Pocket Guide + The Management of Patients With Acute Myocardial Infarction

8/12/2019 Pocket Guide + The Management of Patients With Acute Myocardial Infarction

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TheManagement

of PatientsWithAcute

MyocardialInfarction(A Report of the American Collegeof Cardiology/American Heart Association

Task Force on Practice Guidelines)

April, 2000

ACC/ AHAPocketGuidelines


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ACC/ AHA Pocket Guidelines for

The Management

of Patients withAcute MyocardialInfarction(A Report of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines)

Writing Committee

Thomas J. Ryan, MD, FACC, ChairElliott M.Antman, MD, FACC

Neil H. Brooks, MD, FAAFPRobert M. Califf, MD, FACCL. David Hillis, MD, FACCLoren F. Hiratzka, MD, FACCElliot Rapaport, MD, FACCBarbara Riegel, DNSc, FAANRichard O. Russell, MD, FACCEarl E. Smith, III, MD, FACEPW. Douglas Weaver, MD, FACC

April, 2000

Distributed throughan educational grant from

Genentech, Inc.

Genentech, Inc. was notinvolved in the development ofthis publication and in no way

influenced i ts contents.

Special thanks to


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2000 American College of Cardiologyand American Heart Association, Inc.

The following material was adapted from the AC C/ AH A Gu idelin es for Th e M an agem en t of Pat ien tswith Acute Myocardial Infarction: 1999 Update.For acopy of the full report or Executive Summary as pub-lished in JAC Cand Circulation,visit our Web sites athttp://www.acc.orgor http://www.americanheart.orgorcall the ACC Resource Center at 1-800-253-4636,ext.694.

Contents

II. Initial Assessment and Evaluation . . . . . . . . . . . 6

III. Initial Management . . . . . . . . . . . . . . . . . . . . . .12

IV. Hospital Management . . . . . . . . . . . . . . . . . . . . . . 24

V. MI Management Summary . . . . . . . . . . . . . . . . .27

VI. Preparation forDischarge from the Hospital . . . . . . . . . . . . . . . . . . . 30

I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

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The classification of indications for adiagnostic procedure or a specific therapy isexpressed in the standard ACC/ AHA format:

Class I Conditions for which there is evidence and/orgeneral agreement that a given procedure ortreatment is beneficial, useful, and effective.

Class II Conditions for which there is conflicting evidenceand/or a divergence of opinion about the useful-ness/efficacy of a procedure or treatment.

Class IIa Weight of evidence/opinion is in favorof usefulness/efficacy.

Class IIb Usefulness/efficacy is less well established

by evidence/opinion.

Class III Conditions for which there is evidence and/orgeneral agreement that a procedure/treatment isnot useful/effective and in some cases may beharmful.

I. Introduction

his pocket guideline is a distillation of the publica-tion AC C/A H A Guidelin es for th e M an agem en t of

Patients with Acut e Myocardial Infarction. The guidelines

were initially published in the Journal of th e Am ericanCollege of Cardiologyin 1996 (J Am Coll Cardiol 1996;28:1328-428) and updated in September 1999. Therevised text and recommendations are published in the

J Am Coll Cardiol 1999;34:890-911 and Circulation1999;100:1016-1030 (recommendations only).

The full text guidelines incorporating the updates andrevisions are available on the Web sites of both theACC (http://www.acc.org) and the AHA (http://www.americanheart.org) with deleted text indicted by strike-outs and new text presented in highlighted typeface.

This pocket guideline provides rapid prompts forappropriate patient management that is outlined inmuch greater detail in the full-text guidelines. It is notintended as a replacement for understanding thecaveats and rationales carefully stated in the full-textguidelines. Users should consult the full-text documentfor more information.

