CCU Orientation
Welcome
Daily Schedule
Cardiovascular Lecture Series
Quick Tips for the CCU
Housestaff and Medical Students
Presenting on Rounds
Signout
Labs/Studies and the CCU
Electrolyte Repletion Guide
Basics of ECGs
Cardiac Stress Testing
Basics of Hemodynamics
Stent versus CABG
Post-Cath Management
Treatment of Acute MI
Heart Failure Management
Hypertensive Emergency
Arrhythmias
Anticoagulation Guidelines
Cardiovascular Discharge Checklist
Common Drugs in the CCU
Pharmacology in the CCU
Useful Websites
Helpful Numbers and Extensions
RICHMAN Guide to Running a Code (separate sheet)
Welcome
The CCU is a great rotation. It is a busy service with high turnover, but housestaff like it because it is focused and
there will be a great deal of teaching. You will learn a lot this month. We act as a team and there is a lot of crosscoverage so you are expected to know all the patients, not just your own. It is also expected that you will ask A LOT
of the questions. Your residents, fellows, and attending, are always available to you for any questions. Also, the
nurses in the CCU are an excellent resource, and it is recommended that you use their knowledge and experience to
your advantage.
Daily Schedule
Until 7:45 am: Pre-rounding
7:45-8:15 am: Mon, Wed, Thurs. Daily Lecture A4E122 (4th floor main hall just before cards clinic) conference
room. Topics will be posted in the conference and CCU resident call room. Please be ready to
round by this time.
8:15-9:00 am: FELLOW ROUNDS in 4D. All interns are expected to be present and participate in
rounds on all patients (not just their own) unless dealing with a sick patient.
9:00-11:00 am: ATTENDING ROUNDS (will begin in 4D)
11:00-noon:
Get work done
12:00-1 pm:
Noon lecture. Topic will be posted in the conference and CCU call room
Mon and Wed: Afternoon Cardiology Clinic (except those who have continuity clinic)
Cardiovascular Lecture Series
12:00-1pm:
Monday-Thursday in conference room C2J104 (A) outside cafeteria.
Weekly lecture topics will be posted in the conference and call room.
7:00-8:00 am: Catheterization Conference every Tuesday at USC (see posted schedule for location)
12:00-1 pm:
Journal Club last Tuesday of every month room C2J104 (A) outside cafeteria.
Lecture topic will be posted with that week’s schedule, and copies of the papers to
be discussed will be available in the conference room.
12:00-1 pm:
Morbidity and Mortality Conference first Tuesday of every month room C2J104 (A)
8:00-9:00 am: Advanced Imaging Rounds with Dr Shinbane will alternate between USC UH 2nd floor
and LAC 3rd floor. Contact Dr Shinbane if interested to be placed on his email list.
Quick Tips for the CCU
Pre-rounding for interns:
1. See all your patients and get vitals (including rhythm/pacer), drip rates, swan numbers, vent settings, cath/echo
and stress test results ready to present. Read swan numbers as follows: CVP, PAS/PAD, PCW, CI/CO, SVR.
2. For pts with IABP, use the IABP augmented BPs and check whether the patient is on heparin.
3. Remember that all intubated and sedated pts need to be taken off sedation once a day to make sure they are
neurologically intact and to access respiratory status.
4. If you feel that any gtts need to be adjusted, talk to a resident or fellow first.
5. Always make sure your signout has an updated medication list prior to rounds.
6. Always review and be prepared to present the ECG and CXR. Ask the fellow for echo/ETT/cath results as
applicable.
7. Residents: you are responsible for discussing the plan on each patient with your interns prior to rounds.
Ensure they know the plan because they’ll be the one asked.
8. Call your resident or fellow if somebody looks sick.
Rounds:
Always bring copies of rhythm strips to rounds (interns), and have the chart available to review the ECG. Interns
are expected to present every new patient. Make sure your medication list is updated, because the attending will
always want to know the current medications. The intern not presenting the patient should get the chart and nurse,
write any orders that come up during rounds, AML/PML, and replete lytes if not done already.
General Helpful Tips:
1. 1st day: get set up with Eclypsis password from one of the nurses.
2. On www.amion.com, use the password “usc card” for all cardiology service information (the fellow/attending
on call, EP team, contact info, ect.)
3. There are two teams (blue/green & white/yellow) in the CCU with two different attendings (except weekends).
Each color is composed of one resident and one intern, and is on call Q4. Therefore, you or your sister color is
responsible for presenting new patients every other day.
