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A 62-Year-Old Hospitalized Man Is Evaluated for New-Onset, Right Lower

question 957

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A 62-year-old hospitalized man is evaluated for new-onset, right lower extremity pain. The patient underwent bypass surgery for 3-vessel coronary artery disease 2 months ago. He arrived at the emergency department 2 nights ago due to recurrent chest pains. At that time, ECG showed sinus rhythm with no ST-segment changes, but cardiac troponin I levels were elevated. The patient was initiated on unfractionated heparin, antiplatelet agents, a beta blocker, and a nitrate. A coronary angiogram was performed via the radial artery; it revealed graft insertion site stenosis and was treated with stenting. Postintervention echocardiography revealed left ventricular ejection fraction of 50% with no regional wall motion abnormalities. This morning, the patient had new, sudden-onset, right lower extremity pain. He has never had pain in that extremity before. The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include aspirin, clopidogrel, rosuvastatin, metoprolol, losartan, isosorbide mononitrate, basal-bolus insulins, and subcutaneous heparin at a prophylactic dose. The patient is a former smoker with a 30-pack-year history. Temperature is 37.6 C (99.7 F) , blood pressure is 138/84 mm Hg, pulse is 96/min, and respirations are 18/min. Physical examination reveals normal jugular venous pressure, clear lungs, no heart murmurs, and a soft, nontender abdomen. The right leg is tender and cool to the touch when compared to the left leg. Right lower extremity distal pulses are diminished, but capillary refill is intact. Left leg examination is normal with the exception of healed scars from previous saphenous vein harvesting. Neurological examination is normal. Laboratory results are as follows:
$A 62-year-old hospitalized man is evaluated for new-onset, right lower extremity pain. The patient underwent bypass surgery for 3-vessel coronary artery disease 2 months ago. He arrived at the emergency department 2 nights ago due to recurrent chest pains. At that time, ECG showed sinus rhythm with no ST-segment changes, but cardiac troponin I levels were elevated. The patient was initiated on unfractionated heparin, antiplatelet agents, a beta blocker, and a nitrate. A coronary angiogram was performed via the radial artery; it revealed graft insertion site stenosis and was treated with stenting. Postintervention echocardiography revealed left ventricular ejection fraction of 50% with no regional wall motion abnormalities. This morning, the patient had new, sudden-onset, right lower extremity pain. He has never had pain in that extremity before. The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include aspirin, clopidogrel, rosuvastatin, metoprolol, losartan, isosorbide mononitrate, basal-bolus insulins, and subcutaneous heparin at a prophylactic dose. The patient is a former smoker with a 30-pack-year history. Temperature is 37.6 C (99.7 F) , blood pressure is 138/84 mm Hg, pulse is 96/min, and respirations are 18/min. Physical examination reveals normal jugular venous pressure, clear lungs, no heart murmurs, and a soft, nontender abdomen. The right leg is tender and cool to the touch when compared to the left leg. Right lower extremity distal pulses are diminished, but capillary refill is intact. Left leg examination is normal with the exception of healed scars from previous saphenous vein harvesting. Neurological examination is normal. Laboratory results are as follows: Immunoassay for heparin-induced thrombocytopenia antibody returns positive. His condition improves with treatment. Which of the following is the most accurate statement regarding heparin use and risk of recurrence of this patient's current condition? A) Corticosteroids should be co-administered with heparin to prevent future recurrence B) Heparin avoidance is not necessary for thrombocytopenia alone with no thrombosis C) Heparin can be safely administered after the antibodies dissipate in 2-3 months D) It is recommended to avoid all heparin products for life due to risk of recurrence E) Low-dose heparin such as catheter flushes are safe, but higher doses should be avoided$ Immunoassay for heparin-induced thrombocytopenia antibody returns positive. His condition improves with treatment. Which of the following is the most accurate statement regarding heparin use and risk of recurrence of this patient's current condition?

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