不稳定性心绞痛

ClinicalpathwayofInterventionaltherapybasedonUnstable

Angina

A.Standardhospitalizationprocess

(a)Applicableobjectives

ThefirstdiagnosisisunstableAngina(ICD-10：I20.0/20.1/20.9)Underwentcoronarystenting(ICD-9-CM-3：36.06/36.07)

(b)Diagnosisbasis

《ClinicalPracticeGuidelines-DepartmentofCardiology》(EditedbyChineseMedicalAssociation,People'sHealthPublishingdepartment,2009),《UnstableAnginaandnon-ST-segmentelevationmyocardialinfarctiondiagnosisandtreatmentguidelines》(CardiologyBranchofChineseMedicalAssociation,2007)andthe2007ACC/AHAandESCguidelines.

1.Characteristicsofclinicalonset:theclinicalmanifestationis

Exercise-inducedchestpainorSpontaneouschestpain,itwillbequicklyrelievedwhentakearestorsublingualadministrationofnitroglycerin.

2.TheECG:ST-segmentdepressionorelevation>0.1mVonadjacent

twoormorethantwo-leadECGorT-waveinversion≥0.2mVwhenchestpainisonset,thechangesinST-Tsegmentrecoveritselfwhenthechestpaingetrelieved.

3.Markersofmyocardialinjuryarenotelevatedornotreachthelevel

ofdiagnosisofmyocardialinfarction

4.Clinicaltypes

1)Initialonsetofangina:thenew-occurredangina,whichhasthe

largestdiseasecourseofamonth,canbemanifestedasSpontaneousandexertionalanginaonsetexistatthesametime,andthepaingradingisabovelevelIII.

2)Worseningexertionalangina:patienthasaanginahistory,andthe

anginagetworsened,itattacksfrequently,andtheonsettimeisbecominglongerandlonger,thepainthresholdisgettinglowerandlower(Canadaexertionalanginagrade[CCSI-IV]increasedbyatleastoneclassorreachedatleastClassIII)

3)Restingangina:anginaattackswhenpatientsareatrestorata

quietstate,andseizuredurationisusuallymorethan20minutes.

4)Postinfarctionangina:itreferstotheanginaoccurredbetween24

hoursandamonthaftertheonsetofacutemyocardialinfarction.\

5)Variantangina:theanginaattackswhenthepatientsareatrestor

engagedingeneralactivities,electrocardiogramshowedatransientelevationoftheSTsegmentwhenanginaisonset,mostpatientswillrecoverautomatically,whileafewpatientsgetevolvedintomyocardialinfarction.

(C)Therapyselectionandbasis

《ClinicalPracticeGuidelines-DepartmentofCardiology》(Edited

byChineseMedicalAssociation,People'sHealthPublishingdepartment,2009),《UnstableAnginaandnon-ST-segmentelevationmyocardialinfarctiondiagnosisandtreatmentguidelines》(CardiologyBranchofChineseMedicalAssociation,2007)andthe2007ACC/AHAandESCguidelines.

1.Riskstratification:wedivideitintolow-risks,medium-risksand

high-riskgroupsaccordingtoTIMIriskscoreortheanginatypeandseverityofthepatient,durationofmyocardialischemia,ECGandcardiacinjurymarkersmeasurementresults

2.Drugtherapy:anti-ischemicdrugs,antiplateletdrugs,anticoagulant

drugs,lipidregulatingdrugs.

3.Coronaryarteryrevascularizationtherapy:medium-riskand

high-riskpatientscanhaveapreferredchoiceofpercutaneouscoronaryintervention(PCI)orcoronaryarterybypassgrafting(CABG)onthebasisofintensivedrugtherapy.

1).PCI:underthefollowingcircumstances,wecanhaveanemergencycoronaryangiographyin2hours,andimplementthePCItherapyforthepatientwhodoesn’thaveseverecombineddiseasesandcoronarylesionssuitableforPCI.

①Restingorasmallamountofexercisestillaccompaniedbyrepeatedlyanginaandischemiaonthebasisofintensivedrugtherapy;②Myocardialmarkerselevate(TNTorTNI)③The

new-emergingSTsegmentissignificantlylower;④Symptomsorsignsofheartfailure,new-emergingorworseningmitralregurgitation;⑤Hemodynamicinstability;⑥Sustainedventriculartachycardia.Wecantreatthemedium-riskandhigh-riskpatientswithouttheaboveindicationswithearlyinvasivetherapywithin12-48hoursafterhospitaladmission.