T


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Differential Diagnosisof Prolonged Chest Pain

AMI

Aortic dissection

Pericarditis

Atypical anginal pain associatedwith hypertrophic cardiomyopathy

Esophageal, other upper gastrointestinal,or biliary tract disease

Pulmonary diseasePneumothoraxEmbolus with or without infarctionPleurisy: infectious, malignant, or immune

disease-related

Hyperventilation syndrome

Chest wallSkeletalNeuropathic

Psychogenic

Emergency Department (ED) Algorithm/Protocolfor Patients with Symptoms and Signs of AMI

II. Initial Assessment and Evaluation

Fibrinolytictherapy

Release

Ambulance presentspatient to ED lobby Patient presentsto ED lobby

Onset ofsymptoms

ED triage or charge nurse triages patient

AMI symptoms and signs 12-lead ECG Brief, targeted history

Emergency nurse initiates emergencynursing care in acute care area of ED

Cardiac monitor Oxygen therapy IV D5W

Blood studies Nitroglycerin Aspirin

Emergency physicianevaluates patient

History Physical exam Interpret ECG

Consult

Uncertain

Uncertain

Consult

Yes

Yes

No

AMIpatient?

Candidatefor fibrinolytic

therapy?

Evaluatefurther

No

Admit

Other indicated treatment:

Other drugs for AMI(beta-blockers, heparin,aspirin, nitrates)

Transfer to cath lab forPTCA or surgery forCABG

Conduct education andfollow-up instruction

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Algorithm for Initial Assessment andEvaluation of the Patient with Acute Chest Pain

Algorithm for Initial Assessment and

Evaluation of the Patient with Acute ChestPain in the Emergency Department

The em ergency department should be organized t o facilitate the

rapid triage of chest pain pat ients so that the in itial evaluation,obtaining a 12-lead electrocardiogram (ECG ), an d establishing

intravenous access and continuous m onitoring are accomplished

within 10 minutes. The path in the decision tree is determined by

the results of the 12-lead EC G. T he presence of ST-segment eleva-

tion diagnostic of AM I or of presum ptively new bu ndle branch

block (BBB ) suggestive of this diagnosis should lead to th e imm edi-

ate consideration of the suitability of the patient for reperfusion

therapy, which, if indicated, should be initiated within 30 minutes

of the patients arrival. The primary PT CA option is applicable

only in those settings in which it is imm ediately available and can

be performed by highly qualified interven tiona l cardiologists. In

general, patients should not be transferred for angioplasty if fibri-

nolysis is an option. Fibrinolysis is not in dicated in pat ients with

only S T-segmented depression.

Chest pain consistent with coronary ischemia

Within 10 minutes Initial evaluation Establish IV access Blood for baseline serum

cardiac markers

12 lead ECG Establish continuous ECG monitoring Aspirin 160-325 mg-chewed

ECG suggestive of ischemiaT wave inversion or ST depression

Therapeutic/Diagnostic tracking according to 12 -lead ECG results

Nondiagnostic/normal ECGST segment elevation or new

bundle branch block

Continue evaluation/monitoring in EmergencyDepartment or Chest PainUnit

Serial serum cardiac markerlevels-MB CK subform s

Serial ECGs

Consider noninvasiveevaluation of ischemia

Consider alternativediagnoses

Assess suitability for reperfusion

? Contraindications forfibrinolysis

Availability and appropriatenessof primary angioplasty

Initiate anti-ischemia therapy Beta-blocker Nitroglycerin

Analgesia

Anti-ischemia Therapy

Analgesia

Admit to unit ofappropriate intensity

Admission blood work

- CBC

- Electrolytes, BUN,creatinine

- Lipid profile

No evidence ofMI or ischemia

MI ordemonstrable

ischemia

Initiatefibrinolysis

if indicated. Goal:30 minutes from

entry to ED.

Primary PTCA,if available andsuitable. (Goal:

PTCA within90 30 minutes)

Discharge withfollow-up asappropriate

(Goal: 8-12 hours)

Admit-CCU

Admission blood work

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Chest Pain Checklistfor Use by EMT/ Paramedic for Diagnosis of AcuteMyocardial Infarction and Fibrinolytic Therapy Screening

Check each finding below. If all [yes] boxes are checked and ECG indicatesST elevation or new BBB, reperfusion therapy with fibrinolysis or primaryPTCA may be indicated. Fibrinolysis is generally not indicated unless all [no]boxes are checked and BP 180/110 mm Hg.

