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

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• 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
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Anticoagulants

• Enoxaparin more effective in preventing combined
  end point of death or MI vs Unfractionated
  heparin (UFH).
• Avoid cross-over during PCI
• Last SC dose gt8 hrs, 0.3 mg/kg of iv.
• Last SC dose lt8 hours, no additional
  enoxaparin.

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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.

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Lipid Management

• Fasting lipid profile workup within 24h Class I,
  LOE C
• Statin regardless of LDL-C Class I, LOE A

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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 200316299305.)

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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

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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.

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Optimal Discharge Planning

• Optimal blood pressure
• lt140/90 mm Hg Class I, LOE A
• lt130/80 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

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GET WITh the GUIDELINES TOOL KIT
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Early invasive strategy
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Early conservative strategy
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Cardiac Admission Checklist
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Cardiac Admission Checklist
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Cardiac Discharge Prescription
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Adapted byKamelia Emamian M.D. and Thao Huynh,
MD, MSC.