NonST Segment Elevation Myocardial Infarction Nstemi and Unstable Angina

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1. Admit to: Coronary care unit

2. Diagnosis: Acute coronary syndrome

3 Condition:

4. Vital Signs: q1h. Call physician if pulse >90,<60; BP >150/90, <90/60; R>25, <12; T >38.5"C.

5. Activity: Bed rest with bedside commode.

7. Nursing: Guaiac stools. If patient has chest pain, obtain 12-lead ECG and call physician.

8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol. No caffeine or temperature extremes.

9. IV Fluids: D5W at TKO

10. Special Medications: -Oxygen 2-4 L/min by NC.

-Aspirin 325 mg PO, chew and swallow immediately, then aspirin

EC 162 mg PO qd OR -Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin) OR -Aspirin 325 mg to chew and swallow, then 81-162 mg PO qd

PLUS clopidogrel 300 mg PO x 1, then 75 mg PO qd. -Nitroglycerin infusion 10 mcg/min infusion (50 mg in 250-500 mL D5W, 100-200 mcg/mL). Titrate to control symptoms in 5-10 mcg/min steps, up to 1-3 mcg/kg/min; maintain systolic BP >90 OR

-Nitroglycerin SL, 0.4 mg mg SL q5min until pain-free (up to 3 tabs) OR

-Nitroglycerin spray (0.4 mg/aerosol spray) 1-2 sprays under the tongue q 5min; may repeat 2 times. -Heparin 60 U/kg IV push, then 15 U/kg/hr by continuous IV infusion for 48 hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours after each dosage change.

Glycoprotein Il^/IIIa Blockers in High-Risk Patients and Those with Planned Percutaneous Coronary Intervention (PCI): -Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2 mcg/kg/min for

48-72 hours OR -Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 min, then 0.1 mcg/kg/min for 48-108 hours.

Glycoprotein IIb/IIIa Blockers for Use During PCI:

-Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125 mcg/kg/min

IV infusion for 12 hours OR -Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2 mcg/kg/min for 18-24 hours.

Beta-Blockers: Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses; then 25 mg PO q6h for 48h, then 100 mg PO q12h; keep HR <60/min, hold if systolic BP <100 mm Hg OR -Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes, followed by 50-100 mg PO qd OR -Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max 300 mcg/kg/min).

Angiotensin Converting Enzyme Inhibitors:

-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-20 mg qd.

-Benazepril (Lotensin) 10 mg qd OR -Rampril (Altace) 5-10 mg qd OR -Perindopril (Aceon) 4-8 mg qd.

Long-Acting Nitrates:

-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free period to prevent tachyphylaxis. -Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40 mg] OR

-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.

Statins:

-Rosuvastatin (Crestor) 10 mg PO qd OR -Atorvastatin (Lipitor) 10 mg PO qhs OR -Pravastatin (Pravachol) 40 mg PO qhs OR -Simvastatin (Zocor) 40 mg PO qhs OR -Lovastatin (Mevacor) 20 mg PO qhs OR -Fluvastatin (Lescol)10-20 mg PO qhs.

11. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn chest pain. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Ondansetron (Zofran) 2-4 mg IV q4h prn N/V. -Famotidine (Pepcid) 20 mg IV/PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

12. Extras: ECG stat and in 12h and in AM, portable CXR, impedance cardiography, echocardiogram. Cardiology consult.

13. Labs: SMA7 and 12, magnesium. Cardiac enzymes: CPK, CPK-MB, troponin T, myoglobin STAT and q6h for 24h. CBC, INR/PTT, UA.

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