4. It is the non-post-call team’s job to get the post-call team out on time. Help with notes, discharges, ect. as
needed.
5. The CCU fellow is on until 5 pm each day, then the fellow on call takes over and will hear all new CCU
admissions, as well as answer any question that arise (see amion).
6. On weekends, all teams will round with one attending and one fellow on-call.
7. CCU residents are expected to go to cardiology clinic once a week (either Monday or Wednesday afternoons –
this means the intern is covering the team’s patients/unit responsibilities during this time).
8. Patient lists should be on “My network places” under “Med Red Team” and the “CCU folder,” and should be
accessible on all computers. If you have problems opening the list, it’s likely because it’s open on another
computer somewhere in the CCU.
9. All cardiac patients admitted to the CCU from the emergency room usually come up to the unit with a
cardiology consult note which includes recommendations for management. Call the cards consult resident if
questions arise, as these patients have usually been staffed with a fellow or an attending.
10. If a patient is planned for procedure (e.g. cath) remember to keep NPO after midnight the night before. If the
patient is on coumadin, hold it and start heparin gtt. As important, make sure the patient is feed after the
procedure.
11. STEMI patients go directly to the catheterization lab and are admitted to the CCU post-cath (in which case the
interventional team will write post-cath orders for you). You still need to write general admission orders and a
note. The catheterization team is also responsible for pulling all groin lines post procedure. YOU should always
do post-catheterization groin checks (see below) and call one of the cath fellows if lines are present or concerns
arise.
12. Transfers (usually from Olive-View or some other hospital requesting a higher level of care) will be accepted by
the transfer fellow of the day or night (see amion). Direct any questions to the appropriate fellow. The
transfer fellow should also let the team on call know about any potential transfers that may arrive later in the
evening and provide a plan.
13. If there is an airway problem overnight, call the airway team (NO NEED to overhead page them or call a code
blue, just have the CCU nurse call) and the ER airway team will come up to the CCU to help with intubations
and also with codes if you need help; in the daytime, the fellows should be around to help.
14. Codes: Go and participate! Remember that ABC’s come first, make sure they have IV/O2/monitor, and be
involved in CPR, lines, holding the pulse, etc. Watch the resident that runs the code and observe how they
manage the patient and other participants. Use your RICHMAN protocol as a guide.
Housestaff and Medical Students in the CCU
1. Residents and interns are expected to fully integrate students into the ward team. Provide orientation on the first
day of the rotation as to what the housestaff expects of students and what students may expect of the housestaff.
2. Encourage students to ask questions and to assume as many patient care responsibilities as possible.
3. Residents should assign two to three new patients per week to each student. On the first day of the students’
rotation, residents should assign two new or existing patients to each student.
4. Housestaff should conduct daily morning work rounds and speak with the students regarding their patients. The
student’s job is to collect the data, vitals, ect., and the residents role is to provide a more global picture of the
assessment and plan prior to rounds.
5. Feedback on H&Ps: residents should go over at least one in detail with each student. Have the student practice
the presentation and give advice on presenting in a concise and focused manner. Discuss important physical
findings and diagnostic data, and make sure they have and understand the assessment and plan prior to
presenting on rounds.
6. Review and co-sign the student’s notes daily.
7. It is not only important to discuss important physical findings but to demonstrate them. You should observe at
least one physical exam from each medical student, demonstrating the correct method when indicated.
8. Residents and interns should include students in reviewing x-rays and ECGs.
9. Notify the service fellow as early as possible when there are potential problems with students. Supporting
documents should be provided when appropriate. Reporting potentially unethical behavior involves a special,
confidential form that permits tracking by the Dean’s Office without affecting the student’s formal record.
10. Complete a written evaluation of the student within one week of when the student completes the rotation.
Presenting on Rounds
Each attending has a different style and may ask you to present in a specific way.
The general format should be as follows:
1. Overnight Events
2. Vitals (ranges not data points; changes from yesterday or abnormal)
Tm
HR
BP (if on balloon pump use augmented values; if on pressors note any changes of dose)
I/O: total I / total O (urine vs. drains)
Swan readings (CVP/RA, PAS/PAD, Wedge, CO, CI, SVR)
CVP if no swan (can get from a IJ central line)
Vent Settings with most recent ABG (e.g. AC, RR 20, TV 600, FiO2 80%, Peep +5
…with latest ABG 7.35/45/75/26, 96% on FiO2 80% )
3. Drips – ALL drips with current rate/dose. Comment on recent changes
4. Pertinent physical exam findings – remember to check LINES every day, and know how long they have been
in; all lines should be removed ASAP
5. Labs- comment on changes over time or at least have prior labs available for comparison if asked.
6. Studies- the fellow can help you retrieve angiograms and stress tests if recently completed. Know the results of
the most recent echocardiogram, as well as other pertinent cardiac studies.
