You’ll need to update your ED protocols, clinical pathways
Can you assess risk for patients presenting with chest discomfort? Do you know when to give patients a stress test in the emergency department (ED)? Does your ED use cardiac troponins along with electrocardiogram changes when assessing patients with possible non-ST-segment elevation myocardial infarction (NSTEMI)?
If you answer "no" to these questions, your practice is not consistent with newly updated guidelines for unstable angina (UA) and NSTEMI, which were published jointly by the Bethesda, MD-based American College of Cardiology (ACC) and the Dallas-based American Heart Association (AHA).1 The new guidelines include key changes that impact ED nursing clinical practice, says Sonja D. Brune, RN, MSN, CCRN, CEN, CCNS, cardiovascular clinical nurse specialist at the Central Cardiovascular Institute of San Antonio.
To be sure that these patients are managed appropriately at triage, while being treated, and at discharge, your ED protocols and critical pathways should include these new evidence-based recommendations, recommends Mary Hand, MSPH, RN, coordinator of the National Heart Attack Alert Program at the National Heart, Lung, and Blood Institute in Bethesda, MD.
Update your protocols
As an ED nurse, it is important that you be part of any team convened to update your practices and protocols according to the new guidelines, says Hand. She encourages you to review the full version of the guideline, which includes descriptions of the clinical trials and other research on which the updates are based. (To obtain a copy of the updated guidelines, see resources at the end of this article.) Here are updates in the guidelines that you should use to update your practice:
• The updated guidelines reflect continued use of the term "acute coronary syndrome (ACS)." Hand notes that the ACS group includes patients with symptoms that are compatible with acute myocardial ischemia, patients with acute myocardial infarction (AMI) with ST-segment elevation and depression, Q wave, non-Q wave, and UA. The UA/NSTEMI grouping excludes patients with AMI who are eligible for reperfusion therapy, however, such as individuals with ST-elevation myocardial infarction (MI), according to the new guidelines. Those patients should be managed according to the ACC/AHA 1999 guidelines for AMI, which are being updated and are scheduled for publication in 2003, says Hand.2
Use of the ACS term is encouraged as a preliminary diagnosis, says Brune. The goal is to promote early recognition, efficient diagnosis, and optimal management of patients with life-threatening cardiac ischemia or other potential catastrophic emergencies such as acute aortic dissection, she explains.
• You may need to perform a stress test in the ED. According to the guidelines for patients with confirmed or suspected ischemic heart disease with a normal follow-up electrocardiogram (ECG) and normal cardiac marker measurements, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis shortly after discharge. Low-risk patients with a negative stress test can be managed as outpatients, Hand notes.
• Assess risk for all patients presenting with chest discomfort. When you triage and/or reassess the patient, Brune says your goal should be to answer the following two questions:
— What is the likelihood that the signs and symptoms represent ACS secondary to obstructive coronary artery disease?
— What is the likelihood of an adverse clinical outcome (death, MI, stroke heart failure, recurrent ischemia, or serious arrhythmia)?
UA/NSTEMI constitutes a clinical syndrome that is usually caused by atherosclerotic coronary artery disease and is associated with an increased risk of cardiac death and MI, warns Hand. She explains that UA/NSTEMI often results from the disruption of an atherosclerotic plaque and a subsequent cascade of pathological processes that decrease coronary blood flow. "Most patients who die during UA/NSTEMI do so because of sudden death or the development or recurrence of AMI," she says.
For this reason, Brune says, you should be familiar with methods to risk stratify that will guide therapy. She explains that a thorough evaluation of the patient’s history, physical examination, ECG, and cardiac markers will stratify the patient into a low, intermediate, or high-risk category.
You should base your risk stratification on the patient’s symptoms, the physical exam, ECG, and biomarkers of cardiac injury, says Hand. "A cardiac-specific troponin is the preferred marker," she adds. "If available, it should be measured in all patients." Although troponins are accurate in identifying myocardial necrosis, such necrosis is not always secondary to atherosclerotic coronary artery disease, says Hand. This is why cardiac troponins should be used in conjunction with appropriate symptoms or signs and/or ECG changes in making the diagnosis of NSTEMI, she explains.
Hand says that using isoenzyme of CK-MB (creatine kinase with muscle and brain subunits) by mass assay also is acceptable, according to the guidelines. For patients with negative cardiac markers within six hours of the onset of pain, the guidelines recommend that another sample should be drawn within a six- to 12-hour time frame.
