CCU handover

SpRs covering CCU should update the written handover sheet and give personally to the next SpR covering CCU once their shift is complete.

Clerk in of the 1 North patient

Usual clerk-in including the following:
note time and mode of admission(eg A&E, cardiac ambulance) working diagnosis plans for investigations along with any results already available (eg ECG, CXR) cholesterol falls rapidly thus ensure lipids done on admission dont delay for fasting sample the next morning documentation of any info given to patients and/or relatives

The last entry in the notes should include:

final diagnosis discharge recommendations outstanding investigations/ results pending documentation of any info given to patients and /or relatives plans for review ( discuss with consultant first as not every pt needs reviewed)

JT/IM v01/06/12

Management of Acute Coronary Syndrome

STEMI/ LBBB MI: See separate lytic protocol NSTEMI/ Unstable angina:

Initial management:

Oxygen, sublingual nitrate +/- IV morphine Anti platelet and anticoagulation therapy as listed next should only be given in A&E after discussion with cardiology. -Aspirin- 300mg stat and 75mg daily -Plavix- 300mg stat and 75mg daily -Enoxaparin- usual dose 1mg/kg SC BD (max dose 100mg BD) for 3days then 40mg s/c nocte until discharge. If >75 yrs give 0.75mg/kg SC BD (max dose 75mg BD) for 3days then 40mg s/c nocte until discharge. If GFR is <30 reduce dosing frequency to od. IV or regular buccal nitrate if ongoing pain Integrilin - should be discussed with consultant first

Additional Management:

Beta Blockers, consider first dose IV if ongoing chest pain Other antianginals e.g. ISMN LA 25mg OD. Nicorandil best 4th line as associated with ulceration (NB Nicorandil is given BD not od) High dose statin - e.g Atorvastatin 40mg od ACE inhibitors unless C/I (e.g. perindopril 2-8mg or ramipril 2.510mg)

Risk Stratification (discuss with consultant):

ECHO all patients. Consider spironolcatone 12.5-25mg od if EF<40 Cardiac catheterisation consider for most patients but discuss first with consultant Consider urgent cardiac catheterisation if ongoing pain or dynamic ECG changes,

Discharge medications usually should include -

Aspirin 75mg Clopidogrel dose usually 75mg (150mg for 1st week after stent) & state duration usually 12 months post ACS. 2years post drug eluting stent Betablockers (or other HR limiting agent if BB c/i discuss with consultant) High dose statin ACEi 2

JT/IM v01/06/12

Emergencies- Tachycardia (ACC guidelines):

Broad Complex Tachycardia
-The following are suggestive of VT rather than aberrant conduction: -AV dissociation -RS greater than 100ms in any precordial lead. -QRS in precordial leads with a negative concordance. -Presence of fusion beats and capture beats.

Management:
Unstable Stable DCC IV amiodarone see protocol in BNF for infusion

AF/ Atrial Flutter Persistent severe tachycardia is a medical emergency - aim for control <110bpm ASAP after admission
Unstable (syst BP less than 90): Emergency DCC (irrespective of anticoagulation) Stable (syst BP more than 90): Rate Control- Metoprolol (watch in HF) slow IV 5mg, repeat if unsuccessful up to 15mg, reassessing BP and HR each time Oral betablocker Consider additional antiarr drug DC Cardioversion (DCC) elective after 4+ weeks of full anticoagulation (INR>2) unless certain AF duration is <48hours Ensure the correct consultant name is on request letter for DCC and the DCC discharge letter. Each AF patient is different ensure after a DCC you discuss directly with the relevant consultant to decide on ongoing antithrombotic and other treatment (anticoagulation is usually given lifelong if elevated CHA2DS2VASc score even after successful DCC) and the need or otherwise for further review. If consultant not available on the day, put to be discussed on the arrangements for review line.

JT/IM v01/06/12

Narrow Complex Tachycardia: ?SVT

Management: Vagal manoeuvres Adenosine- see below Beta Blockers DCC- if syst BP less than 90mmHg Usually avoid digoxin and rate limiting calcium channel blockers (discuss first with consultant, C/I in WPW) See repeat 12L ECG in sinus rhythm. If settles quickly in A&E and patient stable does not necessarily require admission. May require outpatient attendance later. IV adenosine -no change in rate -inadequate dose -consider VT -gradual slowing then reacceleration -sinus tachy -focal atrial tachy -sudden termination -AVNRT -AVRT -sinus node re-entry -focal atrial tachy -persistent atrial tachy + high degree AV block -a flutter -atrial tachy

Management in pregnancy:
Vagal manoeuvres Adenosine Possibly metoprolol, DCC

JT/IM v01/06/12

Emergencies- Bradycardias
Remove causes: drugs e.g. BB, rate limiting Calcium Blockers, digoxin, propafenone, flecainide, etc Hypothermia, hypothyroidism, raised ICP etc Look for acute MI/ischaemia, infection e.g. endocarditis, Atropine 0.3mg repeat at 5 min intervals up to 2mg Consider dobutamine/dopamine infusion ?Temporary pacing if inadequate HR increase despite above: -Trancutaneous (external pacing)(with sedation) -Transvenous Note risk of asystole is higher if: Recent asystole Mobitz type 11 CHB with broad QRS Ventricular pause greater than 3 sec

JT/IM v01/06/12

Emergencies- Acute Heart Failure (ESC guidelines)

