From the Guidelines
In a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) and Multivessel Coronary Artery Disease (MV CAD) on heart catheterization, continuous Heparin (unfractionated heparin) infusion is recommended while awaiting Coronary Artery Bypass Grafting (CABG).
Key Considerations
- The heparin drip should be continued until the day of surgery, typically for 24-48 hours, with a goal of maintaining an activated partial thromboplastin time (aPTT) between 50-70 seconds 1.
- The patient should also be on aspirin 81-325 mg daily and a P2Y12 inhibitor, such as clopidogrel 75 mg daily or ticagrelor 90 mg twice daily, until the day of surgery 1.
- It is essential to carefully manage the patient's anticoagulation and antiplatelet therapy to minimize the risk of bleeding and thrombotic complications.
Management Strategy
- Continue UFH as anticoagulant therapy while awaiting CABG 1.
- Discontinue clopidogrel 5 to 7 days before elective CABG, but this may be adjusted based on the urgency of the surgery and the patient's individual risk factors 1.
- Discontinue intravenous GP IIb/IIIa inhibitor 4 hours before CABG 1.
- Carefully manage the patient's anticoagulation and antiplatelet therapy to minimize the risk of bleeding and thrombotic complications, as recommended by the guidelines 1.
From the Research
Patient Management
The management of a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) and Multivessel Coronary Artery Disease (MV CAD) on heart catheterization requires careful consideration of various factors, including the need for continuous Heparin (unfractionated heparin) infusion while awaiting Coronary Artery Bypass Grafting (CABG).
Revascularization Strategies
- The optimal revascularization strategy for patients with NSTEMI and MV CAD is controversial, with some studies suggesting that CABG may be associated with improved outcomes compared to percutaneous coronary intervention (PCI) 2, 3.
- A study published in 2019 found that CABG was associated with a lower risk of 5-year all-cause mortality compared to PCI in patients with NSTEMI and left main or multivessel coronary disease 2.
- Another study published in 2020 found that CABG was associated with improved survival and lower rates of major adverse cardiac and cerebrovascular events (MACCE) compared to PCI in patients with MV CAD and NSTEMI 3.
Use of Heparin
- The use of continuous Heparin infusion in patients with NSTEMI and MV CAD awaiting CABG is not explicitly addressed in the provided studies.
- However, a study published in 2024 found that chronic anticoagulation use was associated with lower in-hospital mortality and no significant difference in major bleeding in patients with NSTEMI 4.
- It is essential to note that the decision to use continuous Heparin infusion should be based on individual patient characteristics and clinical judgment, taking into account the patient's risk of thrombosis and bleeding.
Detection of Multivessel Coronary Artery Disease
- A study published in 2020 found that multivessel coronary artery disease (MVCAD) was present in a considerable number of patients presenting with NSTEMI and markedly raised cardiac troponin T levels 5.
- The study suggests that any patient with elevated troponin T levels, even in the absence of ST segment elevation, should undergo cardiac catheterization to detect the presence of MVCAD, as this subset of patients can benefit from early revascularization, including CABG surgery 5.