2)CABG:CABGisthefirstchoiceforthosepatientswithleftmainstemlesions,3-vesseldiseaseor2vascularlesionsoftheleftanteriordescendingartery,alongwithLeftventriculardysfunctionordiabetes.

4.Intra-aorticballoonpumpsurgery:intra-aorticballoonpumpsurgerycanbeappliedtopatientswiththerecurrenceofmyocardialischemiaafterintensivemedicaltherapyandhemodynamicinstabilitybeforethecompletionofcoronaryangiographyandrevascularization.

5.Conservativetherapy:Ourfirstchoiceisconservativetherapyforthoselower-riskpatients;wecanmakeloadtestchecksafterthediseasestayinastableconditiononthebasisofintensivemedicaltherapy,andthenchoosepropertimeforcoronaryangiographyandrevascularization

6.Improvingtheunhealthylifestylestocontrolriskfactors.

(d)Thestandardhospitalizationdaysare6-8days.

(e)Standardsforentrancepaths

1.ThefirstdiagnosismustmeetwiththeICD-10:I20.0/20.1/20.9unstableanginadiseasecoding.

2.Myocardialinfarction,aorticdissection,pulmonaryembolism,acutepericarditisandsoonareexcluded.

3.Patientssufferingfromothercardiovasculardiseasebutwithoutspecialtreatment(examinationandtreatment)duringhospitalizationandwithouteffectonthefirstdiagnosiscanenterthepath.(f)Preoperativepreparation(preoperativeevaluation)0-3days.

1.Requiredcheckitems

1)Routinebloodtest+Bloodtype,Routineurine+Ketonebodies,Routinestool+occultblood

2)Liverandkidneyfunction,electrolytes,glucose,bloodlipids,serumcardiacinjurymarkers,coagulation,infectiousdiseasescreening(hepatitisB,hepatitisC,HIV,syphilis,etc.);

3)ChestX-ray,electrocardiogram,echocardiography

2.Checkitemsinaccordancewiththespecificsituationofthepatients1)Bloodgasanalysis,brainnatriureticpeptide,D-dimer,erythrocytesedimentationrate,C-reactiveproteinorhigh-sensitivityC-reactiveprotein

2)24-hourambulatoryECG,cardiacstresstest

3)Themyocardialischemiaassess(low-risk,non-emergency

revascularizationpatients)

3.Otherpreoperativepreparation

1)Preoperativeconversation,explainthepossiblecomplications

duringsurgeryandintraoperativeandsignedtheinformedconsent2)Preoperativeantiplateletdrugloadapplications

3)Hydrationtherapyinpatientswithrenalinsufficiency

(g)Choiceofdrugs

1.Dualantiplateletdrugs:Routinedrugsassociatedwithaspirin+clopidogrel.ApplicationofintravenousGPIIb/IIIareceptorantagonistsmaybeconsideredinhigh-riskpatientsundergoinginterventionaltherapy.

2.Anticoagulantdrugs:Lowmolecularweightheparinorunfractionatedheparinandsoon

3.Anti-ischemicdrugs:β-blockers,nitrateesters,calciumantagonistsandsoon.

1)β-blockers:orallytakingforpatientwithoutcontraindicationswithin24hours.

2)Nitrateesters:intravenousinfusionafterSublingualnitroglycerintomaintain,wecanchangeitintonitrateestersoralafterthediseasestayinstablecondition.

3)Calciumantagonists:Patientstillhaveischemicsymptomsorhypertensionaftertheuseofsufficientquantitiesofβ-blockers,and

thentheycantakenon-dihydropyridinecalciumantagonistswithnocontraindications.

4.Sedativeandpainkiller:wecanhaveintravenousinjectionofmorphinewhennitroglycerincannotinstantlyrelievesymptomsorthereisoccurringacutepulmonarycongestion.

5.Antiarrhythmicdrugs：Theapplicationofarrhythmias

6.Lipidregulatingdrugs：Earlyapplicationofstatins

7.Angiotensin-convertingenzymeinhibitors：Applicableforpatients

withleftventricularsystolicdysfunctionorheartfailure,hypertension,anddiabetes,itshouldbeorallytakenwithin24hoursforpatientswithoutcontraindicationsuchashypotensionandsoon,wecanchooseARBtherapyforpatientswhocannottolerateit.

8.Otherdrugs:therapeuticdrugsaccompaniedbydisease.

(h)Thedayofsurgeryisthefirst0-3daysofthehospitaladmission(ifitisnecessarytoundergoasurgery)

1.Anestheticmethod:localanesthesia

2.Surgicalapproach:coronaryangiography+stentimplantation.

