Unstable Angina Pre-CABG management

Specialties CCU


I recently encountered a situation in which a 60-something male with no PMH aside from 30 pack-year smoker was admitted for unstable angina, troponins negative x3. Probable large inferior infarct on Lexiscan, cardiac cath showed severe 3 vessel disease - circ, LAD, RCA all 80% occluded or more with severe left main calcification, no collaterals mentioned on cath report, EF 25-30%, no PCI performed, started on ASA, metoprolol, statin, and subcutaneous heparin BID.

Basically I feel like this guy was one cigarette, a burp and a fart away from a lethal infarct, but hey.

This occurred on a Friday, and the patient was planned for open-heart surgery/revascularization for Monday (no surgery over weekend unless emergent).

That night, the patient began experiencing 10/10 burning CP radiating down right arm while at rest. HR 45-55 sinus brady, BP 154/80. One SL nitro resolved his pain and dropped his pressure to 99/60. The cardiology resident (brand new this month academic teaching service, not one of our usual MDs) was notified and did not wish to obtain EKG/troponin recheck.

At this point the patient admitted he had been having SEVERAL episodes of this chest pain since the previous day without disclosing it to staff, and reported that he was having pain at rest whereas before, it was only with exertion; this info was relayed to the resident. This raised some concerns for me.

Now, in my experience these types of patients earn themselves nitro/heparin infusions until they are ready for surgery, even with negative trops. Given inferior blockages, we use IV fluids (cautiously of course given EF) for BP support. I am inquiring whether that is common practice or the standard elsewhere as well. When my nurses and I expressed our concerns (twice) and asked whether the patient was appropriate for nitro/heparin etc, s/he said, "No, the patient is having angina, his trops were negative, this is chronic disease, we can't just put him on heparin and nitro. He already had a cath and now he is getting surgery. Continue to use SL nitro." (This conversation went in circles for 10 minutes and I felt as though we were being talked over the entire time.)

This is not how I am used to seeing these types of patients being managed pre-operatively so I wanted to see what others thought.

Thank you!

That symptoms of chronic disease and ACS resemble each other is not a reason to treat them the same way.

That symptoms of chronic disease and ACS resemble each other is not a reason to treat them the same way.

I agree, which is why I am scratching my head. Isn't unstable angina considered ACS? And how can we be sure he was not having an acute MI if we neglected to investigate further with additional trops and repeat EKG?

The patient had no interventions performed during cath, shouldn't the goal be to keep him chest pain free until surgery? It was not as though he had a history of PCI/CABG/CHF and was maxed out on medical therapy, ranexa and imdur etc. The resident did not agree with any of it, and left me baffled and questioning my practice. Still scratching my head, by the way...

What did you mean by probable large inferior infarct on Lexiscan?

What did you mean by probable large inferior infarct on Lexiscan?

I wrote this from memory so forgive me for lack of accuracy but this was written in the impression on the stress test: "large fixed defect at the inferior posterior wall highly suspicious for underlying infarct "

Specializes in CVICU.

I'm hoping the pt was in the CCU being continuously monitored. I don't work in a teaching hospital, but can't you page the attending instead of the resident? Or the CV surgeon that should have already been consulted?

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