CHANGING CONCEPT OF MANAGEMENT OF ACS

CHANGING CONCEPT OF MANAGEMENT OF ACS
การรักษาผู้ป่วย Acute coronary syndrome จะตองแยกใหไดว่าผูป่วยเบ่น STEMI หรอ NSTEMI/ Unstable angina เนื่องจาก แนวทางในการรักษาจะแตกต่างกันอย่างชัดเจน
STEMI
เนื่องจาก pathophysiology หรือ STEMI เป็น occlusive thrombus และทำให้เกิด myocardial necrosis มากขึ้นไปเรื่อยๆ เมื่อเวลาผ่านไป โดยเฉพาะอย่างยิ่งเมื่อ 6 ชั่วโมงจะมีการทำลายกล้ามเนื้อหัวใจมากถึง 90%
และอัตราตายของผู้ป่วยในระยะแรก (ภายใน 30 วัน) นันขึนอยู่กับ infarct-relate patency status ที 90 นาที 111 การลดอัตราตายในช่วงแรกโดยเฉพาะอย่าง 3 ชั่วโมงแรก เกิดจากการรักษาที่ไปช่วยลดการทำลายของกล้ามเนื้อหัวใจ (Myocardial salvage) ซึ่งจะเกิดได้จากการทำ reperfusion therapy12 ‘1 ดังนั้น ในผู้ป่วย STEMI ที่พบ EKG เป็นแบบ
1. ST-segment elevation (>0.1 mV, > 2 contiguous leads)
2. New BBB และประวัติ Suggestive acute MI (โดยเฉพาะอย่างยิง new LBBB)
หลังจากให้การรักษาขั้นต้นในห้องฉุกเฉินด้วย ASA, NTG, _+ (1-blocker และ + morphine แลวควรพิจารณา reperfusion therapy อย่างทันที ไม่ว่าจะเป็น pharmacologic คือ การให้ thrombolytic therapy หรอ mechanical คอ การทา primary PTCA ตาม Figure 1
Figure 1. Critical Pathway for STEMI / New LBBB
STEMI / New LBBB
ASA, NTG, (l-blocker, Morphine
Thrombolytic (Door-to-needle < 30 นาท)

Cath/ PCI
(Door-to-balloon 90 ± 30 นาที)
Reperfusion failure
(Angina/ST resolution / hypotension)

D/C home hour 48
PCI
ASA, Clopidogrel, [ร -blocker, ACEI, statin
Critical pathway นี้นำมาจาก The University of California – Los Angeles Cardiovascular Hospitalization Athero¬sclerosis Management Program141 ซงใช้ evidence-based medicine เป็นพนฐานและเพอเป็นแนวทางในการดูแลรก’พาผูปวย อย่างมีประสิทธิภาพ ซึ่งในทางปฏิบัติสำหรับประเทศไทยในบางสถานพยาบาล ในแง่ของเวลาในการดำเนินการอาจมีปิญหา ได้บ้างในบางจุด การให้ thrombolysis สามารถลดอัตราตายภายใน 35 วันได้ถึง 13.8% เมือเทียบกับ pIacebot”11 และการให้ thrombolysis ทำให้เกิด TIMI 3 flow ใน 90 นาที ตั้งแต่ 20-30% ถึง 50-60% (ตาม table 1) แต่พบว่ามีภาวะแทรกซ้อน คือ major hemorrhagic complications ไดประมาณ 2-3% และ intracerebral hemorrhage ประมาณ 1%”°111
