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This worksheet is based on national guidelines for evaluation and disposition of patients with CP and is intended to guide but not substitute for clinical judgment. I.<\/strong> HISTORY, PHYSICAL, EKG:<\/strong> \u00a0 Treat and admit acute MI. \u00a0 If unable to perform EST (disability, age, LBBB, marked chronic EKG changes etc), exit guideline. \u00a0 ANGINA:<\/strong> \u00a0 \u0095<\/p>\nChest pain occurring with exertion or stress and relieved by rest or nitrates.<\/p>\n
\u0095<\/p>\n
Possible anginal equivalent (jaw, neck, ear, arm pain, dyspnea) with exertion or stress and relieved by rest or nitrates.<\/p>\n
Unstable Angina1<\/a>:<\/p>\n Rest angina – occurring at rest > 20 minutes occurring within one week of presentation<\/p>\n \u0095<\/p>\n New onset angina – angina of at least Canadian Cardiovascular Society Classification (CCSC) III severity (walking < 2 blocks or climbing 1 flight stairs) within two months of presentation<\/p>\n \u0095<\/p>\n Increasing angina – previously diagnosed angina that is distinctly more frequent, longer in duration or lower in threshold (but should be increased by at least one CCSC class within 2 months of initial presentation to at least CCSC III)<\/p>\n Definition of unstable angina obtained from the ACC\/AHA 2002 Guideline Update for the Management of Unstable Angina and Non-ST-Segment Elevation Myocardial Infaction. J Am Coll Cardiol<\/em> 2002; 40 (7): pp. 2073-8. Also available at www.acc.org\/clinical\/guidelines\/unstable\/unstable.pdf<\/a>. For description of CCSC classification I-IV see Table 4<\/em>.<\/p>\n <\/p>\n <\/p>\n <\/p>\n ANGINA LIKELIHOOD:<\/strong> \u25a1DEFINITE<\/strong>\u25a1PROBABLE<\/strong>\u25a1PROBABLY NOT<\/strong> II.<\/strong> LIKELIHOOD OF SIGNIFICANT CAD:<\/strong> \u00a0 Y N Hx of prior MI or invasive, corrective procedures (CABG, stent, etc.) \u00a0 Y N Chest or left arm pain or discomfort as chief sx reproducing prior angina. (if pt has no hx of CAD, answer NO) \u00a0 Y N New MR, hypotension, diaphoresis, or rales \u00a0 Y N Dynamic ST segment deviation (>0.5 mm) with sxs \u00a0 Y N T-wave inversion (\u22652 mm) in 2 contiguous leads with sxs \u00a0 Y N ST segment elevation or depression >1 mm Any yes to the above, HIGH<\/strong> likelihood of CAD. Otherwise, continue: \u00a0 Y N Chest or left arm pain or discomfort as chief sx (if clearly not cardiac-chest wall pain, GERD, or pleurisy, answer NO) \u00a0 Y N Chest pain probably not angina with 2-3 cardiac risk factors \u00a0 Y N Diabetes \u00a0 Y N Extracardiac vascular disease (CVA, PVD, bruits, etc.) \u00a0 Y N ST depression 0.5 to 1 mm \u00a0 Y N T wave inversion \u22651 mm in leads w\/ dominant R waves \u00a0 Y N Pathological Q waves Any yes to above, INTERMEDIATE<\/strong> likelihood of CAD. Otherwise, LOW<\/strong> likelihood of CAD, consider outpatient evaluation for noncardiac CP. CAD LIKELIHOOD:<\/strong> \u25a1HIGH<\/strong>\u25a1INTERMEDIATE<\/strong>\u25a1LOW<\/strong> \u00a0 \u00a0 Appendix E1: Part B.<\/p>\n\u00a0 \u0095<\/p>\n III.<\/strong> RISK OF SHORT-TERM DEATH OR MORBIDITY:<\/strong> \u00a0 Y N Accelerating tempo of anginal sxs in preceding 48 hrs \u00a0 Y N Ongoing chest pain > 20 minutes. (Exclude chest pain not relieved by nitrates or analgesics, \u0093probably not angina\u0094.) \u00a0 Y N Angina w\/ physiologic abnormality (S3, new\/worse rales, murmur, hypotension, new or worsening MR). \u00a0 Y N Angina at rest (with dynamic ST changes \u2265 1 mm, new TWI, new BBB, VT) Any yes, HIGH<\/strong> Risk \u2192 admit. Otherwise, continue: \u00a0 Y N Prior MI, PVD, CVA, or CABG \u00a0 Y N Prolonged (>20 min) rest angina resolved (but not low likelihood CAD) \u00a0 Y N Rest angina (<20 min) relieved with rest or sl NTG \u00a0 Y N Age > 70 \u00a0 Y N New onset CCSC III (walking > 2 blocks or climbing 1 flight stairs) or CCSC IV (minimal exertion or rest) but not low likelihood CAD \u00a0 Y N T-wave inversions > 2 mm or pathological Q waves Any yes, INTERMEDIATE<\/strong> Risk \u2192 Med\/Card consult, admit, or go to Page 3. If all no, pt is considered LOW<\/strong> risk, may have outpatient evaluation and\/or 72 hour EST. \u00a0 Y N Increased chest pain frequency, severity, duration, lower threshold but not CCSC III or IV \u00a0 Y N New onset chest pain within 2 weeks to 2 months \u00a0 Y N Chest pain occurred > 24 hours ago? Any yes, LOW<\/strong> Risk \u2192 72 hr EST. Otherwise, follow-up with PMD or routine EST. RISK OF SHORT-TERM MORBIDITY AND MORTALITY:<\/strong> \u25a1HIGH<\/strong>\u25a1INTERMEDIATE<\/strong>\u25a1LOW<\/strong> High risk \u2192 Admit<\/strong>Intermediate risk \u2192 consider CPULow risk \u2192 home<\/strong> (Consult HBS)<\/strong>(Consult HBS)<\/strong> \u00a0 \u00a0 1<\/a><\/p>\n
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