NSTEMI standing orders



Patient ___________________________ ______________________ _______

(LAST NAME) (FIRST NAME) (MI)

Age: ___________ years Weight: __________ kg ( Male ( Female

Admit to: Cardiology

Condition:_______________________________________________________

Diagnosis: ( Unstable angina ( NSTEMI

Medication allergies: ______________________________________________

________________________________________________________________

Check/Initial/Date

( _____/_____ Activity: bed rest

( _____/_____ Cardiac monitor

( _____/_____ Vital signs q4h x 24 h then q8h

( _____/_____ Diet: house/no added salt/low saturated fat; low cholesterol

( _____/_____ Call house officer for T >101(, SBP >190 mm Hg or SBP 120 bpm or HR 30 or RR 90%

Nasal prongs (cannula) 2 L/min

PLEASE CALL HOUSE OFFICER FOR O2 SAT 70 y, SBP 110 bpm or heart rate 0.24 s, second- or third-degree heart block, active asthma, or reactive airway disease).

Choose one:

IV (-Blocker (optional; reserved for patients with refractory tachycardia or refractory hypertension; otherwise, oral β-blockade is sufficient)

( _____/_____ Drug: _____________________________ _______ mg IV every ____ hrs

Oral (-Blocker

( _____/_____ METOPROLOL TARTRATE 50-200 mg bid

( _____/_____ ATENOLOL 50-200 mg/d

( _____/_____ CARVEDILOL 6.25 mg bid, uptitrated to max. 25 mg bid

NITROGLYCERIN

( _____/_____ NITROGLYCERIN 1/150 (0.4 mg) 1 TAB SL q5min x 3 prn chest pain; HOLD IF: SBP 20 min of rest pain, hemodynamic instability, signs of CHF ( INITIAL INVASIVE STRATEGY (Diagnostic angiography with intent to revascularize)

Intermediate risk: no high-risk features, prior MI, prior CABG, T-wave inversions, rest angina 70 years ( EITHER INITIAL INVASIVE OR INITIAL CONSERVATIVE STRATEGY

Low risk: No high- or moderate-risk features, progressive angina without prolonged rest pain, normal cardiac markers, normal ECG with pain ( INITIAL CONSERVATIVE STRATEGY

( _____/_____ ( Invasive strategy

( Conservative strategy

Selection of Initial Treatment Strategy: Patient Characteristics

Invasive Strategy Preferred

● Recurrent angina or ischemia at rest or with low-level activities

● Elevated cardiac biomarkers (TnT or TnI)

● New or presumably new ST-segment depression

● Signs or symptoms of HF or new or worsening mitral regurgitation

● High-risk findings from noninvasive testing

● Hemodynamic instability

● Sustained ventricular tachycardia

● PCI within 6 months

● Prior CABG

● High risk score (eg, TIMI, GRACE)

● Reduced LV function (LVEF 140) to undergo an early invasive strategy within 12 to 24 hours of admission. For patients not at high risk, an early invasive approach is also reasonable (Class IIa, LOE: B).c

*Immediate catheterization/angiography is recommended for unstable patients.

Check/Initial/Date

Initiate at least one (Class I, LOE: A) or both (Class IIa, LOE: B) of the following:

( _____/_____ Clopidogrel 300-600 (__________ insert dose) mg po x 1 (loading dose),b then 75 mg/d po. Withhold for 5 days if CABG is planned.

OR

( _____/_____ Prasugrel (at the time of PCI) 60 mg po x 1 (loading dose),c then 10 mg/d po. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients ≥75 years of age, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior MI) for which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 days before any surgery.

AND/OR

GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY (choose one):

( _____/_____ 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 ................
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