Acute myocardial infarction guidelines: Update the way you treat patients

New doses, interventions, and approaches listed for the ED

When a patient complaining of chest pain walks into your ED, you’ll be using new approaches and interventions, outlined in new guidelines for myocardial infarction (MI).

The updated Guidelines on Management of Acute Myocardial Infarction were published jointly by the Dallas-based American Heart Association (AHA) and the Bethesda, MD-based American College of Cardiology (ACC), and will have a major impact on the ED, according to sources interviewed by ED Nursing.1

Key sections of the guideline, previously published in November 1996, were updated and will have a major impact on how you manage those patients, according to Julie Bracken, RN, MS, CEN, director of nursing education at Cook County Hospital in Chicago and representative to the Heart Attack Alert program for the Des Plaines, IL-based Emergency Nurses Association. (See excerpt of guidelines, inserted in this issue, and flowchart with key changes, right.)

It’s imperative that ED nurses stay abreast of changes in the guidelines, which reflect current research, Bracken emphasizes. "We need to make appropriate science-based changes in our practice."

Thrombolytics are addressed

Here are key changes in the new guidelines:

Give thrombolytics to more patients.

The guidelines state that more patients can safely be given thrombolytics, including patients over 75 and patients with longer intervals from symptom onset, reports Barbara Riegel, DNSc, RN, CS, FAAN, one of the authors of the updated guidelines. Riegel is a member of the executive committee for the AHA Council on Cardiovascular Nursing.

You can be influential in this decision over whether to administer thrombolytics, Riegel suggests: "If you are working with a physician who has dated information and tells you, This patient is too old for a thrombolytic,’ you should cite the new guidelines."

Give a lower heparin dose.

There is a change in the recommended heparin dose for patients treated with thrombolytic therapy. "There are data suggesting that the previous dose is too high and are associated with intracranial hemorrhage," says W. Douglas Weaver, MD, FACC, division head for the department of cardiovascular medicine at Henry Ford Hospital in Detroit and a member of the task force that developed the guidelines. "The new guidelines use weighted doses, and the top dose is lower than in the old protocol."

Look at your own ED’s protocol and bring it up to date for heparin use, urges Weaver. "Know the research behind this, so you can share it with colleagues if they’re not aware of it. Most ED protocols don’t have this new information yet, so ED nurses should drive this change more rapidly."

The new dosage recommendation should be incorporated in your protocol immediately, adds Weaver. "You should absolutely share the guidelines and data at staff meetings and make it happen." (See related story on changing your MI protocols, p. 70.)

Give angioplasty to more patients.

The guidelines stress that angioplasty is beneficial to a larger group of patients. "This is strong evidence that you should triage those patients after diagnosis to a tertiary care hospital if you don’t have a cath lab," says Weaver.

Previously, there was no urgency to make the diagnosis or intervene, he says. Now it’s important that the cardiologist be alerted early, Weaver says. "I suspect this isn’t done as rapidly as it should be."

A key concept change

Consider acute myocardial infarction (AMI) as part of a continuum.

The guidelines label AMI as "acute coronary syndrome," which is a key concept change, stresses Riegel. "It’s now the view that acute MI is the final step in a process."

Patients may have unstable angina, non-Q-wave MI, or an MI aborted by a thrombolytic, leading to confusion, says Riegel. "For example, did a patient have an MI or not; if the patient did not manifest subsequent Q-waves, but did come in with ST-segment elevation, classic symptoms, and received a thrombolytic?"

This confusion led the committee to use the term "acute coronary syndrome," Riegel explains. "The goal is to prevent the patient from having a completed MI by intervening early enough in the acute coronary syndrome," she says. "This is particularly important in patients with nondiagnostic ECG findings."

The labeling as acute coronary syndrome might be a mindshift for many, but it’s important to understand acute MI as occurring along a continuum of physiological changes, says Riegel. "It is not a yes/no or all/none phenomenon. Once understood as a process, interventions aimed at interfering with the process make more sense."

Consider staffing issues.

The guidelines address nursing staffing and institutional changes and the influence of those changes on quality of care and adverse events. "These staffing and organizational change issues have important implications for nurses everywhere," says Riegel.

Since a report on adverse events in medicine was recently published by the Huntingdon Valley, PA-based Institute for Safe Medication Practices, everyone will be watching those issues even more closely, Riegel notes.2 When treating MI patients, you’ll need to document not only adverse events but the context in which those events occurred (patient load, situational factors), she explains. "In this era of evidence, people will be receptive to objective data that help explain why events occurred," Riegel says.

