MI post heparin drip

[RNbubu]

I took care of a patient who was on a heparin drip because of a pulmonary embolism. He came to our unit stable from the ICU. We took him off the heparin drip, and he seemed to be progressing well. When I came backthe next morning, however, i learned the had expired. the night shift RN told me he started to complain of chest pain, which didn't seem alarming at first since he had been coughing intermittently and had complained of pain when coughing. However the pain started to get worse. She got a 12-lead EKG and found out he was having an active STEMI. Rapid response was called, but the doctors decided not to take him to cath lab - instead they wanted to treat him pharmacologically only.He was transferred back to ICU and unfortunately didn't make it.i am trying to understand why he didn't go to cath lab. Is it because he was on the heparin drip just earlier that day?

[MunoRN, RN]

It's actually not at all unusual for a patient to go the cath lab with heparin running, or integrillin or bivalarudin, so I doubt that is why they chose not to take the patient to the cath lab, I would guess there were other factors which didn't make the patient a candidate for cath.

A PE suggests that a patient is hypercoagulable which can also result in a thrombus in a coronary artery causing an MI, which is fixable with a heart cath. Had the patient maybe expressed that they didn't wish to have any invasive treatments? Were they in renal failure? It sounds as though there was some reason to allow nature to take it's course.

[Anna Flaxis, BSN, RN]

I agree with the above. Whatever the reason, it most likely had nothing to do with the heparin.

[NtannRN]

I also agree with MunoRN.

[RNbubu]

Thank you for the replies!

No renal failure and the pt never expressed he didn't want to be treated. What are other reasons why a stemi pt wouldn't go to cath lab?

[MunoRN, RN]

Are you sure it was a STEMI and not an NSTEMI? Could it have been that the cardiologist believed he was having an MI but it was due to demand ischemia secondary to the PE? Had he been bridged to a therapeutic INR prior to stopping the heparin gtt? How long had he been on the heparin gtt?

[RNbubu]

It was a stemi. That's why I'm so puzzled.

[SubSippi]

If a person is having st elevation the only reason I can think of they wouldn't take him to the cath lab is if the patient himself had refused. Unless they knew for a fact the STEMI was caused by a reason other than an occlusion in a coronary artery...but how could they know that for a fact without a cath?

[Anna Flaxis, BSN, RN]

Ask the cardiologist/intensivist/hospitalist next time you see him/her.

[michlynn, BSN, RN]

I'm curious as to why this patient didn't go to the cath lab either. Any time a patient has ST elevation and is actively having chest pain we cardiac alert them and the patient goes straight to the cath lab. Heparin should not have even been a factor in that decision, if our patients are on heparin we usually just them down with it and they turn it off in the lab. It seems this patient should have maybe went for a CT of the chest as well just to see if the PE had gotten worse or migrated.

[CardiacKittyRN]

How could the doctor know that the blockage could be medically managed with doing a heart cath? What if he had significant blockages that needed stents and couldn't be med managed? That doesn't make sense to me.. what was the actual cause of death?

[canned_bread]

If a patient is on heparin and we need to reverse it (which is very rare), we could reverse the heparin. Actually, in the cath lab, we usually GIVE heparin!