A 54-Year-Old Man With an NSTEMI and Upcoming Non-Cardiac Surgery
A 54-year-old man presented by ambulance to the emergency department with several hours of severe substernal chest pain at rest. Prior to presentation, he was physically active, had no history of cardiovascular disease, and took no medications. However, he had recently been diagnosed with stage 3 prostate cancer and had been scheduled for radical prostatectomy in 3 months. At the time of arrival, the patient had received aspirin 325 mg and several doses of sublingual nitroglycerin without pain relief. His initial vital signs showed a heart rate of 64 bpm, blood pressure of 91/67 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 100% on room air. Physical examination was unremarkable. The patient's electrocardiogram showed sinus rhythm with small Q waves in leads III and aVF with T-wave inversions in leads II, III, and aVF and ST depressions in V5 and V6 (Figure 1).
The basic metabolic panel and complete blood count were within normal limits. A point-of-care troponin I level was elevated at 1.8 ng/mL (normal ≤ 0.06 ng/mL). The patient was treated with clopidogrel 600 mg and a heparin infusion. He was then transferred to the cardiac catheterization laboratory where coronary angiography was performed that revealed a right dominant system with an 80% stenosis of the proximal right coronary artery and a 90% hazy lesion in the mid-right coronary artery (Figure 2). The left coronary system had mild luminal irregularities only.
What is the best management of this patient, bearing in mind the need for non-cardiac surgery in the near future?