Yes No

Ongoing chest discomfort ( 20 minutes and < 12 hrs) -

Oriented, can cooperate-

Age >35 y (>40 if female) -History of stroke or TIA -Known bleeding disorder -Active internal bleeding in past 2 weeks -Surgery or trauma in past 2 weeks -

Terminal illness - Jaundice, hepatitis, kidney failure -Use of anticoagulants -Systolic/diastolic blood pressure Right arm / Left arm /

Yes NoECG done - H igh -risk pro file* Yes No

Heart rate 100 bpm -BP 100 mm Hg -Pulmonary edema (rales greater than one half-way up) -Shock -*Transport to hospital capable of angiography and revascularization if needed.

1. Pain began AM/PM 3. Begin transport AM/PM

2. Arrival time AM/PM 4. Hospital arrival AM/PM

EMT indicates emergency medical technician; ECG, electrocardiogram; BBB, bundle branchblock; PTCA, percutan eous translum inal coronary an gioplasty; BP, blood pressure; TIA, tran -sient ischemic attack. Adapted from the Seattle/King County EM S Medical Record.

Serum Cardiac Markers

CK-MB subforms for Dx within 6 hrs of MI onset

cTnI and cTnT efficient for late Dx of MI

CK-MB subform plus cardiac-specific troponin bestcombination

Do not rely solely on troponins because they remainelevated for 7-14 days and compromise ability to diagnoserecurrent infarction

Enzymatic Criteria forDiagnosis of Myocardial Infarction*

Serial increase, then decrease of plasma CK-MB, with achange >25% between any two values

CK-MB >10-13 U/L or >5% total CK activity

Increase in MB-CK activity >50% between any twosamples, separated by at least 4 hrs

If only a single sample available, CK-MB elevation> twofold

Beyond 72 hrs, an elevation of troponin T or I orLDH-1>LDH-2

*Adapted from Alexander RW, Pratt CM, Roberts R. Diagnosis and Management of

Patients with Acute Myocardial Infarction In: A lexander RW, Schlant RC , Fuster V, eds.

Hursts Th e H ear t 19 98 , N ew York, N Y : M cGraw -H ill

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Comparison of Approved Fibrinolytic Agents

Streptokinase Anistreplase Alteplase Reteplase

1.5 MU 30 mg 100 mg 10 U x 2Dose in 30-60 in 5 in 90 over 30

min min min minBolus administration No Yes No Yes

Antigenic Yes Yes No No

Allergic reactions(hypotension Yes Yes No Nomost common)

Systemic fibrinogendepletion Marked Marked Mild Moderate

90-min.patency rates(%) ~50 ~65 ~75 ~75

TIMI grade 3flow (%)

32 43 54 60

Mortality ratein most recent

7.3 10.5 7.2 7.5comparativetrials (%)

Cost per dose (US) $294 $2116 $2196 $2196

TIM I flow indicates Thrombolysis in M yocardial Infarction stu dy flow rate.

Recommendations for theManagement of Patients with ST Elevation

III. Initial Management

All pa ti en ts wi th ST-segm en t eleva tio n on th e el ectroca rdi ogra m shou ld receiv e a sp irin(ASA ). Beta-adrenoreceptor blockers (in the absence of contraindications), and anantithrom bin (p articularly if alteplase/reteplase is u sed for fibrinolytic therapy). W hether heparin is required in patients receiving nonselective fibrinolytic agents remains a matter of

controversy; the small additional risk for intracranial hem orrhage may not be offset by th esurvival benefit afforded by add ing heparin to S K therapy. Patients treated within 1 2 hou rswho are eligible for fibrinolytics should expeditiously receive either fibrinolytic therapy or beconsidered for primar y percutaneous translumina l coronary an gioplasty (PTCA ). PrimaryPTCA is also to be considered when fibrinolytic therapy is absolutely contraindicated.Coronary artery bypass graft (CABG) may be considered if the patient is less than 6 hours from on set of sym pt om s. In divid ua ls t reat ed aft er 12 hour s s hould receiv e t he in it ial m ed-ical therapy noted above and, on an individual basis, may be candidates for reperfusiontherapy or a ngiotensin-converting enzyme (ACE) inhibitors (particularly if left ventricular fu nc tio n is im pa ired ). M od ified from An tm an EM . M edical th erapy for acu te coron ar y syn -drom es: an overview. In: Califf RM. ed. Atlas of Heart Diseases, VIII. Philadelphia, Pa;Current Medicine: 1996.

