Mercy Hospital of Pittsburgh Emergency Department
ACUTE CORONARY SYNDROME GUIDELINES (Unstable Angina / Non Q-Wave MI)
      Oct 6, 2000, Revised Oct 20, 2000
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Patients considered high-risk with one or more of the following:
- Good Story: Prolonged, ongoing rest pain (>20 min) suggestive
  of ischemia with known or high likelihood of CAD (e.g.,
  extracardiac vascular disease/hyperledipemia/HTN/DM)
- Acute CHF: Evidence of ischemia induced pulmonary edema/CHF 
- Significant ECG Changes: New ST segment depressions >1 mm, transient ST 
  segment elevation, or new T-wave inversions in at least two contiguous
  leads
- ECG Changes During Pain: Transient hemodynamic or ECG changes during pain
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Treatment Recommendations*:
 Aspirin 162 mg chew/swallow
 Continuous nitrate therapy (topical/IV)
 MSO4 IV if pain not relieved by nitrates
 Heparin
  IV Heparin (bolus/infusion)[1] or
  LMWH (Lovenox 1 mg/kg sub-q)
 GP Ilb - Ilia Inhibitors
  Integrelin (bolus/infusion)[2] or
  Aggrastat (bolus/infusion)[2]
 Beta-Blocker
  Administer orally if no contraindications[3]
  Administer IV if no contraindications and persistent symptoms despite 
   Nitrates/Heparin/GP Inhibitors[4]
 Add oral Calcium antagonist if:[5]
  Persistent symptoms despite Beta-Blockade
 Persistent symptoms and Beta-Blockade not tolerated 
Consult Cardiology
 Emergent Cardiac Cath
 Coronary Care Unit Admission
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* Endorsed by the ACC, AHA, and ACEP
[1] Use standard Mercy Heparin Height/Weight Nomogram [on the standard Heparin
    Orders --kc]; [or] 70 units/kg bolus followed by 7 units/kg/hour infusion
    (max 800 units/hr) if used with GP inhibitor.
[2] Please refer to specific drug nomogram for dosing based on wgt/renal
    function
[3] Atenolol 25 mg orally; repeat q12h; or Metoprolol 50 mg orally; repeat q12h
[4] Atenolol 5 mg IV over 5 minutes; repeat in 10 minutes; then 50 mg orally if 
    HR >60; or Metoprolol 5 mg IV q10 minutes X 3 doses; then 50 mg orally
    if HR >60
[5] Diltiazem 30 - 60 mg orally q6h; or Verapamil 60 - 120 mg orally q8h