7. Assessment and Plan – Usually Problem oriented but may depend on the attending.
**Have a current medication list with you when rounding if your signout isn’t updated**
A word about new patient H&P presentations. This is a skill you’ve been working on and will continue to work on,
and is very attending dependent as to details and areas of focus. Intern presentations are usually shorter than medical
students, but the students should be encouraged to present any new patients they are following. Work with your
overnight resident or the fellow to run through your presentation before rounds so it is streamlined and you
understand why each intervention was made.
Signout
It is imperative to update your signout every day before you leave. This is especially important on the weekends
when you will have to presents your sister team’s patients and be expected to provide current results.
Medication lists are of particular importance. You should check your patient’s MAR every other day or so and
update the list on your signout. It is also important to have the most current cardiac studies (ECG/Echo,cath, ect)
provided for daily reference. The far right column should be used for communicating active things that need
following up, and when possible, specific instructions on what to do (eg. If SBP >160, give an extra dose of
benazepril). Sign out is designed to ensure important patient info isn’t lost in transition, and aid the post-call team in
getting out on time. It is not acceptable to ask the covering team to complete progress notes, pull lines, check
labs ect., unless you are post-call and need to leave, or these items need to be done in the evening. As a general rule,
don’t sign out anything you wouldn’t want signed out to you.
Labs/Studies and the CCU:
1. ECHOs (TTE/TEE) must be ordered in affinity.
2. For nuclear studies, you must fill out both the radiology and nuclear form, attach a copy of the patient’s most
recent ECG, and take all to Marci in the stress lab.
3. For dobutamine echos, make sure you either order or already have a formal baseline TTE.
4. All labs should be ordered for midnight EVERYDAY (routine AM labs) and should include CHEM 10 if actively
diuresing; other labs should be tailored to specific patient.
5. If a patient is on a lasix drip, then should order q12h labs (noon and midnight)
6. Electrolyte repletion rounds is usually the responsibility of the intern (usually performed around 2 AM as this is
when all the labs are usually back). See how to replete electrolytes below.
7. PTT is performed q6h when a patient is started on a heparin drip; if for any reason the heparin drip is stopped,
then the next PTT check should be six hours after the heparin drip is resumed. Goal PTT for ACS 50-70, for
VTE 60-80.
8. Troponins can be ordered q6h (or q4 if urgent) with EKGs during r/o ACS workup; you can stop following
them as they plateau or begin to trend downward. Otherwise, order troponins only when patients are
symptomatic.
9. ECGs are done routinely on all cardiac patients each morning at around 7-8 AM (don’t forget to check them as
they are usually done whether you ordered them or not).
10.If you ever need a STAT echo, contact the fellow who can have an official bedside done quickly, or the fellow
may perform one himself as a preliminary.
Electrolyte Repletion Guide
For patients at risk for arrythmias (post MI, low EF) and those being actively diuresed, you will likely be checking K
and Mg twice a day. Here is a rough guide to help you. If the patient has a central line, write “mix for central line”. If
they only have a peripheral, try to give replacement PO, but be cautious on an empty stomach. Magnesium is not
absorbed well PO.
The general rule of thumb is to divide the patient’s required electrolyte need by their creatinine.
Example:
Patients K is 3.0 and Cr 1.6Î 100 mEq/1.6Î give the patient 60 mEq.
For normal renal function:
1. K (goal ≥ 4.0): usually 10 mEq will give you a rise of 0.1 mEq/L; IV and PO have an equivalent effect. Fastest
infusion time is 10 mEq/hr through a peripheral line, or 20 mEq/hr for a central line if on a monitored bed.
Examples:
3.0 – 100mEq
3.5 – 60mEq
3.8 – 20mEq
2. Mg (goal ≥ 2.0): usually 1 gm for each 0.1 mEq/L. Magnesium oxide can be used PO (4 tabs being equal to 1
gm) but it is not absorbed well.
Examples:
1.6 – 4 gm IV
1.8 – 2gm IV
3. Phos (goal ≥ 3.0): can choose KPhos or NaPhos. If the patient needs K as well, they will get 4.4 mEq of K for
every 3 mmol of Kphos. Be careful in the setting of hypercalcemia.