การทำ primary PTCA สามารถทำให้เกิด TIMI 3 flow ใน 90 นาทีได้ถึง 73-97%<5’9) จาก meta-analysis ของ 23 randomized trial (ผู้ป่วย 6,889 คน) เมือเปรียบเทียบ primary PTCA vs thrombolysis พบว่าการทำ primary PTCA มีอัตราการตาย, nonfatal MI และ stroke น้อยกว่า thrombolysis ทัง short term (30 วัน) และ long term
Table 1. Comparison of currently available intravenous thrombolytic agents
SK t-PA r-PA A PS AC TNK-tPA
Plasma tl/2 (h) 25 4-8 15 70-100 20-24
Dose 1.5MU over 30-60 min 100 mg over 90 min 10MU X 2 30 min apart 30U over 5 min 0.5 mg/kg
Fibrin specificity No Yes Yes No Yes
90-min TIMI 3flow rates 20-30% 50-60% 50-60% 50-60% 50-60%
Heparin therapy +SQ or IV IV IV SQ or IV IV or LMWH

Indications for primary PTCA
1. Symptomatic AMI in less than 12 hours
2. AMI 12-24 hours with continued chest pain
3. Cardiogenic shock 180/110 or history of chronic severe HT
2. Use of Warfarin with INR > 2 to 3
3. Known bleeding diathesis
4. Recent trauma (within 2 to 4 weeks, including head trauma or traumatic, or prolonged CPR (> 10 min)
5. Major surgery < 3 weeks 6. Noncompressible vascular punctures 7. For streptokinase : prior exposure (within 5 days to 2 years) 8. Pregnancy 9. Active peptic ulcer หลังฉากให้ thrombolysis แล้วถ้าผู้ป่วยมี signs ของ reperfusion failure คอ114, 1. ไม่มี signs ของ reperfusion เช่น a. Resolution of chest pain b. Improvement of ST elevation >70%
c. Reperfusion rhythm (slow VT) d. Rapid rise in cardiac enzymes at 60 min
i. Approximately 90% specificity
ii. 60 min to baseline ratios of> 3.3 for CK-MB and >2.0 for troponin I
2. Recurrent chest pain ควรแยกให้ได้ว่าเป็น
a. Reinfarction ‘พิจารณา catheterization
b. Post-MI angina ~* พิจารณา catheterization
c. Pericarditis
3. Hypotension and pulmonary edema ควรแยกให้ได้ว่าเป็น
a. Coronary problem พิจารณา catheterization
b. Rhythm problem -*ACLS
c. Myocardial problem
i. Contractility problem พิจารณาให inotropes, IABP, + catheterization
ii. Structural problem พิจารณา surgery ขึ้นอยู่กับสาเหตุ
d. Hypovolemia
e. Vasodilatation
Figure 2 และ Table 1 เป็นตัวอย่าง standard checklist ของผู้ป่วย STEMI(15) ขณะที่ได้รับการรักษาอยู่ในห้องอุก เฉนใน ccu, ward ธรรมดาและกอนกลับบาน ชงใน Table 1 นันจะรวม management ทุกอย่างทัง medications, consulta¬tion (for nutrition, cardiac rehabilitation, smoking cessation etc.)
