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					                           The Paul Dudley White Coronary Care System
                                                                                                                   March 2002
                             St. Agnes HealthCare  Baltimore, Maryland

                           Emergency Department Chest Pain Center
                    PATHWAYS FOR PATIENTS PRESENTING WITH
                                  CHEST PAIN (The Tracks)
            Risk Stratification Based On Initial History and EKG Within 5 Minutes
                                   (missiled to ED Physician)



                ACUTE PATHWAYS                                                      OBSERVATION
                                                                                     PATHWAYS


                                                 Non-ST
              ST                               Elevation/MI
         Elevation MI                            Unstable                          Moderate                 Low
            Track I                                                                Probability           Probability
                                                  Angina
                                                 Track II                           Track III             Track IV
      TRACK I ORDERS
          Acute MI
          Primary                       TRACK II ORDERS                              TRACK III – IV ORDERS
         Angioplasty                       Acute Coronary
                                             Syndrome                                     Observation Unit
                                                     (ACS)



         STEMI                                  NSTEMI/UA                                        Observational Services (CPC)
   O2, ASA, Morphine          O2, ASA, Morphine                  Bedside Markers                  Less than 24 hours in ED
           ASA                ASA                                EKG Monitoring                        EKG Monitors
   Nitroglycerine/Tridil      Nitroglycerine/Tridil              Stat Blood Work                      Bedside Markers
          Plavix              Plavix                             Chest X-Ray                      Observational Monitoring

    Heparin/Enoxaparin        Heparin/Enoxaparin                                                         Rest Sestamibi
                                                                                                         (Nuclear Test)
                                                                                                         Stress Testing
     Bedside Markers          High Risk                  Less Risk (moderate)
     EKG Monitoring           (+) Troponin               (-) Troponin
     Stat Blood Work          EKG Changes                Less Pain
       Chest X-Ray            Continued Pain             EKG Minimal Changes

                              Synergy Trial                                                               or        More likely
                              (Crusade Registry)


        Cath Lab              Cath Lab Early             Coronary Care Unit                  Admit                     Home
   Diagnostic Cath and        Diagnostic Cath                                                Telemetry
   PCI as needed (stent)      PCI, Stent if needed       Tridil, Nitroglycerin
    ReoPro/Integrillin        ReoPro/Integrillin         Heparin/Enoxaparin
                              Heparin/Enoxaparin         Consider Integrillin                Stress Test next       and Stress
                              Plavix                     Consider Plavix                     day in hospital        test next day
                                                                   or       more likely                             in office

   Coronary Care Unit         Coronary Care Unit         Cath       Stress Test
        Groin Care            Groin Care                 Diagnostic
     Sheath Removal           Sheath Removal
  D/C Heparin, Reopro or                                            (+)        (-)
       Integrillin            D/C Heparin, Reopro                  Cath    Medical
  Continue ASA, Plavix        Or Integrillin                              Management
    Add Beta Blocker          Continue ASA, Plavix
      ACE Inhibitor           Add Beta Blocker
          Statin              Ace Inhibitor
                              Statin

 General Medical Care and     General Medical Care and
        discharge on          discharge on
        ASA, Plavix           ASA, Plavix
Beta Blocker, ACE Inhibitor   Bata Blocker, Ace Inhibitor
          and Statin          and Statin
Cardiac Rehab counseling on   Cardiac Rehab counseling on
   risk factors, return of    risk factors, return symptoms
symptoms, what to do, when    what to do, when to return
          to return
              Cardiac Cath Lab                                      Coronary Care            CCU/Telemetry                Home
       Primary Angioplasty/CABG Candidate                                 Unit                    Unit

				
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