Examples:
>2.0 – oral neutraphos 2 tabs po TID x 3 doses
1.5- 2.0 – 0.08 mmol/kg IV over 6 hrs
0-1.5 – 0.16 mmol/kg IV over 6 hrs
For decreased renal function:
Always error on the side of UNDER replacement. Calculate their requirement based on their creatinine (formula
above), and round downward if indicated. Patients on hemodialysis should rarely require electrolyte repletion as they
tend to increase. If dangerously low, be cautious in repletion.
Basics of ECGs:
1. Have a systematic approach and use whatever method works for you when analyzing an ECG.
2. The main thing you’re looking for is ST elevation/depression and T wave changes in contiguous leads
suggesting ischemia (UA/NSTEMI) or infarct (STEMI). Don’t worry about the nuances, don’t miss a STEMI!
Vascular territories:
-Septal (V1, V2)Î LAD
-Anterior (V3, V4)Î LAD
-Lateral (V5,V6, I, aVL)Î left circumflex territory or LAD (diagonal)
-Inferior (II, III, aVF)Î RCA (85%), Circumflex (15%), or sometimes wrap-around LAD; one hint is to look
at lead I. If the ST segment is elevated it suggests circumflex, if the ST segment is depressed it suggests RCA.
-Posterior (V1-V3)Î high R, ST depression, and tall T waves in V1-V3 suggests infarct and not
ischemia. Turn the ECG over and V1-V3 looks like an ST elevation. Will almost always have concurrent
inferior infarct (II, III, aVF).
3. If you see ST depressions, check all other leads to ensure no ST elevations present (which sometimes can
be subtle). These depressions could actually be reciprocal changes for a STEMI.
4. Reciprocal changes are more convincing, but are not required to diagnose a STEMI. Reciprocal ST
depressions occur in leads anatomically opposite the area of infarct
Cardiac Stress Testing
1. To get one ordered you must fill out the form at the nursing station and attach a copy of a recent EKG; for a
nuclear stress test you must also attach a standard Radiology form. These documents go to Marci the stress test
NP who will review and perform the testing.
2. Absolute contraindications to ALL stress testing: acute PE, MI within 48 hours, aortic dissection,
uncontrolled BP (usually SBP >180), uncontrolled arrhythmias, uncontrolled CHF.
3. There are three typical options to “stress” a patient (treadmill, pharmacologic, and vasodilator), and three
typical forms of evaluating the hearts response (ECG, echo, nuclear). These six variables can be mixed in any
combination, but use the steps below as a guide for which test is best.
A. Can patient exercise? If YES and functional status adequate (can walk two blocks without stopping),
always choose exercise.
B. Does ECG show: LBBB, WPW, paced rhythm, on digoxin, major ST/TW changes at baseline, LVH
D. If NO to B aboveÎ exercise ECG (treadmill) test.
E. If YES to B aboveÎ can choose exercise echo or exercise with nuclear imaging. These two have similar
sensitivities/specificities, but stress echo is technically more difficult to organize and perform. For this
reason nuclear stress tests are most commonly done under these circumstances.
F. Patient CANNOT exerciseÎ dobutamine (pharmacologic stress) + echo, or regadenoson (next generation
adenosine, also known as lexiscan). Dobutamine is a positive inotrope with mainly β1 activity used to
simulate exercise and increase myocardial workload. Regadenoson (Lexiscan) is a single bolus, selective
adenosine receptor agonist (vasodilator stress) which vasodilates the coronary arteries, and must be
combined with nuclear imaging.
Nuclear stress testing
1. Done with thallium injected at rest (thallium tends to distribute over a period of hours at rest)
2. The stress portion is then performed (either exercise or regadenoson) and technecium (brand names Cardiolite
(sestaMIBI) or Myoview (tersoriform)) is injected at the peak of stress (technecium is more specific in terms of
its redistribution). So when you hear “I want a rest myoview”, the sequence is: thallium at rest, regadenoson at
rest, technecium at rest. “I want a stress thallium,” the sequence is: thallium at rest, exercise, technicium at peak
exercise.