Figure 2. ST-Elevation MI (STEMI): emergency department standard orders
Initial Orders Checks all the apply
DIAGNOSTICS
อ Stat EKG, obtain old EKG record
อ Repeat stat EKG 60 minutes after initial bolus of fibrinolytic therapy
□ Stat ACS Lab Panel : CMP, CB C/d iff, PT/INR/aPTT, CK+CK-MB (site specific), Troponin-1, Magnesium,
hs-CRP, lipid profile (routine)
□ Stat portable CXR
□ Cardiac monitor and SaO monitors
อ Other

แผ่นติดเท้า

ANTI-ISCHEMIC THERAPY:
□ Oxygen 2L/min Nasal Cannula (titrate to keep pulse oximetry saturation > 94%)
□ IV-0.9 NS: □ Trap KVO ml/hr
□ Opiate: mg IV (suggest Morphine Sulfate)

NITROGLYCERIN THERAPY (Hold if patient has taken Sildenafil (Viagra) within 24 hours)
EH Nitroglycerin 0.4 mg SL q5min X 3 doses or until pain relief or SBP < 100 mmHg
□ Nitroglycerin paste inch (es) topically X 1
□ rv – start Nitroglycerin infusion at 10 mcg/min, then titrate as per pharmacy protocol (use lOOmg in 250 mg D พ)
ANTI-THROMBOTIC THERAPY:
EH Aspirin 162 mg po (2 chewable 81 mg tablets)
FIBRINOLYTIC THERAPY
Indications: Chest pain < 12 hours. EKG ST -elevations or new left bundle branch block
Access for contraindications for fibrinolytic therapy:
1. History of hemorrhagic stroke at any time; other stroke or cerebrovascular event within 1 yr
2. Know intra-cranial neoplasm
3. Active internal bleeding
4. Suspected aortic dissection (consider CT of chest)
EH If fibrinolytic contraindicate, call STAT cardiology consult Dr
EH Reteplase (Retevase) 10 units IV bolus, repeat 10 unit IV bolus at 30 minutes
HEPARIN THERAPY: (administer simultaneously with Retevase):
I I Unfractionate heparin: units IV bolus (1000 units/ml),then units/hr infusion
Note: When using a fibrinolytic (e.g.reteplase): Use Cardiac Unfractionated Heparin Dosing Nomogram on back of form
B-BLOCKER THERAPY
EH Metoprolol (Lopressor) 5 mg IV q5min X 3 dose
(Hold for SBP < 90, HR < 50, AV block > Is’ degree, decompensated CHF, severe CORD/Asthma)
Assess for reperfusion based on angina intensity, ST resolution, and/or hypotension EH Cardiology consultation, if possible reperfusion failure
Table 1. Acute coronary syndromes: ST segment elevation myocardial infarction (chest pain>30 min. in last 24 hrs; ECG w/ST elevation or LBBB)
ED< 60 minutes First 24-48 hours 48 hours Discharge At discharge Assessment Triage & vs per protocol EKG, Monitor, Pulse Oximetry vs per condition EKG monitor, Cath lab Orders VS per order, Postcath lab care Telemetry or transfer to med bed Tests Interventions EKG- with RV leads if IWMI Chem panel, Mg, LipidsCK-MB, Troponin CBC, PT/Aptt CXR Repeat EKG as per Order/ protocol CBC/a PTT as needed CPK-MB Q8h x3 (or until MB peaks) Troponin -I with 3ฬ draw If no re-perfusion – cath lab CBC/aPTT pmCath/Possible PCI Consider Echo Consider Stress Test-day4 EKG prior to D/C if ordered Medications ASA (2 chewable 81 mg tabs) &/or clopidogrel Beta-Blocker -if indicated Nitrates Analgesia-as indicated Anticoagulation Reperfusion therapy ECASA &/or clopidogrel Beta-Blocker Anticoagulant ACEI Lipid lowering agent Consider llb/llla inhibitor & nitrates ECASA &/or clopoidogrel Beta-Blocker Anticoagulant Lipid lowering agent ACEI Consider llb/llla inhibitor & Nitrates ECASA &/or clopidogrel Beta-Blocker ACEI Lipid-lowering agent Consider Nitrates Consultations Notify PCP Designate Cardiology consult(If indicated) Cardiac rehab Social Work as needed Chaplain In-Patient Dietary Consult (asappropriate) as needed Consider Referrals to : Outpatient Nutrition Services Phase II Cardiac Rehab Smoking Cessation Treatments IV KVO Oxygen per