82 Is it time for standardization of timing and dosing of intra-coronary unfractionated heparin for diagnostic coronary angiogram using radial access in a tertiary care centre?

Introduction There are no established ESC/NICE guidelines for specific timing and dosage of intra-coronary unfractionated heparin for diagnostic coronary angiogram using radial access. A lack of standardisation of timing and dosage of heparin for invasive angiogram can lead to potentially serious or life-threatening implications such as coronary thromboembolism, or radial artery occlusion due to clot formation following the lack of timely delivery of anti-thrombotic agent. Purpose Our primary aim was to standardize the timing and dosing of intra-coronary unfractionated heparin for radial coronary angiogram and our further objectives were to understand reasons for controversies between inter-operator variabilities of timing of heparin and delivery of specified dose for high-thrombotic patient population. Materials and methods A total of 50(n=50) patients were assessed for eligibility for radial coronary angiogram from 2nd September 2023 to 25th January 2024. High-bleeding risk patients (such as age>75, renal failure, active cancer, active bleeding, etc) and femoral access were excluded from this study. Out of there 30 (n=30) received coronary angiogram using radial access (our study population). Delivery of intra-coronary heparin counted from the time radial access obtained up to the diagnostic sheath removal was assessed in two domains, including specified timing and dosing of each heparin within the procedure. A final study questionnaire was conducted upon the reasons for inter-operator variabilities of timing and dosage delivery of intra-coronary heparin among each procedure. An acceptable target standard was devised as 100% of compliance of timing and dosing of heparin in all patients proceeding radial coronary angiogram, which was standardized as specified timing (after initial radial sheath or before engaging coronary catheters) and target dosage (100IU/kg) of intra-coronary heparin delivery within each procedure. Results It was found that only 20 out of 30 patients (67%) achieved the target standard of full compliance in heparin timing and dosage delivery. In 10 of the 30 patients, who didn't meet the target standard, the main reasons are the lack of specified timing of intra-coronary heparin, prior to engaging the coronary catheters, and lack of standardized protocol for awareness of coronary complications such as radial artery occlusion, coronary thrombosis following delayed delivery of anti-thrombotic agent during invasive procedure. A final survey was conducted that almost one-third of patients (33%) proceeding radial coronary angiogram were delivered intra-coronary heparin in accordance with inter-operator preferences and lack of robust evidence upon standardised timing and dosing of study population. A standardised timing and dosing of intra-coronary heparin should have been devised to improve upon quality of angioplasty. This involves designating the on-call cardiology registrar to flag up the importance of intra-coronary heparin delivery within timely fashion with correct dosage taking account on patient co-morbidities and thrombotic risk factors. A multi-professional disciplinary team discussion of raising awareness and compliance with heparin should be implemented as a quality control measure with creation of an ongoing annual audit following guideline recommendations. Conclusion The incorporation of standardised timing and dosing of intra-coronary heparin in patients proceeding radial coronary angiography has led to significant improvement in patient quality of care and potential reduction in risk of serious outcomes such as radial artery occlusion or coronary thromboembolism. This study highlights the necessity of robust evidence around early timing with correct dosage of intra-coronary heparin and its impact on cardiovascular outcomes in high-thrombotic patient populations following radial coronary angiogram Conflict of Interest no