3. Images are then taken during exercise (if done) with a gamma camera and at rest.
4. If perfusion is normal at rest and with stress, then the study is considered normal.
5. If perfusion is normal at rest but abnormal with stress, this is a reversible defect signifying ischemia.
6. If perfusion is abnormal during rest and stress, this is considered nonreversible and likely scar (old MI)
7. Nuclear stress testing can give you an idea of how much myocardial viability there is by reimaging typically 24
hours later. Based on the “washout” characteristics of the nuclear agent, one can determine whether viable tissue
remains and whether the patient would benefit from revascularizaztion (PCI vs CABG).
Basics of Hemodynamics:
You will get more detailed teaching, but this is so you can follow along from day one on rounds.
Right atrium = central venous pressure (CVP): 2-8mmHg
Right ventricle (not measured on swan readings): 15-25/2-8 (note RV diastolic = CVP)
Pulmonary artery systolic (PAS): 15-25 mmHg
Pulmonary artery diastolic (PAD): 6-12 mmHg
Pulmonary Vascular Resistance (PVR): 150-300 dynes
Pulmonary capillary wedge pressure (PCWP, wedge): 4- 12 mmHg
Cardiac Output (CO): 4-8 L/min
Cardiac Index (CI): 2.5-4 L/min (goal is usu. to keep above 2.0)
Stroke Volume (SV): 60-130 ml
Systemic vascular resistance (SVR): 900-1300 dyne*sec/cm5 (goal for most CHF is 1000ish)
If you are called about abnormal readings on the Swan-Ganz Catheter, first make sure that the Swan is properly
wedging (have the nurse level, rezero and flush the lines; check all stopcocks and connections); if there is any doubt
in your mind, you can always get a CXR and see where the Swan is (it’s usually in the right pulmonary artery about
2-3 cm above and right of the right hilum). Swans should be pulled as soon as it is not necessary as they are a nidus
for infection.
Stents versus CABG
1. Indications for CABG:
-3 vessel disease (left circumflex, right coronary, left anterior descending).
-Left main coronary artery disease >50% (although stenting of the left main is becoming more common).
-Diffuse disease (e.g. multiple plaques along the same artery) that is not amenable to stenting
2. Usually a saphenous vein graft (SVG) will not remain patent for as long a duration as internal mammary grafts
(LIMA) so LIMAs are preferred to SVG. You can identify a LIMA graft by the multiple staples seen along the
left sternal border on a CXR.
3. Two types of stents available:
-Bare metal stent (BMS): requires ASA 325 for one month and then 81 mg for life, and plavix for 1 month to
ideally 1 year. BMS are often placed because patient’s compliance and follow-up are questionable, and as
you’ll see below, a drug-eluting stent requires longer plavix duration and noncompliance is much more
dangerous.
-Drug eluting stent (DES): sirolimus (Cypher or Nevo) requires 3 months of ASA 325 then 81 mg for life, and
at least 1 year of plavix. Paclitaxel (Taxus) requires ASA 325 for 6 months then 81 mg for life, and at least 1
year of plavix.
4. Major drawback of BMS is in-stent restenosis (typically a gradual return of anginal symptoms). This
complication was significantly reduced with DES, but at the cost of stent thrombosis if plavix is discontinued
prematurely (sudden crushing chest pain, ST elevation, generally a poor outcome with 50% mortality).
5. If a patient has a STEMI, typically only the suspected coronary artery will be stented (as complication rate of
multi-vessel stenting during a STEMI is high) and typically a small percentage of STEMI patients have multivessel disease. A BMS is usually used because the patient’s compliance is unknown in acute setting.
6. Ensure everyone is on high-dose ASA and plavix 75 following any stent placement. See above for duration of
these agents.
7. After placement of stent, patients should not undergo vigorous exercise for first 3 weeks as the stent needs
to endothelialize to prevent complications.
Post-Cath Management
1. Get catheterization report from your fellow (there is a required password)
2. Catheterizations can be left heart only (which includes coronary arteries +/- left ventriculogram done to assess
wall motion, ejection fraction, and mitral regurg if present); right heart only (to assess hemodynamics +/oxygenation levels); both right and left heart catheterization.
3. There is a post-cath nurse that is responsible for checking the groin shortly after the procedure to ensure no
hematoma or vascular complications have developed, and the cath fellows are responsible for removing any lines
present if not needed. Sometimes these lines are missed or forgotten, and the on-call team should always check
the patient approximately 12 hours post-procedure. If any lines are present notify the nurse and she will call the
cath fellow to have them removed. Do not attempt to remove them yourself.
4. The post-cath check consists of the following:
-Checking the distal pulses bilaterally to ensure they’re equal.
