Cardiology Cheat Sheet
Acute Coronary Syndrome 1. Orders: IV, oxygen, monitor, 12-lead EKG, CXR, troponin, CK-MB, CBC w/diff (r/o anemia or acute infection), echocardiogram 2. Initiate therapy with ASA, B-blockade, statin, heparin/LMWH, nitrates/narcotics, anxiolytics • ASA 325mg chewed • Metropolol 5mg IV up to x3 (if active chest pain) then 25-50mg po q6h • Statin: atorvastatin 80mg po qd1; alt: simvistatin 20mg po qd • Heparin by nomogram or enoxaparin 1mg/kg SC bid2 3. Non ST elevation MI - Early Risk Stratification • Low risk: normal ST segments, normal cardiac markers OR TIMI risk 0-2 o Continue medical management, functional study for further risk stratification • Intermediate risk: ST depression OR positive cardiac markers OR TIMI risk 3-4 o Glycoprotein IIb/IIIa inhibitor or clopidogrel (300mg loading, 75mg qd, t½ = 5-7d)3 o Cardiac catheterization4 • High risk: ST depression AND positive cardiac markers OR TIMI risk 5-7 o Glycoprotein IIb/IIIa inhibitor (bolus then gtt) o Cardiac catheterization 4. ST elevation MI – cardiac catheterization or thrombolytics 5. ACE inhibitor indicated with anterior MI, clinical evidence of CHF, EF < 40%. Avoid with hypotension, hyperkalemia, creatinine > 3.0, bilateral renal artery stenosis 6. TIMI Risk Score (THREATS)5 – each worth one point • T = Troponin or other cardiac enzyme elevated • H = History: >= 3 CAD risk factors • R = Restricted coronary artery: prior history of >= 50% stenosis • E = Elderly > 65 yo • A = Aspirin, use of daily • T = Two or more episodes of angina • S = ST deviation 7. Risk of adverse cardiac event (MI, death, persistent ischemia requiring urgent revascularization) with TIMI risk: • 0-1 = 4.7% • 2 = 8.3% • 3 = 13.2% • 4 = 19.9% • 5 = 26.2% • 6-7 = 41.0% Presenting Patients on Rounds Age, race, sex, cardiac risk factors/known cardiac disease, prior cardiac risk stratification (exercise treadmills, adenosine-thallium, stress echo), prior cardiac catheterizations or CABG (with data), presents with… Meds: Cardiac meds first with dosage Check daily: EKG, telemetry, administration of meds (MAR)
MIRACL study Can be safely combined with GP IIb/IIIa inhibitors (INTERACT trail) CREEDO 4 Early invasive coronary angiography decreases 6 month triple endpoint (death/MI/ACS rehosp) in TIMI risk scores of intermediate (20.3% 16.1%), and high (30.6% 19.5%) [TACTICS + TIMI 18, FRISC II] 5 MKSAP 13
2 3 1
M. Alaric Franzos, MD
Admission Checklist 1. 2. Admission request Orders a. ASA b. B-blocker if HD stable c. ACE after B-blocker d. Antiplatlet i. Enoxaparin preferred if CrCl >30, otherwise heparin gtt without bolus ii. Transfer to ICU with eptifibitide bolus then gtt if troponin > 1.0 or persistant pain iii. Clopidogrel after percutaneous coronary intervention (PCI) with balloon angioplasty or stent placement. Hold clopidogrel if patient may go to CABG. e. Pain relief i. Nitrates (NTG SL, NTG paste, NTG gtt) ii. Morphine 2mg IV q2h prn f. Antilipid – continue statin or add simvastatin 20mg po qd g. Nephroprotection i. Hold metformin ii. If creatinine > 1.4 or diabetic: 1. Acetylcysteine 600mg po q12h x4 2. Bicarb gtt (3 amps Bicarb in 1L D5W at 3ml/kg per hour 1 hr prior and 1ml/kg per hour 6 hrs post cath) h. EKG on admission and qAM. i. Cardiac enzymes q8 x3. If positive, repeat until trending down. j. CXR k. Bedrest l. Strict I./O Prior procedures a. Cardiac catheterization (CHCS or CV tech 301-285-0262) b. CABG op report (CT surgery file room – call CT Surgery Intern) c. Echocardiogram, nuc med perfusion studies (CHCS or call CV tech) d. Exercise treadmill test (call CV tech) Advise PCM (or pass PCM name on to resident)
3.
4.
Discharge Checklist 1. 2. 3. 4. 5. 6. Meds: ASA, B-blocker, ACE-I, Statin, NTG, CLOPIDOGREL/PLAVIX!!! a. Enter in CHCS as well as listing on CIS Discharge Summary Cardiac follow up 295-4500 PCM follow up Include specific results of procedures in Discharge Summary Post cath activity restrictions: no driving for 24 hours, no vigorous activity or lifting more than 10 pounds for one week (post pacemaker/ICD placement o driving for 24 hours, no vigorous activity or lifting more than 10 pounds or raising arm above shoulder for two weeks). Copies of Discharge Summary to cardio (via fellow), PCM (via resident)
M. Alaric Franzos, MD