to 8 days
- ❑ Discontinue bivalirudin or continue, 0.25 mg/kg/hour for up to 72 hours
| | ❑ Administer aspirin for life
❑ Administer a loading dose of P2Y12 receptor inhibitor (if not initially started)
- ❑ Clopidogrel 600 mg
- ❑ Ticagrelor 180 mg
- ❑ Prasugrel 60 mg
❑ Discontinue anticoagulant therapy following PCI in uncomplicated cases (I-B) | |
❑ Continue aspirin (I-A)
❑ Discontinue IV GP IIb/IIIa inhibitors (4 hours before CABG) (I-B)
❑ Manage the P2Y12 receptor inhibitor therapy as follows if CABG can be delayed (depending on whether benefits of CABG outweigh the risk of bleeding) (I-B):
- ❑ Discontinue clopidogrel (5 days prior to CABG) (I-B)
- ❑ Discontinue ticagrelor (5 days prior to CABG) (I-C)
- ❑ Discontinue prasugrel (7 days prior to CABG) (I-C)
❑ Manage the anticoagulation therapy
- ❑ Continue UFH (I-B)
- ❑ Discontinue enoxaparin (12-24 hours prior to CABG) and dose with UFH (I-B)
- ❑ Discontinue fondaparinux (24 hours prior to CABG) and dose with UFH (I-B)
- ❑ Discontinue bivalirudin (3 hours prior to CABG) and dose with UFH (I-B)
| | | |