AMI protocol

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AMI protocol

• 2004 ACC/AHA Guidelines for the Management of
  Patients With
• ST-Elevation Myocardial Infarction

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Admission order

• 1. Condition Serious
• 2. IV NS on D5W to keep vein open. Start a
  second IV if IV medication is being given. This
  may be a saline lock.
• 3. Vital signs q1.5h until stable, then q4h and
  as needed.

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• 4. Monitor ECG monitoring for arrhythmia and
  ST-segment deviation. Pulse oximetry monitoring.
• Complete EKG st. (q5-10min if needed)
• Right-side EKG if inferior STEMI to exclude RV
  infarct
• 5. Diet NPO except for sips of water until
  stable. Then start 2 grams sodium/day, low
  saturated fat (less than 7 of total
  calories/day), low cholesterol (less than 200
  mg/d) diet, such as Total Lifestyle Change (TLC)
  diet.

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• 6. Activity Bedside commode and light activity
  when stable.
• 7. Oxygen Nasal cannula at 2 L/min when stable
  for 6 h, reassess for oxygen need (i.e., O2
  saturation less than 90), and consider
  discontinuing oxygen.

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Medications

• a. Nitroglycerin
• 1. Use sublingual NTG 0.4 mg every 5 min as
  needed for chest discomfort.
• ltNitrostat sublingual (0.6 mg) 2/3 q5min x3
  doses, then iv NTG if neededgt
• 2. Intravenous NTG for CHF, hypertension, or
  persistent ischemia.
• ltNTG IV with titration, initial infusion rate
  5- 10 mcg /min gt

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Contraindication of NTG

• SBP lt 90 mmHg or lt baseline - 30 mm Hg
• Severe bradycardia (lt 50 bpm)
• Tachycardia (gt 100 bpm), or suspected RV
  infarction.
• Phosphodiesterase inhibitor for erectile
  dysfunction within the last 24 hours.

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Medication

• b. Aspirin
• 1. If aspirin not given in the ED, chew
  nonenteric-coated aspirin 162 to 325 mg. (in
  first 24 hr)
• ltTapal(100mg) 23 po (chew) st.gt
• 2. If aspirin has been given, start daily
  maintenance of 75 to 162 mg. May use
  enteric-coated for gastrointestinal protection.
• ltTapal(100mg) 1 po QDgt
• 3. If allergy to Aspirin
• ltClopidogrel (Plavix 75mg) 1 po QDgt

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CABG Anti-platelet

• Aspirin should not be withheld before elective or
  nonelective CABG after STEMI.
• Aspirin (75 to 325 mg/d) should be prescribed as
  soon as possible (within 24 hours) after CABG
  unless contraindicated.
• In patients taking clopidogrel in whom elective
  CABG is planned, the drug should be withheld for
  5 to 7 days.

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Medication

• c. Beta-Blocker
• 1. If not given in the ED, assess for
  contraindications, i.e., bradycardia and
  hypotension. Continue daily assessment to
  ascertain eligibility for beta-blocker.
• 2. If given in the ED, continue daily dose and
  optimize as dictated by HR and BP.
• ltMetoprolol (Betaloc)(100mg) 1/4 po q6h x
  48hr , then 1/2 po bidgt

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Relative contraindications of beta-blocker

• HR lt 60 bpm
• Systolic arterial pressure lt100 mmHg
• Moderate or severe LV failure
• Signs of peripheral hypoperfusion
• Shock
• PR interval greater than 0.24 second, second- or
  
• 
  third-degree AV block
• Active asthma, or reactive airway disease

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beta-blocker

• If IV beta-blockade induces an untoward effect,
  such as AV block, excessive bradycardia, or
  hypotension
• ? beta-adrenergic agonist
• (i.e., isoproterenol 1 to 5 mcg/min).

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Medications

• d. ACE Inhibitor
• Give in the first 24 hrs when anterior
  infarction, pulmonary congestion, or LVEF less
  than 40
• ltCaptopril (Capoten 25mg) 1/4 po st.,
• then 1/2 tid x 48hr, then titrate to 2 tid
  as toleratedgt
• 2. Contraindication hypotension (SBP less than
  100 mm Hg or less than 30 mm Hg below baseline)
• 3. Use ARB orally in patients who are intolerant
  of ACE inhibitors

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Medication

• f. Pain Medications
• 1. IV morphine sulfate 2 to 4 mg with
  increments of 2 to 8 mg IV at 5- to 15-minute
  intervals as needed to control pain.
• ltMorphine sulfate 3ml (3mg) iv. st prn with
  titrationgt
• g. Anxiolytics (based on a nursing assessment)
• h. Daily Stool Softener
• ltMgO (250mg) 2 po TIDgt
• i. Lipid-lowering agents
• ltAtorvastatin(10mg) 1 po HSgt
• j. Mg supplement if deficiency or Torsade de
  pointes, (no routine use)

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• 9. Laboratory Tests
• CK, CKMB, TnI, CBCPLT, INR, aPTT,
  electrolytes, magnesium, BUN, creatinine,
  glucose, serum lipids
• 10. CXR (portable)

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Reperfusion therapy
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Fibrinolytic agents
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Contraindications and Cautions for Fibrinolysis

• Absolute contraindications
• Any prior ICH
• Known structural cerebral vascular lesion (e.g.,
  arteriovenous malformation)
• 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
• History of chronic, severe, poorly controlled
  hypertension
• Severe uncontrolled hypertension on presentation
  (SBP greater than 180 mm Hg or DBP greater than
  110 mm Hg)
• History of prior ischemic stroke greater than 3
  months, dementia, or known intracranial pathology
  not covered in contraindications
• Traumatic or prolonged (greater than 10 minutes)
  CPR or major surgery (within less than 3 weeks)
• Recent (within 2-4 weeks) internal bleeding
• Noncompressible vascular punctures
• For streptokinase/anistreplase prior exposure
  (more than 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

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Noninvasive findings suggestive of reperfusion

• 60 to 180 minutes after initiation of
  fibrinolytic therapy
• the pattern of ST elevation
• cardiac rhythm
• clinical symptoms
• F/U cardiac enzyme

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