Care Process Model

MARCH

2013

GUIDELINES FOR DIA GNOSIS AND MANA GEMENT OF

Acute Coronary Syndrome (ACS)

at Intermountain Healthca r e Em er gency Department s
03/04/2013 update
These guidelines were developed by Intermountain Healthcares Cardiovascular Clinical Program. They are intended to guide diagnosis and treatment of patients presenting to any Intermountain Emergency Department with signs and symptoms that suggest acute coronary syndrome (ACS). Recommendations are based on stratification into ACS-probability categories, along with capabilities of individual facilities. The guidelines may need to be adapted to meet the individual needs of a specific patient and should not replace clinical judgment. The inside pages of this tool provide a quick reference table to guide the diagnosis and management of ACS. The table can be folded open and posted in your facility. Medication dosing tables are on the back side (page 4). Links are provided for medication guidelines and other related resources.
required.

Basic Principles for ACS:

All STEMI patients should have rapid reperfusion (unless contraindicated): - Primary PCI (PPCI) in <90 minutes is preferred (on-site or transfer to a hospital with interventional capabilities) OR - If PPCI in 90 minutes cannot be achieved, fibrinolytic in 30 minutes from ED presentation along with rapid transfer to an interventional facility for rapid angiography OR - If transfer PPCI can be assured within 120 minutes, consider PPCI instead of fibrinolytic All HIGH Probability ACS patients should be transferred to a hospital with interventional capabilities within 24 hours. This will allow diagnostic catheterization and revascularization to be performed within the time requirements of national guidelines. All STEMI and High Probability ACS patients should have evaluation of left ventricular function performed during their initial hospitalization. For MODERATE and LOW Probability ACS patients presenting to the ED, initial negative Troponinand ECG are not enough to rule out ACS. Also required are a second set of Troponin-I and follow-up ECG at 3 hours from ED arrival. In most cases, a negative stress test is also

Key References:
OGara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):485-510. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST- elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60(7):645-81.

GUIDELINES FOR DIAGNOSIS AND MANAGEMENT OF

Acute Coronary Syndrome (ACS) - 2013 update (Rev 03/04/2013)

Use the tables below to guide the diagnosis and management of ACS presenting at Intermountain emergency departments.

Diagnosis:
Symptoms ECG

Assign the patient to an ACS-probability category based on signs and symptoms.

STEMI
(ST-elevation MI)

HIGH Probability ACS: NonST-Elevation MI (NSTEMI) OR Definite Unstable Angina

MODERATE Probability ACS

LOW Probability ACS

Suggestive but atypical for ischemia Normal or non-specific, with or without pain. (Must be normal at 0 hours and at 3 to 6 hours from ED arrival. If abnormal, continue with HIGH Probability ACS column.)

Typical of or consistent with ischemia/ infarction

Strongly suggestive of ischemia/infarction Strongly suggestive of ischemia Normal or non-specific, with or without pain. (Must be normal at 0 and 3 hours from ED arrival, and consider ECG at 6, 12, and 18 hours. If abnormal, continue with HIGH Probability ACS column.)

Ischemic ST elevation in 2 or more ST depression >1 mm OR contiguous leads OR Deep T-wave inversion Hyperacute T-waves OR Signs of acute posterior MI OR LBBB obscuring ST-segment analysis with MI symptoms May or may not be elevated at 0 hours; typically elevated at 6 hours Carefully evaluate signs, symptoms, ECG, and risks to establish diagnosis. Elevated troponin is most helpful (see below), but Initial diagnosis and reperfusion decision consider other causes for troponin elevation, must be made immediately, before Troponin-I (both absolute and change in CtNI levels). results are available.