ST elevation

AspirinBeta-blocker

> 1 2 h

Fibrinolytic therapycontraindicated

Not a candidate forreperfusion therapy

12 h

Fibrinolytic therapy

Eligible forfibrinolytic therapy

Primary PTCAor CABG

Yes

ConsiderReperfusion

Therapy

Persistent symptom s?

No

Other medical therapy:ACE inhibitors

? NitratesAnticoagulants

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Primary Percutaneous TransluminalCoronary Angioplasty Recommendations

Class I Recommendations

1. As an alternative to fibrinolytic therapy if:

ST-segment elevation or new or presumed

new LBBBWithin 12 hrs of symptoms or >12 hrs of

persistent painIn a timely fashion (9030 min)By experienced operatorsIn appropriate laboratory environment

2. In cardiogenic shock patients 180/110 mm Hg)

History of prior cerebrovascular accident or knownintracerebral pathology not covered in contraindications

Current use of anticoagulants in therapeutic doses(INR 2-3); known bleeding diathesis

Recent trauma (within 2-4 wks), including head traumaNoncompressible vascular puncturesRecent (within 2-4 wks) internal bleeding

For streptokinase/anistreplase: prior exposure(especially within 5d-2y) or prior allergic reaction

PregnancyActive peptic ulcerHistory of chronic hypertension

IN R in di cat es In ter na tio nal N orm ali ze d R at io.

Viewed as a dvisory for clinical decision m aking and may not be all-inclusive or definitive.

Could be an absolute contraindication in low-risk patients with m yocardial infarction.

*

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Advantages of Fibrinolytic Therapy

More universal access

Shorter time to treatment

Greater clinical trial evidence of:reduction in infarct sizeimprovement of LV function

Results less dependent on physician experience

Lower system cost

Advantages of Primary PTCA

Higher initial reperfusion rates

Lower recurrence rates of ischemia/infarction

Less residual stenosis

Less intracranial bleeding

Defines coronary anatomy and LV function

Utility when fibrinolysis contraindicated

Class IIb Recommendations

1. In patients with AMI who do not present with

ST elevation but who have reduced [less than

TIMI (Thrombolysis in Myocardial Infarction)

grade 2] flow of the infarct-related artery and

when angioplasty can be performed within 12

hrs of onset of symptoms.

Class III Recommendations

1. This classification applies to patients with AMI

who

Undergo elective angioplasty in a noninfarct-related artery at the time of AMI

Are beyond 12 hrs after the onset of symptomsand have no evidence of myocardial ischemia

Have received fibrinolytic therapy and have nosymptoms of myocardial ischemia

Are fibrinolytic-eligible and are undergoingprimary angioplasty by an unskilled operator in alaboratory that does not have surgical capability.

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Recommendations for the Managementof Patients with Non-ST Elevation MI

ST depression/T-wave inversion:Suspected AMI

Heparin+ AspirinNitrates for recurrent angina

Antithrombins: LMWH high-risk patientsAnti-Platelets: Gpllb/IIIa inhibitor

MedicalTherapy

Yes

Revascularization(PTCA, CABG)

Patients without prior beta-blockertherapy or who are inadequately

treated on current dose of beta-blocker

Persistent symptoms in patientswith prior beta-blocker therapy or who

cannot tolerate b eta-blockers

Establish adequate beta- blo ckade Add c alc ium a ntagonist

Assess clinical status

Clinical stability

High-risk patient:1. Recurrent ischemia

2. Depressed LV function3. Widespread ECG changes4. Prior MI

Catheterization: Anatomy suitablefor revascularization?

Continued observation in hospitalConsideration of stress testing

No

Algorithm for the Management

of Patients with Non-ST Elevation MI

Al l p at ien ts wit hou t ST eleva tio n shou ld be trea ted wi th an

antithrombin and aspirin (ASA). Nitrates should be administered

for recu rren t epi sodes o f a ng ina. Adeq ua te bet a-a dren ocep tor

blockade should then be established; when th is is not possible or

contraindications exist, a calcium antagonist can be considered.

Current data indicate that either an invasive or non-invasive

treatment strategy is suitable for non-ST-elevation A MI p atients.