• Pain doesn’t rule out ACS. If a patient has pain not typically associated with cardiac ischemia, Brune cautions that this doesn’t exclude the possibility of ACS. She points to the Multicenter Chest Pain Study, which showed that acute ischemia was diagnosed in 22% of patients who presented to the ED with sharp or stabbing pain, in 13% of patients with pleuritic pain, and in 7% of patients whose pain was reproducible on palpation.3
• Some treatment recommendations have been modified for antiplatelet and anticoagulation therapy. Brune explains that platelet glycoprotein (GP) IIb/IIIa antagonists should be used in addition to the aspirin, clopidogrel, and low molecular weight heparin (LMWH) or unfractionated heparin (UFH) in patients who have a percutaneous coronary intervention (PCI) planned. She adds that eptifibatide or tirofiban, two of the glycoprotein IIb/IIIa antagonists, may be used in addition to aspirin and LMWH or UFH in patients with continuing ischemia and/or elevated troponin or other high-risk features, even if a PCI is not planned.
However, abciximab (the third GP IIb/IIIa antagonist) should not be given in patients in whom a PCI is not planned, says Brune. The guidelines also state that LMWH is preferable to UFH in all patients except those in whom a coronary artery bypass graft (CABG) is planned within 24 hours, she says.
• Invasive strategies will be used more often. Brune notes that early catheterization with possible PCI will be performed in patients with recurrent angina at rest, elevated troponin I or troponin T, new or presumably new ST-segment depression, congestive heart failure symptoms, high-risk findings on noninvasive testing such as sestamibi, depressed left ventricular systolic function, hemodynamic instability, sustained ventricular tachycardia, PCI within the last six months, or prior CABG.
• Risk-factor modification is stressed in the new guidelines. Hand says that aggressive risk-factor modification should be the "mainstay of management" for this high-risk patient group, at discharge and on an ongoing basis. She points to the National Cholesterol Education Program’s Adult Treatment Panel III Report, which states that low-density lipoprotein (LDL) cholesterol should be measured on admission or within 24 hours for patients who have had a major coronary event.4
Therefore, you may see a higher incidence of lipid testing in the ED, says Hand. She adds that patients discharged on a statin have been shown to reach their LDL goal and to still be on the statin one year after discharge.5 "Thus, you should see some patients discharged to home on statin therapy," she says.
References
1. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA Guideline Update for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina). 2002. Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
2. Ryan TJ, Anderson JL, Antman EM, et al. 1999 update ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999; 4:890-911.
3. Lee TH, Cook TF, Weisburg M, et al. Acute chest pain in the emergency room: Identification and evaluation of low-risk patients. Arch Int Med 1985; 145:65-69.
4. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High-Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001; 285:2,486-2,497.
5. Schwartz GG, Olsson AG, Ezekowitz MD, et al., for the Myocardial Ischemia Reduction with Aggressive Cholesterol-Lowering (MIRACL) Study Investigators. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: The MIRACL study: A randomized controlled trial. JAMA 2001; 285:1,711-1,718.
Sources and resources
For more information about the guidelines, contact:
• Sonja D. Brune, RN, MSN, CCRN, CEN, CCNS, Cardiovascular Clinical Nurse Specialist, Central Cardiovascular Institute of San Antonio, 927 McCullough Ave., San Antonio, TX 78215. Fax: (210) 223-9600. E-mail: [email protected].
• Mary M. Hand, MSPH, RN, Coordinator, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, 31 Center Drive, MSC 2480, Room 4A10 Bethesda, MD 20892-2480. Telephone: (301) 594-2726. Fax: (301) 402-2405. E-mail: [email protected].
The ACC/AHA 2002 Guideline Update for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction is available on the American College of Cardiology web site (www.acc.org). (Click on "Clinical Statements/ Guidelines," and "Practice Guidelines Update: Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction.") A summary article highlighting the changes to the guideline from 2000 to 2002 will be published in an upcoming issue of the Journal of the American College of Cardiology and Circulation. Reprints of Clinical Statements and Guidelines are $5 each, plus shipping and handling. To order, contact:
• American College of Cardiology, Resource Center, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. Telephone: (800) 253-4636 or (301) 897-5400. E-mail: [email protected]. To obtain a reprint of the shorter version (summary article describing the changes to the guidelines) planned for subsequent publication in Journal of the American College of Cardiology and Circulation, ask for reprint No. 71-0227.
The American College of Cardiovascular Nursing (ACCN) provides standard educational guidelines and Cardiovascular Nursing Board Certification for all levels of cardiovascular nurses, including the non-acute cardiac emergency nurse. The ACCN’s Working Congress on Cardiovascular Nursing extracts guidelines from physician groups and equates them to nursing practice. Nurses interested in learning more about the certification and standards should visit the ACCN’s web site (www.accn.net). Click on "ACCN/CVN Certification" and "Now Offering BACCN & FACCN Credentials for Non-Acute/Non-Invasive and Acute/Invasive Cardiac and Emergency Nurses & Nurse Practitioners." For more information, contact:
• Jonni Cooper, PhD, MBA, BSN, BC, CVN-V, MACCN, CVN Board Certification Exam Director, P.O. Box 3345, Riverview, FL 33568-3345. Telephone: (813) 677-1116. Fax: (813) 671-8912. E-mail: [email protected].
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