Protocols for the Management of Cardiac Conditions

By Pam Bayles, RN, BSN

2

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.

0

200

400

600

800

1,000

00 10 20 30 40 50 60 70 80 90 00 06

Years

Death

s i

n T

ho

usan

ds

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 STEMI2007 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

• As needed to keep SaO2 > 90%

NTG

• 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

Morphine

• IV if uncontrolled ischemic chest pain despite NTG (class IIa)

Additional Anti-ischemic Therapy

Beta Blockers• Oral within 24 hrs. as with

STEMI

• IV beta blocker for HTN if no contraindications (class IIa)– 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

Calcium Channel Blockers• 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)

Anti-ischemic Therapy continued

• If pulmonary congestion or LVEF ≤ 40%

• Class IIa recommendations for all patients with UA/NSTEMI

ARBsIf patient intolerant of ACEI

• If clinical or X-ray signs of HF

• LVEF ≤ 40%

ACEIOral within 24 hours

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

• 600 mg recommended

• Up to 900 mg has be used

IIb/IIIa Inhibitor

• Eptifibatide (Integrilin) or Tirofiban (Aggrastat) preferred

• Abciximab (ReoPro) only if there is no delay to angiography and PCI is planned for sure

Anticoagulant TherapyShould be added to antiplatelet therapy ASAP

Invasive Therapy

• Enoxaparin (lovenox) or UFH

• Bivalirudin (Angiomax) or fondaparinux (Arixtra) are acceptable alternatives

Medical Therapy

• 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

ASA PlavixBeta

Blocker

ACEI• 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

• 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)

Right sided

Heart Failure

• 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, Beta-blockers 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