AM I in dicat es acu te m yoca rdi al in far cti on ; C AB G, corona ry

artery bypass graft; ECG, electrocardiographic; GpIIb/GpIIIa,

Glycoprotein IIb/IIIa receptor for platelet aggregation; LM W H,

low molecular weight h eparin; LV, left ventricular; PTCA , per-

cutaneous translum inal coronary angioplasty.

M od ified from An tm an EM . M edi cal th erap y for acu te corona rysyndromes: an overview. In Califf RM , editor. A tlas of Heart

D isea ses, VI II. Ph ilad elphia , PA: Cur ren t M edicin e; 1 99 6.

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Pharmacologic Management of Patients with MI

Heparin Recommendations

Class I Recommendations

1. In patients undergoing percutaneous or surgicalrevascularization.

Class IIa Recommendations

1. Intravenously in patients undergoing reperfusion therapywith alteplase/reteplase. See table below for dosing:

Change in Heparin (Unfractionated) Dose

with alteplase/reteplase

1999 1996Recommendations Recommendations

Bolus Dose 60 U/kg 70 U/kg

Maintenance 12 U/kg/hr 15 U/kg/hr

Maximum 4000 U bolus None1000 U/h if >70 kg

aPTT 1.5-2.0 x control 1.5-2.0 x control(50-70 sec) for 48 hrs (50-70sec) for 48 hrs

2. Intravenous unfractionated heparin (UFH) or low molecu-lar weight heparin (LMWH) subcutaneously for patients withnon-ST elevation MI.

3. Subcutaneous UFH (eg, 7,500 U b.i.d.) or low molecularweight heparin (eg, enoxaparin 1 mg/kg b.i.d.) in all patientsnot treated with fibrinolytic therapy who do not have a con-traindication to heparin. In patients who are at high risk for

systemic emboli (large or anterior MI, AF, previous embolus,or known LV thrombus), intravenous heparin is preferred.

4. Intravenously in patients treated with nonselective fibri-nolytic agents (streptokinase, anistreplase, urokinase) who areat high risk for systemic emboli (large or anterior MI, AF, pre-vious embolus, or known LV thrombus).

Class IIb Recommendations

1. In patients treated with nonselective fibrinolytic agents,not at high risk, subcutaneous heparin, 7,500 U to 12,500 Utwice a day until completely ambulatory.

Class III Recommendations

1. Routine intravenous heparin within 6 hrs to patientsreceiving a nonselective fibrinolytic agent (anistreplase, strep-tokinase, urokinase) who are not at high risk for systemicembolism.

GP IIb/ IIIa InhibitorsNew Recommendations

Class IIa Recommendations

For use in patients experiencing an MI without ST segmentelevation who have some high-risk features and/or refractoryischemia, provided they do not have a contraindication dueto a bleeding risk.

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A Classification of Inotropic Agents

Agent Mechanism Inotropic Vascular Effect Major Use

Isoproterenol -1 receptor ++ Dilatation Hypotension due to bradycardia;no pacing available

Dobutamine -1 receptor ++ Mild dilatation Low output with SBP >90 mm Hg

Dopamine Low dose: ++ Renovascular dilatation Hypoperfusion with SBPdopaminergic receptor


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Sample Admitting Orders

Condition Serious

IV NS or D 5W to keep vein open

Vital signs q 1/2 hr until stable, then q 4 hrs and p.r.n.Notify if HR 110; BP 150;RR 22. Pulse oximetry x 24 hrs.

Activity Bed rest with bedside commode and progress astolerated after approximately 12 hrs.

Diet NPO until pain free, then clear liquids. Progressto a heart-healthy diet (complex carbohydrates=50-55% of kilocalories, monounsaturated and unsatu-rated fats ( 30% of kilocalories), including foods highin potassium (eg, fruits, vegetables, whole grains, dairyproducts), magnesium (eg, green leafy vegetables,whole grains, beans, seafood), and fiber (eg, fresh fruitsand vegetables, whole-grain breads, cereals).