NC Admission weight IV-Trap or KVO Oxygen per NC I/O Admission weight IV-Trap or KVO Diet/Nutrition Cardiac diet Cardiac Diet -caffeine allowed Cardiac Diet -caffeine allowed change AHA Step II Diet-lifestyle Activity Bed rest Advance as Tolerated Cardiac Rehab interaction Advance as Tolerated Cardiac Rehab interaction Home Walking Cardiac Rehab interaction Recommendations Patients Education Explain initial therapy Cardiac Rehab to see Instruct post cath as appropriate Give MI packet/TV videos Initiate MI teaching Dx/recovery process Continue Rehab/MI teaching Meds-Risk Factors Activity/ walking program Sx recurrent/ NTG use F/U Medical Plan Review Discharge instruction Form Written information packet for discharge Instruct info to be brought to Is1 MD visit Discharge Obtain Appropriate level of care/Monitored Bed Assess for specific Discharge needs Consider Discharge Day 2-4 pending risk and intervention needs Expected Outcome Upon transfer from ED: ‘Initial EKG w/1 15 mins. of arrival * Therapy initiated w/1 30 mins. of arrival * Lytic initiated w/1 30 mins Upon transfer: * No comp from cath lab proc * VS w/1 normal limits/ baseline * CP absent or controlled * Understanding of Dx verbalized Transfer in designated timeframe Upon Discharge: * VS WNL/baseline CPabsent/ controlled Ischemia/ventricular function testing complete as per path Discharge meds initiated per ACSGuidelines cv risk factors Identified with life style modification Patient understands Discharge Instructions Discharge w/I designated timeframe Post -discharge physician visit: Risk Factor Management: Continue aggressive risk factor and medication management withevery visits 1. NSTEMI/Unstable angina ในผู้ป่วยที่ไม,มี EKG เปลี่ยนแปลงชัดเจน หรือมี ST -depression ควรให้การรักษาแบบ Unstable angina หรือ NSTEMI ซึง pathology จะเป็น non occlusive thrombus วัตถุประสงคในการรักษาจะเพอลด thrombus burden, limit thrombus progression และ promote healing/homeostasis ชงใน ACC/AHA guideline 2002 update1″” มีการเปลยนแปลง ดังนี้ Table 2: Summary of or reiterated recommendations from the 2002 guidelines updates.’171 General Recommendation Revised or Reiterated Recommendation Upgrade/Downgrade/ NewUnchanged Since September 2002 Risk stratification Rapid and accurate risk stratification of Patients with chest pain in essential NO change, but TIMI risk score receives special emphasis. Optimal management strategy 1. Early (23-36h) interventional strategy when high-risk features present 2. Intervention management includes glycoprotein Ilb/IIIa receptor blockage 1. Upgrade (B-*IA) 2. Unchanged Use of clopidogrel 1. Clopidogrel for patients with acute coronary syndrome and aspirin allergy 2. Clopidogrel in addition to aspirin on admission if on interventional management planned 3. Clopidogrel continued 1 to 9 mo after intervention 4. Delay or withhold clopidogrel 5 to 7 days if coronary artery bypass grafting is anticipated 1. Upgrade (IB-MA) 2. New 3. New 4. New Use of anticoagulants 1. Anticoagulation with unlractionated or low- molecular-weight heparin 2. Enoxaparin specifically preferred over unfractionated heparin unless coronary artery bypass grafting is anticipated within 24 h 1. Upgrade (IB-* IA) 2. New Glycoprotein Ilb/IIIa agents in medical therapy 1. Small-molecule glycoprotein Ilb/IIIa agent in high-risk patients managed without intervention 2. Small-molecule glycoprotein Ilb/IIIa agent not indicated in non-high risk patients being managed without intervention 3. Abciximab not indicated if intervention not planned 1. Refinement (IA-MlaA) 2. New 3. New   1. Risk stratification เน้นการใช้ TIMI risk score”8’19’ 7 ประการอันประกอบไปด้วย – Risk factors > 3 +1
