Cardiac ChecklistapplCLCA-CH00CH00_CH00CH00CH00VCH00cCH00CH00 CH00 CH00 CH01CH01SCH01CH01CH01CH01BCH01ACH01CH01CH01 CHEKCHSTCHSTMBAR~MBARTaltTaltTbmp4codeCcodeCcodeadatacpprefctAIBctAINhEtFRMhWtFRMLitFRMlAtFRMmEtFRMxnStSTRo#tSTRo-tSTRo6tSTRptversAspirin 160 to 325 mg po daily. If contraindicated, use clopidogrel alone. Clopidogrel Loading dose 300 mg po x 1, followed by 75 mg daily. Heparin (or low-molecular weight heparin) Enoxaparin is the preferred heparin (and LMWH). On the basis of randomized trials showing superiority to unfractionated heparin, dosing is 1 mg/kg subcutaneously q 12 with a 30-mg IV bolus optional. For patients with renal dysfunction (creatinine >2.0), reduction in dose by one-half is suggested. Unfractionated heparin is administered as a 60- to 70-unit/kg bolus IV and a 12- to 15-unit/kg/hr infusion, adjusted to an APTT of 50 to 70 seconds. GP IIb/IIIa inhibitor In high-risk patients (positive troponin, positive ST-segment changes, TIMI Risk Score > 3), a small molecule GP IIb/IIIa inhibitor is recommended. Tirofiban dosing is 0.4 mcg/kg/min x 30 minutes followed by an infusion of 0.1 mcg/kg/min for 48 to 96 hours. In patients with severe renal insufficiency (creatinine clearance < 30 ml/min), the loading dose and maintenance infusion should be reduced by 50%. Eptifibatide 180 mcg/kg bolus followed by an infusion of 2.0 mcg/kg/min for 48 to 96 hours. In patients with serum creatinine between 2 and 4 mg/dl, a 180 mcg/kg bolus should be used followed by 1.0 mcg/kg/hr infusion. Contraindicated in patients with serum creatinine > 4 mg/dl. Beta blocker Intravenous beta blockade is recommended for patients with ongoing pain followed by oral beta blockade. An example is metoprolol 5 mg IV q 5 minutes x 3, followed by metoprolol 25 mg q.i.d., with the dosing titrated to a heart rate of between 50 and 60. Nitrate Sublingual nitroglycerin 0.4 mg sublingual q 5 minutes x 3, followed by topical nitropaste or intravenous nitroglycerin for ongoing pain. ACE inhibitor Recommended for patients with acute hypertension and for long-term secondary prevention. Any type of ACE inhibitor is probably equivalent, since reductions in MI have been seen in trials with ramipril (HOPE), captopril (SAVE), and enalapril (SOLVD). Cath/revasc in med-high risk pts Cardiac catheterization is recommended for intermediate or high-risk patients (positive troponin, positive ST changes, TIMI Risk Score >= 3 on the basis of TACTICS-TIMI 18). Catheterization is also recommended for patients with recurrent ischemia at rest or a positive stress test, or in people with prior revascularization or known left ventricular dysfunction. Cholesterol-check + treat A full lipid panel is recommended on admission within the first 24 hours. Treatment with a statin is recommended for patients with LDL > 130 and probably indicated for any LDL > 100, and potentially for all patients regardless of LDL on the basis of the Heart Protection Study. Dosing is generally recommended to begin with 40 mg of either pravastatin or simvastatin on the basis of CARE, LIPID, WOSCOPS, and HPS studies. Atorvastatin has been used at a dose of 80 mg in its two clinical trials, although 10 mg is generally the starting dose used clinically. Treat other risk factors Smoking cessation counseling should be given. Control of diabetes, especially on admission, has been shown to improve mortality. Control of hypertension is also important. Aspirin A dose of 81 to 325 mg daily is recommended. Recent data suggests that bleeding is lower, with the lowest dose of aspirin. If contraindicated, use clopidogrel alone. Clopidogrel Clopidogrel should be given with aspirin at a dose of 75 mg daily on the basis of the CURE Study for at least one year. In addition, in the CAPRIE trial benefit of clopidogrel over aspirin was seen out to 3 years. In patients who have gastrointestinal bleeding, ulcers, or even dyspepsia, consideration of clopidogrel alone, without aspirin, should be given. Statin Statin therapy is recommended for all patients with LDL > 130 in the NCEP Guideline. It should probably also be given in patients with an LDL of > 100 and probably even for patients with lower LDLs on the basis of the Heart Protection Study. Dosing is generally recommended to begin with 40 mg of either pravastatin or simvastatin on the basis of CARE, LIPID, WOSCOPS, and HPS studies. Atorvastatin has been used at a dose of 80 mg in its two clinical trials, although 10 mg is generally the starting dose used clinically. Beta blocker Oral beta blockade should be used in patients without