Medications Nasal 0 2 2 L/min x 3 hrsEnteric-coated aspirin daily (165 mg)Stool softener dailyBeta-adrenoceptor blockers?Consider need for analgesics, nitroglycerin, anxiolytics

Treatment Strategy forRight Ventricular Ischemia/ Infarction

Maintain right ventricular preload

Volume loading (IV normal saline)Avoid use of nitrates and diureticsMaintain AV synchrony

AV sequential pacing for symptomatic high-degreeheart block unresponsive to atropinePrompt cardioversion for hemodynamically significant SVT

Inotropic support

Dobutamine (if cardiac output fails to increase aftervolume loading)

Reduce right ventricular afterload

with left ventricular dysfunction

Intra-aortic balloon pumpArterial vasodilators (sodium nitroprusside, hydralazine)

ACE inhibitorsReperfusion

Fibrinolytic agentsPrimary PTCACABG (in selected patients with multivessel disease)

N ot e: IV in di cat es in tra ven ou s; A V, at riov en tri cu lar; SVT, su pra ven tri cu lar ta chycardia ;

AC E, an giot ensin con vert in g enz ym e; PTC A, per cut an eou s t ran slu m in al corona ry an gio-

pla sty ; C AB G, corona ry art ery byp ass gra ft.

V. Hospital Management

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Initial Management in ED

Initial evaluation with ECG in < 10 minutes

O2 by nasal prongs, IV access, continual ECG

Sublingal TNG unless SBP1mV orLBBB(goal: door-needle


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In-Hospital Management

Aspirin indefinitely

Beta-blocker indefinitely

ACE inhibitor (DC at ~6 wks if no LVdysfunction)

If spontaneous or provoked ischemiaelective cath

Suspected pericarditisASA 650 mg q4-6 hrs

CHFACE inhibitor and diuretic as needed

Shockconsider intra-aortic balloon pump+cath with PTCA or CABG

RV MI-fluids (NS)+inotropics if hypotensive

Age 32%

Systolic BP 24%

Heart rate 12%

AMI location 6%

Other10%

(DM, smoking, BP;

Height/ Weight; Prior CVD;

Time to Rx; Choice of

fibrinolytic therapy;UShospital)

Killip class 15%

*Circulation 91 : 1659, 1 995

Does not to ta l 1 00% du e t o rou nd in g.

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Predictors of 30 day Mortalityin Fibrinolysis Patients*

Proportion of Risk

Associated with Variable


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Clinical Indications of High Risk at Predischarge

VI. Preparation for Discharge from the Hospital

Strategy III

Submaximal Exercise Testat 5-7 days

Mildly Abnormal

Exercise Imaging Study

Reversible Ischemia NoReversible Ischemia

Absent

Strategy II

Symptom-Limited Exerciseat 14-21 Days

MarkedlyAbnormal

MildlyAbnormal


ReversibleIschemia

No ReversibleIschemia

Strat egies for exercise test evaluations soon after m yocardial infarction (MI) . If patients are at high risk for ischemic events based on clinical criteria, they should undergo invasive evaluationto determ ine if they are candidates for coronar y revascularization procedures (S trategy I). For pa tie nt s i nit ially dee m ed to be at low risk at tim e o f d isch arge aft er M I, tw o s tra tegi es for per - form in g ex ercis e t est in g ca n be us ed. O ne is a sym pt om -lim ite d tes t at 14 to 21 da ys (S tra tegy II) . If th e p ati en t is on digox in or if b aseli ne elect roca rdi ogra m pre clud es accu rat e i nt erp ret a-tion of ST-segment changes (e.g., baseline left bundle branch block of left ventricular hypertro- ph y), th en an ini tia l ex ercis e i m agin g st ud y c an be per form ed. Re sult s o f ex ercis e t est ing sho uld be stratified to determine need for additional invasive or exercise perfusion studies. A third strategy is to perform a subm axim al exercise test at 5 to 7 da ys after MI or just before hospitaldischarge. The exercise test results could be stratified using the guidelines in Strategy I. If exer-cise test studies are negative, a second symptom-limited exercise test could be repeated at 3 to 6 weeks for patients undergoing vigorous activity during leisure or at work.

Negative

Medical Treatment

Strategy I

Present Absent

Negative

No Reversible Ischemia

Strenuous Leisure Activity or Occupation

Symptom-Limited Exercise Testing at 3- 6 Weeks

MildlyAbnormal Negative


Medical Treatment

Markedly Abnormal

MarkedlyAbnormal

Reversible Ischemia

Cardiac Catheterization

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Energy Levels Required toPerform Some Common Activities

Self-Care WashingShavingDressingDesk workWashing dishes

Driving autoLight housekeeping

Cleaning windowsRakingPower lawn mowingBedmaking/strippingCarrying objects

(15-30 lb.)