– Age > 70 +1
– Abnormal EKG +1
– Chest pain score > 10 +1
– Previous significant CAD +1
– ASA taking in 7 days +1
– Positive cardiac markers +1
0-2 = low risk
3-4 = intermediate
5-7 = high risk
Total risk score

แผ่นแปะเท้า

การ management หลังจาก risk stratification แล้วอาจใช้ Figure 3. เป็นแนวทางดังนี้
ในผูป่วย low risk ควรให้การรักษาแบบ conservative strategy และผู้ป่วย high risk ควรให้การรักษาแบบ invasive
strategy
ส่วนผู้ป่วย intermediate risk นันควรพิจารณาเป็นรายๆ ไปหลังจากให้การรักษาแบบ conservative strategy แล้ว ถาผูป่วยยังมีอาการหรอมี clinical evidence ของ ischemia ควรพิจารณา invasive strategy ต่อไป
อย่างไรก็ตาม guideline ดังกล่าวน่าจะมีการเปลี่ยนแปลงในกรณีที่มี New Imaging techniques เช่น CT-64 หรือ cardiac MRI ซึ่งแปลผลโดยแพทย์ผู้มีความชำนาญเพียงพอ
Figure 4 และ Table 3 เป็นตัวอย่าง standard checklist และ order ของการรักษาผู้ป่วย unstable angina / NSTEMI*151 ตั้งแต่ผู้ป่วย อยู่ในห้องฉุกเฉิน การรักษาหลังจากนั้นและก่อนส่งผู้ป่วยกลับบ้าน
Figure 5 เป็น medication checklist 13 ก่อนผู้ป่วยกลับบ้านว่าผู้ป่วยควรได้รับ aspirin, (1-blocker, ACE inhibitors และ statin ไปตลอดชีวิตรวมทัง clopidogrel อย่างน้อยเป็นเวลา 9 เดือนตาม evidence-based medicine ทีผ่านมา ถ้าไม,ได้รับยาตัวไหน ควรบันทึกไว้ด้วยว่าเนื่องจากสาเหตุใด
การนำเสนอแนวทางการ management ผู้ป่วย acute coronary syndrome ทังหมดทีกล่าวมาขางตน เปนตัวอย่างการ ใช้ clinical evidence-based medicine และ ACC/AHA guideline เป็นสำคัญ แต่การปฏิบัติในประเทศไทยนั้น อาจขึ้นอยู่กับ สถานการณ์ ความเหมาะสม และความพร้อมของแต่ละสถานพยาบาล
Figure 4. Suspected unstable angina/non-ST elevation MI (NSTMI): emergency department orders.
Allergies Actual Weight:
Height:
Initial Orders Check all that apply
DIAGNOSTICS:
□ Stat EKG, obtain old EKG record
□ Stat ACS Lab panel: CMP, CBC/diff, PT/INR/aPTT, CK + CK-MB (site specific), Troponin, Magnesium, hs- CRP lipid profile (routine)
□ Stat portable CXR
□ Cardiac monitor and Sa02 monitors
□ Other
ANTI-ISCHEMIC THERAPY
n Oxygen 5L/min Nasal Cannula (titrate to keep pulse oximetry saturatin > 94%)
D IV – 0.9 NS: D Trap D KVO ml/hr
CH Opiate: _mg IV (suggest morphine sulfate)
Nitroglycerin Therapy (Hold id patients has taken Sildenafil (Viagra) within 24 hours)
CD Nitroglycerin 0.4 mg SL q5min X 3 doses or until pain relief or SBP < 100 mmHg EH Nitroglycerin paste inch (es) topically X 1 dl Start IV infusion of Nitroglycerin at 10 mcg/min, then titrate as per pharmacy protocol (use 100 mg in 250ml DW) ACS ANTI-THROMBOTIC TREATMENT GUIDE (I) Possible ACS: □ Aspirin 162 mg po (2 chewable 81 mg tablets) II) Likely /Definite ACS (without continuing ischemic pain or high risk features) a) Chief symptom: chest or left arm discomfort and/or b) Prior MI, Hx of CAD, extra-cardiac vascular disease, age > 70 years and/or
c) EKG: Fixed Q wave, presumed old abnormal ST segments or T waves im Aspirin 162 mg po (2 chewable 81 mg tablets)
□ Clopidogrel (Plavix) 300 mg po (loading dose) HOLD IF CABG IS ALREADY SCHEDULED OR CURRENTLY ON PLAVIX
Enoxaparin (Lovenox) mg SQ x 1 (1 mg/kg dose) (Note: Use unfractionated heparin in severe
renal impairment (creatinine clearance < 30 ml/min) and morbidly obese patients) III) Definite ACS with ANY of the following features: a) Continuing ischemic pain (despite ASA, clopidogrel, IV NTG, heparin) High – risk (of death or non-fatal MI) features: positive cardiac enzymes, new or transient ST- segment changes (> 0.05mV), pain at rest > 20 minutes, diabetes, pulmonary edema, recent MI, age > 75 years, hypotension, sustained VT.