contraindications. Typical contraindications to beta blockade include first-degree AV block with PR interval of > 0.24 or higher degree AV block, bradycardia with heart rate < 50, severe asthma or bronchospasm. ACE inhibitor Any type of ACE inhibitor is probably equivalent, since reductions in MI have been seen in trials with ramipril (HOPE), captopril (SAVE), and enalapril (SOLVD). Use with caution in patients with renal insufficiency. An Angiotensin receptor blocker can probably be substituted if the patient has a cough to ACE I. Calcium blocker (if needed) A calcium antagonist can be added as anti-ischemic therapy if needed beyond beta blockade. Heart rate-lowering calcium blockers are usually suggested, such as diltiazem or verapamil. However, other agents can be used such as amlodipine or felodipine or even nifedipine extended-release if the latter is used in conjunction with beta blockade. Nitrates are generally not suggested at discharge unless needed for control of stable angina beyond beta-blockers and calcium blockers. Blood pressure controlled On the basis of HOT Study, good blood pressure control with a blood pressure of < 140/85 has been shown to be associated with better long-term outcomes. Diabetes controlled Recent data demonstrate that good glycemic control is associated with improved acute and long-term outcomes. Thus, careful monitoring and appropriate diet, oral drugs and/or insulin therapy should be administered. Smoking cessation counseling (if applicable) Smoking cessation counseling should be given to all patients who have been recent or are active smokers. Pharmacologic therapy can be a useful adjunct in referral to cardiac rehabilitation and/or smoking cessation clinic. Cardiac rehabilitation/lifestyle change Studies have shown cardiac rehabilitation to be beneficial following acute coronary syndromes. Lifestyle changes, including increase in exercise, weight loss, and improved diet, all are strongly recommended. AdmissionDischarge AspirinClopidogrelHeparin or LWMHGP llb/lla inhibitorBeta blockerNitrateACE inhibitorCath/revasc in med-high risk ptsCholesterol-check + treatTreat other risk factors AspirinClopidogrelStatinBeta blockerACE inhibitorCalcium blocker (if needed)Blood pressure controlledDiabetes controlledSmoking cessation counseling (if applicable)Cardiac rehab/lifestyle changeY/ RBDZAfOptionsDisclaimerAboutY/ d5M3 tDA'C'SOptionsDisclaimerAboutEditCopySelect AllUnsupported DeviceThis program requires PalmOS 2.0 or greaterOKOut of MemoryThere is not enough memory to load this checklistOKdd@x@ =Fxg9jWi8+p@_ h$v @@@`@"pW* >`?@@=p`< 0 p@DGc@"x>xp` C@O#O .(@ ` 0" t`@`1 (`] ' '0A>L/@p> |<0 0p 1  O ;0L'ldh ;$`#l70р7 ?`~? 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S`$H jgPfg!D`$Hx a40!DBf&`%HL N^NuNV n0. ". P` hgPf/(/NON^NuNVH0&nBg/|||||||||>NOs&'C?</NO?/NOO 'H&+?</NO?/NOO 'HBg/NV .fp/NON^NuNV .g/NON^NuNVH8:.(. 6.E•G4I8ʹc [?/?NPbL8N^NuNVH8:.(. 6.GtI8E<˹d b?/?NPeL8N^NuNVH8G2E>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>vvvv>>>vvvv>>>>>>vvvvvv>vvovvv>>>>>vvvvvvvvvvv>>>>>vvvvvvvvvov>>>>>vvvvvvvvvvvvvv>>>>vvvvvvvvvvvvvv>>>>>vvvvvvvvvvvv>>>>>>vvvvvvvvvvovvv>>>>>>>vvvvvvvvvvv>>>>>>>>>vvvvvvvovv>>>>>>>>>>vvvvvoovv>>>>>>>>>>>vvvvvvv>>>>>>>>>>>>vvvvv>>>>>>>>>>>>vvv>>>>>>>>>>>>v>>>>>>>>>>>>>>>>>>>>>>>>Cardiac Checklist b (0Cardiac Checklists UA/NSTEMI#@  #2'Christopher P. Cannon, M.D.L h $<Rh1234567890123456789012345678901234567890L}@           }MO N P  b 1234567890123456789012345678901234567890}}  2 b About Cardiac Checklistpp'Version 1.0.0. March 11, 2002' * Dismiss2x \t Disclaimerx}}y' * DismissChecklistcompleteThis program was developed by Christopher P. Cannon, M.D., Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School. The software was developed by PDA Verticals Corporation. This program was supported by an unrestricted educational grant from Bristol-Myers Squibb. Cardiac checklist copyright 2002, Christopher P. Cannon, M.D. Software copyright 2002, PDA Verticals Corporation. All rights reserved.This checklist was developed as a clinical aid to physicians in treating patients with unstable angina and non-ST elevation myocardial infarction. The recommendations are based on the ACC/AHA Guidelines for management of patients with UA/NSTEMI (Sept 2000 and Mar 2002 update) Braunwald et al. JACC 200036;970-1062; www.acc.org. However, in all cases, clinical judgement should be used when utilizing the information found in this program. Please refer to prescribing information listed for a complete list of contraindications for the selected medications.1.0.0