A 65-year-old woman is admitted to the hospital on Friday night
with an episode of squeezing, substernal chest pain that
occurred while the patient was watching her favorite TV show.
The pain lasted for twenty minutes and was not relieved by
nitroglycerin. A dobutamine stress echocardiogram was done a
month ago by her private physician, which showed posterior
and lateral wall motion abnormalities. Her past medical history is
significant for diabetes mellitus.
On arrival at the hospital, an EKG shows ST-segment
depression in the lateral leads. She is started on aspirin,
nitrates, beta-blockers, and intravenous unfractionated heparin.
Three sets of cardiac enzymes are negative. A complete blood
count shows a white cell count of 7,800/mm3, a hematocrit of
37%, and a platelet count of 180,000/mm3. The medications are
continued, and she is transferred from the cardiac care unit on
Sunday evening with plans for a coronary angiography the next
day.
On Monday, the patient complains of pain in the right leg. The
physical examination is unremarkable, except for moderate
right-calf tenderness. The venous Duplex shows thrombosis of
the right popliteal vein. Another complete blood count shows:
WBC 9,900/mm3, hematocrit 38.8%; and platelets 45,000/mm3.
The prothrombin time (PT) is 13.6 seconds, INR 1.0, and partial
thromboplastin time (PTT) 68 seconds.
What is your next step in the management of this patient?
(A) Continue unfractionated heparin and start coumadin after the
angiogram
(B) Switch unfractionated heparin to low-molecular-weight
heparin
(C) Immediately stop heparin and remove heparin-coated
catheters
(D) Corticosteroids
(E) Switch unfractionated heparin to lepirudin
he is presenting with HIT after 3 days. this is very rare in HIT. at least 5 days are needed. m confused...
with an episode of squeezing, substernal chest pain that
occurred while the patient was watching her favorite TV show.
The pain lasted for twenty minutes and was not relieved by
nitroglycerin. A dobutamine stress echocardiogram was done a
month ago by her private physician, which showed posterior
and lateral wall motion abnormalities. Her past medical history is
significant for diabetes mellitus.
On arrival at the hospital, an EKG shows ST-segment
depression in the lateral leads. She is started on aspirin,
nitrates, beta-blockers, and intravenous unfractionated heparin.
Three sets of cardiac enzymes are negative. A complete blood
count shows a white cell count of 7,800/mm3, a hematocrit of
37%, and a platelet count of 180,000/mm3. The medications are
continued, and she is transferred from the cardiac care unit on
Sunday evening with plans for a coronary angiography the next
day.
On Monday, the patient complains of pain in the right leg. The
physical examination is unremarkable, except for moderate
right-calf tenderness. The venous Duplex shows thrombosis of
the right popliteal vein. Another complete blood count shows:
WBC 9,900/mm3, hematocrit 38.8%; and platelets 45,000/mm3.
The prothrombin time (PT) is 13.6 seconds, INR 1.0, and partial
thromboplastin time (PTT) 68 seconds.
What is your next step in the management of this patient?
(A) Continue unfractionated heparin and start coumadin after the
angiogram
(B) Switch unfractionated heparin to low-molecular-weight
heparin
(C) Immediately stop heparin and remove heparin-coated
catheters
(D) Corticosteroids
(E) Switch unfractionated heparin to lepirudin
he is presenting with HIT after 3 days. this is very rare in HIT. at least 5 days are needed. m confused...