不稳定性心绞痛
Clinical pathway of Interventional therapy based on Unstable
Angina
A. Standard hospitalization process
(a) Applicable objectives
The first diagnosis is unstable Angina(ICD-10:I20.0/20.1/20.9) Underwent coronary stenting(ICD-9-CM-3:36.06/36.07)
(b) Diagnosis basis
《Clinical Practice Guidelines - Department of Cardiology 》(Edited by Chinese Medical Association, People's Health Publishing department, 2009), 《Unstable Angina and non-ST-segment elevation myocardial infarction diagnosis and treatment guidelines 》(Cardiology Branch of Chinese Medical Association,2007) and the 2007 ACC / AHA and ESC guidelines.
1. Characteristics of clinical onset: the clinical manifestation is Exercise-induced chest pain or Spontaneous chest pain, it will be quickly relieved when take a rest or sublingual administration of nitroglycerin.
2. The ECG: ST-segment depression or elevation> 0.1mV on adjacent two or more than two-lead ECG or T-wave inversion ≥ 0.2mV when chest pain is onset, the changes in ST-T segment recover itself when the chest pain get relieved.
3. Markers of myocardial injury are not elevated or not reach the level
of diagnosis of myocardial infarction
4. Clinical types
1) Initial onset of angina: the new-occurred angina, which has the largest disease course of a month, can be manifested as Spontaneous and exertional angina onset exist at the same time, and the pain grading is above level III.
2) Worsening exertional angina: patient has a angina history, and the angina get worsened, it attacks frequently, and the onset time is becoming longer and longer, the pain threshold is getting lower and lower(Canada exertional angina grade [CCS I-IV] increased by at least one class or reached at least Class III)
3) Resting angina: angina attacks when patients are at rest or at a quiet state, and seizure duration is usually more than 20 minutes.
4) Postinfarction angina: it refers to the angina occurred between 24 hours and a month after the onset of acute myocardial infarction.\
5) Variant angina: the angina attacks when the patients are at rest or engaged in general activities, electrocardiogram showed a transient elevation of the ST segment when angina is onset, most patients will recover automatically, while a few patients get evolved into myocardial infarction.
(C )Therapy selection and basis
《Clinical Practice Guidelines - Department of Cardiology》(Edited
by Chinese Medical Association, People's Health Publishing department, 2009), 《Unstable Angina and non-ST-segment elevation myocardial infarction diagnosis and treatment guidelines 》(Cardiology Branch of Chinese Medical Association,2007) and the 2007 ACC / AHA and ESC guidelines.
1. Risk stratification: we divide it into low-risks, medium-risks and high-risk groups according to TIMI risk score or the angina type and severity of the patient, duration of myocardial ischemia, ECG and cardiac injury markers measurement results
2. Drug therapy: anti-ischemic drugs, antiplatelet drugs, anticoagulant drugs, lipid regulating drugs.
3. Coronary artery revascularization therapy: medium-risk and high-risk patients can have a preferred choice of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on the basis of intensive drug therapy.
1).PCI: under the following circumstances, we can have an emergency coronary angiography in 2 hours, and implement the PCI therapy for the patient who doesn’t have severe combined diseases and coronary lesions suitable for PCI .
① Resting or a small amount of exercise still accompanied by repeatedly angina and ischemia on the basis of intensive drug therapy; ② Myocardial markers elevate (TNT or TNI ) ③ The
new-emerging ST segment is significantly lower; ④Symptoms or signs of heart failure, new-emerging or worsening mitral regurgitation; ⑤Hemodynamic instability; ⑥Sustained ventricular tachycardia. We can treat the medium-risk and high-risk patients without the above indications with early invasive therapy within 12-48 hours after hospital admission.
2) CABG: CABG is the first choice for those patients with left main stem lesions, 3-vessel disease or 2 vascular lesions of the left anterior descending artery, along with Left ventricular dysfunction or diabetes.
4. Intra-aortic balloon pump surgery: intra-aortic balloon pump surgery can be applied to patients with the recurrence of myocardial ischemia after intensive medical therapy and hemodynamic instability before the completion of coronary angiography and revascularization.
5. Conservative therapy: Our first choice is conservative therapy for those lower-risk patients; we can make load test checks after the disease stay in a stable condition on the basis of intensive medical therapy, and then choose proper time for coronary angiography and revascularization
6. Improving the unhealthy lifestyles to control risk factors.
(d) The standard hospitalization days are 6-8 days.
(e) Standards for entrance paths
1. The first diagnosis must meet with the ICD-10: I20.0/20.1/20.9 unstable angina disease coding.
2. Myocardial infarction, aortic dissection, pulmonary embolism, acute pericarditis and so on are excluded.
3. Patients suffering from other cardiovascular disease but without special treatment (examination and treatment) during hospitalization and without effect on the first diagnosis can enter the path.