Troponin-I (cTnI)

Baseline cTnl (ng/mL) <0.04 ng/mL Low clinical risk and cTnl more than 4-6 hrs since onset of chest pain Higher clinical risk 0.04 to <0.1 ng/mL Retest cTnl at 3 hrs
Increase <50% Increase >50%

0.1 to <2.0 ng/mL Retest cTnl at 3 hrs

Increase <20% Increase >20%

>2.0 ng/mL AMI

Non-AMI Causes of Elevated Troponin-I CHF Malignancy Viral or stress cardiomyopathy Pulmonary us embol es Myocarditis, pericarditis Infiltrative diseas Trauma Toxicity or sepsis Stroke Renal failure res Subarachnoid hemorrhage Ablation procedu

Retest cTnl at 3 hrs <0.04 0.04 to <0.1 Retest at 3 hrs Stress test <0.1 >0.1

Stress test >0.1 AMI

AMI

Stress test

AMI

Early invasive strategy*

Early invasive strategy*

*Admit to hospital: ASA, enoxaparin; consider BB; eptifibatide if ongoing chest pain; cath procedure

Early invasive strategy*

High-risk indicators for adverse CV event

Note: Presence of risk indicators may warrant moving patient to a higher ACS probability category.

Anteroseptal MI Hypotension, cardiogenic shock ST changes of inferoposterolateral MI RV infarction New significant arrhythmia or heart block Heart failure Age >75

Elevated troponin 3 traditional risk factors for CAD Hypotension Prior coronary stenosis >50% Dynamic ECG changes with pain Use of ASA within past 7 days Prolonged ischemic pain or recurrent pain Recurrence of pain after initial relief after initial relief >2 anginal events within prior 24 hours New significant arrhythmia or heart block Heart failure >2 anginal events within the prior 24 hours Age >75 Heart failure Age >75 If evaluation is negative f or ischemia, consider pulmonary embolism, pericarditis

3 traditional risk factors for CAD

Prior coronary stenosis >50% Use of ASA within past 7 days Recurrence of pain after initial relief >2 anginal events within the prior 24 hours Heart failure Age >75

, aortic dissection, and GI as potential causes.

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Management:
Admit Status Diagnostic and therapeutic care

Admit and treat patient based on ACS-probability category.

STEMI
(ST-elevation MI)
Non-ST-Elevation MI (NSTEMI) OR Definite Unstable Angina
CCU

HIGH Probability ACS:

MODERATE Probability ACS

Hospital telemetry >18 hours ECG and Troponin-I at 0 and 3 hours from ED arrival (consider 6, 12, and 18 hours from arrival) If higher risk: Transfer for cath/PCI within 48 hours (preferably <12 hours) immediately if ongoing pain. If low-moderate risk with normal enzymes, negative ECG, and no recurrent chest pain, imaging stress test before discharge. OR, discharge after 24 hours on aspirin and beta blocker; arrange for imaging stress test within 48 hours. Aspirin, NTG, and O2 Enoxaparin (see Enoxaparin
dosing on back)

LOW Probability ACS

ER/Observation ECG and Troponin-I at 0 and 3 hours from ED arrival (consider 6, 12, and 18 hours from arrival) Lipids and BNP If higher risk: imaging stress test before discharge or within 48 hours. If low-moderate risk and stable vitals: consider discharge and imaging stress test within 72 hours. Medications as

Cath lab / CCU

Immediate Cath/PCI1 ( 90 minute door to PCI)

URGENT REPERFUSION Primary PCI (PPCI) in 90 minutes door-to-balloon time (see STEMI Orders: Primary PCI) ECG and Troponin-I at 0, 3 to 6, 12 and 18 hours from ED arrival Lipids and BNP

Delayed Cath/PCI (>90 minutes door to PCI)

Onsite Urgent or Early Invasive (<12 hours)

Elective Invasive or Transport Patient (Ideally <48 hours)

URGENT REPERFUSION ECG and Troponin-I at ECG and Troponin-I at 0, 3-6, 12, and 18 hours 0, 3-6, 12 and 18 hours Fibrinolytic in 30 from ED arrival from ED arrival minutes (see dosing on back). Do not give GPI (GP IIb/IIIa Cath with Cath or transfer to inhibitor) with fibrinolytic interventional center intervention within ECG and Troponin-I at (ASAP 24 hours (preferably 12) or 0, 3 to 6, 12 and 18 hours for ongoing chest pain or immediately if ongoing from ED arrival hemodynamic pain. instability) Transfer immediately to interventional center for Lipids and BNP Lipids and BNP cath/PCI Lipids and BNP In the ED: Aspirin, NTG, and O2 Heparin (see ACS/NonSTEMI UFH... on back)

