ST-Elevation MI (STEMI)
STANDING ORDERS
Based on 2007 ACC/AHA STEMI Focused Updatea
and 2009 ACC/AHA STEMI/PCI Guidelines Focused Updatesb
Patient ___________________________ ___________________________ _______
(LAST NAME) (FIRST NAME) (MI)
Age: ______ Weight: _________ Height: __________ Male Female
Medication allergies: _______________________________________________
Initial Orders: Check all that apply
Stat ECG, obtain old ECG and medical record
Stat ACS lab panel: complete metabolic panel, magnesium, CBC/diff., T/INR/aPTT, CK+CK-MB, troponin-I, lipid profile
Calculate creatinine clearance (CrCl) : ________________ mL/min
CrCl mL/min = (140 – age) ´ weight (kg)/(serum creatinine ´ 72) multiply by 0.85 if female
Stat portable CXR
Cardiac monitor and SaO2 monitor
Other _________________________________________________________
STEMI confirmed (check all that apply)
Anterior Inferior Lateral Posterior LBBB
Oxygen 2 L/min nasal cannula (titrate to keep arterial saturation >90%)
IV – D5W KVO _______mL/hr
Opiate: ____________________________________ ______ mg IV (suggest morphine sulfate)
Discontinue all NSAIDs except aspirin. Do not initiate during acute phase of management.
Aspirin 162-325 mg po chewed
Nitroglycerin 0.4 mg SL q5min x 3 prn chest pain; HOLD IF: SBP <100 mm Hg
Nitroglycerin IV – start infusion at 10 µg/min, then titrate up by 10-20 µg/min every 5-10 min as needed to control pain, if BP permits
Nitroglycerin, transdermal, 0.2 to 0.8 mg/h q12h, tolerance in 7 to 8 h
Oral b-Blocker
Metoprolol tartrate ____________ mg _____________________
IV b-Blocker (optional; recommended if persistent ischemic symptoms, hypertension, or tachycardia and no signs of hemodynamic instability)
Drug: _____________________________ _______ mg IV for ____ doses every __ hrs
Fibrinolytic Therapy: Within 12 hours of symptom onset and primary PCI cannot be achieved in <90 minutes of first medical contact OR patient cannot be transferred to primary PCI center with anticipated time from first medical contact to balloon to be <90 minutes
® Fibrinolytic Therapy Orders (goal door to needle <30 min)
Primary PCI: Within 12 hours of symptom onset, with primary PCI facility available, with anticipated first medical contact to balloon time <90 minutes
® Primary PCI Orders (goal door to balloon <90 min)
Medical Management: Contraindications to reperfusion therapy
® Medical Management Strategy Orders
Indications: chest pain <12 hours, ECG ST elevations or new left bundle branch block
Assess for contraindications to fibrinolytic therapy:
Absolute contraindications:
Any prior ICH
Known structural cerebral vascular lesion (eg, AVM)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head or facial trauma within 3 months
Relative contraindications:
Hx of chronic, severe, poorly controlled HTN
Severe uncontrolled HTN on presentation (SBP >180 mm Hg or DBP >110 mm Hg)
Hx of prior ischemic stroke >3 months, dementia, or known intracranial pathology not covered in contraindications
Traumatic or prolonged (>10 min) CPR or major surgery (<3 wk)
Recent (within 2-4 wk) internal bleeding
Noncompressible vascular punctures
For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
If fibrinolytic contraindicated, call STAT cardiology consult Dr. _________________
FIBRINOLYTIC THERAPY (choose one):
Reteplase 10 U IV over 2 minutes, repeat after 30 minutes
or
Tenecteplase 30-50 mg IV over 5 seconds, based on weight:
- 30 mg for weight <60 kg
- 35 mg for 60-69 kg
- 40 mg for 70-79 kg
- 45 mg for 80-89 kg
- 50 mg for ≥90 kg
or
Streptokinase 1.5 MU IV over 30-60 minutes
ANTICOAGULANT THERAPY (choose one with fibrinolytics):
Unfractionated Heparin: 60 U/kg IV bolus (maximum 4000 U), followed by IV infusion of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain goal aPTT 1.5 to 2.0 times control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as indicated. When using a fibrinolytic, use Unfractionated Heparin Dosing Chart. Note: Regimens other than UFH are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment (see appendix for titration nomogram)
or
Enoxaparin (provided the serum creatinine is <2.5 mg/dL in men and 2.0 mg/dL in women):
- Patients <75 years of age: 30 mg IV bolus, followed 15 min later by 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1 mg/kg every 24 h). Continue for at least 48 hours, and preferably for the duration of hospitalization, up to 8 days.
- Patients ≥75 years of age: No bolus; 0.75 mg/kg SC q12h. Continue for at least 48 hours, and preferably for the duration of hospitalization, up to 8 days.
or
Fondaparinux 2.5 mg IV initially, followed by 2.5 mg SC once daily (avoid if CrCl <30 mL/min). Continue for at least 48 hours, and preferably for the duration of hospitalization, up to 8 days.