3.Surgicalimplant:coronaryarterystent.

4.Intraoperativemedication:antithrombotics(heparinized,whennecessary,makeauseofGPIIb/IIIareceptorantagonist)vasoactivedrugs,anti-arrhythmicdrugsandsoon.

5.Requiredinspectionitemsimmediatelyaftertheinterventionsurgery:Checkingofvitalsigns,ECGmonitoring,ECG,examinationofthepuncturesite.

6.LetthepatientliveintheICUaftertheinterventionsurgerywhenitisnecessary.

7.Requiredinspectionitemsinthefirstdayaftertheinterventionsurgery:Routinebloodtest,routineurine,electrocardiogram,myocardialinjurymarkers.Wecanalsohaveothernecessarychecksinaccordancewiththediseasesituation:fecaloccultblood,liverandkidneyfunction,electrolytes,glucose,coagulationfunction,echocardiography,chestX-ray,bloodgasanalysis.

(i)Inspectionitemsmustbereviewedafter3-5days’postoperativehospitalization.

1.Timelydetectionandtreatmentofcomplicationsobservedinpatientswithmyocardialischemiaandsymptoms

2.Continuetokeepacloseobservationofthepuncturesitebleeding,oozingsituation.

3.Observingthechangesofcardiacenzymesandkidneyfunctionaftersurgery.

(j)Dischargecriteria

1.Vitalsignswerestable

2.Hemodynamicwasstable

3.Myocardialischemicsymptomswereeffectivelycontrol

4.Therewerenocomplicationsneedextrahospitalization.

(k)Varianceandthereasons

1.Patientwasturnedtosurgicaldepartmenttoundergoemergencysurgeryofcoronaryarterybypassgraftingaftercoronaryangiography.

2.WaitingforthesecondaryPCIorchoosethepropertimetodothecoronaryarterybypassgrafting

3.Criticalcondition

4.Withtheappearanceofseriouscomplications

BTableofClinicalpathwayofInterventionaltherapybasedonUnstableAnginaApplicableobjectives:ThefirstdiagnosisisunstableAngina(ICD-10：I20.0/20.1/20.9)

Underwentcoronarystenting(ICD-9-CM-3：36.06/36.07)

Themain

diagnosis

and

treatment

activities

Focuson

medical

advice

Primary

nursing

work

□no□yes，reason

Record

the

variation

ofdisease

Patientname:Gender:Age：Patientnumber：hospitalization

number：

hospitalizationdate：yearmonthdayDischargedate：yearmonthday

Standardhospitalizationdays7-14days

TimeTime

ofonset：yearmonthdayhourminute

ofarrivalattheemergencydepartment：yearmonthdayhourminute

arrivalattheemergencydepartment

(0—10minutes)

□Completethecollectionofdiseasehistoryandphysicalexamination

□tracings18leadECG,evaluatingtheinitial18-lead

□ECGconfirmthediagnosis,takeaspirinandclopidogrelorallyandtimely(patientwithcontraindicationsareexcluded)

□Starttheconventionaltherapy(unstableanginadiagnosisandconventionaltherapy)

Time

arrivalattheemergencydepartment

(0—30minutes)

□ConsultationofspecialistatthedepartmentofCardiology

□riskstratification,assesstheindicationsandcontraindicationsofearlyrevascularizationtherapeuticorconservativetherapy

□determinethetherapyschemeofemergency

coronaryarteryrevascularizationemergencyCABG)

angiography(directPCI

andand

□weshouldtimelytransferpatientstotheCCUtocontinuethetreatmentforthosewhodidnotundergoearlyinvasivetherapy,andthenre-evaluatethenecessityandriskofearly

Long-termmedicaladvice:

□IntensiveCare

□ContinuouslymonitorofECG,bloodpressureandoxygensaturation

□oxygeninhalationTemporarymedicaladvice

□tracing18leadECG,chestX-ray

□measurementofserumcardiacinjurymarkers

□routinebloodtest+bloodtype

□routineurine+microscopicexamination

□stool+occultblood

□lipids,bloodglucose,liverandkidneyfunction,electrolytes

□functionofbloodcoagulation

□screeningofinfectiousdisease

□establishmentofintravenousaccess

□otherspecialmedicaladvice

□assistpatientsortheirfamiliestocompleteemergencyregistration,payment,andtransacthospitaladmissionformalitiesandsoon

revascularizationLong-termmedicaladvice:

□careroutineofunstableangina

□levelonecareorspecialcare

□24hoursintakeandoutput

□bedrest

□intensivecare(ContinuouslymonitorofECG,bloodpressureandoxygensaturation)

□oxygeninhalation

□sedativeanalgesics:morphine(inaccordancewiththesituationofthepatient)

□intravenousinfusionofnitroglycerin

□careroutineofunstableangina

□specialcare

□collectbloodofvenous□no□yes，reason：

.