Occupational Sitting(clerical/assembly)

TypingDesk workStanding (store clerk)

Stocking shelves(light objects)Auto repairLight welding/carpentry

Recreational Golf (cart)KnittingHand sewing

Dancing (social)Golf (walking)Sailing

Tennis (doubles)Volleyball (6 persons)

Physical conditioning Walking (2 mph)Stationary bikeVery light calisthenics

Level walking (3-4 mph)Level biking (6-8 mph)Light calisthenics

Easy digging in gardenHandlawnmowing(level)Climbing stairs (slowly)Carrying objects(30-60 lb.)

Digging vigorously

Sawing woodHeavy shovelingClimbing stairs(moderate speed)Carrying objects

(60-90 lb.)

Carrying loads upstairs(objects >90 lb.)Climbing stairs (quickly)Shoveling heavy snow

Carpentry (exterior)Shoveling dirtSawing woodOperating pneumatictools

Digging ditches(pick and shovel)

Lumber jackHeavy laborer

Badminton (competitive) Tennis (singles)Snow skiing (downhill)Light backpackingBasketballFootballStream fishing

CanoeingMountain climbingPaddle ball

HandballSquashSki touringVigorous basketball

Level walking(4.5-5.0 mph)Bicycling (9-10 mph)Swimming, breast stroke

Level jogging (5 mph)Swimming (crawl stroke)Rowing machineHeavy calisthenicsBicycling (12 mph)

Running (>6 mph)Bicycling (>13 mph)Rope jumpingWalking uphill (5 mph)

5-7 METs 7-9 METs >9 METs


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Recommendations forHormone Replacement Therapy(HRT) After Acute MI *

Class IIa Recommendations1. HRT with estrogen and progestin for secondaryprevention of coronary events should not be givende novo to postmenopausal women after AMI.

2. Postmenopausal women who are already takingHRT with estrogen plus progestin at the time of AMI can continue their therapy.

*HERS S tudy: JAMA 1998;280:605-13

D i s c h a r g e

Sample Patient Education Form

Acute Coronary Syndrome:

Acute Myocardial Infarction(Heart Attack)

Unstable Angina

Other

DiagnosisI understand that I have Coronary Heart Disease andthat my diagnosis was confirmed by:

symptoms stress testresults

changes in my ECG heart catheterization

Cholesterol TC LDL HDL Ejection Fraction %

Medication I understand there are certain medications which mayhelp to prevent a future attack and may help to extend my life.

Aspirin:81mgqd indefinitely Beta-blocker -

Sublingual ACE Inhibitor -nitroglycerin tablets Cholesterol lowering -

I understand that I have not received a prescription for one or moreof these medications because

Smoking I understand that smoking increases my chances of suffer-ing a future heart attack and that smoking causes other illnesseswhich can shorten my life. Yes NoI smoke and have been counseled to stop.I do not smoke.

Heart Attack Patients Only:I understand that I have had a heart attackand that the diagnosis was confirmed by:

changes in my electrocardiogram (ECG)changes in the enzyme levels in my blood

continued on next page

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Diet

I understand that a diet that is low in cholesterol and fat may help toreduce my chances of suffering a future heart attack and may help toextend my life.

I have received I have not received counseling about a low fat diet.

Exercise

Heart Attack Patients Only: I have undergone an exercise test during my hospitaliza-tion or I am scheduled to undergo an exercise test to help determine whether I cansafely participate in a cardiac rehabilitation program.

I have received I have not received activity instructions for the next 4-6 weeks,beforeI start cardiac rehabilitation.

I have received I have not received a referral to an outpatientcardiac rehabilitation program.

Education

I have received I have not received cardiac education duringmy hospitalization.

I know I do not know warning signs and symptoms ofheart attack and action to take if they occur.

I have received I have not received instructions on m y dischargemedications.

Patient Signature Date

Nurse Signature Date

D i s c h a r g e


21/21

Pocket Guide + The Management of Patients With Acute Myocardial Infarction

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Transcript of Pocket Guide + The Management of Patients With Acute Myocardial Infarction