For patients treated initially with fondaparinux who later undergo PCI, administer additional IV treatment with an anticoagulant possessing anti-IIa activity (such as UFH or bivalirudin), taking into account whether GP IIb/IIIa inhibitors have been administered. Note: Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI.
ANTIPLATELET THERAPY
Clopidogrel 300 mg po loading dose if age <75 years
(75 mg po loading dose if age ≥75 years)
ASSESS FOR REPERFUSION
ECG 60 minutes after initial bolus of fibrinolytic.
Assess for reperfusion based on angina intensity, ST resolution on 60-minute ECG and/or hypotension.
Cardiology consultation, if possible reperfusion failure
Call Dr. __________________________________________________________________
Physician/NP/PA Signature: _________________________ Date: _______ Time: _______
High risk (recommend early transfer <6 hours for PCI)
Low risk (recommend admission to CCU; monitor for ischemia)
If high risk:
Transfer for PCI
Initiate preparatory antithrombotic (anticoagulant plus antiplatelet)
Anticoagulant: _________________________ at _______________________
Antiplatelet: __________________________ at _______________________
It is reasonable for high-risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility to be transferred as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (Class IIa, LOE: B).b
Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (Class IIb, LOE: C).b
Triage and Transfer for PCIb
Adapted with permission from Kushner FG, et al. J Am Coll Cardiol. 2009;54(23):2205-2241.
Note: A planned perfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful and is not recommended.
ANTIPLATELET THERAPY (choose one):
Clopidogrel 300-600 mg po loading dose
or
Prasugrel 60 mg po loading doseb,c
and/or
GP IIb/IIIa inhibitor
GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY (choose one):
Abciximab 0.25 mg/kg IV bolus, followed by IV infusion of 0.125 µg/kg/min (to a maximum of 10 μg/min). Continue for 12 hours.
or
Tirofiban 25 µg/kg IV bolus, followed by IV infusion at 0.15 µg/kg/min. Continue for
18 to 24 hours.
or
Eptifibatide 180 µg/kg IV bolus x 2, 10 min apart, followed by IV infusion of 2.0 µg/kg/min, reduce to 1.0 µg/kg/min if CrCl <50 mL/min. Continue until hospital discharge or for 12 to 18 hours.
It is reasonable to start treatment with glycoprotein IIb/IIIa receptor antagonists (abciximab [Class IIa, LOE: A], tirofiban [Class IIa, LOE: B], or eptifibatide [Class IIa, LOE: B]) at the time of primary PCI (with or without stenting) in selected patients with STEMI.b
ANTICOAGULANT THERAPY (choose one):
Unfractionated Heparin (for at least 48 hours) 60 U/kg IV bolus (not to exceed 4000 U), followed by IV infusion of 12 U/kg/h (not to exceed 1000 U/h) to achieve goal aPTT 1.5 to 2.0 times control (approximately 50 to 70 s). Target ACT in catheterization lab: 200-250 sec if concomitant GP IIb/IIIa inhibitor therapy, 250-300 sec if no concomitant GP IIb/IIIa inhibitor therapy; administer additional boluses to achieve target ACT if measured values below recommended ranges (see appendix for dosing)
or
Enoxaparin 30 mg IV, followed by 1 mg/kg SC q12h, first dose 15 minutes after bolus (if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 h after bolus). If the last SC dose was given less than 8 hours prior to PCI, no additional enoxaparin required; if last SC was given 8 to 12 hours earlier or never given, an IV dose of 0.3 mg/kg of enoxaparin should be given. Discontinue after completion of the PCI procedure, unless continued anticoagulation is indicated. Enoxaparin can be used to support PCI after fibrinolysis; no additional anticoagulant is needed.
or
Bivalirudin 0.75 mg/kg IV bolus, followed by infusion of 1.75 mg/kg/h. If UFH was given previously, start bivalirudin 30 minutes later but before PCI.
For patients proceeding to primary PCI who have been treated with ASA and a thienopyridine, recommended supportive anticoagulant regimens include the following:
a. For prior treatment with UFH, additional boluses of UFH should be administered as needed to maintain therapeutic activated clotting time levels, taking into account whether GP IIb/IIIa receptor antagonists have been administered (Class I, LOE: C).b
b. Bivalirudin is useful as a supportive measure for primary PCI with or without prior treatment with UFH (Class I, LOE: B).b
In STEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin anticoagulation is reasonable (Class IIa, LOE: B).b
For prior treatment with fondaparinux, administer additional intravenous treatment with an anticoagulant possessing anti-IIa activity (such as UFH or bivalirudin), taking into account whether GP IIb/IIIa inhibitors have been administered. Note: Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI.