Educate patients on risk factors.

The guidelines recommend that you take steps to modify risk factors. "Increasingly, the medical/nursing community is willing to accept responsibility for risk factor modification, even in acute care settings," notes Riegel.

For example, discuss smoking cessation with patients, Riegel advises. "A significant number of patients quit smoking just with advice about the wisdom of doing so. Even brief interventions are extremely powerful."

In a nonconfrontational manner, briefly state factual information such as: "Your illness/disease/child’s asthma would improve if you quit smoking. Is there anything I can do to help you achieve such a goal?’" suggests Riegel, adding that the same type of nonconfrontational message can be used with other behaviors such as diet and exercise.

The guidelines also stress that diagnostic and treatment delays should be reduced, due to patient or family hesitation, or prehospital treatment, transport, or treatment delays, says Dorothy M. Lanuza, PhD, RN, FAAN, a professor at Niehoff School of Nursing in Maywood, IL.

Educate the public, patients, and families about what to do if the patient has chest pain, Lanuza says. "You should also work on committees to minimize system problems [that] may delay prompt diagnosis and treatment once the patient enters the ED."

Administer beta blocker therapy routinely.

According to the guidelines, routinely give beta blockers to patients with suspected MI (with or without ST elevation), with the exception of patients who have had prior beta blocker therapy and still have persistent symptoms or cannot tolerate beta blockers, Lanuza says. (See related story on new medications used in MI patients, below.)

References

1. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999; 34:890-911.

2. Cohen MR, Proux SM, Crawford SY, et al. Survey of hospital systems and common serious medication errors. J Healthc Risk Manag 1998; 18:16-27.

The complete text of the new recommendations can be downloaded from the following Web sites:

American College of Cardiology, www.acc. org. After registering, click on "clinical information" and then "clinical guidelines."

American Heart Association, www. americanheart.org. Under the "science and professional" heading, choose "publications." Click on "scientific publications" and then "scientific statements."

The 1996 and 1999 guidelines are available by mail for $5. (Ask for document XG015.) The Executive Summary and Recommendations published in the Aug. 31, 1999, issue of Circulation (document XS015) are also available for $5. Contact:

American College of Cardiology, 9111 Old Georgetown Road, Bethesda, MD 20814. Telephone: (800) 253-4636 ext. 694. Fax: (301) 897-9745.

The Institute of Medicine issues a report on medication errors. A complete copy of the report, To Err is Human: Building a Safer Health Care System, is available for $45 plus $4.50 shipping and handling. To order, contact:

National Academy Press, 2101 Constitution Ave. N.W., Lockbox 285, Washington, DC 20055. Telephone: (888) 624-8373 or (202) 334-3313. Fax: (202) 334-2451. E-mail: zjones@nas.edu.

Resources are available from the National Heart Attack Alert Program (NHAAP), part of the National Heart Lung and Blood Institute (NHLBI). The NHAAP has as its goal the reduction of the morbidity and mortality associated with acute myocardial infarction (including sudden death) through rapid identification and treatment. The following publications can be downloaded at no charge from the NHLBI Web site: www.nhlbi.nih.gov/about/nhaap/ index.htm. The price listed is for ordering by mail.

Patient/Bystander Recognition and Action: Rapid Identification and Treatment of Acute Myocardial Infarction (Publication 3303, $3);

Rapid Identification and Treatment of Acute Myocardial Infarction (Publication 3302, $3);

Emergency Medical Dispatching: Rapid Identification and Treatment of Acute Myocardial Infarction (Publication 3287, $3);

Staffing and Equipping Emergency Medical Services Systems: Rapid Identification and Treatment of Acute Myocardial Infarction (Publication 3304, $3);

Emergency Department: Rapid Identification and Treatment of Patients With Acute Myocardial Infarction (Publication 3278, $3);

Emergency Department: Rapid Identification and Treatment of Patients With Acute Myocardial Infarction Slide/Lecture Resource (Publication 55-709, free while supplies last);

Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction (Publication 3787, $3);

The Physician’s Role in Minimizing Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: Recommendations From the National Heart Attack Alert Program (Publication 55-823, $1.50);

An Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: Executive Summary of a National Heart Attack Alert Program Working Group Report (Publication 55-819, $1.50).

To order by mail, contact :

Mary M. Hand, MSPH, RN, Coordinator, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, 31 Center Drive, MSC 2480, Room 4A16, Bethesda, MD 20892-2480. Telephone: (301) 594-2726. Fax: (301) 592-8563. E-mail: NHLBIinfo@rover.nhlbi.nih.gov.