(f) Preoperative preparation (preoperative evaluation) 0-3 days. 1. Required check items
1) Routine blood test + Blood type, Routine urine + Ketone bodies, Routine stool + occult blood
2) Liver and kidney function, electrolytes, glucose, blood lipids, serum cardiac injury markers, coagulation, infectious disease screening (hepatitis B, hepatitis C, HIV, syphilis, etc.);
3) Chest X-ray, electrocardiogram, echocardiography
2. Check items in accordance with the specific situation of the patients 1) Blood gas analysis, brain natriuretic peptide, D-dimer, erythrocyte sedimentation rate, C-reactive protein or high-sensitivity C-reactive protein
2) 24-hour ambulatory ECG, cardiac stress test
3) The myocardial ischemia assess (low-risk, non-emergency
revascularization patients)
3. Other preoperative preparation
1) Preoperative conversation, explain the possible complications during surgery and intraoperative and signed the informed consent 2) Preoperative antiplatelet drug load applications
3) Hydration therapy in patients with renal insufficiency
(g) Choice of drugs
1. Dual antiplatelet drugs: Routine drugs associated with aspirin + clopidogrel. Application of intravenous GPIIb / IIIa receptor antagonists may be considered in high-risk patients undergoing interventional therapy.
2. Anticoagulant drugs: Low molecular weight heparin or unfractionated heparin and so on
3. Anti-ischemic drugs: β-blockers, nitrate esters, calcium antagonists and so on.
1) β-blockers : orally taking for patient without contraindications within 24 hours.
2) Nitrate esters: intravenous infusion after Sublingual nitroglycerin to maintain, we can change it into nitrate esters oral after the disease stay in stable condition.
3) Calcium antagonists: Patient still have ischemic symptoms or hypertension after the use of sufficient quantities of β-blockers, and
then they can take non-dihydropyridine calcium antagonists with no contraindications.
4. Sedative and painkiller: we can have intravenous injection of morphine when nitroglycerin cannot instantly relieve symptoms or there is occurring acute pulmonary congestion .
5. Antiarrhythmic drugs:The application of arrhythmias
6. Lipid regulating drugs:Early application of statins
7. Angiotensin-converting enzyme inhibitors :Applicable for patients with left ventricular systolic dysfunction or heart failure, hypertension, and diabetes, it should be orally taken within 24 hours for patients without contraindication such as hypotension and so on, we can choose ARB therapy for patients who cannot tolerate it.
8. Other drugs: therapeutic drugs accompanied by disease.
(h) The day of surgery is the first 0-3 days of the hospital admission (if it is necessary to undergo a surgery)
1. Anesthetic method: local anesthesia
2. Surgical approach: coronary angiography +stent implantation. 3. Surgical implant: coronary artery stent.
4. Intraoperative medication: antithrombotics(heparinized, when necessary, make a use of GPIIb / IIIa receptor antagonist) vasoactive drugs, anti-arrhythmic drugs and so on.
5. Required inspection items immediately after the intervention surgery: Checking of vital signs, ECG monitoring, ECG, examination of the puncture site.
6. Let the patient live in the ICU after the intervention surgery when it is necessary.
7. Required inspection items in the first day after the intervention surgery: Routine blood test, routine urine, electrocardiogram, myocardial injury markers. We can also have other necessary checks in accordance with the disease situation: fecal occult blood, liver and kidney function, electrolytes, glucose, coagulation function, echocardiography, chest X-ray, blood gas analysis.
(i) Inspection items must be reviewed after 3-5 days ’ postoperative hospitalization.
1. Timely detection and treatment of complications observed in patients with myocardial ischemia and symptoms
2. Continue to keep a close observation of the puncture site bleeding, oozing situation.
3. Observing the changes of cardiac enzymes and kidney function after surgery.
(j) Discharge criteria
1. Vital signs were stable
2. Hemodynamic was stable
3. Myocardial ischemic symptoms were effectively control
4. There were no complications need extra hospitalization.
(k) Variance and the reasons
1. Patient was turned to surgical department to undergo emergency surgery of coronary artery bypass grafting after coronary angiography .
2. Waiting for the secondary PCI or choose the proper time to do the coronary artery bypass grafting
3. Critical condition
4. With the appearance of serious complications
B Table of Clinical pathway of Interventional therapy based on Unstable Angina Applicable objectives: T he first diagnosis is unstable Angina(ICD-10:I20.0/20.1/20.9)
Underwent coronary stenting(ICD-9-CM-3:36.06/36.07)
Patient name:::number :
hospitalization date : year month day Discharge date : year month day Standard hospitalization days 7-14 days
Time of onset: year month day hour minute