c) Planned intervention
□ Aspirin 162 mg po (2x chewable of 81 mg tablets)
D Clopidogrel (Plavix) 300 mg po (loading dose) HOLD IF CABG IS ALREADY SCHEDULED OR CURRENTLY ON PLAVIX
n Eptifibatide (Integrilin) ml IV bolus, then ml/hr IV infusion (dosing nomogram on back of
form) (Note: Half infusion rate if serum creatinine is between 2-4 mg/dl)
Unfractionated heparin units IV bolus (1000 units/ml) then units/hr IV infusion (Note:
When using GP llb/llla inhibitor (e.g. eptifibatide): Use Cardiac Unfractionated Heparin Dosing Nomogram on back of form.
B-Blocker Therapy:
n Metoprolol (Lopressor) 5 mg IV q 5 min X 3
(Hold to SBP < 90, HR < 50 , AV block > 1st degree, decompensated CHF, severe COPD/Asthma)
Physician /NP/PA Signature: Date Time
Additional Orders:
ED< 60 minutes First 24-48 hours 48 hours Discharge At discharge
Assessment Triage & vs per protocol EKG, Monitor, Pulse Oximetry vs per condition EKG monitor, Cath lab Orders vs per order, Post cath lab care Telemetry or D/C per protocol
Tests
Interventions EKG-consider posterior leads Chem panel. Mg, LipidsCK-MB, Troponin CBC, PT/aPTT CXR Repeat EKG as per Order/protocol CBC/aPTT as needed CPK-MB Q8h x3 (or until MB peaks) Troponin -I with 3rf draw Cath/ possible emergent ACEI CBC/aPTT pm PCI Cath/Possible
Possible CABG
Medications ASA (2 chewable 81 mg
tabs) &/or clopidogrel
Beta-Blocker
-if indicated Nitrates
Analgesia -as indicated
Anticoagulation llb/llla
inhibitor ECASA &/or clopidogrel Beta-Blocker Anticoagulant llb/llla inhibit or Lipid lowering agent Consider ACEI Nitrate, Statin ECASA &/or clopoidogrel Beta-Blocker Anticoagulant if necessary llb/llla if necessary ACEI Consider Nitrate, Statin ECASA &/or clopidogrel Beta-Blocker ACEI Stain Consider Nitrate
Consultations Notify PCP Designate Cardiology consult (If indicated) Cardiac rehab Social Work as needed Chaplain as needed In-Patient Dietary Consult (as appropriate) Consider Referrals
to: Outpatient Nutrition
Services
Phase II Cardiac
Rehab Smoking Cessation
Treatments IV KVO Oxygen per NC Admission weight IV-Trap or KVO Oxygen per NC I/O Admission weight IV-Trap or KVO
Diet/Nutrition Cardiac diet Cardiac Diet -caffeine allowed Cardiac Diet-caffeine allowed AHA Step II Diet- lifestyle change
Activity Bed rest Advance as ToleratedCardiac Rehab interaction Advance as Tolerated Cardiac Rehab interaction Home Walking Cardiac rehab Recommendations
Patients Education Explain initial therapy Cardiac Rehab to see Instruct post cath as appropriate Give MI packet/ TV videos Initiate MI teaching Dx/ recovery process Continue Rehab/Ml teaching Meds-Risk Factors Activity/ walking program Sx recurrent/ NTG useF/U Medical Plan Review Discharge instruction Form Written information packet for Discharge Instruct info to be brought to 1 “ MD visit
Discharge Obtain Monitored Bed Assess for specific Discharge needs Consider Discharge Day 2-4
Expected
Outcome Upon transfer from ED:
* Initial EKG w/1 15 mins of arrival
* Therapy initiated w/1 30 mins. of arrival Upon transfer:
* No comp from cath lab proc
* VS w/1 normal limits
* CP absent or controlled
* Understanding of Dx verbalized Transfer in designated timeframe Upon Discharge:
* VS WNL/baseline CP absent/ controlled Ischemia/ventricular function testing complete as per path Discharge meds initiated per ACS Guidelines cv risk factors identified with life style modification Patient understands Discharge Instructions Discharge w/1 designated timeframe
Table 3. ACS Unstable Angina NSTEMI Care Path
Post -discharge physician visit : Risk Factor Management : Continue aggressive risk factor and medication management with every visits

Acute Coronary Syndrome Discharge Medications
Primary Care Physician
Discharge Diagnosis Angina (“heart pain”) MI (“heart attack”)_
See your Doctor in Weeks Phone
See your Cardiologist in Weeks
Health Insurance: 1—1 Comm. Blue CD IHA [—I Univera CH Other

ACSETS MEDICATION CHECTLIST
For long-term drug treatment following an acute coronary syndrome event, the American College of Cardiology and the American Heart Association recommend (unless contraindicated): an aspirin, beta blocker, ACE inhibitor, and statin indefinitely, and clopidogrel for at least nine months.
FOR EACH DRUG CLASS BELOW: PLEASE check Yes if patient is discharged on medication. If patients is not discharged on medication , check No and Why ?
Aspirin : (81 mg qd, if coronary stented 325 mg qd)
YES D NO D if NO, WHY? Allergy Contraindicated Other
Statin ะ e.g. atorvastain (Lipitor), fluvastatin (lescol), lovastatin (Mevacor),
Pravastatin (Pravachol), simvastatin (Zocor)
YES n NoDifNO, WHY? Allergy Contraindicated Other
Beta Blocker : e.g. atenolol (Tenormin), metoprolol (Lopressor), carvedilol (Corge)
YES □ NO □ if NO, WHY? Allergy Contraindicated Other
ACE Inhibitor ะ e.g. benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec),
Fosinopril (Monopril), lisinopril (Prinivil), quinapril (Accupril), ramipril (Altace)
YES □ NO □ if NO. WHY? Allergy Contraindicated Other
Clopidogrel: (Plavix 75 mg qd)
YES □ NO □ if NO, WHY? Allergy Contraindicated Other
Provider Signature (RN, MD, DO, PA, NP, PharmD, RPh) Completing the Form:
Date
Patient Signature
References
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2. Gersh BJ. Current issues in reperfusion therapy. Am J Cardiol 1998;82:3P-11P.
3. Gersh BJ, Anderson JL. Thrombolysis and myocardial salvage: results of clinical trials and the animal paradigm-paradoxic or predictable? Circulation 1993;88:296-306.
Fonarow GC, Gawlinsski A, Watson K, et al. In-hospital Initiation of Cardiovascular protective Therapies to Improve Treatment Rates and Clinical Outcomes. The University of Califomia-Los Angeles Cardiovascular Hospitalization Atherosclerosis Management Program. Critical Pathway in Cardiology 2003;2:61-70.
Zijlstra F, DeBoer MJ, Hoomtje JCA, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in myocardial infarction. N Engl J Med 1993;328:680-4.
Gnnes CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993;328:673-9.
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