-Vital signs. The first sign of a bleeding complication such as a retroperitoneal bleed is hypotension, so in a
hypotensive patient post cath bolus with IVF and call your fellow. Tachycardia may be pain induced and
is a late sign of this complication.
-Ask the patient about pain or other complaints. Back pain may be a sign of retroperitoneal bleeding. Ongoing
chest pain is concerning and may be a sign of stent occlusion or coronary dissection. Get an ECG and call your
fellow.
-Check the femoral site for bleeding or hematomas and notify the nurse if either is present.
-A hemoglobin and creatinine check 8 hours post-procedure. A slight bump in creatinine may occur, and don’t
allow a drop in hemoglobin to scare you. The patient can be phlebotomized quite a bit in the cath lab
(+ dilutional from periprocedural IVF), and a one to two unit drop can be expected. The goal is to ensure the
hemoglobin level stabilizes, so base your suspicion of bleeding on the physical exam and clinical status of the
patient, and keep checking hemoglobin levels Q6-Q8 to make sure it plateaus.
5. Checking troponins are not necessary post-PCI unless requested by the cath team or the patient is having
recurrent chest pain. It will likely be elevated any time stent/balloons are inflated in a coronary artery, and chest
pain is a more reliable sign of complications.
6. The patient may come out of the cath lab with a fem stop (pressure device applied to the arterial closure site), or
after an arterial line is removed in the CCU. These devices should never be left in place over 6 hours to prevent
arterial thrombosis, and the patient should lie flat an additional 6 hours after removal.
7. Possible complications post-catheterization:
-Bleeding
-Infection
-AV fistula (pulsatile mass and systolic bruit) – order Doppler ultrasound of femoral artery is suspected, and
call the fellow if confirmed.
-Arterial thrombosis (cold extremity, loss of pulses)
-Retroperitoneal hematoma (especially if back pain, hypotension, drop in hemoglobin) – order CT abdomen if
suspected, and call the fellow if confirmed or patient looks unstable
-Emboli (signs of CVA, big rise in creatinine, cold extremity)
-Contrast-induced renal failure. Just watch and hydrate (usu. 3-5 days post-procedure)
-Arrhythmias
-Arterial dissection/stent thrombosis: chest pain post procedure.
TREATMENT ALGORYTHM FOR ACUTE MI STEMI
1. In the event of a STEMI in the ER, a STEMI code will be called and the patient is usually taken straight to
cardiac catheterization.
2. Patient will be admitted to the CCU post-catheterization with post-cath orders (will include aspirin, plavix, diet
orders, fem-stop orders if used, and any drips the cath team wants e.g. integrillin for 18 hours)
3. Draw troponins q8 to find peak level, as there is some prognostic value (and also sometimes the ER does not
draw troponin prior to STEMI activation)
4. Start patient post cath on meds as indicated above:
-Theraputic heparin or fragmin is not indicated post cath and should be D/Cd
-Lipitor 80 mg po qHS irrespective of LDL
-ACE (within 1st 24 hours)
-Beta-blocker (PO in 1st 24 hours); avoid IV in most cases; metoprolol if unknown EF
-Aspirin 325 mg po daily (usually already in cath orders); duration of high dose determined by type of stent
-Plavix 75 mg Qday regardless of whether a stent was placed or not; the patient was likely loaded with either
300mg or 600mg in cath lab. If patient has three vessel disease and no stents were placed, no plavix has been
given and should not be given, as this will delay CABG 5-7 days. Duration determined by type of stent. If
no stents plavix for 14 days
-Nitroglycerin 0.4 mg SL q5 min prn chest pain (may repeat up to 3x); long-acting nitrates should be reserved