Initial medications and treatment

(unless contraindicated; see footnotes and back for notes and contraindications) Note: See Antiplatelet Guidelines for Stent Placement for details on dosing P2Y12 agents (clopidogrel, prasugrel, ticagrilor) and P2Y12 function

In the ED: Aspirin, NTG, and O2 Heparin bolus only (see STEMI UFH Bolus... on back) Morphine, prn

In the ED: Aspirin, NTG, and O2 Clopidogrel: Age <75, 300 mg by mouth In the cath lab: Age 75, 75 mg by mouth Clopidogrel 600 mg Enoxaparin (see OR ticagrelor 180 mg OR dosing on back) prasugrel2 60 mg Morphine, PO (load) prn Anticoagulant: heparin or bivalirudin (GPI or anticoagulant GPI per cardiologist (eg, for agent administered in cath high clot burden) lab per cardiologist)

In the ED: Aspirin, NTG, and O2 Enoxaparin (see dosing

on back)

indicated

Eptifibatide or GPI per cardiologist (see

dosing on back)

Eptifibatide or GPI per cardiologist (see dosing

o n back)

Oral beta blocker3 Morphine, prn

Morphine, prn Morphine, prn In the cath lab: In the cath lab: Clopidogrel 600 mg OR ticagrelor 180 mg OR Clopidogrel 600 mg OR prasugrel2 60 mg ticagrelor 180 mg OR 2 PO (load) if PCI prasugrel 60 mg Additional enoxaparin PO (load) if PCI (per guideline) Heparin or bivalirudin Statin As indicated ACEI (or ARB) when BP stable if EF <40% Aldosterone blocker if EF <40% and symptomatic HF or DM If PCI, P2Y12 inhibitor for at least 12 months5 for bare metal stent or drug-eluting stent clopidogrel (75 mg/day) OR ticagrelor (90 mg twice daily) OR prasugrel2 (10 mg/day)

Adjunct care

(unless contraindicated; see footnotes and back for notes and contraindications)

Statin - high dose; start ASAP GPI - consider discontinuing 4 hrs after clopidogrel load or 2 hrs after prasugrel/ticagrilor load, or consider infusing up to 18 hours for highest risk cases Bivalirudin without GPI - requires concomitant P2Y12 therapy (see Antiplatelet Guidelines); consider discontinuing shortly after stenting Oral beta blocker3 ACEI (or ARB) - when BP stable (required for EF <40%) Aldosterone blocker - if EF <40% and symptomatic heart failure or diabetes P2Y12 inhibitor for at least 12 months4 clopidogrel (75-150 mg/day for one week followed by 75 mg/day) OR ticagrelor (90 mg twice daily) OR prasugrel (10 mg/day)2 Aspirin 81 mg per day

1. Immediate Cath/PCI: On-site cath lab or transferable to interventional center in <60 minutes from ER to receiving hospital cath lab. Refer to STEMI Orders: Primary PCI or STEMI Orders: Fibrinolytic Pathway. 2. Prasugrel: Avoid if CVA or TIA history; increases bleeds in patients >75 years or <60 kg. In patients <60 kg, manufacturer suggests 5 mg daily maintenance dose, but no prospective clinical trial data exist to support this recommendation. Clopidogrel, prasugrel, and ticagrelor: Consider platelet function testing for all ACS and high-risk elective PCI patients; see Antiplatelet Guidelines. without signs of HF, low-output, risk for cardiogenic shock, or other relative contraindications. 4. May discontinue P2Y12 inhibitor earlier, especially for bare metal stent, if patient is at high bleeding
3. Oral beta blocker (BB) within 24 hours for patients without signs of HF, low-output, risk for cardiogenic shock, or other relative contraindications. Avoid IV BB except in STEMI patients with hypertension or tachyarrythmias and

risk.

