Unstable Angina /Non-ST Elevation Myocardial Infarction Critical Pathway Toolkit Adapted from Dr Chris Cannon STRIVE Scientific Committee – 2008 Based on ACC/AHA Guidelines

Anticoagulants Enoxaparin more effective in preventing combined end point of death or MI vs Unfractionated heparin (UFH). Avoid cross-over during PCI Last SC dose >8 hrs, 0.3 mg/kg of iv. Last SC dose <8 hours, no additional enoxaparin.

Anticoagulants Bivalirudin (single therapy) lower risk of bleeding compared to Enoxaparin and UFH. Approved only for early PCI. Fondaparinux Lower risk of bleed but increased risk of catheter- related thrombi, to switch to UFH in Cath Lab.

Lipid Management Fasting lipid profile workup within 24h [Class I, LOE: C] Statin regardless of LDL-C [Class I, LOE: A]

Beta-blockers Ellis K, et al. 6-month mortality in ACS pts undergoing PCI 1.7% Beta-blockers vs 3.7% without beta-blockers. (Pooled results from EPIC, EPILOG, RAPPORT, CAPTURE and EPISTENT J Interv Cardiol 2003;16:299–305.)

Beta-blockers ACC/AHA 2007 Class 1 (LOE B)# Oral therapy initiated ≤24 h if NO Heart failure Low-output state Increased risk for cardiogenic shock Relative contraindications PR ›0.24 s 2 nd or 3 rd degree heart block Reactive airway disease

Angiotensin-aldosterone inhibitors Pulmonary congestion or LVEF ≤ 40% - ACEI within 24h or ARB if intolerant. LV dysfunction, hypertension or diabetes – Long-term ACEI or ARB. LVEF ≤ 40% and symptomatic heart failure or diabetes (without renal dysfunction/hyperkalemia) Aldosterone-receptor blockade in addition to ACEI.

Optimal Discharge Planning Optimal blood pressure <140/90 mm Hg [Class I, LOE: A] <130/80 in diabetes or chronic kidney disease mm Hg [Class I, LOE: A] Discharge education Medication use, cardiac rehabilitation, lifestyle modification (diet, exercise & smoking cessation) [Class I, LOE: C] Follow-up 2-6 weeks in low risk, medically treated, revascularized, 14 days high risk [ Class I, LOE : C]

Cardiac Admission Checklist

Cardiac Discharge Prescription

Adapted by Kamelia Emamian M.D. and Thao Huynh, MD, MSC.