for patient with known CAD and ongoing chronic chest pain
5. CXR if not already performed by ER
6. Draw A1c, fasting lipid panel (remember that lipids are lower post-MI than actual)
7. Order TTE to evaluate for ejection fraction (even if left ventriculogram done in cath lab)
8. Type of BB determined by EF (see above)
9. Consider aldosterone antagonist (see above)
10. Consider nutrition consult (especially for those with STEMI and no significant PMHx which is quite frequent).
11. Aggressive risk factor modification (smoking cessation, diabetes, cardiac rehab)
12. Sudden cardiac risk based on EF <35% and cannot be determined until 40 days post MI
NSTEMI
1. Troponin positive with convincing story or EKG changes (ST depression, T wave changes)
2. Start heparin drip/fragmin SubQ (hold heparin 2 hours before cath or dose of fragmin prior to cath)
3. Optimize medical management
-BP control with beta blocker and ACE (both PO within 1st 24 hours)
-Aspirin 325 mg po daily prior to cath, 81mg Qd if medical management only. ASA dose post cath will be
determined by type of stent if one placed (see stents vs CABG)
-Lipitor 80 mg po qHS irrespective of LDL
-NTG gtt can be started for ongoing chest pain/HTN or both prior to cath
4. Integrillin drip, plavix, or both can be started pror to cath if continued chest pain despite maximal medical
therapy (discuss with your fellow)
5. Draw A1c, fasting lipid panel
7. Order TTE to evaluate for EF if none recently
8. Type of BB determined by EF (see above)
9. Consider aldosterone antagonist (see above)
10. Consider nutrition consult (especially for those with no significant PMHx which is quite frequent).
11. Aggressive risk factor modification (smoking cessation, diabetes, cardiac rehab)
12. Sudden cardiac risk based on EF <35% and cannot be determined until 40 days post MI
HEART FAILURE MANAGEMENT PATHWAY HEART FAILURE MANAGEMENT PATHWAY (CONTINUED) Congestive Heart Failure
1. Often patients will be admitted to the CCU for better dieresis (i.e. a lasix drip (usu. start at 5 mg/hr))
2. Patients may also be on nitroglycerin gtt to help decrease preload, which is very useful if CHF is caused by
CAD, in which case you get the coronary vasodilatory effects as well as synergistic diusresis.
3. Can consider addition of nesiritide instead of NTG (see above), but discuss with your fellow before starting. Is
effective but also very expensive. Addition of zaroxylin (2.5 or 5mg 30 minutes prior to lasix bolus or anytime if
on gtt is also effective).
4. Do not order another TTE in a patient with known CHF and an obvious reason for exacerbation (dietary or
medication noncompliance) if an echo has been performed in the last year.
5. Optimize CHF meds as detailed above.
6. If patient has never had a cath it is recommended to r/o CAD if EF <40%. This is debatable in patients with a
clear global hypokinesis on echo and obvious nonischemic etiology (heavy EtOH or methamphetamine use).
7. Cath should be done after adequate dieresis and right and left heart cath is usually ordered.
Hypertensive Emergencies
1. Usually ER/consult service will have already started a drip to control blood pressure (frequently nitroglycerin). It
is important to know that patients can become resistant to the effects of nitro fairly quickly, so this medication is
useful only in the acute setting.
2. If nitroglycerin alone not controlling blood pressure, can consider switching to nitroprusside (which is a venous
and arterial dilator) but know your renal and hepatic function prior to starting to avoid toxicity. Esmolol can also
be an effective gtt in the acute setting that is easily titratable.
3. The reason for starting with one of these drips is their short half-life and rapid onset allows you to closely
monitor the degree of blood pressure drop in the first 6-12 hours after presentation. Your goal is to decrease the
mean BP by no more than 20% in first hour and down to 160/110 mm Hg in first 2-6 hours.
4. You should then start the PO meds before titrating off the drips.
5. Once patients are off drips with stable blood pressure, they can be transferred to medicine if there are no other
significant issues.
Arrhythmias (refer to RICHMAN guide of acute management)
1. For EP patients admitted post-ablation (e.g. for SVT), the most important complication to watch for is AV blocks
(second or third degree) due to possibility of damage to the AV node during the procedure.
2. Patients with a pacemaker placed will usually be observed overnight for complications and need follow-up in
device clinic (call Susie Song for an appointment) in 2 weeks after placement. The pacemaker will always be
interrogated by the company the day after placement (don’t need to contact- standard procedure). Most of these
patients will also be followed in the EP clinic which occurs once a month.
3. For bradyarrhythmias that are asymptomatic, just observe. If symptomatic, have the nurse place the
transcutaneous pacemaker pads on the patient first, use your RICHMAN guide for additional management
options, and call the fellow.
4. Once a pacemaker is placed, do not worry about slowing the patient’s heart rate with medications. The
pacemaker is your built in protection and will pace if the heart rate becomes too slow.
5. Atrial fibrillation:
-Two questions: rate vs rhythm AND do they need anticoagulation
-Use CHADS (CAD, hypertension, age > 75, diabetes, stroke or TIA = 2 points, ) score (if ≥ 2 probably need
Coumadin) to determine anticoagulation versus aspirin.