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TNKase Dosing Instructions (See TNKase guideline )

Weight (kg) <60 kg 6069 kg 7079 kg 8089 kg >90 kg Dose 30 mg 35 mg 40 mg 45 mg 50 mg IV bolus IV bolus IV bolus IV bolus IV bolus over over over over over 5 seconds 5 seconds 5 seconds 5 seconds 5 seconds

Enoxaparin Dosing Instructions (See Enoxaparin guideline )

Age (yr)

Notes: Do not give if GPI (GP IIb/IIIa inhibitor) was given (e.g., abciximab, eptifibatide, or tirofiban). With TNK bolus, also begin enoxaparin (see table at right). Cautions and Relative Contraindications Severe, uncontrolled hypertension on presentation
(>180/110 mm Hg) or hx of chronic severe hypertension History of CVA or known intracerebral pathology Current anticoagulant therapy (INR >2-3); known bleeding diathesis Recent trauma, prolonged CPR (>10 min) or major surgery (<3 weeks) Noncompressible vascular punctures Recent (within 2-4 weeks) internal bleeding Age > 75 years Pregnancy Active peptic ulcer

FIBRINOLYTIC STEMI
CrCl > 30 mL/min CrCl < 30 mL/min

Non-STEMI
CrCl > 30 mL/min CrCl < 30 mL/min

<75

Indications ECG showing any of the following: Ischemic ST elevation

Contraindications Previous

75

hemorrhagic stroke at (>1 mm) in 2 or more any time; other strokes contiguous leads or cerebrovascular Hyperacute T-waves events within 1 year Signs of acute posterior MI Known or LBBB obscuring ST intracranial segment analysis with MI neoplasm History Active internal History of acute coronary syndrome bleeding (does not Pain/symptoms within the past 24 include menses) hours, with or without Suspected ongoing symptoms aortic

Contraindications: Hemodialysis; active major bleeding; recent or planned epidural or dural anesthesia; known
or suspected heparin-induced thrombocytopenia (HIT).

30 mg IV bolus followed 15 min later by 1 mg/kg subcut every 12 hours (max 100 mg first 2 doses) No bolus. 0.75 mg/kg subcut every 12 hours (max 75 mg first 2 doses)

30 mg IV bolus followed 15 min later by 1 mg/kg subcut once daily (max 100 bolus. mg first12mg/kg doses) No subcut once daily (max 75 mg first 2 doses)

1 mg/kg subcut every 12 hours

1 mg/kg subcut once daily

Laboratory monitoring: Draw a baseline BMP, aPTT STAT (include CBC, PT/INR if not done in last 24 hours);
draw CBC every other day while hospitalized; monitor BMP if clinical situation suggests risk of decline in renal function. Cautions: Thrombocytopenia (platelet count less than 100,000/mm3) or known bleeding diathesis; recent internal bleeding or uncontrollable active bleeding (hospital admission or transfusion in last 30 days); recent (within the previous 2 weeks) surgery, major trauma, or thrombotic stroke; acute peptic ulcer disease

Eptifibatide Dosing Instructions (See Ep guideline )

Start with BOLUS Followed by INFUSION
(Consider discontinuing 4 hours after clopidogrel load or 2 hours after prasugrel or ticagrelor load. However, consider infusing up to 18 hrs for highest risk cases.) If CrCl <50 mL/min, continuous infusion at 1 mcg/kg/min 3 mL/hour 3.5 mL/hour 4 mL/hour 4.5 mL/hour 5 mL/hour 5.5 mL/hour 6 mL/hour 6.5 mL/hour 7 mL/hour 7.5 mL/hour 8 mL/hour 8.5 mL/hour 9 mL/hour 9.5 mL/hour 10 mL/hour (180 mcg/kg over 1-2 minutes)*

STEMI: UFH Bolus Only Patients Going to Cath Lab Weight (kg) IV Bolus Dose (60 unit/kg)
Less than 46 kg 4652 kg 5361 kg 6270 kg 7180 kg 8190 kg Over 90 kg 2500 units 3000 units 3500 units 4000 units 5000 units 5500 units 6000 units