Signature

ofnurse

Signature

of

physician

time

main

treatment

activities

Focuson

medical

advice

arrivalattheemergencydepartment

(0—60minutes)Forhigh-riskpatientswhoneedemergencycoronaryarteryangiographyandrevascularization：

□explainthediseaseandtreatmentmeasurestopatientsandtheirfamilies

□signthe“surgicalinformedconsent”

□applythe“emergencycoronaryarteryangiographyandrevascularization”therapy

□takingadequateamountsofantiplateletdrugsbeforesurgery(aspirinandclopidogrel)

□Preoperativehydration(kidneyfunctioninsufficiency)

□maintainappropriatebloodpressure,heartrate,cardiacfunctionandvitalorganfunction,soitcanwithstandcoronaryarteryangiographyandrevascularization

□completeroutinepreoperativemedicaladvice(preventiveantibiotics)

□transferpatientstoCCUorrecoveryroomofsurgicaldepartmenttocontinuethetherapyaftersurgery

Long-termmedicaladvice:

□careroutineofunstableangina

□levelonecareorspecialcare

□24hoursintakeandoutput

□bedrest

□intensivecare(ContinuouslymonitoringofECG,bloodpressureandoxygensaturation)

□oxygeninhalation

□sedativeanalgesics:morphine(inaccordancewiththesituationofthepatient)

□intravenousinfusionofnitroglycerin

□therapyofemergencyrevascularization

Thefirstdayofhospitalization

□monitorthesituationofBloodpressure,heartrate,urineoutput,respiratory,drugreactionsandsoon

□observethepuncturesiteandthesurroundingcircumstances;observewhethertheECGchanges;checkifthehemoglobindecreasedandthemarkersofmyocardialinjuryelevated

□superiorphysicianwardround:riskstratification,careintensityandtreatmenteffectsassessment,formulatethenexttreatmentscheme

□completemedicalrecordandsuperiorphysicianwardroundrecord

□routinedrugtherapyofunstableangina

□preventionofsurgicalcomplications

□preventionofinfection(whenitisnecessary)

□weshoulddoriskstratificationagain,andaccessthenecessaryandriskofthesurgeryforpatientswhodidnotundergoinvasivetherapyattheemergencydepartment,asforthemedium-riskandhigh-riskpatientweshouldcompleteemergencycoronaryarteryangiographyandrevascularizationwithin12-48hoursafterhospitalization

Longtermmedicaladvice:

□careroutineofunstableangina

□levelonecareorspecialcare

□oxygeninhalation

□notificationofcriticalcondition

□bedrestorbedsideactivities

□liquidfoodorsemi-liquidfood

□intensivecare(ContinuouslymonitoringofECG,bloodpressureandoxygensaturation)

□maintainsmoothstool

□β-blockers(theroutineuseforpatientswithnocontraindications)

□ACEI(itshouldbeorallytakenwithin24hoursforpatientswithoutcontraindicationsuchashypotension,pulmonarycongestionorLVEF≤0.40,highbloodpressureordiabetes,wecanchooseARBtherapyforpatientswhocannottolerateit)

□nitrateestersdrugs

□applicationofaspirin+clopidogrel

□makeauseoflowmolecularweightheparinfor2-8daysaftersurgery

□lipidmodificationtherapy:statins

□calciumantagonists(inaccordancewiththe

situationofpatients)

temporarymedicaladvice:

□ECG

□dynamicmonitoringofmarkersofmyocardialinjury

□bedsidechestX-ray

□bedsideechocardiography

Primary

nursing

work

Record

the

variation

ofdisease

Signature

ofnurse

Signature

of

physician

□careroutineofunstableangina

□specialcare

□no

1.

2.

□psychologicalandlifecareduringrecoveryperiod

□guideandsupervisetreatmentandactivitiesduringrecoveryperiodaccordingtotheirsituationandriskstratification

□yes，reason：

□no1.2.