-Four agents used for rate control: BB (probably 1st line, and usu start with metoprolol), CCB (diltiazem),
digoxin (usually used with another agent and poor control of heart rate during exertion), amiodarone.
-Rhythm control complicated and attending dependent, but amiodarone usually the drug of choice
-At LAC most attendings will attempt to convert all patients back to normal sinus rhythm at least once (usually
electrical) and either TEE to rule out clot prior to inpatient conversion, or 1 month coumadin and done as an
outpatient.
-Workup for atrial fibrillation (hypertension is probably most common cause with left atrial enlargement). Get
an echo to rule out valvular heart disease/structural abn, TSH for hyperthyroidism, utox for drugs)
Anticoagulation (per LAC-USC anticoagulation guidelines)
1. Heparin
-For ACS/AMI, bolus with 60 units/kg, then infuse at 12 units/kg/hr
-If no thrombus is present/suspected, start infusion at 14 units/kg/hr
-Check aPTT 6 hrs after loading or changing the infusion
-Adjust infusion as follows:
ƒ PTT < 60Æ repeat bolus as above; increase by 200 units/hr
ƒ PTT 50-64Ægive ½ of bolus as above; increase by 100 units/hr
PTT 65-100ÆNO CHANGE NEEDED
PTT 101 – 130Ædecrease by 100 units/hr
131-170Æhold for 1 hour, then decrease by 150 units/hr
171-201Æ hold for 2 hours, then decrease by 200 units/hr
> 201Æhold for 2 hours, then recheck aPTT; continue to hold until < 130, then restart at 300
units/hr slower
-If platelets continue to fall by > 50% or < 100,000, then consider HIT
-Reverse heparin with protamine 1 mg per 100 units of heparin administered in prior 2.5 hours (no more than
50 mg protamine over 10 minutes)
2. Fragmin (dalteparin)
-DVT prophylaxisÆ 5000 units SubQ Qday
-DVT/PE treatmentÆ 200 units/kg/day SubQ divided Qd-BID
-UA/NSTEMI treatmentÆ 120 units/kg SubQ Q12H x 5-8 days
3. Warfarin
ƒ
ƒ
ƒ
ƒ
Day
1
2
3
4
5
INR
<1.5
Dose
5 mg
>1.5
2.5 mg
<1.5
5 mg
1.5-1.9
2.5 mg
2.0-2.5
1-2.5 mg
>2.5
<1.5
0
5-10 mg
1.5-1.9
2.5-5 mg
2.0-3.0
0-2.5 mg
>3.0
<1.5
0
10 mg
1.5-1.9
5-7.5 mg
2.0-3.0
0-5 mg
>3.0
<1.5
0
10 mg
1.5-1.9
7.5-10 mg
2.0-3.0
0-5 mg
>3.0
0
-Initate dose at 25-50% lower dose if liver dysfunction or high bleeding risk or advanced age
-Therapeutic range of INR with warfarin
ƒ INR 2-3
ƒ Atrial fibrillation
ƒ Treatment of atrial or ventricular thrombus
ƒ Treatment of DVT/PE
ƒ INR 2.5-3.5
ƒ Mechanical heart valves regardless of site
ƒ Antiphosphlipid syndrome/lupus anticoagulant
CARDIOVASCULAR PATIENT DISCHARGE CHECKLIST COMMON DRUGS IN THE CCU COMMON DRUGS IN THE CCU PHARMACOLOGY IN THE CCU PHARMACOLOGY IN THE CCU PHARMACOLOGY IN THE CCU Useful Websites
www.usc.edu/ecg (Dr Shinbane’s ecg tutorial)
www.blaufuss.com (good for heart anatomy and heart sounds) www.amion.com (for both IM and cardiology) usccvmfax@gmail.com (to view ECGs; password cardiac1); fax: (323) 446‐7694 Helpful Numbers and Extensions
CCU 4D……………………………………….....x97111
CCU 4M………………………………………....x97112, x97113
Echo reading room……………………………….x97520
Echo front desk…………………………………..x97444
ECG tech on call…………………………...….…x96705
Holter room……………………………….……...x97442
Marci (nuclear)……………………………..…….x97468
Janet (NP for stress lab/echos)………….….…….x91799
Cath lab……………………………………....…..x97601
Cath recovery room……………………….……..x95284
Cardiology clinic (Jay or Letty)…………..…...…x95442
Clinic appts for patients…………………..……...x95267
Susie Song (EP pacemaker clinic)………..……...(323) 442-5689
Anticoagulation....................................................(323) 226-7606