ACS/Non-STEMI: UFH Bolus + Infusion

(See Heparin, unfractionated for ACS guideline )
Table 1. Non-STEMI initial dosage and infusion rate (standard concentration of 100 units/mL)
Weight (kg) Bolus Dose Infusion Rate

Weight (kg)

Less than 46 kg 4652 kg 5361 kg 6270 kg 7077 kg Over 77 kg

2500 units 3000 units 3500 units 4000 units 4000 units 4000 units

500 units/hour 600 units/hour 700 units/hour 800 units/hour 900 units/hour 1000 units/hour

Steps (non-STEMI): 1. Draw baseline aPTT STAT (include CBC, PT/INR if not done in last 24 hours). 2. Give initial dosage as in Table 1 above. 3. Use aPTT testing to monitor and adjust dose as per Table 2 at right.

Table 2. Monitoring and adjustment (non-STEMI) PTT Heparin Infusion rate Labs Less than 40 sec Bolus 3000 units Increase by 100 units/hr aPTT every 6 hr x 2 None Increase by 50 units/hr aPTT every 6 hr x 2 4049 sec 5070 sec None No change aPTT per protocol* None Decrease by 50 units/hr aPTT every 6 hr x 2 7185 sec 86100 sec Hold for 30 min Decrease by 100 aPTT every 6 hr x 2 units/hr by 150 Hold for 30 min Decrease aPTT every 6 hr x 2 101150 sec units/hr Over 150 sec Hold for 1 hr Decrease by 300 aPTT every 6 hr x 2 units/hr * After 2 consecutive aPTTs in the therapeutic range of 50-70 seconds, draw aPTT daily in am.

If CrCl >50 mL/min, continuous infusion at 2 mcg/kg/min 3741 kg 3.4 mL 6 mL/hour 4246 kg 4.0 mL 7 mL/hour 4753 kg 4.5 mL 8 mL/hour 5459 kg 5.0 mL 9 mL/hour 6065 kg 5.6 mL 10 mL/hour 6671 kg 6.2 mL 11 mL/hour 7278 kg 6.8 mL 12 mL/hour 7984 kg 7.3 mL 13 mL/hour 8590 kg 7.9 mL 14 mL/hour 9196 kg 8.5 mL 15 mL/hour 97103 kg 9 mL 16 mL/hour 104109 kg 9.5 mL 17 mL/hour 110115 kg 10.2 mL 18 mL/hour 116121 kg 10.7 mL 19 mL/hour >121 kg 11.3 mL 20 mL/hour major trauma or thrombotic stroke; acute peptic ulcer disease

Amount (mL)

UFH Contraindications: Active major bleeding; recent or planned epidural anesthesia; known or suspected heparininduced thrombocytopenia (HIT). For HIT, DO NOT use heparin or LMWH; use a direct thrombin inhibitor. Cautions: Thrombocytopenia (platelets less than 100,000/mm3) or bleeding diathesis; recent internal bleeding or uncontrollable active bleeding (admission or transfusion in past 30 days); recent surgery (within the past 2 weeks),

*Notes: If patient presents to cath lab within 2 hours of first bolus, re-bolus with 180 mcg/kg over 12 minutes. Do
NOT re-bolus if >2 hours after first bolus (platelet inhibition should be therapeutic)

Start aspirin and unfractionated heparin (UFH) or enoxaparin, if not previously done and PCI has not been done: UFH: Follow conventional ACS/Non-STEMI UFH dosage/admin at left. Enoxaparin (Lovenox): Follow dosing/admin instructions above. Obtain platelet count 3 hours after initial eptifibatide bolus. Eptifibatide Contraindications: Active abnormal bleeding within previous 30 days or history of bleeding diathesis;
stroke within past 30 days or history of hemorrhagic stroke; severe hypertension (systolic >200 or diastolic >110) not
adequately controlled on antihypertensive therapy; major surgery within past 6 weeks; dependency on hemodialysis

2008-2013 Intermountain Healthcare. All rights reserved. Cardiovascular Clinical Program. Patient and Provider Publications. 801-442-2963 CPM026 - Rev 03/04/2013

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