Page 464 - Cardiac Nursing

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440 P A R T III / Assessment of Heart Disease
2. Patients with episodic chest pain accompanied by transient ST-
DISPLAY 20-1 Noninvasive Tests Results Predicting High segment elevation. (Level of evidence: B)
Risk for Adverse Outcome
1. Severe resting left ventricular dysfunction (LVEF 0.35)
2. High-risk treadmill score Recommendations for Coronary
3. Severe exercise left ventricular dysfunction Angiography in Patients With
(exercise LVEF 0.35) Postrevascularization Ischemia:
4. Stress-induced large perfusion defect (particularly if 7
anterior) ACC/AHA Practice Guidelines
5. Stress-induced multiple perfusion defects of moderate
size Class I indications:
6. Large, fixed perfusion defect with left ventricular dilata- 1. Suspected abrupt closure or subacute stent thrombosis after
tion or increased lung uptake (thallium-201) percutaneous revascularization. (Level of evidence: B) (Chapter
7. Stress-induced moderate-size perfusion defect with left- 23).
ventricular dilatation or increased lung uptake 2. Recurrent angina or high-risk criteria on noninvasive evalua-
(thallium-201)
8. Echocardiographic wall motion abnormality (involving tion within 9 months of percutaneous revascularization. (Level
more than two segments) developing at low-dose dobu- of evidence: C) (Display 20-1).
tamine or at low heart rate
9. Stress echocardiographic evidence of extensive
ischemia Recommendations for Coronary
Angiography in Patients During the
LVEF, left ventricular ejection fraction.
Adapted from Gibbons, R. J., Abrams, J., Chatterjee, K., et al. (2003) ACC/AHA Initial Management of Acute
2002 guideline update for the management of patients with chronic stable angina. Myocardial Infarction:
Journal of American College of Cardiology, 41, 159–168.
ACC/AHA/Society for Cardiovascular
Angiography and Interventions
(SCAI) Practice Guidelines 11
Recommendations for Coronary
Angiography in Patients With Class I indications:
Unstable Angina (UA/NSTEMI: 1. Coronary angiography and primary PCI should be performed
ACC/AHA Practice Guidelines) 9 in patients with STEMI or myocardial infarction (MI) with
new or presumably new left bundle-branch block who can un-
Class I indications: dergo PCI of the infarct artery within 12 hours of symptom
onset. (Level of evidence: A)
1. An early invasive strategy (i.e., diagnostic angiography with in-
tent to perform revascularization) is indicated in UA/NSTEMI 2. Patients younger than 75 years with ST elevation or presum-
patients who have refractory angina or hemodynamic or electri- ably new left bundle-branch block who develop shock within
cal instability (without serious comorbidities or contraindica- 36 hours of MI and are suitable for revascularization that can
tions to such procedures. (Level of evidence: C) (See Table 20-1). be performed within 18 hours of shock. (Level of evidence: A)
2. An early invasive strategy (i.e., diagnostic angiography with in- 3. Patients with severe congestive heart failure and/or pulmonary
tent to perform revascularization) is indicated in initially stabi- edema and onset of symptoms within 12 hours. (Level of evi-
lized UA/NSTEMI patients (without serious comorbidities or dence: B)
contraindications to such procedures) who have an elevated
risk for clinical events. (Level of evidence: A)
Recommendations for Patients After
Patients with UA/NSTEMI who have had prior PCI or coro- Fibrinolytic Therapy: ACC/AHA
nary artery bypass graft surgery should be considered for early Practice Guidelines 12
coronary angiography, unless data from previous coronary an-
giography indicate that further revascularization is unlikely to be Class I indications:
possible. 9
1. A strategy of coronary angiography with intent to perform PCI
(or emergency coronary artery bypass graft surgery) is recom-
Recommendations for Coronary mended for patients who have received fibrinolytic therapy and
Angiography in Patients With have any of the following:
Variant (Prinzmetal’s) Angina: a. Cardiogenic shock in patients younger than 75 years who
ACC/AHA Practice Guidelines 9 are suitable candidates for revascularization. (Level of evi-
dence: B)
Class I indications: b. Severe congestive HF and/or pulmonary edema. (Level of
evidence: B)
1. Diagnostic investigation is indicated in patients with a clinical c. Hemodynamically compromising ventricular arrhythmias.
picture suggestive of coronary spasm, with investigation for the (Level of evidence: C)
presence of transient myocardial ischemia and ST-segment ele-
vation during chest pain. (Level of evidence: A) Care of patients with STEMI is presented in Chapter 22.