I



I. Appropriate Standards of Care for Coronary Heart Disease

A. Before disease diagnosis:

1. Check blood pressure and weight every visit; take appropriate actions for abnormal values.

2. Check total cholesterol and HDL or full lipid profile in men by age 45 or women by age 55; treat abnormal values.

3. Encourage healthy diet and exercise habits.

4. Obtain adequate family history; follow up closely if strong family history of early coronary heart disease.

5. Treat diabetes as if patient has coronary heart disease.

6. Regularly recommend, and work towards, smoking cessation.

7. Appropriate use of screening exercise stress tests, aspirin, and pediatric cholesterol testing.

B. At time of diagnosis:

1. Appropriate work up and classification: stable angina, ACS with and without ST-segment-elevation-MI

2. Use of indicated interventions:

a. Aspirin (all)

b. Fibrinolytics (New left bundle branch block, ST elevated MI [if not PCI])

c. Prompt ER/CCU care, with monitoring (ACS)

d. Cardiac enzymes (ACS)

e. EKG with interpretation (all)

f. Sublingual nitroglycerin (all acute chest pains)

g. Morphine (CP persisting after nitroglycerin in ACS)

h. Oxygen (all ACS, until adequate oxygen saturation on room air)

i. IV nitroglycerin (persistent pain after SL nitroglycerin morphine)

j. Beta blockers (all ACS, some stable aginal)

k. CA channel blockers (3rd line for pain in non-ST-elevated ACS)

l. ACE inhibitors (large anterior wall MI, MI with congestive heart failure, myocardial infarction with lung dysfunction)

m. Plevix (aspirin intolerance, or non-ST-elevated ACS with no coronary artery bypass graft planned)

n. Glycoprotein IIB/IIIA inhibitors: IV form (non-ST elevated myocardial infarction-favor abciximab (Reopro) with stent placement, eptifibatide (Integrilin) for those not getting PCI)

o. Low-molecular weight heparin (Non-ST-elevated myocardial infarction)

p. Heparin (with fibrinolytics in ST-elevation – myocardial infarction and with large anterior myocardial infarction)

q. Statins (primary/secondary/tertiary prevention, and possibly during acute myocardial infarction)

r. Dietary therapy (standard low-fat, vegetarian, Mediterranean)

s. Control of hypertension, diabetes mellitus, dyslipidemias

C. Maintenance therapy:

1. Keep blood pressure controlled to near 120/80

2. Keep LDL cholesterol 65 years

b. Prior stenosis > 80%

c. > 3 coronary heart disease risk factors

d. Aspirin in last 7 days

e. > 2 anginal events in last 24 hours

f. ST deviation

g. Elevated biomarkers

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