PCI PROCEDURES (check if applicable)
Aspiration thrombectomy
Aspiration thrombectomy is reasonable for patients undergoing primary PCI (Class IIa, LOE: B).b
Stent Use (check one if applicable):
DES
BMS
It is reasonable to use a drug-eluting stent (DES) as an alternative to a bare-metal stent (BMS) for primary PCI in STEMI (Class IIa, LOE: B).b
A DES may be considered for clinical and anatomic settings in which the efficacy/safety profile appears favorable (Class IIb, LOE: B).b
ANTICOAGULANT THERAPY (choose one):
Unfractionated Heparin: 60 U/kg IV bolus (maximum 4000 U), followed by IV infusion of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain goal aPTT 1.5 to 2.0 times control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as indicated. When using a fibrinolytic, use Unfractionated Heparin Dosing Chart. Note: Regimens other than UFH are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment.
or
Enoxaparin 30 mg IV, followed by 1 mg/kg SC q12h, first dose 30 minutes after bolus (if age >75 years, give 0.75 mg/kg every 12 hours with no bolus; if CrCl <30 mL/min, give 1 mg/kg every 24 h after bolus). Continue for at least 48 hours, and preferably for the duration of hospitalization, up to 8 days in patients with no contraindications to anticoagulation.
or
Fondaparinux 2.5 mg IV initially, followed by 2.5 mg SC once daily (avoid if CrCl <30 mL/min). Continue for at least 48 hours, and preferably for the duration of hospitalization, up to 8 days in patients with no contraindications to anticoagulation.
Check/Initial/Date
_____/_____ DOCUSATE SODIUM 100 mg po bid
_____/_____ MAALOX PLUS EX STR 15 mL po q6h prn indigestion
_____/_____ OXAZEPAM 15-30 mg po qhs prn insomnia
_____/_____ ACETAMINOPHEN 650 mg po q4h prn headache
_____/_____ MAGNESIUM HYDROXIDE 30 mL po daily prn constipation
_____/_____ MAGNESIUM SULFATE Sliding Scale IV daily
Call house officer if serum Mg <1.2; hold order for creatinine >1.9
If serum Mg <1.4 give 5 g MgSO4 IV
If serum Mg <1.6 give 4 g MgSO4 IV
If serum Mg <1.8 give 3 g MgSO4 IV
If serum Mg <2.0 give 2 g MgSO4 IV
_____/_____ LAB, MG, K daily
_____/_____ KCL IMMEDIATE REL Sliding Scale Target K >4.5 mg/dL po daily
Call house officer if K <3.4; hold order for creatinine >1.9
If K <3.7 give 60 mEq
If K <4.1 give 40 mEq
If K <4.6 give 20 mEq
Additional Orders:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____/_____ CHEST PAIN PROTOCOL
_____/_____ ECG x 1 prn chest pain
_____/_____ For CP: check VS, call house officer
_____/_____ Mark if cardiac cath is planned: Time _________________
_____/_____ NPO except meds Now After midnight
_____/_____ LAB, TYPE AND HOLD NEXT AVAILABLE
_____/_____ NUTRITION CONSULT
Patient admitted to cardiology ischemia pathway with known or suspected CAD. Please facilitate outpatient education in low-cholesterol, low-salt diet
_____/_____ SOCIAL SERVICE CONSULT
Patient admitted to cardiology ischemia pathway with known
or suspected CAD. Please assess and assist in need for outpatient support (including VNA) services
Check/Initial/Date
_____/_____ If on UFH (consult Unfractionated Heparin Dosing Chart)
_____________________________________________
_____/_____ Calcium channel blocker (if β-blocker contraindicated)
Drug: _______________________ ___mg ____times/d
_____/_____ ACE inhibitor or ARB; recommended if diabetic
Drug: _______________________ ___mg ____times/d
_____/_____ Lipid-lowering therapy (statins) regardless of LDL; dose target to LDL <100 mg/dL (further reduction to <70 mg/dL reasonable)
Drug: ____________________________ ___mg once daily
_____/_____ Echocardiography. FIRST 24 HR if evidence of CHF, hemodynamic instability, mechanical complication
_____/_____ Warfarin: RECOMMENDED if LV thrombus, extensive wall dyskinesis, LVEF <20%-30%
Check/Initial/Date
_____/_____ Patient had stent implanted
OR
_____/_____ Patient had medical therapy without stenting
MEDICATIONS
_____/_____ Aspirin ________ mg/d for _________________________
_____/_____ Clopidogrel _________ mg/d for ______________________
OR
_____/_____ Prasugrel 10 mg/d for ______________________________
_____/_____ b-blocker
Drug: __________________________________________
Dosage: ________________________________________
_____/_____ ACE inhibitor or ARB
Drug: __________________________________________
Dosage: ________________________________________
_____/_____ Aldosterone receptor blocker
Drug: __________________________________________
Dosage: ________________________________________