AHF evaluation Symptoms and signs

-peripheral circulation, venous filling, peripheral Temperature

Presence of Heart Disease? If normal consider alternative diagnoses ECG unusual to be normal in AHF Look at rhythm, presence of atrial or ventricular strain, L/R ventricular hypertrophy, evidence of ischaemia/infarction Bloods ABG (or pulse oximetry) FBP, U&E, Gluc, TropT, BNP +/- D Dimer, urinanalysis CXR pulmonary oedema (or lung infection or inflammation) +/- CT chest ?major PE or aortic dissection

Evaluate function Echo

If normal consider alternative diagnoses

JT/IM v01/06/12

AHF Management
yes

Pain/distress
no

analgesia/sedation increase FiO2 +/- CPAP/NIPPV

no

SaO2 greater 95% Normal HR/rhythm

yes

antiarrhythmics/pacing as appropriate vasodilator -nitrate, titrate to BP (not less than 90-100)SL/buccal initially then possibly IV -diuretic, if large boluses required consider IVI frusemide 120mg200mg/4hrs
no

Syst BP greater 90mmHg

Adequate Pre-load?

Cautious Fluid challenge (consider in context of inferior STEMI and RV infarction

Adequate Cardiac Output Reversal of metabolic acidosis? Clinical signs of adequate organ perfusion?

no

Consider inotropes

Reassess frequently

JT/IM v01/06/12

Some Cardiac Drugs

1. Anti platelet drugs
Aspirin: Prophylaxis in atherosclerotic disease: Aspirin 75mg daily orally Acute coronary syndromes (STEMI/ NSTEMI/ unstable angina): Aspirin 300mg dispersible or chewed stat Aspirin 75mg daily Clopidogrel: NSTEMI/ unstable angina/ prior to PCI: Clopidogrel 300mg stat followed by 75mg daily for 1 year Prophylaxis in-stent thrombosis following PCI: Clopidogrel 75mg daily for 1 year. Patients intolerant of aspirin: Clopidogrel 75mg daily Prasugrel NICE indications: pPCI, NSTEACS with diabetes or stent thrombosis 60mh load then 10mg od for one year DO NOT GIVE if >75yrs age, wt<60kg or previous TIA/CVA. GP IIb/IIIa inhibitors- eptifibatide (Integrilin): All GP IIb/IIIa inhibitors are only licensed for use with aspirin and heparin. FBP required 2hrs after the start of the infusion starting Daily FBP, U&E and urinalysis required.

2. Anti-arrhythmics
Amiodarone: Amiodarone loading infusion 300mg in 250ml 5% dextrose over 30mins, followed by Amiodarone 900mg in 500ml 5% dextrose over 24 hrs Amiodarone must be infused via a central line or if not available, a green cannula in a brachial vein. Do NOT give via smaller cannulas or more peripheral veins. JT/IM v01/06/12 8

3. Cardiac Glycosides
Digoxin: Digoxin oral loading dose (for atrial fibrillation or flutter) rapid digitalisation 0.75-1.0mg in divided doses over 24 hours e.g. 500micrograms at 0700, 250micrograms at 1500, 250micrograms at 2300 Maintenance dose (for atrial fibrillation or flutter) 62.5-250micrograms daily (N.B. 250micrograms rarely indicated) Heart failure patients who are in sinus rhythm do not require a loading dose. A satisfactory plasma digoxin concentration can be achieved over a period of about a week. Dose in heart failure (for patient in sinus rhythm) 62.5-125micrograms once daily Prescribing notes: Digoxin is indicated for rate control in atrial fibrillation and symptomatic heart failure even in sinus rhythm; it has no role in the prophylaxis of paroxysmal atrial fibrillation For urgent rate control in atrial fibrillation, a loading dose of digoxin may be given intravenously or orally. Intravenous digoxin is potentially hazardous and should be reserved for patients with a clear need for urgent digitalisation Regular measurements of plasma digoxin concentrations are not usually required except to confirm toxic levels or to check compliance. There is no therapeutic dose response relationship for digoxin in heart failure. Increasing doses .250microgrmas just increases toxicity If toxicity occurs, digoxin should be withdrawn; serious manifestations require urgent specialist management. For further information on the management of toxicity see www.toxbase.org Digoxin should not be used in the treatment of patients with pre-excitation syndromes e.g. Wolff-Parkinson-White Syndrome, unless specifically prescribed by a specialist. Cautions: Loading and maintenance doses of digoxin should be adjusted according to renal function. Age, sex and weight need to be considered. A maintenance dose of 125 micrograms daily is adequate in most patients. A lower maintenance dose (i.e. 62.5microgrmas daily) is often adequate in older patients, in patients with renal failure and in patients taking potentiating therapy e.g. amiodarone Digoxin should be used with particular caution in the elderly and patients with renal impairment Digoxin has a reduced renal excretion in the elderly which puts them at increased risk of side-effects such as sickness, diarrhoea, slow pulse and other heart rhythm disorders causing dizziness, fainting or falls Hypokalaemia predisposes to digoxin toxicity. Care should be taken to monitor the electrolytes when prescribing diuretics, potassium supplementation or combination with ACE inhibitor/ ARB as appropriate Digoxin may be a useful adjunct to a beta-blocker for heart rate control but assessment of heart rate/ rhythm is required and doses more than 125micrograms in this setting are generally best avoided