# Presentation: 788753

## TIME IS LIFE

- Update of diagnosis and
- treatment of
- Acute Coronary Syndromes (ACS)

- Stephanie Allen, MSN, MS, RN  Nurse Educator
- Doreen A. Mays, NP, MS,  Program Manager, Urgent Care
- Kathleen Smith, RN  Case Manager, Cardiology
- Kathleen Woods, RN, MSN, NP  Clinical Cardiology

**D****EPARTMENT OF ****V****ETERANS ****A****FFAIRS**
**Hudson Valley Health Care System**** **
**Montrose and Castle Point Medical Centers**

## Objectives

- Apply knowledge to effectively identify and treat veterans with signs and symptoms of Acute Coronary Syndrome
- Increase knowledge of the VA’s _Time is Life_ Heart Attack Program in order to reinforce the education of patients in:
- Recognizing signs and symptoms of a heart attack
- Calling 911
- Preparing an action plan in the case of a heart attack

## Objectives

- Recognize the importance of timely interventions for the diagnosis and treatment of ACS.

## Acute Coronary Syndrome

*    *_Definition_* - ACS includes myocardial infarction (MI) and the various patterns of *unstable* angina:  new-onset angina, rest angina, or crescendo-pattern angina (more frequent, prolonged, or severe episodes in a patient with known angina). *
*    *These entities should be identified quickly so that immediate treatment to prevent MI or salvage the myocardium can be initiated.

## Did You Know?

- 931,108 people died in 2001 from acute coronary syndrome (AHA, 2004)
- Mortality related to Acute Coronary Syndromes is divided almost equally between males and females
- More than half of these deaths occurred suddenly, within one hour of the onset of symptoms and outside of the hospital setting

##  Study Reported in The New England Journal of Medicine

-    The VA contracted with researchers from the Harvard Medical School, Price Waterhouse Coopers, IBM, and the Lewin Group to evaluate outcomes of patients treated for heart attacks.  The study used administrative data to compare mortality data for VA and Medicare patients who had suffered heart attacks.

##     New England Journal StudyResults

-    From 1997-1999, there was a statistically significant higher mortality rate among VA patients    at 30 days after their heart attack and at 1, 2, and 3 year points.

##     New England Journal StudyResults

-   Veterans were less likely than Medicare patients to undergo invasive cardiac procedures such as angiography, angioplasty and surgery.
-    On average, veterans traveled twice as far for VA cardiac care compared to Medicare patients.

## We can  MAKE A  DIFFERENCE !!!

_**Goals for patients with **_
_**Chest Pain**_
- 1.  Immediate assessment of patients
-       with chest pain.
- 2.  Timely initiation of treatment.
- 3.  Rapid determination of need for transfer to another facility.

## CBOC PATIENTS

- Call 911
- Obtain 12 lead EKG
- EMT’s will administer medications and treatments per their protocol

- Determine cardiac rhythm on monitor.
- Labs – CBC, SMA7, CK-MB, PT, PTT, U/A
- Troponin with results within 1 hour of draw
- Aspirin 325 mg chewable, if no ASA taken in
-               past 3 hours.
- Nitroglycerine 0.4 mg sl if BP>100 systolic.
-           Repeat x 2 five minutes apart  if needed.
- Insert saline lock.
- Monitor vital signs q 15 minutes.
- Morphine IV as per provider if chest pain not relieved by nitroglycerine.
- Beta blockers as per provider if deemed beneficial.

-  Orders for Immediate Treatment

##  If EKG shows –                        ST elevation or new LBBB 

- Provider to call ER to obtain accepting physician:
-    Vassar- 454-8500 for Castle Point pts
-    HVH- 737-9000 for Montrose pts
- Initiate immediate ACLS transport.
- Start lovenox 1mg/kg sq if no contraindications.

## If EKG shows -  No ST elevation:

- Determine TIMI Score
- Page cardiology at Castle Point for consultation or call  Manhattan VA during WHEN hours.
-  Determine disposition based            on provider assessment, and TIMI score recommendations.* **   *

## What is a TIMI Score?

-     TIMI is the Thrombolysis in Myocardial Infarction risk score.  This score is a simple prognostic tool used to categorize a patient’s risk of death and ischemic events, and provides a basis for therapeutic decision-making.
**         **_**Score **_**                           **_**Risk Factor**_
-             0-1    	                              4.7%
-                2    	                              8.3%
-                3    	                            13.2%
-                4    	                            19.9%
-                5    	                            26.2%
-             6-7    	                            40.9%

## TIMI Score

- ___ Age over 65
- ___  3 or more risk factors for coronary disease*
- ___  Established CAD
- ___  2 or more angina events in past 24 hours
- ___  Use of ASA in past 7 days
- ___  Elevated enzymes
- ___  ST depression _>_ 0.5mm
- Number of checks = TIMI Score   ______
- Risk Factors = hypertension, cigarette smoking, obesity, physical inactivity, dislipidemia, DM, micro-albuminuria,
-      GFR <60/min, family h/o premature CVD

## “Time is Life” Heart Attack Education Program

-    This program was developed to assist clinicians in encouraging veterans to develop a personal acute myocardial infarction survival plan, and to seek medical attention as quickly as possible after symptoms first appear.

## Key Objectives of the Patient Education Program

- Recognize the signs and/or symptoms of a heart attack
- Call 911 for initiation of early treatment and emergency transport to the nearest hospital facility
- Develop a personal survival plan

## Recognize the Signs and/or Symptoms of a Heart Attack

- Reinforce the common warning signs (chest pain/pressure/squeezing, neck/shoulder/ back/arm pain, chest discomfort with lightheadedness/fainting/ sweating/ nausea/vomiting/shortness of breath, or chest discomfort with feeling of doom or imminent death)
- Instruct that women may also experience fatigue, shortness of breath without chest pain, or lower chest pain

## Call 911 for theInitiation of Early Treatment

- If the patient is having signs/symptoms of a heart attack, instruct him/her:
- Don’t delay
- Call 911 immediately
- Tell the ambulance driver s/he is having chest pain
- Take 1 regular aspirin unless allergic
- Don’t drive to the hospital

## Develop a Personal Survival Plan

- Emphasize the need for the patient to know the importance of:
- Learning the heart attack warning signs
- Reducing the risks of heart attack
- Completing a Survival Plan Wallet Card
- Sharing the plan with family and friends

## Modalities of Patient Education

-    Patients will have access to and be exposed to the “Time is Life” Education Program through:
- Clinicians
- “Combat Heart Attack and Survive: Time is Life” video
- “Time is Life” brochure, poster, and wallet card
- Risk Assessment Action Plan

## WE CAN MAKE A  DIFFERENCE !!!

- Remember, for patients with chest pain:
- Start oxygen, get a 12-lead EKG and have it read within 10 minutes!
- If ST changes are present, initiate immediate transfer to nearest private hospital.
- If no ST changes are present, include the TIMI score in determining disposition of the patient.
- Educate your patients on action to take if chest pain occurs.