□yes，reason：

Theseconddayofhospitalization

□continueintensivecare

□observethepuncturesiteandthesurroundingcircumstances

□observewhethertheECGchanges

□checkifthehemoglobindecreasedandthemarkersofmyocardialinjuryelevated

□Superiorphysicianwardround:accesstherapyeffect,andamendtherapyscheme

□Completemedicalrecord,diseasecourserecord,superiorphysicianwardroundrecord

□Continuetheroutinedrugtherapyofunstableangina

□Weshouldevaluatethenecessityofemergencyrevascularizationatanytimeforpatientsappliedconservativetherapy,andstrengthentheanti-ischemicdrugtherapy

Thethirddayofhospitalization

□continueintensivecare

□monitoringofECG

□Superiorphysicianwardround：evaluatecardiacfunction

□Completesuperiorphysicianwardroundrecordanddiseasecourserecord

□Continueandregulatedrugtherapy

□Duringtheobservationperiod,lower-riskpatientswithnorecurrenceofangina,noischemicchangesonECG,noclinicalevidenceofleftventricularfailurecanbedischargedafter24-48hourshospitalizationobservationwhilethereisnoelevationofmyocardialinjurymarkersduring2-24hourshospitalizationobservation

time

Themain

diagnosis

and

treatment

activities

Focuson

medical

advice

Long-termmedicaladvice:

□careroutineofunstableangina

□levelonecareorspecialcare

□bedrest

□bedsideactivities

□semi-liquidfoodorlow-saltlow-fatnormaldiet

□ContinuouslymonitoringofECG,bloodpressureandoxygensaturationandsoon

□maintainsmoothstool

□β-blockers(theroutineuseforpatientswithnocontraindications)

□ACEIorARBtherapy(inaccordancewiththesituationofthepatient)

□nitrateestersdrugs

□applicationofaspirin+clopidogrel

□makeauseoflowmolecularweightheparinfor2-8daysaftersurgery

□lipidmodificationtherapy:statins

□calciumantagonists(inaccordancewiththesituationofpatients)

Long-termmedicaladvice:

□careroutineofunstableangina

□levelonecareorspecialcare

□bedrest

□rbedsideactivities

□low-saltlow-fatnormaldiet

□maintainsmoothstool

□β-blockers(theroutineuseforpatientswithnocontraindications)

□ACEIorARBtherapy(inaccordancewiththesituationofthepatient)

□nitrateestersdrugs

□applicationofaspirin+clopidogrel

□makeauseoflowmolecularweightheparinfor2-8daysaftersurgery

□lipidmodificationtherapy:statins

□calciumantagonists(inaccordancewiththe

situationofpatients)

temporarymedicaladvice:

□ECG

□Markersofmyocardialinjury

Primary

nursing

work

temporarymedicaladvice:

□ECG

□Markersofmyocardialinjury

□cooperationinfirstaidandmedical□cooperationinmedicalworkdiagnosisandtreatment□lifeandpsychologicalcare

□lifeandpsychologicalcare□cooperatewiththerecoveryexercise

□guidetherecoveryandexerciseforandpreachoflevel2preventionpatientsduringtherecoveryperiod

inaccordancewiththeirsituation

andriskstratification

Recordthevariation

□no□yes，reason：

1.

□no1.

□yes，reason：

ofdisease

2.

2.

Signature

ofnurse

Signature

of

physician

time

Thefourthdayof

hospitalization

Thefifthdayof

hospitalization

Thesixth-eighthdayof

hospitalization

(dischargedday)

revascularizationtherapy，includingPCI、CABG

Themain

diagnosis

and

treatment

activities

Focuson

medical

advice

□superiorphysicianwardround:assessmentofheartfunctionandtherapyeffect

□determinethenexttreatmentscheme

□completetherecordofsuperiorphysicianwardround

□revascularization(PCIorCABG)withpostoperativetherapyinpatients

□preventionofsurgicalcomplications

Long-termmedicaladvice:

□careroutineofunstableangina

□level2care

□bedsideactivities

□lowsaltlow-fatnormaldiet

□β-blockers(theroutineuseforpatientswithnocontraindications)

□ACEIorARBtherapy(inaccordancewiththesituationofthepatient)

□Orallytakingdrugofnitrateesters

□applicationofaspirin+clopidogrel

□makeauseoflowmolecularweightheparinfor2-8daysaftersurgery

□lipidmodificationtherapy:statins

□calciumantagonists(inaccordancewiththesituationofpatients)

□superiorphysicianwardroundandassessmentof

therapy□complete

superior

therecordofphysicianward

of

the

round

□prevention

complications

□reevaluate

□completethescheduledPCI

□reevaluationofcardiacfunction

□assessmentoftherapeuticeffect,post-preventionanddischarge

□